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RULE §108.1413Family Monthly Maximum Payment

(a) The family monthly maximum payment is the total amount of money collected from a family in one month, including family fees, co-pays, co-insurance, and deductibles. The assigned family monthly maximum payment does not increase if the family has more than one child receiving IFSP services.

(b) The contractor may not charge a family a co-pay or any co-insurance, deductibles or family fees for children in receipt of Medicaid.

(c) The contractor determines the family's assigned family monthly maximum payment based on the family's placement on the DARS ECI sliding fee scale. Placement on the sliding fee scale is based on family size and annual adjusted income. The sliding fee scale is based on the formula in the figure in this subsection. The sliding fee scale must be provided to the parent and additional copies can be obtained from DARS.

  (1) For children and families enrolled in ECI services before January 1, 2014, the family monthly maximum payment shall be pursuant to the figure located in this paragraph until the family's annual IFSP review. Thereafter, the family monthly maximum payment shall be pursuant to the figure located in paragraph (2) of this subsection.

Attached Graphic

  (2) For children and families who enroll in ECI services on or after January 1, 2014, the family monthly maximum payment shall be pursuant to the figure located in this paragraph.

Attached Graphic

(d) Family size is calculated by adding: the child, the number of parents living in the home, and the number of the parent's other dependents.

(e) The annual adjusted income is calculated by subtracting allowable deductions from the annual gross income.

(f) The contractor calculates the allowable deductions amount using:

  (1) the actual amounts that were paid over the previous 12 months and are expected to continue during the IFSP period; and

  (2) projections for new expenses expected to occur during the IFSP period.

(g) Allowable deductions are limited to the following family expenses that are not reimbursed by other sources:

  (1) medical or dental expenses that meet the requirements in subsection (h) of this section;

  (2) childcare and respite expenses;

  (3) costs and fees associated with the adoption of a child; and

  (4) court-ordered child support payments for children who were not counted as family members or dependents in calculating the adjusted income and family monthly maximum payment.

(h) Allowable deductions for medical and dental expenses are costs to primarily alleviate or prevent a physical or mental defect or illness. Allowable deductions for medical and dental expenses are limited to the cost of:

  (1) diagnosis, cure, alleviation, treatment, or prevention of disease;

  (2) treatment of any affected body part or function;

  (3) legal medical services delivered by physicians, surgeons, dentists, and other medical practitioners;

  (4) medication, medical supplies, and diagnostic devices;

  (5) premiums paid for insurance that covers the expenses of medical or dental care;

  (6) transportation to receive medical or dental care; and

  (7) medical or dental debt that is being paid on an established payment plan.

(i) In situations where there is shared physical custody or shared legal or financial responsibility for a child, the adjusted income(s) of the parent who financially supports the child will be considered unless conditions warrant otherwise.

(j) The parent must sign a family cost share agreement acknowledging the family monthly maximum payment calculated according to the figures in subsection (c) of this section. The contractor must not provide IFSP services subject to a family cost share amount until the parent signs a family cost share agreement.

Source Note: The provisions of this §108.1413 adopted to be effective September 1, 2011, 36 TexReg 5408; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective December 31, 2012, 37 TexReg 9786; amended to be effective September 1, 2013, 38 TexReg 5540

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