Prior to authorizing Personal Care Services, HHSC or its designee will require completion of:

• A thorough evaluation of the beneficiary along with an assessment form approved by the HHSC

• Submission of any documentation that is required by the HHSC.

Within 60 days of the initial start of care, a written statement of need by the beneficiary’s physician that is HHSC-approved must be on file with HHSC or its designee.

The HHSC or its designee will evaluate the request for Personal Care Services and will determine the amount and duration of Personal Care Services by taking into account the following aspects:

• If the recipient has a physical, cognitive, or behavioral limitation caused by his/her disability or chronic health condition that prevents the ability to accomplish activities of daily living,
  instrumental activities of daily living, and/or related health functions;

• The beneficiary’s parent/guardian needs to sleep, work, go to school, and meet their own health
  and medical needs;

• The beneficiary’s parent/guardian has legal obligation to meet the medical, educational, and
  psycho-social health requirements of other dependents;

• The beneficiary’s parent/guardian has the capability to render the Personal Care Services; and

• Whether or not the need to assist family members in providing Personal Care Services is related to a medical, cognitive, or behavioral condition that may result in a level of functional capability that is below that expected of a normal developing child of the same age.

The HHSC will not promptly deny the approval of Personal Care Services or lower the number of hours requested for the service based entirely on the recipient’s illness, diagnosis, or health condition.

A beneficiary may receive Personal Care Services through the Consumer Directed Services (CDS) option.

The limitations for the Personal Care Services include:

The HHSC will not refund for Personal Care Services that are used for or intended to provide for:

• Respite care

• Child care

Parents or designated guardians of the beneficiary shall not be replaced as the primary caregiver when Personal Care Services are acquired. This program nor will not provide all the care a client requires in order to remain living at home. The primary care givers remain accountable for a portion of the beneficiary’s daily care needs.

The HHSC or the designee can terminate the authorization for Personal Care Services if:

• The recipient is no longer qualified for Texas Medicaid;

• The recipient no longer meets the Personal Care Services’ medical necessity criteria;

• The place of service(s) can no longer provide the recipient’s health and safety requirements;

• The care provider requests for termination since the beneficiary will not comply with the service plan; or

• The authorization for Personal Care Services expires.

A fair hearing can be requested by the beneficiary in the event that services are denied,
reduced, suspended, or terminated.