Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM
Subchapter B - PRESCRIBED PEDIATRIC EXTENDED CARE CENTER SERVICES
Section 363.209 - Benefits and Limitations

Universal Citation: 1 TX Admin Code § 363.209

Current through Reg. 50, No. 13; March 28, 2025

(a) Comprehensive plan of care (POC) and PPECC permissible services.

(1) A PPECC must develop, implement, and monitor a comprehensive POC that:
(A) is provided to a medically dependent or technologically dependent participant;

(B) is developed in collaboration with the participant's ordering physician, responsible adult, and interdisciplinary team, as well as the participant's existing service providers as needed to coordinate care;

(C) specifies the following prescribed services needed to address the medical, nursing, psychosocial, therapeutic, dietary, functional, and developmental needs of the participant and the training needs of the participant's responsible adult:
(i) skilled nursing;

(ii) personal care services to assist with activities of daily living while in the PPECC;

(iii) functional developmental services;

(iv) nutritional and dietary services, including nutritional counseling;

(v) occupational, physical and speech therapy;

(vi) respiratory care;

(vii) psychosocial services; and

(viii) training for the participant's responsible adult associated with caring for a medically or technologically dependent participant;

(D) specifies whether the participant is stable as determined by the participant's ordering physician;

(E) if the participant is stable, the participant's ordering physician, in collaboration with the PPECC, specifies one of the following to be on board the transport vehicle to assist the participant during transportation:
(i) a registered nurse (RN);

(ii) a licensed vocational nurse (LVN); or

(iii) direct care staff;

(F) is reviewed and revised for each authorization period of services per § 363.211(d) of this subchapter or more frequently as the ordering physician deems necessary;

(G) is signed and dated by the participant's ordering physician;

(H) is developed and established with the participant or the participant's responsible adult;

(I) includes a nursing addendum signed by the participant or the participant's responsible adult;

(J) meets additional requirements prescribed in 26 TAC § 550.607 (relating to Initial and Updated Plan of Care); and

(K) meets requirements contained in the Texas Medicaid Provider Procedures Manual.

(2) Transportation Services.
(A) A PPECC must provide transportation of a participant to and from the PPECC when:
(i) the participant's ordering physician determines the participant is stable; and

(ii) the responsible adult wants the participant to receive transportation.

(B) When a PPECC provides transportation for a participant, an RN, LVN, or direct care staff, as determined by the participant's ordering physician in collaboration with the PPECC, must be on board the transport vehicle to assist the participant during transportation.

(C) A PPECC must ensure that the driver and the RN, LVN, or direct care staff on board the transport vehicle maintain a daily transportation log that must include:
(i) the driver's name;

(ii) the name of the PPECC staff member and whether the staff member is an RN, LVN, or direct care staff;

(iii) the date;

(iv) the name of the participant;

(v) the time the participant is put on the transport vehicle to deliver the participant to the PPECC;

(vi) the time the participant arrives at the PPECC;

(vii) the time the participant is put on the transport vehicle to return to the responsible adult or an adult authorized by the participant's responsible adult;

(viii) the time the participant arrives at the participant's return destination and the name of the person to whom the participant was released; and

(ix) for a participant who is in transport for longer than one hour traveling to the PPECC or for longer than one hour traveling to their return destination, the reason that the transport time was longer than one hour.

(D) Payment for transportation services not substantiated by the documentation required in subparagraph (C) of this paragraph may be recouped.

(E) A responsible adult is not required to accompany a participant when the participant receives transportation services to and from the PPECC.

(F) A participant or participant's responsible adult may decline a PPECC's transportation services entirely, on a specific date, or for part of a specific date and choose to be transported by other means.

(G) A non-emergency ambulance may not be used for transport to and from a PPECC.

(3) PPECC services, including training provided to the participant's responsible adult associated with caring for a medically or technologically dependent participant, must be provided by the PPECC with the following intended outcomes:
(A) optimizing the participant's health status and outcomes; and

(B) promoting and supporting family-centered, community-based care as a component of an array of service options by:
(i) preventing prolonged or frequent hospitalizations or institutionalization;

(ii) providing cost-effective, quality care in the most appropriate environment; and

(iii) providing training and education of caregivers.

(4) A PPECC must provide written documentation about a participant's care each day to the participant's responsible adult, including documentation of medication given, services provided, and other relevant health-related information. A PPECC must provide documentation to the participant's responsible adult each day following service delivery when the responsible adult picks up the participant or when the PPECC transports the participant to the participant's return destination.

(5) For each day that PPECC services are provided, a participant's medical record must identify the specific person, for example, nursing, direct care staff, or therapist providing services, the type of services performed, and the start and end times of services performed.

(b) Amount and duration.

(1) HHSC evaluates the amount and duration of PPECC services requested upon review of:
(A) a physician's order;

(B) a PPECC POC;

(C) a completed request for authorization, including all required documentation, as indicated in the Texas Medicaid Provider Procedures Manual; and

(D) the full array of Medicaid services the participant is receiving at the time the plan of care is developed.

(2) HHSC re-evaluates the amount of PPECC services when:
(A) there is a change in the frequency of skilled nursing interventions, other PPECC medical services, or the complexity and intensity of the participant's care, or the authorized services are not commensurate with the participant's medical needs and additional authorized hours are medically necessary;

(B) the participant or the participant's responsible adult chooses alternate resources for comparable care; or

(C) the responsible adult becomes available and is willing to provide appropriate care for the participant.

(c) PPECC service limitations.

(1) The Medicaid rate for PPECC services does not include a PPECC providing the following services:
(A) services intended to provide respite care or child care, or services not directly related to the participant's medical needs or disability;

(B) services that are the legal responsibility of a local school district, including transportation;

(C) services covered separately by Texas Medicaid, such as:
(i) speech therapy, occupational therapy, physical therapy, respiratory care practitioner services, and early childhood intervention services;

(ii) durable medical equipment (DME), medical supplies, and nutritional products provided to the participant by Medicaid's DME and medical supply service providers; and

(iii) Private Duty Nursing (PDN), skilled nursing, and aide services provided in the home setting when medically needed in addition to the PPECC services authorized;

(D) baby food or formula;

(E) services to participants related to the PPECC owner by blood, marriage, or adoption;

(F) services rendered to a participant who does not meet the definition of a medically or technologically dependent participant; and

(G) individualized comprehensive case management beyond the service coordination required by the Texas Occupations Code Chapter 301.

(2) PPECC services are limited to 12 hours per day. Services begin when the PPECC assumes responsibility for the care of the participant (the point the participant is boarded onto PPECC transportation or when the participant is brought to the PPECC) and ends when the care is relinquished to the participant's responsible adult or an adult authorized by the participant's responsible adult.

(3) A participant who is eligible to receive PDN services may also receive PPECC services. A participant may choose to receive all authorized continuous skilled nursing service hours through PPECC services only, PDN services only, or a combination of both PPECC and PDN services. If a participant chooses to receive both PPECC and PDN services, the participant must not receive service hours in addition to what was initially authorized for PPECC and PDN, unless additional hours are medically necessary.

(4) The following medically necessary services may be billed on the same day as PPECC services, but may not be billed simultaneously with PPECC services. These services may be billed before or after PPECC services:
(A) PDN;

(B) home health skilled nursing;

(C) home health aide services; and

(D) personal care services.

(d) Parental accompaniment is not required for PPECC services, including therapy services rendered in a PPECC setting.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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