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 ยง 363.209
Current through Reg. 49, No. 38; September 20, 2024
(a) Comprehensive plan of care; permissible PPECC services.
(1) The PPECC must develop, implement, and
monitor a comprehensive plan of care 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 if transportation is
needed;
(E) is reviewed and revised
for each authorization of services per subsection (d) of this section or more
frequently as the ordering physician deems necessary;
(F) is signed and dated by the participant's
ordering physician;
(G) is signed
and dated by the participant or the participant's responsible adult;
(H) meets additional requirements prescribed
in 40 TAC §RSA
15.607(relating to Initial and Updated Plan
of Care); and
(I) meets
requirements contained in the Texas Medicaid Provider Procedures
Manual.
(2)
Transportation Services.
(A) The PPECC must
provide transportation between the participant's residence and the PPECC when a
participant has a stated need or prescription for such
transportation.
(B) When a PPECC
provides transportation to a PPECC participant, an RN or LVN employed by the
PPECC must be on board the transport vehicle.
(C) The PPECC must:
(i) sign, date, and indicate the time the
participant is put on the transport vehicle to deliver the participant to the
PPECC;
(ii) sign, date, and
indicate the arrival time of the participant at the PPECC;
(iii) sign, date, and indicate the time the
participant is put on the transport vehicle to return the participant to their
place of residence; and
(iv) sign,
date, and indicate the arrival time at the participant's residence.
(D) A responsible adult is not
required to accompany a participant when the participant receives
transportation services to and from the PPECC.
(E) A participant or participant's
responsible adult may decline a PPECC's transportation and choose to be
transported by other means.
(F) 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) The PPECC must provide written
documentation about the participant's care each day to the participant's
responsible adult, including documentation of medication given, services
provided, and other relevant health-related information. The documentation must
be provided each day following service delivery when the responsible adult
picks up the participant or when the PPECC transports the participant to his or
her residence.
(5) For each day
that PPECC services are provided, the participant's medical record must
identify the specific person (e.g., nursing, direct care staff, therapist)
providing services, the type of services performed, and the start and end times
of services performed. The PPECC must be able to calculate the cost by
practitioner and type of service provided as requested by HHSC.
(b) Amount and duration.
(1) HHSC evaluates the amount and duration of
PPECC services requested upon review of:
(A)
a physician order;
(B) a PPECC plan
of care;
(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'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 the following PPECC services:
(A) services intended to provide mainly
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, 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.
(3) A participant who is eligible may receive
both PDN and PPECC services on the same day. However, PPECC services are
intended to be a one-to-one replacement of PDN hours unless additional hours
are medically necessary. The following medically necessary services may be
billed on the same day as PPECC services, but they may not be billed
simultaneously with PPECC services. These services may be billed before or
after PPECC services:
(A) private duty
nursing;
(B) home health skilled
nursing; and
(C) home health aide
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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
