Current through Reg. 49, No. 38; September 20, 2024
(a)
Personal care services (PCS) include:
(1)
Assistance with Activities of Daily Living (ADLs) and Instrumental Activities
of Daily Living (IADLs);
(2)
Nurse-delegated tasks and Health Maintenance Activities (HMAs) as permitted by
program policy and 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed
Personnel and Tasks not Requiring Delegation in Independent Living Environments
for Client's with Stable and Predictable Conditions); and
(3) Hands-on assistance, cueing, redirecting,
or intervening, to accomplish the approved PCS task.
(b) Prior to authorizing PCS, HHSC will
require completion of:
(1) An assessment of
the recipient with an HHSC-approved assessment form;
(2) Additional documentation required by HHSC
to support the need for PCS and complete the authorization process;
and
(3) An HHSC-approved
Practitioner Statement of Need (PSON) by a practitioner who is known by and has
an ongoing clinical relationship with the recipient and familiarity with the
recipient's diagnosis.
(A) The PSON must be
on file with HHSC prior to the initiation of PCS.
(B) If a recipient or intended recipient is
entering or is in the conservatorship of the state, PCS may be provisionally
initiated for up to 60 days once eligibility has been established through the
assessment.
(C) HHSC will accept
the PSON only if:
(i) The individual who
completes the PSON is a physician, advanced practice registered nurse, or
physician assistant; and
(ii)
Unless otherwise authorized by HHSC, the practitioner is a Medicaid enrolled
provider.
(c) In evaluating the request for PCS, HHSC
will determine the amount and duration of PCS by taking into account the
following:
(1) Whether the recipient has a
physical, cognitive, or behavioral limitation related to a disability or
chronic health condition that inhibits the recipient's ability to accomplish
ADLs, IADLs, or HMAs;
(2) The
responsible adult's need to sleep, work, attend school, and meet their own
medical needs;
(3) The responsible
adult's legal obligation to care for, support, and meet the medical,
educational, and psycho-social needs of their other dependents;
(4) The responsible adult's physical ability
to perform the personal care services;
(5) Whether requiring the responsible adult
to perform the personal care services will put the recipient's health or safety
in jeopardy;
(6) The time periods
during which the personal care service tasks are required by the recipient, as
they occur over the course of a 24-hour day, and a 7-day week;
(7) Whether or not the need to assist the
family in performing personal care services on behalf of the recipient is
related to a medical, cognitive, or behavioral condition that results in a
level of functional ability that is below that expected of a typically
developing child of the same chronological age; and
(8) Whether services are needed based on:
(A) the PSON; and
(B) the recipient's personal care
assessment.
(d) HHSC will not arbitrarily deny
authorization of PCS or reduce the number of requested hours of services based
solely on the recipient's diagnosis, type of illness, or condition.
(e) A recipient may receive PCS through the
Consumer Directed Services (CDS) option defined in 40 TAC Chapter 41 (relating
to Consumer Directed Services Option).
(f) PCS limitations include the following:
(1) HHSC or its designee will not reimburse
for PCS used for or intended to provide:
(A)
Respite care;
(B) Child care;
or
(C) Restraining of a
recipient.
(2) PCS shall
neither replace the responsible adult as the primary care giver, nor provide
all the care a recipient requires to live at home. Primary care givers remain
responsible for a substantial portion of a recipient's daily care, and PCS are
intended to support the care of the recipient living at home.
(3) PCS will not be authorized to overlap
with duplicative services provided by another Medicaid program or a Medicaid
waiver program.
(4) PCS may be
authorized for a provider to recipient ratio greater than one-on-one in
settings in which PCS are provided in homes with more than one recipient
receiving PCS, foster care services, and/or independent living arrangements per
program policy.
(5) PCS do not
include the payment for transportation services available through the Medical
Transportation Program (MTP).
(g) HHSC will require the reassessment of the
recipient's need for PCS every 12 months, or when requested due to a change in
the recipient's health or living condition. A new PSON will be required at each
annual reassessment. If a reassessment is requested, due to a change in the
recipient's health condition, a new PSON indicating a the change in the
recipient's functional need or condition must be submitted.
(h) Authorization for PCS will be terminated
by HHSC or its designee when:
(1) The
recipient is no longer eligible for Texas Medicaid;
(2) The recipient no longer meets the
criteria for PCS;
(3) The place of
service(s) can no longer meet the recipient's health and safety needs;
or
(4) The authorization for PCS
expires.
(i)
Authorization for PCS may be suspended by HHSC or its designee when:
(1) The recipient or their family creates an
unsafe environment for the attendant's health and safety; or
(2) The provider requests suspension for
reasons as outlined in PCS program policy.
(j) A recipient may request a fair hearing in
the event that PCS are denied, reduced, suspended or terminated, as per Chapter
357 of this title (relating to Hearings).
