Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 266 - MEDICAID HOSPICE PROGRAM
Subchapter B - UTILIZATION REVIEW
Section 266.213 - Extension of Continuous Home Care

Universal Citation: 26 TX Admin Code ยง 266.213

Current through Reg. 49, No. 38; September 20, 2024

(a) If the hospice believes that the period of crisis will extend beyond five consecutive days, the IDT must discuss the temporary alternate placement available to meet the needs of the individual during the period of crisis, such as a hospital or nursing facility. This discussion must occur and be documented before the fifth day of the crisis. If, after this discussion, the hospice believes that an extension of CHC is necessary instead of alternate placement, the hospice must fax a Request for CHC Extension Form to HHSC.

(1) The extension request must be faxed to HHSC by the fourth day of the CHC period.

(2) The extension request must include:
(A) a description of the specific crisis and how the hospice plans to resolve the crisis;

(B) documentation of all CHC provided during the period of crisis for which the hospice is seeking the extension;

(C) physician's orders;

(D) documentation of daily physician plan of care oversight;

(E) documentation that skilled nursing care was provided as more than half of the care given in a 24-hour period for each of the three days of CHC;

(F) documentation of the IDT's discussion regarding alternate placement prior to the initiation of CHC; and

(G) documentation of the reasons the CHC period must be extended, including the reasons the originally documented alternate placement is no longer appropriate or desired.

(b) HHSC denies the CHC extension request if the documentation is incomplete.

(c) HHSC reviews documentation faxed on or before the fourth consecutive day of the period of crisis within 16 work hours of receiving the documentation if it is sent in accordance with the instructions in subsection (a)(1) of this section.

(d) HHSC will not consider requests faxed after the fourth consecutive day of the period of crisis.

(e) HHSC will not consider multiple requests for extensions for the same period of crisis.

(f) HHSC notifies a hospice in writing, via fax, of its decision no later than the end of the fifth consecutive day of the period of crisis.

(g) If HHSC denies the request for an extension of CHC, HHSC sends a notice of denial to the individual whose CHC the hospice was seeking to extend. The notice of denial informs the individual of the individual's right to request a Medicaid fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).

(h) If HHSC denies the request for an extension of CHC, HHSC pays the hospice at the routine home care rate or inpatient care rate, if applicable, for subsequent days of care.

(i) The approval of a CHC extension request is not an approval of the initial CHC period, nor an approval for the care provided during the extension period. HHSC will conduct a review of all paid CHC claims to determine compliance with eligibility requirements for the hospice payment.

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