Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 270 - CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)
Section 270.16 - Medical Necessity Assessments

Universal Citation: 26 TX Admin Code ยง 270.16

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

(a) The provider agency must complete a medical necessity and level of care assessment based on the client's total needs.

(b) The provider agency must electronically transmit the medical necessity and level of care assessment to the agency with which the Texas Health and Human Services Commission (HHSC) contracts for medical necessity determinations.

(c) The provider agency must enroll any eligible applicant within 60 calendar days after the date of the medical necessity and level of care assessment.

(d) The provider agency must complete another medical necessity and level of care assessment and submit it to the agency with which HHSC contracts for medical necessity determinations 12 months after the initial assessment.

(1) If the client meets the state's medical necessity criteria and the client has an irreversible or progressive diagnosis, or a terminal illness that could reasonably be expected to result in death in the next six months, and the Department of Aging and Disability Services (DADS) determines that there is no reasonable expectation of improvement or significant change in the client's condition because of severity of a chronic condition or the degree of impairment of functional capacity, DADS will permanently waive the annual recertification requirement and the client may be deemed to be continually eligible for PACE. The medical necessity and level of care assessment must have sufficient documentation to substantiate the client's prognosis and the client's functional capacity.

(2) In addition, if DADS determines that a PACE client no longer meets the medical necessity criteria for nursing facility care, the client may be deemed to continue to be eligible for PACE until the next annual reassessment, if, in the absence of PACE services, it is reasonable to expect that the client would meet the nursing facility medical necessity criteria within the next six months.

(e) The provider agency's licensed nurse must complete the medical necessity and level of care assessment for the provider agency. The licensed nurse must be registered with the agency with which HHSC contracts for medical necessity determinations as having, within the last two years, received and passed a state-approved training on the medical necessity and level of care assessment.

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