1 Tex. Admin. Code § 363.209 - Benefits and Limitations
(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.
Notes
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No prior version found.