| (a) Subject to the specifications, conditions, limitations,
and requirements established by HHSC or its designee, in-home respiratory
therapy services are available to eligible recipients who:
(1) are ventilator-dependent for life support at least
six hours per day;
(2) have been so dependent for at least 30 consecutive
days as an inpatient in one or more hospitals, skilled nursing facilities
(SNF), or intermediate care facilities (ICF);
(3) but for the availability of these respiratory care
services at home, would require respiratory care as an inpatient in
a hospital, SNF, or ICF;
(4) would be eligible to have payment made for such
inpatient care under the state Medicaid plan;
(5) have adequate social support services to be cared
for at home; and
(6) wish to be cared for at home.
(b) Covered respiratory therapy services must be reasonable,
medically necessary, and prescribed by the recipient's physician (MD
or DO). The physician must be licensed in the state in which the physician
practices.
(c) HHSC or its designee must authorize the services
prior to their delivery. Prior authorization requests must include
all pertinent medical records and other information as required by
HHSC or its designee to justify the medical necessity of and/or dependency
on the ventilator support and therapy services and to ensure that
the requirements in subsection (a) of this section are met. Prior
authorization is a requirement for payment. HHSC or its designee may
extend the prior authorization based upon an interim report from the
physician documenting the medical necessity and appropriateness of
continued in-home respiratory therapy services.
(d) Covered services include:
(1) respiratory therapy services and treatments prescribed
by the recipient's physician; and
(2) education of the recipient and/or appropriate family
members/support persons regarding the in-home respiratory care. Education
must include the use and maintenance of required supplies, equipment,
and techniques appropriate to the situation.
(e) Providers of respiratory therapy services must
meet the following requirements:
(1) comply with all applicable federal, state, and
local laws and regulations;
(2) be certified by the Texas Medical Board to practice
under Chapter 604 of the Texas Occupations Code;
(3) be enrolled and approved for participation in the
Texas Medical Assistance Program;
(4) sign a written provider agreement with HHSC or
its designee. By signing the agreement, the provider agrees to comply
with the terms of the agreement and all requirements of the Texas
Medical Assistance Program including regulations, rules, handbooks,
standards, and guidelines published by HHSC or its designee; and
(5) bill for covered services in the manner and format
prescribed by HHSC or its designee.
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