|(a) Comprehensive plan of care; permissible PPECC services.
(1) The PPECC must develop, implement, and monitor
a comprehensive plan of care that:
(A) is provided to a medically dependent or technologically
(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
(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
(D) specifies if transportation is needed;
(E) is reviewed and revised for each authorization
of services per subsection (d) of this section or more frequently
as the ordering physician deems necessary;
(F) is signed and dated by the participant's ordering
(G) is signed and dated by the participant or the participant's
(H) meets additional requirements prescribed in 40
TAC §15.607 (relating to Initial and Updated Plan of Care); and
(I) meets requirements contained in the Texas Medicaid
Provider Procedures Manual.
(2) Transportation Services.
(A) The PPECC must provide transportation between the
participant's residence and the PPECC when a participant has a stated
need or prescription for such transportation.
(B) When a PPECC provides transportation to a PPECC
participant, an RN or LVN employed by the PPECC must be on board the
(C) The PPECC must:
(i) sign, date, and indicate the time the participant
is put on the transport vehicle to deliver the participant to the
(ii) sign, date, and indicate the arrival time of the
participant at the PPECC;
(iii) sign, date, and indicate the time the participant
is put on the transport vehicle to return the participant to their
place of residence; and
(iv) sign, date, and indicate the arrival time at the
(D) A responsible adult is not required to accompany
a participant when the participant receives transportation services
to and from the PPECC.
(E) A participant or participant's responsible adult
may decline a PPECC's transportation and choose to be transported
by other means.
(F) 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
(ii) providing cost-effective, quality care in the
most appropriate environment; and
(iii) providing training and education of caregivers.
(4) The PPECC must provide written documentation about
the participant's care each day to the participant's responsible adult,
including documentation of medication given, services provided, and
other relevant health-related information. The documentation must
be provided each day following service delivery when the responsible
adult picks up the participant or when the PPECC transports the participant
to his or her residence.
(5) For each day that PPECC services are provided,
the participant’s medical record must identify the specific
person (e.g., nursing, direct care staff, therapist) providing services,
the type of services performed, and the start and end times of services
performed. The PPECC must be able to calculate the cost by practitioner
and type of service provided as requested by HHSC.
(b) Amount and duration.
(1) HHSC evaluates the amount and duration of PPECC
services requested upon review of:
(A) a physician order;
(B) a PPECC plan of care;
(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
(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 '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
the following PPECC services:
(A) services intended to provide mainly 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,
(i) speech therapy, occupational therapy, physical
therapy, respiratory care practitioner services, and early childhood
(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, 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;
(G) individualized comprehensive case management beyond
the service coordination required by the Texas Occupations Code Chapter
(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
(3) A participant who is eligible may receive both
PDN and PPECC services on the same day. However, PPECC services are
intended to be a one-to-one replacement of PDN hours unless additional
hours are medically necessary. The following medically necessary services
may be billed on the same day as PPECC services, but they may not
be billed simultaneously with PPECC services. These services may be
billed before or after PPECC services:
(A) private duty nursing;
(B) home health skilled nursing; and
(C) home health aide services.
(d) Parental accompaniment is not required for PPECC
services, including therapy services rendered in a PPECC setting.