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RULE §363.209Benefits and Limitations

(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 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 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 physician;

    (G) is signed and dated by the participant or the participant's responsible adult;

    (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 transport vehicle.

    (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 PPECC;

      (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 participant's residence.

    (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 or institutionalization;

      (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 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 '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, 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, 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.

  (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.

Source Note: The provisions of this §363.209 adopted to be effective November 1, 2016, 41 TexReg 8284

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