| (a) Personal care services (PCS) include:
(1) Assistance with Activities of Daily Living (ADLs)
and Instrumental Activities of Daily Living (IADLs);
(2) Nurse-delegated tasks and Health Maintenance Activities
(HMAs) within the scope of PCS, as permitted by program policy and
22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel
and Tasks not Requiring Delegation in Independent Living Environments
for Clients with Stable and Predictable Conditions); and
(3) Hands-on assistance, cueing, redirecting, or intervening,
to accomplish the approved PCS task.
(b) Prior to authorizing PCS, HHSC will require completion
of:
(1) An assessment of the recipient with an HHSC-approved
assessment form;
(2) Additional documentation required by HHSC to support
the need for PCS and complete the authorization process; and
(3) An HHSC-approved Practitioner's Statement of Need
(PSON) completed by a practitioner who has personally examined the
recipient within the last twelve (12) months and reviewed all appropriate
medical records.
(A) The PSON must be on file with HHSC prior to the
initiation of PCS.
(B) If a recipient or intended recipient is entering
or is in the conservatorship of the state, PCS may be provisionally
initiated for up to 60 days once eligibility has been established
through the assessment.
(C) HHSC will accept the PSON only if:
(i) The individual who completes the PSON is a physician,
advanced practice registered nurse, or physician assistant; and
(ii) The practitioner is a Medicaid enrolled provider.
(c) In evaluating the request for PCS, HHSC will determine
the amount and duration of PCS by taking into account the following:
(1) Whether the recipient has a physical, cognitive,
or behavioral limitation related to a disability or chronic health
condition that inhibits the recipient's ability to accomplish ADLs
or IADLs;
(2) The responsible adult's need to sleep, work, attend
school, and meet their own medical needs;
(3) The responsible adult's legal obligation to care
for, support, and meet the medical, educational, and psychosocial
needs of their other dependents;
(4) The responsible adult's physical ability to perform
the personal care services;
(5) Whether requiring the responsible adult to perform
the personal care services will put the recipient's health or safety
in jeopardy;
(6) The time periods during which the personal care
service tasks are required by the recipient, as they occur over the
course of a 24-hour day, and a 7-day week;
(7) Whether or not the need to assist the family in
performing personal care services on behalf of the recipient is related
to a medical, cognitive, or behavioral condition that results in a
level of functional ability that is below that expected of a typically
developing child of the same chronological age; and
(8) Whether services are needed based on:
(A) the PSON; and
(B) the recipient's personal care assessment.
(d) HHSC will not arbitrarily deny authorization of
PCS or reduce the number of requested hours of services based solely
on the recipient's diagnosis, type of illness, or condition.
(e) A recipient may receive PCS through the Consumer
Directed Services (CDS) option defined in 40 TAC Chapter 41 (relating
to Consumer Directed Services Option).
(f) PCS limitations include the following:
(1) HHSC will not reimburse for PCS used for or intended
to provide:
(A) Respite care;
(B) Child care; or
(C) Restraining of a recipient.
(2) PCS shall neither replace the responsible adult
as the primary care giver, nor provide all the care a recipient requires
to live at home. Primary care givers remain responsible for a substantial
portion of a recipient's daily care, and PCS are intended to support
the care of the recipient living at home.
(3) PCS may be delivered in a recipient to provider
ratio other than one-on-one as long as each recipient's care is based
on an individualized plan of care (POC) and each recipient's needs
are being met. Only the time spent on authorized PCS tasks for each
client is eligible for reimbursement. Total PCS billed for all clients
cannot exceed an individual attendant's total number of hours at the
place of service.
(4) PCS do not include the payment for transportation
services available through the Medical Transportation Program (MTP).
(g) HHSC will require the reassessment of the recipient's
need for PCS every 12 months, or when requested due to a change in
the recipient's health or living condition. A new PSON will be required
at each annual reassessment. If a reassessment is requested due to
a change in the recipient's health condition, HHSC must obtain a new
PSON indicating a change in the recipient's functional need or health
condition.
(h) Authorization for PCS will be terminated by HHSC
when:
(1) The recipient is no longer eligible for Texas Medicaid;
(2) The recipient no longer meets the criteria for
PCS; or
(3) The authorization for PCS expires.
(i) Authorization for PCS may be suspended by HHSC
when:
(1) An unsafe environment exists in the recipient's
place of service which places the attendant's health and safety at
risk; or
(2) The provider requests suspension for reasons as
outlined in PCS program policy.
(j) A recipient may request a fair hearing in the event
that PCS are denied, reduced, suspended or terminated, as per Chapter
357 of this title (relating to Hearings).
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