<<Prev Rule

Texas Administrative Code

Next Rule>>
TITLE 26HEALTH AND HUMAN SERVICES
PART 1HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 554NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION
SUBCHAPTER YMEDICAL NECESSITY DETERMINATIONS
RULE §554.2401General Qualifications for Medical Necessity Determinations

Medical necessity is the prerequisite for participation in the Medicaid (Title XIX) Long-term Care program. This section contains the general qualifications for a medical necessity determination. To verify that medical necessity exists, an individual must meet the conditions described in paragraphs (1) and (2) of this section.

  (1) The individual must demonstrate a medical condition that:

    (A) is of sufficient seriousness that the individual's needs exceed the routine care which may be given by an untrained person; and

    (B) requires licensed nurses' supervision, assessment, planning, and intervention that are available only in an institution.

  (2) The individual must require medical or nursing services that:

    (A) are ordered by a physician;

    (B) are dependent upon the individual's documented medical conditions;

    (C) require the skills of a registered or licensed vocational nurse;

    (D) are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and

    (E) are required on a regular basis.


Source Note: The provisions of this §554.2401 adopted to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871

Link to Texas Secretary of State Home Page | link to Texas Register home page | link to Texas Administrative Code home page | link to Open Meetings home page