TO:
Health and Human Services Commission Council
DATE:
November 21, 2014
FROM:
Laurie Vanhoose, Medicaid/CHIP, Director of Policy
Development, HHSC
SUBJECT: Item 5.f. Prescribed Pediatric Extended Care Centers (PPECCs)
New Rules: Title 1, Part 15, Chapter 363, Subchapter B, Prescribed Pediatric Extended Care
Center Services, §§363.201 to 363.217
BACKGROUND: Federal Requirement
Legislative Requirement
Other
S.B. 492, 83rd Legislature, Regular Session, 2013, establishes Prescribed Pediatric Extended
Care Centers (PPECCs) in Texas. PPECCs provide non-residential, facility-based care as an
alternative to private-duty nursing (PDN) for individuals under the age of 21 with complex
medical needs. The bill restricts service hours to no more than 12 hours in a 24-hour period per
child and directs HHSC to establish a reimbursement rate that is no more than 70 percent of the
average hourly PDN rate. Receiving services in a PPECC setting does not supplant a child’s right
to PDN services when they are determined medically necessary, but the PDN and PPECC
services cannot be provided at exactly the same time (concurrently) in a given day. Rather, PDN
services would be rendered before and/or after PPECC services are rendered.
S.B. 492 limits PPECC services to individuals who are “medically dependent or technologically
dependent.” This term is defined in S.B. 492 as a child who, “due to an acute, chronic, or
intermittent medically complex or fragile condition or disability requires physician prescribed,
ongoing, technology-based skilled nursing care to avert death or further disability or the routine
use of a medical device to compensate for a deficit in a life-sustaining body function.” This
definition “does not include minor or occasional medical conditions that do not require
continuous nursing care…"
Policy staff determined PPECC services should be considered Medicaid State Plan services,
requiring the creation of new payable provider type and enrollment processes for Texas
Medicaid. PPECC services will be made available in traditional Medicaid and managed care
(STAR, STAR+PLUS, STAR Health, and eventually STAR Kids).
The Department of Aging and Disability Services is responsible for licensing PPECCs.
ISSUES AND ALTERNATIVES:
Issues related to the benefit include the following:
1


PPECC providers have expressed concern that they cannot receive a license unless they
are observed by the Department of Aging and Disability Services (DADS) serving up to
three clients. They contend that this licensure requirement compels them to provide
unlicensed care which raises liability concerns. Additionally, HHSC cannot render
payment until the provider is fully licensed and enrolled as a Medicaid provider.
SB 492 does not provide an explicit exemption from parental accompaniment
requirements in THSteps services, per rule §354.1133. It would be helpful to have this
exemption spelled out in future legislation.
These proposed new rules are intended to implement a legislatively mandated program.
Therefore, there are no alternatives to implementing this program.
STAKEHOLDER INVOLVEMENT:




An email box was created to receive Medicaid-related inquiries:
HHSC_PPECC@hhsc.state.tx.us.
An informal stakeholder forum was held August 4, 2014 in the DADS Public Hearing
Room in Austin. Some individuals participated by phone. Draft rules were disseminated
to external stakeholders for review and comment at the meeting and were also provided
upon request. Comments received from stakeholders were reviewed by HHSC staff and
taken into consideration in the development of the rules.
HHSC also held a separate meeting with managed care health plans to provide
information on the benefit.
External stakeholders include PPECC providers from other states, Medicaid managed
care plans, disability rights advocacy groups, and current providers in Texas with an
interest in learning more about PPECCs.
FISCAL IMPACT:
None (if no, delete the table below)
Yes (if yes, complete the table below)
State
FY 2015
$68,946
FY 2016
$801,194
FY 2017
$1,584,669
FY 2018
$2,088,034
FY 2019
$2,603,518
Federal
$95,407
$1,071,192
$2,111,783
$2,782,585
$3,469,535
Total
$164,353
$1,872,386
$3,696,452
$4,870,619
$6,073,053
SERVICES IMPACT STATEMENT:
The anticipated services impact of the proposed rules will be the creation of a new PPECC
provider type that will offer an alternative to Private Duty Nursing services for medically or
technologically dependent children. The rules provide a description of the services, medical
necessity criteria, and general requirements for receiving the services.
2
RULE DEVELOPMENT SCHEDULE:
November 7, 2014
November 21, 2014
February 20, 2015
May 22, 2015
June 1, 2015
Present to Medical Care Advisory Committee
Present to HHSC Council
Publish proposed rules in Texas Register
Publish adopted rules in Texas Register
Effective date
REQUESTED ACTION:
The Council recommends to the Executive Commissioner that the proposed rule be
published in the Texas Register and later adopted should there be no substantive
comment.
3
TITLE 1
PART 15
CHAPTER 363
PROGRAM
ADMINISTRATION
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PROPOSED PREAMBLE
The Texas Health and Human Services Commission (HHSC) proposes new Subchapter
B, Prescribed Pediatric Extended Care Center Services, including new rules §§363.201
to 363.217.
Background and Justification
As adopted by the 83d Legislature in 2013, Texas Health and Safety Code chapter
248A establishes Prescribed Pediatric Extended Care Centers (PPECCs) in Texas.
See Act of May 22, 2013, 83d Leg., R.S., ch. 1168, §1, 2013 Tex. Gen. Laws 2898
(S.B. 492). A PPECC provides non-residential, facility-based care as an alternative to
private-duty nursing (PDN) for individuals under the age of 21 with complex medical
needs. Under the terms of its license, a PPECC may provide services to minors for no
more than 12 hours in a 24-hour period. Tex. Health & Safety Code § 284A.051(c)(3).
Also in 2013, by the adoption of the same bill, the Texas Legislature adopted Human
Resources Code section 32.024(jj), requiring HHSC to establish PPECCs as a separate
Medicaid provider type and limiting the HHSC-established reimbursement rate to no
more than 70 percent of the average hourly PDN rate. See Act of May 22, 2013, 83d
Leg., R.S., ch. 1168, §§6, 8(c), 2013 Tex. Gen. Laws at 2907.
PPECC services may be provided only to individuals who are “medically dependent or
technologically dependent.” Tex. Health & Safety Code §§ 248A.001(10),
248A.151(a)(1). The term "medically dependent or technologically dependent minor" is
a child who, “because of an acute, chronic, or intermittent medically complex or fragile
condition or disability requires ongoing, technology-based skilled nursing care
prescribed by the minor's physician to avert death or further disability or the routine use
of a medical device to compensate for a deficit in a life-sustaining body function.” Id.
§248A.001(8). The term does not, however, "include minor or occasional medical
conditions that do not require continuous nursing care…." As indicated by the definition,
nursing services received in a PPECC must be prescribed by the client’s physician.
Policy staff determined PPECC services should be considered Medicaid State Plan
services, requiring the creation of new payable provider type and enrollment processes
for Texas Medicaid. PPECC services will be made available in traditional Medicaid and
managed care (STAR, STAR+PLUS, STAR Health, and eventually STAR Kids).
Receiving services in a PPECC setting does not supplant a child’s right to PDN services
when they are determined medically necessary, but the PDN and PPECC services
cannot be provided at exactly the same time (concurrently) in a given day. Rather, PDN
services may be rendered before and after PPECC services are rendered.
4
Section-by-Section Summary
New rule §363.201, Purpose, introduces the new subchapter and the concept of
Prescribed Pediatric Extended Care Centers.
New rule §363.203, Definitions, clarifies words and terms used throughout the new
subchapter related to Prescribed Pediatric Extended Care Centers.
New rule §363.205, Provider Participation Requirements, outlines the requirements for
a facility to participate in Medicaid as a Prescribed Pediatric Extended Care Center.
New rule §363.207, Client Eligibility Criteria, describes who is eligible to be served in a
Prescribed Pediatric Extended Care Center.
New rule §363.209, Medical Necessity Criteria for Prescribed Pediatric Extended Care
Centers, further delineates eligibility criteria based on medical necessity of the services
provided in a Prescribed Pediatric Extended Care Center.
New rule §363.211, Benefits and Limitations, outlines the services that may be offered
in a Prescribed Pediatric Extended Care Center, the limits on those services, and how
authorization for services is obtained.
New rule §363.213, Physician Prescription and Plan of Care, specifies the physician
and plan-of-care requirements for each recipient receiving services in a Prescribed
Pediatric Extended Care Center.
New rule §363.215, Place of Service, clarifies that only facilities licensed by DADS
specifically for Prescribed Pediatric Extended Care Center services may provide such
services and that each facility must be enrolled in Medicaid.
New rule §363.217, Termination of Authorization for Prescribed Pediatric Extended
Care Center Services, delineates the HHSC process for approving, reducing, or denying
services, including notifications and appeals.
Fiscal Note
Greta Rymal, Deputy Executive Commissioner for Financial Services, has determined
that during the first five-year period the proposed rules are in effect, there will be a fiscal
impact $68,946 General Revenue (GR), ($164,353 All funds (AF)) in State Fiscal Year
(SFY) 2015; $801,194 GR ($1,872,386 AF) in SFY 2016; $1,584,669 GR ($3,696,452
AF) in SFY 2017; $2,088,034 GR ($4,870,619 AF) in SFY 2018; $2,603,518 GR
($6,073,053 AF) in SFY 2019; and $3,165,330 GR ($7,383,554 AF) in SFY 2020 to
5
state government. The proposed rules will not result in any fiscal implications for local
health and human services agencies. Local governments will not incur additional costs.
Small and Micro-business Impact Analysis
HHSC has determined that there will be no effect on small businesses or micro
businesses to comply with the proposed rules, as they will not be required to alter their
business practices as a result of the proposed rules. There are no anticipated
economic costs to persons who are required to comply with the proposed rules. There is
no anticipated negative impact on local employment.
Public Benefit
Chris Traylor, Chief Deputy Commissioner, has determined that for each year of the first
five years the proposed rules are in effect the public will benefit from the adoption of the
rules. The anticipated public benefit of enforcing the proposed rules will be the creation
of a new PPECC provider type that will offer an alternative to Private Duty Nursing
services for medically or technologically dependent children. The services must be
offered at a rate no greater than 70 percent of the average hourly PDN rate, and may
result in cost savings.
Regulatory Analysis
HHSC has determined that this proposal is not a “major environmental rule” as defined
by §2001.0225 of the Texas Government Code. A “major environmental rule” is defined
to mean a rule the specific intent of which is to protect the environment or reduce risk to
human health from environmental exposure and that may adversely affect, in a material
way, the economy, a sector of the economy, productivity, competition, jobs, the
environment, or the public health and safety of a state or a sector of the state. This
proposal is not specifically intended to protect the environment or reduce risks to human
health from environmental exposure.
Takings Impact Assessment
HHSC has determined that this proposal does not restrict or limit an owner’s right to his
or her property that would otherwise exist in the absence of government action and,
therefore, does not constitute a taking under §2007.043 of the Government Code.
Public Comment
Written comments on the proposal may be submitted to Amanda Hudgens, Policy
Analyst, 4900 North Lamar Blvd., Austin, Texas 78751; or by e-mail to
amanda.hudgens@hhsc.state.tx.us within 30 days of publication of this proposal in the
Texas Register.
6
Public Hearing
A public hearing is scheduled for (Date) from (Start Time) to (End Time) (central time) in
the (Location and Address). Persons requiring further information, special assistance,
or accommodations should contact Leigh Van Kirk at 512-462-6284.
Statutory Authority
These new rules are proposed under Texas Government Code §531.033, which
provides the Executive Commissioner of HHSC with broad rulemaking authority; and
Texas Human Resources Code §32.021 and Texas Government Code §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas. The rules specifically implement Texas Human
Resources Code §32.024(jj), which directs HHSC to establish Prescribed Pediatric
Extended Care Centers as a separate provider type.
The proposed new rules affect Texas Human Resources Code Chapter 32 and Texas
Government Code Chapter 531. No other statutes, articles, or codes are affected by
this proposal.
7
Legend:
Single Underline = Proposed new language
[Strikethrough and brackets] = Current language proposed for deletion
Regular print = Current language
(No change) = No changes are being considered by the designated subdivision
TITLE 1
PART 15
CHAPTER 363
PROGRAM
SUBCHAPTER B
SERVICES
RULE §363.201
ADMINISTRATION
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PRESCRIBED PEDIATRIC EXTENDED CARE CENTER
Purpose
(a) This subchapter defines the Prescribed Pediatric Extended Care Center services benefit
available through the Early and Periodic Screening, Diagnosis and Treatment Comprehensive
Care Program, which in Texas is known as the Texas Health Steps Comprehensive Care
Program.
(b) This subchapter applies to Medicaid Fee-for-Service and Medicaid managed care
organizations that contract with the Texas Health and Human Services Commission to provide
Medicaid services.
8
TITLE 1
PART 15
CHAPTER 363
PROGRAM
SUBCHAPTER B
SERVICES
RULE §363.203
ADMINISTRATION
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PRESCRIBED PEDIATRIC EXTENDED CARE CENTER
Definitions
The following words and terms, when used in this subchapter, have the following meanings
unless the context clearly indicates otherwise.
(1) Activities of daily living (ADLs)--Activities that include eating, toileting, personal
hygiene, dressing, bathing, transferring, positioning, and locomotion or mobility.
(2) Basic Services--Basic services include:
(A) the development, implementation, and monitoring of a comprehensive protocol of care
that:
(i) is provided to a medically dependent or technologically dependent recipient;
(ii) is developed in conjunction with the recipient's responsible adult;
(iii) specifies the medical, nursing, psychosocial, therapeutic, and developmental services
required by the recipient; and
(B) the caregiver training needs of a medically dependent or technologically dependent
recipient's parent or responsible adult.
(3) Contingency plan--A structured process, developed by the recipient or the responsible
adult and the Medicaid-enrolled provider, by which a recipient will receive care when the
PPECC is unexpectedly unavailable to render covered PPECC services, or an emergency arises
while the recipient is receiving PPECC services, as indicated in the PPECC plan of care.
(4) Contractor --The entity with which HHSC contracts to administer prior authorization for
Prescribed Pediatric Extended Care Center (PPECC) services, pursuant to the requirements of
the Code of Federal Regulations, Title 42, Part 434.
(5) Correct or ameliorate--To improve, maintain, or slow the deterioration of the recipient’s
health status.
(6) Delegated nursing--Nursing services delegated by a Registered Nurse (RN) to a qualified
aide in accordance with the nurse delegation rules of the Board of Nurse Examiners, 22 TAC
Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to
Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments).
9
(7) Early and Periodic Screening, Diagnosis and Treatment Comprehensive Care Program
(EPSDT-CCP)--The child and adolescent health component of the Medicaid program for
recipients under 21 years of age, defined in the United States Code, Title 42, §1396d(r), and the
Code of Federal Regulations, Title 42, §440.40(b). EPSDT-CCP means screening, vision,
dental, hearing, laboratory, health care, treatment, diagnostic services, and other measures
necessary to correct or ameliorate defects and physical and mental illnesses and conditions.
(8) Fair hearing--The process HHSC has adopted and implemented in Chapter 357,
Subchapter A of this title (relating to Uniform Fair Hearing Rules) in compliance with federal
and state regulations governing Medicaid Fair Hearings.
(9) HHSC--The Texas Health and Human Services Commission or its designee. HHSC is the
single state agency charged with administration and oversight of the Texas Medicaid program.
HHSC's authority is established in Texas Government Code Chapter 531.
(10) Licensed Vocational Nurse (LVN)--A person who is licensed by the Texas Board of
Nursing to practice vocational nursing in Texas at the time and place the service is provided, in
accordance with Texas Occupations Code §301.
(11) Medicaid Managed Care Organization (MCO)--Any entity with which HHSC contracts to
provide Medicaid services and that complies with Chapter 353 of this title (relating to Medicaid
Managed Care).
(12) Medically or technologically dependent recipient--An individual 20 years of age or
younger who, because of an acute, chronic, or intermittent medically complex or fragile
condition or disability, requires continuous skilled nursing care (beyond the level of skilled
nursing visits normally authorized under Texas Medicaid Home Health Skilled Nursing and
Health Aide (HHA) services) prescribed by a physician to avert death or further disability, or the
routine use of a medical device to compensate for a deficit in a life-sustaining bodily function.
The term does not include a recipient with a controlled or occasional medical condition that does
not require continuous nursing care.
(13) Notice--A letter provided by HHSC, or an MCO to a recipient informing the recipient of
any reduction, denial, or termination of a requested service, as described in the Code of Federal
Regulations, Title 42, §§431.206 and 431.210.
(14) Plan of care--A comprehensive, interdisciplinary protocol of care that includes the
physician's order for needed services, nursing care plan, and protocols establishing delegated
tasks, psychosocial needs, personal care services for assistance with activities of daily living, and
therapeutic and developmental service needs required by a recipient and family served.
(15) Prescribed Pediatric Extended Care Center (PPECC)--A center operated on a for-profit or
nonprofit basis that provides non-residential basic services to four or more medically dependent
or technologically dependent recipients who require the services of the center and who are not
related by blood, marriage, or adoption to the owner or operator of the center.
10
(16) Primary physician--A doctor of medicine or doctor of osteopathy (M.D. or D.O.) legally
authorized to practice medicine or osteopathy at the time and place the service is provided, who
in addition provides continuing medical care for the recipient and continuing medical supervision
of the recipient's plan of care.
(17) Private Duty Nursing (PDN)--Nursing, as described by the Texas Nursing Practice Act,
Texas Occupations Code §301.002, and its implementing regulations at 22 TAC Part 11 (relating
to the Texas Board of Nursing), that provides a recipient with more individual and continuous
care than is available from a visiting nurse or than is routinely provided by the nursing staff of a
hospital or skilled nursing facility. PDN services include observation, assessment, intervention,
evaluation, rehabilitation, care and counsel, or health teachings for a recipient who has a
disability or chronic health condition or who is experiencing a change in normal health
processes. PDN services exclude the supervision of delegated nursing.
(18) Recipient--An individual who is eligible to receive PPECC services under Texas Health
Steps Comprehensive Care Program (THSteps-CCP) from a provider enrolled in the Texas
Medicaid program.
(19) Registered Nurse (RN)--A person who is licensed by the Texas Board of Nursing to
practice professional nursing in Texas at the time and place the service is provided, in
accordance Texas Occupations Code §301.
(20) Respite--Services provided for the purpose of providing relief to the primary care giver.
(21) Responsible Adult--An adult, as defined by Texas Family Code §101.003, who has
agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and
supervision for a recipient who:
(A) is under the age of 18; or
(B) is 18 years of age or older and the responsible adult is the managing conservator or legal
guardian.
Responsible adults include biological parents, adoptive parents, foster parents, guardians, courtappointed managing conservators, and other family members by birth or marriage.
(22) Skilled nursing--Services provided by a registered nurse or by a licensed vocational
nurse, as authorized by Texas Occupations Code Chapter 301 and 22 TAC §§217.11 (relating to
Standards of Nursing Practice) and 217.12 (relating to Unprofessional Conduct).
(23) Stable--Status determined by the recipient's physician that the recipient's health condition
does not prohibit utilizing transportation to access outpatient medical services, and does not
present significant risk to other recipients or personnel at the center, as defined at 40 TAC
§15.6001 (relating to Admission Criteria). The recipient must be able to utilize transportation
services offered by the PPECC with the assistance of a nurse to and from the PPECC.
11
(24) Texas Health Steps Comprehensive Care Program (THSteps-CCP)--A federal program
known as EPSDT which is required of states by Medicaid for children under 21 years of age who
meet certain economic criteria for eligibility. See definition for Early and Periodic Screening,
Diagnosis, and Treatment-Comprehensive Care Program (EPSDT-CCP).
12
TITLE 1
PART 15
CHAPTER 363
PROGRAM
SUBCHAPTER B
SERVICES
RULE §363.205
ADMINISTRATION
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PRESCRIBED PEDIATRIC EXTENDED CARE CENTER
Provider Participation Requirements
(a) A PPECC service provider must be independently enrolled in the Texas Medicaid Program to
be eligible to receive Medicaid reimbursement for providing PPECC services through THStepsCCP.
(b) To participate in THSteps-CCP, a PPECC service provider must:
(1) be currently licensed under and comply with 40 TAC Chapter 15 (relating to Licensing
Standards for Prescribed Pediatric Extended Care Centers);
(2) be enrolled and approved for participation in the Texas Medicaid Program;
(3) comply with the terms of the Texas Medicaid Provider Agreement;
(4) agree to provide services in compliance with all applicable federal, state, and local laws
and regulations, including Texas Occupations Code Chapter 301;
(5) comply with all state and federal regulations and rules relating to the Texas Medicaid
program;
(6) comply with the requirements of the Texas Medicaid Provider Procedures Manual,
including all published updates and revisions and all handbooks, standards, and guidelines
published by HHSC or an MCO; and
(7) comply with accepted professional standards and principles of nursing practice.
(8) comply with Texas Family Code Chapter 261, and Texas Health and Safety Code Chapter
260A, concerning mandatory reporting of suspected abuse or neglect of children and adults with
disabilities; and
(9) maintain written policies and procedures for obtaining consent for medical treatment for
recipients in the absence of the responsible adult that meet the standards of Texas Family Code
§32.001 relating to consent by non-parent.
(c) PPECC providers must comply with 40 TAC §15.6008 (relating to Discharge or Transfer
Notification).
(d) The PPECC must provide written documentation of medication, services provided, and other
relevant health-related information about the recipient's care each day to the recipient's
13
responsible adult. The documentation must be provided each day following service delivery
when the responsible adult picks up the recipient or when the PPECC transports the recipient to
his or her residence.
14
TITLE 1
PART 15
CHAPTER 363
PROGRAM
SUBCHAPTER B
SERVICES
RULE §363.207
ADMINISTRATION
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PRESCRIBED PEDIATRIC EXTENDED CARE CENTER
Client Eligibility Criteria
(a) To be eligible for Prescribed Pediatric Extended Care Center (PPECC) services, a recipient
must:
(1) be age 20 or younger and eligible for THSteps-CCP services and
(2) meet medical necessity criteria for PPECC services in §363.209 of this subchapter (relating
to Medical Necessity Criteria for Prescribed Pediatric Extended Care Center Services).
(b) HHSC may waive any recipient’s eligibility criteria in any part of this section upon review of
a recipient’s specific circumstances.
(c) Admission must be voluntary, based on the responsible adult's preference for PPECC
services, in both managed care and non-managed care service delivery systems.
15
TITLE 1
PART 15
CHAPTER 363
PROGRAM
SUBCHAPTER B
SERVICES
RULE §363.209
Center Services
ADMINISTRATION
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PRESCRIBED PEDIATRIC EXTENDED CARE CENTER
Medical Necessity Criteria for Prescribed Pediatric Extended Care
(a) Medically necessary THSteps/EPSDT services are health care services, diagnostic services,
treatments, and other measures necessary to correct or ameliorate any disability, physical or
mental illness, or chronic conditions.
(b) PPECC services are considered medically necessary when a recipient:
(1) is eligible for THSteps-CCP;
(2) is age 20 or younger;
(3) requires continuous skilled nursing care and supervision and skilled observations,
judgments, and potentially therapeutic interventions all or part of the day to correct or ameliorate
his or her health status, such that delayed skilled intervention is expected to result in:
(A) deterioration of a chronic condition;
(B) loss of function;
(C) imminent risk to health status due to medical fragility; or
(D) risk of death;
(4) is considered to be a medically dependent or technologically dependent recipient;
(5) is stable for outpatient medical services in accordance with 40 TAC §15.6001 (relating to
Admission Criteria) and does not present significant risk to other recipients, clients or personnel
at the center;
(6) has a prescription for PPECC services signed by a physician who has personally examined
the recipient within 30 days prior to admission and reviewed all appropriate medical records;
(7) has a consent to the recipient’s admission to the center signed by a responsible adult;
(8) resides with the responsible adult; and
(9) does not reside in a 24-hour inpatient facility, including a:
16
(A) general acute hospital;
(B) skilled nursing facility;
(C) intermediate care facility; or
(D) special care facility, including sub-acute units or facilities for the treatment of acquired
immune deficiency syndrome (AIDS).
(c) THSteps-CCP recipients are eligible for all medically necessary PPECC services that are
required to meet the recipient’s documented skilled nursing needs.
17
TITLE 1
PART 15
CHAPTER 363
PROGRAM
SUBCHAPTER B
SERVICES
RULE §363.211
ADMINISTRATION
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PRESCRIBED PEDIATRIC EXTENDED CARE CENTER
Benefits and Limitations
(a) Prescribed Pediatric Extended Care Center (PPECC) benefits include the following services:
(1) The development, implementation, and monitoring of a comprehensive plan of care that:
(A) is provided to a medically dependent or technologically dependent recipient;
(B) is developed in conjunction with the recipient's responsible adult;
(C) specifies the services needed to address the medical, nursing, psychosocial, therapeutic,
dietary, functional, educational, and developmental needs of the recipient and the training needs
of the recipient's responsible adult;
(D) specifies if transportation is needed; and
(E) is revised for each authorization of services per subsection (d) of this section, or more
frequently as the physician deems necessary.
(2) Direct skilled nursing care and caregiver training and education intended to:
(A) optimize the recipient’s health status and outcomes; and
(B) promote and support 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.
(3) Transportation to and from the PPECC if the recipient requires it. The recipient must be
accompanied by a nurse. Transportation that is the responsibility of a local school district is not
a covered Medicaid service.
(4) Dietary services, including meals and snacks as specified in 40 TAC §15.5011 (relating to
Dietary Services) or as outlined in a recipient's plan of care, as well as nutritional counseling.
18
(b) Amount and duration.
(1) HHSC will evaluate the amount and duration of PPECC services requested upon review of:
(A) physician order;
(B) PPECC plan of care;
(C) completed request for authorization, including all required forms as indicated in the Texas
Medicaid Provider Procedures Manual; and
(D) the full array of Medicaid services the recipient is receiving at the time the plan of care is
developed.
(2) HHSC will re-evaluate the amount of PPECC services when:
(A) there is a change in the frequency of skilled nursing interventions or the complexity and
intensity of the recipient’s care;
(B) alternate resources for comparable care become available; or
(C) the responsible adult becomes available and is willing to provide appropriate care for
the recipient.
(c) PPECC service limitations.
(1) PPECC services that are intended to provide the following are not covered Medicaid
services:
(A) services that are mainly respite care or child care, or that do not directly relate to the
recipient's medical needs or disability;
(B) services that are the primary responsibility of a local school district;
(C) baby food or formula;
(D) total parenteral or enteral nutrition supplies;
(E) supportive or contracted services, including therapies;
(F) Durable Medical Equipment (DME) and medical supplies provided to an individual
recipient by Medicaid DME and supply services; or
(G) individualized comprehensive case management beyond the service coordination
required by the Texas Occupations Code Chapter 301.
19
(2) PPECC services are limited to up to 12 hours per day.
(3) Private duty nursing may not be performed or billed concurrently with PPECC services.
(d) Authorization of services.
(1) Authorization is required for payment of services.
(2) Only those services that HHSC determines to be medically necessary and appropriate will
be reimbursed.
(3) Initial authorization may not exceed 90 days. Following the initial authorization, no
authorization for payment of PPECC services may be issued for a single service period
exceeding six months. In addition, specific authorizations may be limited to a time period less
than the established maximum based on factors such as the stability and predictability of the
recipient's medical condition.
(4) Services will not be authorized when:
(A) the client does not meet the medical necessity and admission criteria;
(B) the client does not have a primary treating physician;
(C) the client is not 20 years of age or younger;
(D) the services requested are not covered under this subchapter;
(E) the client's needs do not exceed the scope of services available through Medicaid Title
XIX Home Health Skilled Nursing or Home Health Aide Services because the needs can be met
on a part-time or intermittent basis; or
(F) the client will be receiving PDN services during the same period of time as PPECC
services.
(5) All authorization requests, including initial authorization and authorization of extensions or
revisions to an existing authorization, must be submitted in writing.
(6) Initial authorization requests for PPECC services must include the following:
(A) physician order for services;
(B) plan of care developed by the PPECC and signed and dated by the recipient's primary
physician. The PPECC reviews and revises the plan of care with each authorization, or more
frequently as the physician deems necessary; and
(C) current forms, completed by the provider and primary physician, including:
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(i) THSteps-CCP Plan of Care;
(ii) THSteps-CCP Addendum to Plan of Care;
(iii) THSteps-CCP 24-hour flow chart; and
(iv) THSteps-CCP Prior Authorization request form, or health plan-specific form that
captures the same information.
(7) Required documentation for recertification of PPECC service authorization after the initial
authorization or after an authorization period ends includes:
(A) current HHSC authorization form or health plan authorization form;
(B) plan of care developed by the PPECC and signed and dated by the recipient's primary
physician;
(C) additional HHSC forms, including THSteps-CCP PPECC services Addendum to Plan
of Care, signed and dated by the recipient's primary physician; and
(D) Signed consent from the responsible adult.
(7) If inadequate or incomplete information is provided, HHSC will request additional
documentation from the provider to enable HHSC to make a decision on the request.
(8) During the authorization process, providers are required to deliver the requested services
from the start of care date. Providers are responsible for a safe transition of services when the
authorization decision is a denial or reduction in the PPECC services being delivered.
(9) Revisions during an existing authorization period may be requested at any time if
medically necessary.
(e) A responsible adult is not required to accompany a recipient when the recipient receives
services in a PPECC, including transportation services to and from the center and therapy
services that are billed separately.
21
TITLE 1
PART 15
CHAPTER 363
PROGRAM
SUBCHAPTER B
SERVICES
RULE §363.213
ADMINISTRATION
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PRESCRIBED PEDIATRIC EXTENDED CARE CENTER
Physician Prescription and Plan of Care
(a) A physician in an employment or contractual relationship with a Prescribed Pediatric
Extended Care Center (PPECC) cannot provide the required physician's order unless the
physician is the recipient’s treating physician and is familiar with and has examined the recipient
outside of the PPECC setting.
(b) The primary physician responsibilities include:
(1) providing a signed prescription or written, dated physician’s order for PPECC services
within 30 calendar days before the recipient’s start of services, which is valid through the initial
authorization period ;
(2) providing a signed prescription or written, dated physician’s order for PPECC services at
least every 180 days, once the initial prescription or order is no longer valid;
(3) performing a face-to-face evaluation of the recipient each year;
(4) reviewing, approving, signing, and dating a plan of care including any updates or changes;
(5) providing a statement that PPECC services are medically necessary for the recipient;
(6) providing a statement that the recipient's medical condition is sufficiently stable to permit
safe delivery of PPECC services as described in the plan of care; and
(7) providing continuing care and medical supervision, including examination or treatment
within 30 days before the start of PPECC services.
(c) A prescription for PPECC services must include:
(1) recipient's name, date of birth, gender, and Medicaid ID number;
(2) current medical diagnosis;
(3) current medical conditions, including medical history;
(4) approval of the recipient's admission to the PPECC;
(5) authorization for transportation, if applicable;
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(6) nursing services required, including duration and frequency;
(7) medications required, including doses, frequency, and method of administration;
(8) description of other treatments or medical services required;
(9) dietary needs;
(10) permitted activities and restrictions on activities;
(11) documentation of hospitalizations in the last six months;
(12) medical equipment needs;
(13) allergies, including medication allergies;
(14) therapies required;
(15) provider name, address, phone number, and driver's license number;
(16) date physician last examined the recipient; and
(17) signed statement of need that the PPECC services are medically necessary, and that the
recipient's medical condition will allow safe delivery of PPECC services as described in the
PPECC-developed Plan of Care.
(d) A plan of care must meet PPECC requirements prescribed in 40 TAC §15.6007 (relating to
Initial and Updated Plan of Care) and must contain the following elements:
(1) the recipient's Medicaid number;
(2) the prescribing physician's license number;
(3) the provider's Medicaid number;
(4) date the recipient was last seen by the prescribing physician;
(5) the start of care date for PPECC services;
(6) all pertinent diagnoses and description of current medical conditions, including known
allergies, hospitalizations in the last six months, and risk factors associated with the recipient's
medical diagnosis;
(7) nursing services to be provided, including amount, duration, and frequency;
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(8) the recipient's mental status;
(9) the prognosis with rehabilitation potential;
(10) the types of service requested, including the amount, duration, and frequency;
(11) the equipment or supplies required, including a plan to monitor equipment and supplies;
(12) therapies, including those accessed outside of the PPECC, and amount and duration;
(13) other prescribed services;
(14) nutritional requirements, including type, method of administration, and frequency;
(15) medications, including the dosage, route, and frequency, and any medication-related
allergies if known;
(16) treatments, including amount and frequency;
(17) wound care orders and measurements;
(18) safety measures to protect against injury;
(19) the responsible adult for the recipient;
(20) contingency plan;
(21) all community or state agency services the recipient receives in the home (including Early
Childhood Intervention, therapies, school-based services, personal care services, private duty
nursing, therapies, skilled home health, case management services, and Medicaid waiver
programs such as Medically Dependent Children's Program, Home and Community-based
Services, Deaf-Blind Multiple Disabilities, Texas Home Living, and Community Living
Assistance and Support Services);
(22) instructions for timely discharge or referral;
(23) recipient-specific measureable goals;
(24) methods to demonstrate, train, and teach the responsible adult or other relevant
caregivers;
(25) prior and current functional or medical limitations with permitted activities;
(26) dates of certification period;
(27) recipient's scheduled days and hours of attendance;
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(28) discharge plan;
(29) signed consent of recipient's responsible adult documenting the choice of PPECC
services, and permission to transfer a recipient to a hospital or other health facility in case of an
emergency;
(30) emergency contact information;
(31) method of transportation;
(32) proof of required immunizations; and
(33) a physician-signed statement of need that PPECC services are medically necessary.
25
TITLE 1
PART 15
CHAPTER 363
PROGRAM
SUBCHAPTER B
SERVICES
RULE §363.215
ADMINISTRATION
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PRESCRIBED PEDIATRIC EXTENDED CARE CENTER
Place of Service
Prescribed Pediatric Extended Care Center (PPECC) services may be rendered only in a
Medicaid-enrolled PPECC licensed by the Texas Department of Aging and Disability Services
under the Texas Health and Safety Code Chapter 248A, in compliance with licensing standards
prescribed in 40 TAC Chapter 15 (relating to Licensing Standards for Prescribed Pediatric
Extended Care Centers).
26
TITLE 1
ADMINISTRATION
PART 15
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 363
TEXAS HEALTH STEPS COMPREHENSIVE CARE
PROGRAM
SUBCHAPTER B
PRESCRIBED PEDIATRIC EXTENDED CARE CENTER
SERVICES
RULE §363.217
Termination of Authorization for Prescribed Pediatric Extended
Care Center Services
(a) HHSC will terminate authorization for Prescribed Pediatric Extended Care Services (PPECC)
when:
(1) the recipient is no longer eligible for THSteps-CCP;
(2) the recipient no longer meets the medical necessity criteria for PPECC services;
(3) the PPECC can no longer accommodate the health and safety of the recipient; or
(4) the recipient or responsible adult refuses to comply with the primary physician's plan of
care.
(b) Notifications related to approval, reduction, or denial of requested PPECC services.
(1) HHSC will notify the recipient and the responsible adult in writing of the approval,
reduction, or denial of PPECC services.
(2) HHSC will notify the provider in writing of the approval, reduction, or denial of PPECC
services.
(3) The effective date of the service reduction or denial is 30 days after the date on the
individual's notification letter.
(4) HHSC will notify the individual in writing of the process to appeal the reduction or denial
of services.
(c) All clients of Medicaid-funded services have the right to appeal actions or determinations
made by HHSC as described in Chapter 357, Subchapter A of this title (relating to Uniform Fair
Hearing Rules).
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