1 Tex. Admin. Code § 363.605

Current through Register Vol. 49, No. 48, November 29, 2024

Section 363.605 - Benefits and Limitations

(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) 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 Client's 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 Statement of Need (PSON) by a practitioner who is known by and has an ongoing clinical relationship with the recipient and familiarity with the recipient's diagnosis.

(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) Unless otherwise authorized by HHSC, 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, IADLs, or HMAs;

(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 psycho-social 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 or its designee 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 will not be authorized to overlap with duplicative services provided by another Medicaid program or a Medicaid waiver program.

(4) PCS may be authorized for a provider to recipient ratio greater than one-on-one in settings in which PCS are provided in homes with more than one recipient receiving PCS, foster care services, and/or independent living arrangements per program policy.

(5) 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, a new PSON indicating a the change in the recipient's functional need or condition must be submitted.

(h) Authorization for PCS will be terminated by HHSC or its designee when:

(1) The recipient is no longer eligible for Texas Medicaid;

(2) The recipient no longer meets the criteria for PCS;

(3) The place of service(s) can no longer meet the recipient's health and safety needs; or

(4) The authorization for PCS expires.

(i) Authorization for PCS may be suspended by HHSC or its designee when:

(1) The recipient or their family creates an unsafe environment for the attendant's health and safety; 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).

1 Tex. Admin. Code § 363.605

The provisions of this §363.605 adopted to be effective September 1, 2007, 32 TexReg 5355; Amended to be effective September 1, 2014, 39 TexReg 5890