SECTION 354.1035. Recipient Qualifications for Home Health Services

(a) An eligible Medicaid recipient must meet the following requirements to qualify for Medicaid home health services.

(1) An eligible recipient must be under the continuing care and medical supervision of a physician or an allowed practitioner who has established a plan of care or submitted a request form for the recipient in accordance with §354.1037 or §354.1039 of this division (relating to Written Plan of Care and Benefits and Limitations of Home Health Services). A recipient must be seen by the recipient's physician or allowed practitioner within 30 days prior to the start of home health services. This visit may be waived when a diagnosis has already been established by the physician or allowed practitioner and the recipient is under the continuing care and medical supervision of the physician or allowed practitioner. Any waiver must be based on the physician's or allowed practitioner's statement that an additional evaluation visit is not medically necessary.

(2) An eligible recipient must have a medical need for covered home health services as documented in the recipient's plan of care or request form for the recipient in accordance with §354.1037 or §354.1039 of this division.

(3) An eligible recipient must receive services that meet the recipient's existing medical needs, subject to §354.1039 of this division and that can be safely provided in the recipient's home.

(b) The home health service, supply, or item of durable medical equipment must:

(1) be prior authorized by HHSC, unless otherwise specified by HHSC;

(2) be prescribed by a physician or an allowed practitioner who is currently licensed;

(3) be medically necessary, as documented in the plan of care or the request form for the recipient in accordance with §354.1037 and §354.1039 of this division;

(4) be provided to a recipient in the recipient's place of residence; and

(5) meet accepted industry standards for safety where applicable.

Source Note: The provisions of this §354.1035 adopted to be effective June 26, 1997, 22 TexReg 5826; amended to be effective July 1, 1999, 24 TexReg 4365; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective November 14, 2002, 27 TexReg 10588; amended to be effective September 21, 2022, 47 TexReg 5779