SECTION 354.1401. In-home Respiratory Therapy Services for Ventilator-Dependent Persons

(a) Subject to the specifications, conditions, limitations, and requirements established by HHSC or its designee, in-home respiratory therapy services are available to eligible recipients who:

(1) are ventilator-dependent for life support at least six hours per day;

(2) have been so dependent for at least 30 consecutive days as an inpatient in one or more hospitals, skilled nursing facilities (SNF), or intermediate care facilities (ICF);

(3) but for the availability of these respiratory care services at home, would require respiratory care as an inpatient in a hospital, SNF, or ICF;

(4) would be eligible to have payment made for such inpatient care under the state Medicaid plan;

(5) have adequate social support services to be cared for at home; and

(6) wish to be cared for at home.

(b) Covered respiratory therapy services must be reasonable, medically necessary, and prescribed by the recipient's physician (MD or DO). The physician must be licensed in the state in which the physician practices.

(c) HHSC or its designee must authorize the services prior to their delivery. Prior authorization requests must include all pertinent medical records and other information as required by HHSC or its designee to justify the medical necessity of and/or dependency on the ventilator support and therapy services and to ensure that the requirements in subsection (a) of this section are met. Prior authorization is a requirement for payment. HHSC or its designee may extend the prior authorization based upon an interim report from the physician documenting the medical necessity and appropriateness of continued in-home respiratory therapy services.

(d) Covered services include:

(1) respiratory therapy services and treatments prescribed by the recipient's physician; and

(2) education of the recipient and/or appropriate family members/support persons regarding the in-home respiratory care. Education must include the use and maintenance of required supplies, equipment, and techniques appropriate to the situation.

(e) Providers of respiratory therapy services must meet the following requirements:

(1) comply with all applicable federal, state, and local laws and regulations;

(2) be certified by the Texas Medical Board to practice under Chapter 604 of the Texas Occupations Code;

(3) be enrolled and approved for participation in the Texas Medical Assistance Program;

(4) sign a written provider agreement with HHSC or its designee. By signing the agreement, the provider agrees to comply with the terms of the agreement and all requirements of the Texas Medical Assistance Program including regulations, rules, handbooks, standards, and guidelines published by HHSC or its designee; and

(5) bill for covered services in the manner and format prescribed by HHSC or its designee.

Source Note: The provisions of this §354.1401 adopted to be effective February 17, 2004, 29 TexReg 1344; amended to be effective March 15, 2017, 42 TexReg 1118