SECTION 363.203. 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 participant;

(ii) is developed in conjunction with the participant's responsible adult; and

(iii) specifies the medical, nursing, psychosocial, therapeutic, and developmental services required by the participant; and

(B) the caregiver training needs of a medically dependent or technologically dependent participant's parent or responsible adult.

(3) Correct or ameliorate--To improve, maintain, or slow the deterioration of the participant’s health status.

(4) 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.

(5) HHSC--The Texas Health and Human Services Commission or its designee, including a contractor or MCO. 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.

(6) Licensed Vocational Nurse (LVN)--A person 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 Chapter 301.

(7) 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).

(8) Medically or technologically dependent participant--

(A) An individual 20 years of age or younger:

(i) who has an acute or chronic medically complex or fragile condition or disability; and

(ii) whose condition or disability, as stated in clause (i) of this subparagraph, requires:

(I) ongoing skilled nursing care beyond the level of skilled nursing visits normally authorized under Texas Medicaid home health skilled nursing and health aide services, prescribed by a physician to avert death or further disability; or

(II) the routine use of a medical device to compensate for a deficit in a life-sustaining bodily function.

(B) The term does not include a participant with a controlled or occasional medical condition that does not require ongoing nursing care.

(9) Notice (or notification)--A letter provided by HHSC or an MCO to a participant informing the participant 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.

(10) Ordering 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 provides ongoing medical care for the participant and continuing medical supervision of the participant's plan of care.

(11) Participant--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.

(12) 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, plans to address functional developmental needs, plans to address psychosocial needs, personal care services for assistance with activities of daily living, and therapeutic service needs required by a participant and family served.

(13) 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 participants 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.

(14) Private Duty Nursing (PDN)--Nursing, as described by Texas Occupations Code Chapter 301, and its implementing regulations at 22 TAC Part 11 (relating to the Texas Board of Nursing), that provides a participant with more individual and ongoing 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 participant who has a disability or chronic health condition or who is experiencing a change in normal health processes.

(15) 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 with Texas Occupations Code Chapter 301.

(16) Respite--Services provided to relieve a participant's primary care giver.

(17) 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 participant. Responsible adults include biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage. If the participant is 18 years of age or older, the responsible adult must be the participant's managing conservator or legal guardian.

(18) 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).

(19) Stable--Status determined by the participant's ordering physician that the participant's health condition does not prohibit utilizing transportation to access outpatient medical services and does not present significant risk to other participants or personnel at the center, as defined at 40 TAC §15.601 (relating to Admission Criteria). The participant must be able to use transportation services offered by the PPECC with the assistance of a PPECC nurse to and from the PPECC, whether or not the participant uses the PPECC's transportation service.

(20) Texas Health Steps Comprehensive Care Program (THSteps-CCP)--A federal program, required by Medicaid and known as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), for children under 21 years of age who meet certain criteria for eligibility. Services are defined in the United States Code, Title 42, §1396d(r), and the Code of Federal Regulations, Title 42, §440.40(b).

Source Note: The provisions of this §363.203 adopted to be effective November 1, 2016, 41 TexReg 8284