SECTION 363.207. Participant Eligibility Criteria

(a) All requests for PPECC services must be based on the current medical needs of a participant who meets the following admission criteria for a PPECC:

(1) is eligible for THSteps-CCP;

(2) is age 20 or younger;

(3) requires ongoing skilled nursing care and supervision and skilled observations, judgments, and 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 participant;

(5) is stable and eligible for outpatient medical services in accordance with 40 TAC §15.601 (relating to Admission Criteria);

(6) has a prescription for each authorization period for PPECC services signed and dated by the ordering physician who has examined the participant within 30 days prior to admission and reviewed all appropriate medical records;

(7) resides with the responsible adult and does not reside in a 24-hour inpatient facility, including a:

(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; and

(8) has a consent to the participant's admission to the PPECC signed and dated by the participant or by the participant's responsible adult.

(b) THSteps-CCP participants are eligible for all medically necessary PPECC services that are required to meet the participant’s documented needs.

(c) Admission must be voluntary, based on the participant's, or the participant's responsible adult's choice for PPECC services.

(d) An authorized admission for PPECC services is not intended to supplant the right to a Medicaid PDN benefit, when medically necessary.

Source Note: The provisions of this §363.207 adopted to be effective November 1, 2016, 41 TexReg 8284