4400, Prescribed Pediatric Extended Care Centers

Revision 22-3; Effective Dec. 1, 2022

Prescribed Pediatric Extended Care Center (PPECC) services is a benefit of the Texas Health Steps Comprehensive Care Program (THSteps-CCP). It is for STAR Kids members who meet the following medical necessity criteria for admission:

  • eligible for THSteps-CCP;
  • 20 years or younger
  • have an acute or chronic condition that requires ongoing skilled nursing care and supervision, skillful observations, judgments and therapeutic interventions all or part of the day to correct or ameliorate health status;
  • considered to be a medically dependent or technologically dependent member;
  • stable for outpatient medical services, and does not present a significant risk to other individuals or personnel at the PPECC;
  • requires ongoing and frequent skilled interventions to maintain or ameliorate health status, and delayed skilled intervention is expected to result in:
    • deterioration of a chronic condition;
    • loss of function;
    • imminent risk to health status due to medical fragility; or
    • risk of death;
  • has a prescription for PPECC services signed and dated by an ordering physician who personally examined the member within 30 calendar days before admission and reviewed all appropriate medical records;
  • has consent for the member's admission to the PPECC signed and dated by the member or the member's responsible adult. Admission must be voluntary and based on the preference for PPECC services in place of private duty nursing (PDN) by the member or member's responsible adult in both managed care and non-managed care service delivery systems; and
  • lives with the responsible adult and not in any 24-hour inpatient facility, including a general acute hospital, skilled nursing facility (SNF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or special care facility.

PPECC services require prior authorization and are intended as an alternative to PDN. Members who receive PDN or qualify for PDN also qualify for PPECC services. However, an admission authorized under this section is not intended to supplant the right of a member to access PDN, personal care services (PCS), home health skilled nursing (HHSN), home health aide (HHA), and therapies (physical therapy, occupational therapy, speech therapy), as well as respiratory therapy and early childhood Intervention services rendered in the member's residence when medically necessary.

Note: PPECC services may be billed on the same day as PDN, PCS, HHSN and HHA, but must not be billed for the same span of time a member receives these other services.

A member who is eligible may receive both PDN and PPECC services. PPECC benefits include the following services:

  • The development, implementation and monitoring of a comprehensive plan of care that:
    • is provided to a medically dependent or technologically dependent member;
    • is developed in conjunction with the member’s caregiver(s), ordering physician and interdisciplinary team;
    • specifies the services needed to address the medical, nursing, psychosocial, therapeutic, dietary, functional, and developmental needs of the member and the training needs of the member’s caregiver(s);
    • specifies if transportation to and from the PPECC is needed; and
    • is revised for each authorization of services, or more frequently as the ordering physician deems necessary.
  • Direct skilled nursing care and caregiver training and education intended to:
    • optimize the member’s health status and outcomes; and
    • promote and support family-centered, community-based care as a component of an array of service options by:
      • preventing prolonged or frequent hospitalizations or institutionalization;
      • providing cost-effective, quality care in the most appropriate environment; and
      • providing training and education of caregivers;
  • nutritional counseling and dietary services as specified in a member’s plan of care;
  • help with activities of daily living while the member is in the PPECC;
  • psychosocial and functional development services; and
  • transportation services to and from a PPECC.
    • Transportation must be provided by a PPECC when a member has a stated need or a prescription for transportation to the PPECC.
    • When a PPECC provides transportation to a member, a nurse employed by the PPECC must be on board the transport vehicle.
    • The member must be able to utilize transportation services offered by the PPECC with the help of a PPECC nurse to and from the PPECC, rather than a non-emergency ambulance.
    • Transportation is billed separately by the PPECC when used by a member.
    • A non-emergency ambulance may not be used for transport to and from a PPECC.

Note: A separate authorization is not required for transportation to a PPECC. A member or LAR may decline PPECC transportation services.

PPECC services do not include services that are mainly respite care or child care, or that do not directly relate to the member’s medical needs or disability, nor for services that are the primary responsibility of a local school district. PPECC services also do not include:

  • baby food or formula;
  • services to members that are related to the PPECC owner by blood, marriage or adoption; and
  • services covered separately by Texas Medicaid, such as;
    • therapies;
    • durable medical equipment; or
    • individualized comprehensive case management beyond that is required for service coordination.

Find more information about PPECC services in the STAR Kids Managed Care Contract Section, the Uniform Managed Care Manual Chapter 16.1, and the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Chapter 2.14, Prescribed Pediatric Extended Care Centers.
Medicaid managed care organizations also must comply with Title 1 Texas Administrative Code, Part 15, Chapter 363, Subchapter B, Prescribed Pediatric Extended Care Centers.

4410 Assessment for Prescribed Pediatric Extended Care

Revision 22-2; Effective September 1, 2022

The Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for services in a Prescribed Pediatric Extended Care Center (PPECC). The following information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires ongoing nursing services:

  • A current authorization for private duty nursing (PDN);
  • A skilled nursing visit or PDN is provided in a school or day program;
  • Member experienced one or more planned or unplanned inpatient acute hospital admissions or a nursing home stay in the past year;
  • Member requires enteral or parenteral feeding;
  • Member received any of the following treatments in the last 30 days:
    • Chemotherapy;
    • Dialysis;
    • Intravenous (IV) medication;
    • Oxygen therapy;
    • Radiation;
    • Suctioning;
    • Tracheotomy care;
    • Transfusion;
    • Ventilator;
    • Wound care;
    • Nebulizer;
    • Urinary catheter care –insertion or maintenance;
    • Comatose or persistent vegetative state – manage care'
    • Continuous positive airway pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP);
    • Chest percussive therapy;
    • Active medication adjustment;
    • Intermittent positive pressure breathing (IPPB); and/or
    • Seizure management; and
  • The member is being assessed for Community First Choice (CFC) services or the Medically Dependent Children Program (MDCP).

If triggered, the service coordinator completes the NCAM to determine the member's nursing needs. Based on the assessment, the service coordinator develops a recommended service plan for the services of a PPECC. The service coordinator works with the member or their legally authorized representative to locate an appropriate provider and sends an authorization to the selected provider.

Members who have received an NCAM assessment and been approved for PDN services do not require a new assessment if they choose a PPECC unless there is a change in condition and additional nursing hours are needed. MCOs who have PPECC providers available in the service area are expected to provide information to members who qualify for ongoing nursing services about their options of PDN, PPECC or a combination of both.

A member has a choice of PDN, PPECC or both, as long as the services are not provided at the same time. Example: Member has PDN from 7 a.m. to 8 a.m., PPECC from 9 a.m. to 2 p.m. and PDN in the evening.

Note: If an individual qualifies for PDN, the individual will qualify for PPECC.

4411 Authorization Requirements

Revision 20-2; Effective September 1, 2020

Initial, reauthorization and revision requests for Prescribed Pediatric Extended Care Center (PPECC) services must include the following documentation:

  • physician order for services (a physician signature on the PPECC plan of care (POC) serves as a physician order for authorization purposes);
  • a POC developed by the PPECC;
  • all required prior authorization forms listed in the Texas Medicaid Provider Procedures Manual or MCO forms if they contain comparable content; and
  • signed consent of the participant or participant's responsible adult documenting the choice of PPECC services. The signed consent must include:
    • an acknowledgement by the participant or the participant's responsible adult that they have been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services; and
    • consent to share the participant's personal health information with the participant's other providers, as needed to ensure coordination of care.

Forms available online for PPECC include:

  • Comprehensive Care Plan (CCP) Prior Authorization Request (requires ordering physician signature).
  • PPECC POC (requires ordering physician, PPECC registered nurse (RN) and member/responsible adult signature). Note: Providers may use their own POC form, but it must contain the required elements per the Texas Medicaid Provider Procedures Manual.
  • Nursing Addendum to Plan of Care for Private Duty Nursing and/or PPECC (requires ordering physician, PPECC RN and member/responsible adult signature). This form contains required individual and physician acknowledgements and consent.

When an MCO decides to use its own forms for PPECC authorizations, the forms must be equivalent to the fee-for-service forms and are subject to approval by HHSC.

Note: A separate authorization is not required for transportation to a PPECC. A member or LAR may decline PPECC transportation services.

4412 Reassessment and Reauthorization

Revision 20-2; Effective September 1, 2020

The need for, and the amount and duration of services from, a Prescribed Pediatric Extended Care Center (PPECC) must be reassessed by the PPECC provider:

  • 90 days following initial authorization; and
  • every 180 days thereafter; or
  • when requested due to a change in the member's health; or
  • when the authorized services are not commensurate with the Member’s medical needs.

A physician order must be renewed with any reassessment.

4420 Providers of Prescribed Pediatric Extended Care

Revision 22-2; Effective September 1, 2022

A Prescribed Pediatric Extended Care Center (PPECC) must be currently licensed (temporary, initial or renewal license), comply with 56 Texas Administrative Code. Chapter 550 (relating to Licensing Standards for Prescribed Pediatric Extended Care Centers), and be contracted with a member’s STAR Kids managed care organization (MCO) to provide services to that member. Contractual provisions for continuity of care apply. PPECCs do not provide emergency services. PPECCs must follow the safety provisions in state PPECC licensure requirements, including the adoption and enforcement of policies and procedures for a member’s medical emergency. PPECCs must call for emergency transport to the nearest hospital when emergency services are needed by a member in a PPECC. Per PPECC licensure requirements, services are non-residential, must be included in a PPECC plan of care (POC), and are limited to no more than 12 hours in a 24-hour period. Services must not be rendered overnight (9 p.m. to 5 a.m.).

A POC must include components as detailed in the Texas Medicaid Provider Procedure Manual and PPECC medical policy. These components include:

  • Member's name, date of birth and Medicaid number;
  • PPECC's name, Texas Provider Identifier (TPI), National Provider Identifier (NPI) and hours of operation, as well as address, telephone and fax numbers;
  • Ordering physician's name, telephone number, TPI and NPI;
  • Date the PPECC nursing assessment was completed and name, title and credentials of the registered nurse (RN) who completed the POC with their dated signature;
  • Name, title and credentials of the team member who completed the POC with their dated signature;
  • Date the member was last seen by the ordering physician;
  • Requested start of care date for PPECC services;
  • All pertinent diagnoses and known allergies;
  • Nursing services to be provided, including amount, duration and frequency;
  • Member's prognosis;
  • Member's mental status;
  • Rehabilitation potential;
  • Equipment and/or supplies required;
  • Therapies (occupational, physical, speech, and respiratory care), including how those therapies are accessed, amount, duration and frequency. Therapies provided in the PPECC, as well as outside the PPECC (e.g., school based), must be documented;
  • Other prescribed services, including amount, duration and frequency;
  • Nutritional requirements, including type, method of administration and frequency;
  • Medications, including the dose, route, frequency and any medication-related allergies if known;
  • Treatments, including amount and frequency;
  • Wound care orders and measurements;
  • Safety measures to protect against injury;
  • Functional developmental services and psychosocial services, including amount, duration and frequency;
  • Name, telephone number and signature of the responsible adult;
  • Member’s emergency contact name and telephone number;
  • Confirmation that a signed contingency plan is in place in circumstances when PPECC services are not available (e.g., fire, flood, windstorm or electrical malfunctions), and for emergencies that occur while the member is in the care of the PPECC;
  • List of services the member receives in the home and school settings. [e.g., Early Childhood Intervention (ECI), therapies, School Related Health Services (SHARS), personal care services (PCS), private duty nursing (PDN), therapies, skilled home health, case management services, hospice, and Medicaid waiver programs such as Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD), Texas Home Living (TxHmL) and Community Living Assistance and Support Services (CLASS)].
    • Note: Services provided under these programs will not prevent a member from obtaining medically necessary services;
  • Member-specific measurable goals, including, if receiving PDN, the goal of ensuring coordination of ongoing skilled nursing services with the PDN provider;
  • Responsible adult training needs;
  • Prior and current functional or medical limitations;
  • Permitted activities;
  • Member's scheduled days and hours of attendance;
  • Confirmation of a discharge plan, including instructions for timely discharge or referral;
  • Method of transportation;
  • PDN provider name, TPI, NPI, telephone, address and fax number, if known;
  • Ordering physician signature and date of signature;
  • Transportation services needed by a member to access PPECC service (a non-emergency ambulance must not be used for transport to and from a PPECC); and
  • Services outlined in the Texas Administrative Code, Title 1, Part 15, Chapter 363 (Texas Health Steps Comprehensive Care Program), Subchapter B (Prescribed Pediatric Extended Care Center Services), §363.209 (Benefits and Limitations).

The following services may be rendered at a PPECC place of service, but are not considered part of the PPECC services and must be billed separately by a provider contracted with the STAR Kids MCO:

  • Speech, physical, and occupational therapies (including therapies rendered by a home health agency);
  • Certified respiratory care services;
  • Early intervention services provided through the ECI program, which are subject to ECI policies.

In accordance with 2.14.1 of the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, therapy services (occupational, speech, physical and respiratory) rendered in a PPECC must be provided by:

  • therapists employed by or contracted with the PPECC; or
  • therapists contracted with the MCO but not employed by, or contracted with, the PPECC.

Therapy providers must be Medicaid enrolled and separately contracted and credentialed with the MCO, even if they are employed by, or contracted with, the PPECC. Therapy services must be authorized and billed separately from PPECC services, and the MCO's claims systems must accommodate PPECCs as a place of service for therapy services.

4430 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 20-2; Effective September 1, 2020

See 4310, Private Duty Nursing and Prescribed Pediatric Extended Care Services, for details on coordination of services between PDN and PPECC. Both PDN and PPECC are ongoing skilled nursing services and are considered equivalent levels of nursing care. A member has a choice to receive PDN, PPECC or a combination of both services.