Form 3230, Application for HHSC Approval to Operate a Hospital at Home Program

Instructions

Updated: 2/2024

Purpose

HHSC requires hospitals to submit Form 3230 to receive approval from HHSC to operate a hospital at home program. These hospitals must first have Centers for Medicare and Medicaid Services (CMS) approval to participate in the CMS Acute Hospital Care at Home Program.   

Procedure

When to Prepare

An applicant must submit the application form, fee, and other applicable documents. They must complete all actions as required by Texas Administrative Code Title 25 (25 TAC) Section 133.54, Hospital at Home Program Application and Operational Requirements.

Initial Application

A hospital applying for initial HHSC approval to operate a hospital at home program must submit the following to HHSC:

• A completed Form 3230.
• An application fee of $350.
  • Make checks payable to the Texas Health and Human Services Commission.
  • Application fees are not refundable.
• A copy of the CMS approval to participate in the CMS Acute Hospital Care at Home Program.

Renewal Application

A hospital must apply to HHSC to renew its approval for the hospital to operate the hospital's hospital at home program when applying to renew the hospital's license under 25 TAC Section 133.23.

To apply for renewal, a hospital must pay a nonrefundable renewal application fee of $390 per 10 beds the hospital designates for the hospital at home program, which is in addition to the hospital's license renewal fee.

Refer to Table 1 below for an example of the total renewal application fees due per block of 10 beds up to 100 beds.

Note: A hospital may apply for HHSC approval to designate more than 100 beds for the hospital’s hospital at home program. The table below is provided only to demonstrate an example of fee calculations up to 100 beds.

Table 1: Renewal Application Fee by Hospital at Home Bed Count

Important Items to Note

• More than one hospital may share a CMS CCN number and CMS may approve all hospital locations at once. However, HHSC requires a separate Form 3230 for each licensed hospital location.
• A facility must submit one application form for each licensed hospital location, even when licensed hospitals operate under the same CMS CCN number. Multiple-license hospitals must differentiate between each location.
• HHSC must be able to confirm each hospital address by reviewing the CMS approval documentation the applicant submits with Form 3230.
• When a hospital increases the number of beds designated for its hospital at home program between license renewal periods, the hospital must notify HHSC and pay a nonrefundable fee of $390 per block of 10 beds the hospital adds to their program.

Mailing Address for Applications with Fees:

HHSC Accounts Receivable 
P.O. Box 149055, Mail Code 1470
Austin, Texas 78714-9055

Overnight Address for Applications with Fees:

HHSC Accounts Receivable 
4601 W. Guadalupe Street, Mail Code 1470
Austin, TX 78751