The commission must develop and use an objective process for assessing a recipient’s need for acute nursing services, and the review rules must include RN qualifications, timing, referral screening, prior-authorization paperwork, and a review process for disputed results.
Sec. 532.0304. NURSING SERVICES ASSESSMENTS. (a) In this section, "acute nursing services" means home health skilled nursing services, home health aide services, and private duty nursing services. (b) If cost-effective, the commission shall develop an objective assessment process for use in assessing a recipient's need for acute nursing services. If the commission develops the objective assessment process, the commission shall require that: (1) the assessment be conducted: (A) by a state employee or contractor who is a registered nurse licensed to practice in this state, and who is not: (i) the individual who will deliver any necessary services to the recipient; or (ii) affiliated with the person who will deliver those services; and (B) in a timely manner so as to protect the recipient's health and safety by avoiding unnecessary delays in service delivery; and (2) the process include: (A) an assessment of specified criteria and documentation of the assessment results on a standard form; (B) an assessment of whether the recipient should be referred for additional assessments regarding the recipient's need for therapy services, as described by Section 532.0305, attendant care services, and durable medical equipment; and (C) completion by the individual conducting the assessment of any documents related to obtaining prior authorization for necessary nursing services. (c) If the commission develops the objective assessment process under Subsection (b), the commission shall: (1) implement the process within the Medicaid fee-for-service model and the primary care case management Medicaid managed care model; and (2) take necessary actions, including modifying contracts with Medicaid managed care organizations to the extent allowed by law, to implement the process within the STAR and STAR+PLUS Medicaid managed care programs. (d) Unless the commission determines that the assessment is feasible and beneficial, an assessment under Subsection (b)(2)(B) of whether a recipient should be referred for additional therapy services assessments shall be waived if the recipient's need for therapy services has been established by a recommendation from a therapist providing care before the recipient is discharged from a licensed hospital or nursing facility. The assessment may not be waived if the recommendation is made by a therapist who: (1) will deliver any services to the recipient; or (2) is affiliated with a person who will deliver those services after the recipient is discharged from the licensed hospital or nursing facility. (e) The executive commissioner shall adopt rules providing for a process by which a provider of acute nursing services who disagrees with the results of the assessment conducted under Subsection (b) may request and obtain a review of those results. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.