1. (a) HHSC terminates authorization for PPECC services when:

   1. (1) the participant is no longer eligible for the Texas Health Steps Comprehensive Care Program;
   2. (2) the participant no longer meets the medical necessity criteria for PPECC services;
   3. (3) the PPECC cannot ensure the health and safety of the participant;
   4. (4) the participant or the participant's responsible adult refuses to comply with the plan of care, and compliance is necessary to assure the health and safety of the participant;
   5. (5) the participant changes PPECC providers, and the change of notification is submitted to HHSC in writing with a prior authorization request from the new PPECC provider; or
   6. (6) the participant declines to continue receiving PPECC services and chooses to receive services at home.

2. (b) Notice to approve, reduce, deny, or terminate requested PPECC services.

   1. (1) HHSC notifies the participant and the responsible adult in writing of the approval, reduction, denial, or termination of PPECC services.
   2. (2) HHSC notifies the provider in writing of the approval, reduction, denial, or termination of PPECC services.
   3. (3) The effective date of the service reduction or denial is 30 calendar days after the date on the individual's notification letter.
   4. (4) HHSC notifies the individual in writing of the process to appeal the reduction or denial of services.
3. (c) All participants of Medicaid-funded services have the right to appeal actions or determinations made by HHSC as described in Chapter 357, Subchapter A of this title (relating to Uniform Fair Hearing Rules).

Source Note:The provisions of this §363.215 adopted to be effective November 1, 2016, 41 TexReg 8284; amended to be effective February 19, 2025, 50 TexReg 831.