Prescribed Pediatric Extended Care Center (PPECC) Benefit Criteria Updates for Texas Medicaid

Date: December 31, 2024 

Subject: Prescribed Pediatric Extended Care Center (PPECC) Benefit Criteria Updates for Texas Medicaid

Effective date: December 1, 2024

Call to action: The purpose of this communication is to inform providers that Texas Children’s Health Plan (TCHP) is in alignment with the Prescribed Pediatric Extended Care Center (PPECC) benefits have been updated to support the implementation of HB 3550, 88th Legislature, Regular Session, 2023. The benefit changes are effective December 1, 2024.

The benefit updates include changes to the following criteria: 

• The Plan of Care (POC) requirements 

• Prior Authorization Requirements

• Recertification or Extension Request

• Appeal of Authorization Decisions

• Documentation Requirements

• Coordination with Private Duty Nursing

• Reimbursement

For more information on the prior authorization requirements and the benefit updates described please review the following.  

• Texas Medicaid Provider Procedures Manual, Children’s Services Handbook 2_04_Childrens_Services.fm (tmhp.com)

• Texas Medicaid Provider Procedures Manual, Home Health and Private Duty Nursing Services Handbook 2_10_HH_Nursing_and_PDN_Srvs.fm (tmhp.com)

• TMHP Bulletin released 10/14/24: PPECC Benefit Criteria Updates Effective December 1, 2024   PPECC Benefit Criteria Updates Effective December 1, 2024 | TMHP

• TCHP Prior Authorization Guidelines: Prior Authorization Information | Texas Children's Health Plan (texaschildrenshealthplan.org)

How this impacts providers: TCHP is following Texas Medicaid’s guidance for prior authorization review and will adhere to the updated criteria for medical necessity for PPECC services. 

Next step for Providers: Providers should share this communication with their staff and adhere to the updates. 

If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org. 

For access to all provider alerts: https://www.texaschildrenshealthplan.org/providers/provider-news/provider-alerts.