Texas health officials proposed a rule published Aug. 21 that would let the state’s most medically fragile children get nursing care at home without first spending time in a nursing facility and without waiting their turn on a list that runs years long.
The change, filed by the Texas Health and Human Services Commission, creates what the agency calls diversion slots in the Medically Dependent Children Program. That program is a Medicaid waiver — a federal permission slip that lets a state pay for care at home for a child who would otherwise qualify for a nursing home. Under current rules families reach it two ways: by climbing an interest list, which is the state’s term for a waiting list, or by first being admitted to a nursing facility and then transferring out.
The proposed rule states the purpose without hedging. “Adding diversion slots allows HHSC to enroll eligible medically fragile children in the MDCP waiver before the child reaches the top of the interest list and without requiring admission to a nursing facility.”
Emily Zalkovsky, the commission’s chief Medicaid and CHIP services officer, wrote in the filing that the slots “will allow children with serious medical needs to access MDCP services immediately, without having to go through the interest list process or enter a nursing facility,” and that the approach “helps families care for their children at home and may also reduce unnecessary nursing facility stays.”
The gate is narrow and clinical. A child must be, in the rule’s words, “too medically fragile to complete a stay in a nursing facility,” a slot must be available, and the child must meet two or more of twelve conditions. Those include being on a ventilator that breathes for the child, having a functioning surgical opening in the windpipe, needing kidney dialysis, depending on oxygen around the clock, taking all nutrition through a feeding tube or intravenously, being in hospice, having had an organ transplant within the past year, relying on a breathing mask at least 20 hours a day, and “three or more admissions to a medical facility for status epilepticus within the last twelve months” — that is, prolonged seizures that will not stop on their own.
A child who misses the two-condition threshold is not automatically turned away. Under the rule, a commission utilization review nurse routes the case to an agency physician on a diversion slot attestation form, and the physician decides using medical judgment.
Two things in the filing deserve scrutiny. The commission’s fiscal note reports no foreseeable cost implications and assumes no change in future legislative appropriations — an unusual claim for a rule whose stated effect is to enroll more children into a service. And the rule keeps a long-standing ceiling requiring that a child’s home care cost no more than half of what a nursing facility would cost, with any exception subject to commission review and state general revenue. The proposal also removes Medicaid Buy-In for Children, a program that lets families above the ordinary income limit pay a premium for coverage, from the list of financial eligibility paths into the waiver, saying the deletion is “for consistency with existing eligibility policy.”
Texas has been shedding insured children faster than most states, a trend the Dispatch reported in July, and the interest list for this particular waiver has long been one of the sharper edges of that record. Families have described admitting a child to a nursing home for no medical reason other than to unlock home care — precisely the maneuver the agency now says it wants to make unnecessary.
The decision is open. Comments run 31 days from Aug. 21 and go to the commission’s rules coordination office under the subject line “Comments on Proposed Rule 26R040.” The earliest the executive commissioner, Stephanie Muth, can adopt the rule is Sept. 20.
What the filing does not say is how many diversion slots there will be. The rule authorizes them; it does not count them. Until the commission says otherwise, the number of Texas children who skip the list will be whatever the agency decides it can afford at no stated cost.