Texas Department of Aging and Disability Services
Nursing Facility Requirements for Licensure and Medicaid Certification Handbook
Revision: 08-1

Subchapter N

§19.1301  Provision of Rehabilitative Services

(a)
Provision of services. If rehabilitative services, such as, but not limited to, physical therapy, speech/language pathology, occupational therapy, mental health rehabilitative services for mental illness and mental retardation are required in the resident's comprehensive plan of care, the facility must:
(1)
provide the required services; or
(2)
obtain the required services from an outside resource, in accordance with §19.1906 of this title (relating to Use of Outside Resources), from a provider of specialized rehabilitative services.
(b)
Rehabilitative services. The facility must ensure that rehabilitative services are provided under a written plan of treatment based on the physician's diagnosis and orders, and that services are documented in the resident's clinical record.

§19.1302  Qualifications

Rehabilitative services must be provided under the written order of a physician by qualified personnel.

(1)
A qualified therapist is:
(A)
a speech-language pathologist who:
(i)
is a Texas licensed speech-language pathologist; or
(ii)
meets the educational requirements for license and has accumulated, or is in the process of accumulating, the supervised professional experience (the internship) required for license;
(B)
an audiologist who:
(i)
is a Texas-licensed audiologist; or
(ii)
meets the educational requirements for license and has accumulated, or is in the process of accumulating, the supervised professional experience (the internship) required for license;
(C)
an occupational therapist (a qualified consultant) who is currently licensed by the Texas Board of Occupational Therapy Examiners;
(D)
an occupational therapy assistant who is currently licensed by the Texas State Board of Occupational Therapy Examiners;
(E)
a physical therapist who is currently licensed as a physical therapist by the Texas State Board of Physical Therapy Examiners; or
(F)
a physical therapist assistant who is licensed as a physical therapist assistant by the Texas State Board of Physical Therapy Examiners.
(2)
A physical therapy aide is a person who assists in the practice of physical therapy and whose activities require on-the-job training and on-site supervision by a physical therapist or physical therapist assistant. A physical therapy aide is not a certified corrective therapist or an adaptive or corrective physical education specialist.

§19.1303  Specialized Services in Medicaid-Certified Facilities

Specialized Services are physical, occupational, and speech therapy evaluations and services provided to eligible Medicaid recipients identified by the Preadmission Screening and Resident Review (PASARR) team.

§19.1304  Rehabilitative Services in Medicaid-Certified Facilities

(a)
Rehabilitative Services are physical therapy, occupational therapy, and speech therapy services for Medicaid nursing facility residents who are not eligible for Medicare or other insurance. The cost of therapy services for residents with Medicare or other insurance coverage or both must be billed to Medicare or other insurance or both.
(b)
Coverage for physical therapy, occupational therapy, or speech therapy services includes evaluation and treatment of functions that have been impaired by illness. Rehabilitative services must be provided with the expectation that the resident's functioning will improve measurably in 30 days.

§19.1306  Payment for Specialized and Rehabilitative Services


(a)
DADS reimburses a nursing facility for specialized and rehabilitative services based on fees determined by the Health and Human Services Commission in accordance with 1 TAC §355.313 (relating to Reimbursement Methodology for Specialized and Rehabilitative Services).
(b)
The services must:
(1)
be ordered by the attending physician; and
(2)
except as provided in subsection (c)(1) of this section, be pre-certified by DADS.
 
(c)
A session is one physical, occupational, or speech therapy service performed for one resident. An evaluation is reimbursed at the same rate as a session.
(1)
One evaluation is reimbursed without being pre-certified by DADS.
(2)
An additional evaluation must be supported by the attending physician's documentation that indicates a new illness or injury, or a substantive change in a pre-existing condition.
(d)
A complete and accurate claim for services must be received by DADS within 12 months after the last day services are provided in accordance with a single pre-certification by DADS.
 
(e)
A claim rejected during the 12-month period through no fault of the provider may be reimbursed upon approval by DADS.
(f)
A resident whose request for pre-certification of Medicaid rehabilitative or specialized services is denied is entitled to a fair hearing in accordance with rules of HHSC regarding Medicaid fair hearings. A request for a fair hearing must be made to: Texas Department of Aging and Disability Services, Attn: Rehabilitative Services, P.O. Box 149030 (MC W-400), Austin, Texas 78714-9030. The request must be received by DADS within 90 days after the date the notice of action is mailed to the resident.