Eligibility

Nursing home residents eligible for Specialized Services must:

  • Be Medicaid-eligible
  • Reside in a Medicaid-certified nursing facility
  • Have a diagnosis of severe mental illness, intellectual disability onset before age 18, or a developmental disability (related condition) onset before age 22
  • Have a positive PASRR Evaluation on file in the Texas Medicaid Healthcare Partnership (TMHP) or Simple LTC online portal
  • Have habilitative (maintenance-based) physical, occupational or speech therapy recommended in their comprehensive care plan

Resources

Medicare/Medicaid Requests for PT/OT/Speech (PDF)

Rehabilitative vs. Habilitative Therapies

Habilitative Services Definitions

CMS Glossary of Health Coverage and Medical Terms: “Habilitative services, including devices, are provided for a person to attain, maintain, or prevent deterioration of a skill or function never learned or acquired due to a disabling condition.”

45 CFR §156.115 Provisions of Essential Health Benefits: “With respect to habilitative services and devices — cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services). Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.”

Rehabilitative Services Definitions

Federal Register, February 27, 2015, Vol. 80, No. 39, pg. 10811: “Rehabilitative services, including devices, are provided to help a person regain, maintain, or prevent deterioration of a skill or function that has been acquired but then lost or impaired due to illness, injury, or disabling condition.

CMS Glossary of Health Coverage and Medical Terms: “Rehabilitative services are health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and outpatient settings.”

Rehabilitative Services vs. Habilitative Services

Habilitation Benefits Coalition, “Coverage of Habilitation Services and devices in the Essential Benefits Package under the Affordable Care Act.” October 25, 2011: “The professionals and the settings are often the same. The functional deficits and the improvements in functional outcomes that result from treatment can often be similar. The primary reason for a distinction is the different reason for needing the service and the length of time services may be required.”

Health Reform Commission — Essential Health Benefits Work Group, August 6, 2012: “Rehabilitation therapy is designed to improve functioning — somewhat finite, ending when further improvement is no longer likely. Once therapy has achieved the maximum level of functioning, the common practice is not to then provide intervention to maintain function. Habilitation is not typically episodic — many people require services throughout their lifetime.”

Requesting Habilitative Services

A speech, occupational or physical therapist may request habilitative therapies (physical, occupational or speech therapy) for a PASRR-positive person for up to 6 months at a time.

Requests for Authorization of Specialized Services for Residents of Nursing Facilities

Requesting Authorization of Habilitative Physical, Occupational or Speech Therapy

To request Habilitative therapies, nursing facility providers must submit a Nursing Facility Specialized Service (NFSS) form on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. Additionally, each request must be accompanied by corresponding signature sheets or other attachments.

A licensed therapist must complete and submit the following for each type of habilitative therapy service requested.

New Request

New (Submit initial assessment) – An initial therapy assessment completed by a licensed therapist is required. The service request must include a treatment plan.

  • PASRR NF Specialized Services (NFSS) - Therapy Signature Page (for Therapist, Referring Physician and Nursing Facility Administrator signatures)

Request for Extension/Recertification

An updated assessment completed by a licensed therapist is not required if the frequency, duration, and intensity remain the same (Does not require updated treatment plan).

If the frequency, duration, and intensity have changed, a new assessment is required and must include therapist and physician signature.

When requesting an extension of therapy (recertification), a licensed therapist must complete and submit the following:

  • Enter the information from the latest therapy assessment into the NFSS on the LTC Portal
  • If the information has previously been submitted on an NFSS form in the LTC Portal, for therapy recertification requests, the data will be auto-populated and captures data from the previous assessment, but this information will not be able to be edited.
  • PASRR NF Specialized Services (NFSS) - Therapy Signature Page (for Therapist and Nursing Facility Administrator signatures)

Restarting Therapy

To restart therapy that was interrupted (e.g., the individual was temporarily hospitalized), An updated assessment completed by a licensed therapist must be submitted. The service request must include a treatment plan. The licensed therapist must complete and submit the following:

  • Submit an updated assessment on the NFSS form that includes a treatment plan
  • PASRR NF Specialized Services (NFSS) - Therapy Signature Page (for Therapist and Nursing Facility Administrator signatures)

Request for Customized Manual Wheelchair

To request a customized manual wheelchair, the NFSS form must be completed by a licensed therapist. A supplier representative will provide the therapist with information to complete the “Supplier Information and MSRP Quote” section of the NFSS form. The following must be submitted with a customized manual wheelchair request:

  • PASRR NF Specialized Services (NFSS) - CMWC/DME Signature Page
  • PASRR NF Specialized Services (NFSS) - CMWC Supplier Acknowledgment and Signature Page
  • PASRR NF Specialized Services (NFSS) - CMWC/DME Receipt Certification

Request for Other Durable Medical Equipment

To request other durable medical equipment the NFSS form must be completed by a licensed therapist. A supplier representative will provide the therapist with information to complete the “Supplier Information and MSRP Quote” section of the NFSS form. The following must be submitted with a durable medical equipment request:

  • For DME:PASRR NF Specialized Services (NFSS) - CMWC/DME Signature Page
  • PASRR NF Specialized Services (NFSS) - DME Supplier Acknowledgment and Signature Page
  • PASRR NF Specialized Services (NFSS) - CMWC/DME Receipt Certification

These requests are limited to gait trainer, standing board, special needs car seat or travel restraint, specialized/treated pressure-reducing support surface/mattress, positioning wedge, prosthetic device, orthotic device (such as ankle-foot orthotic and knee-foot orthotic), and a manual wheelchair.

Once the NFSS forms are submitted, the NF provider will receive an alert. NF providers must check the LTC Portal daily for alerts related to the status of their NFSS requests.