Revision 17-2

 

§19.1300 Purpose

 

(a) This subchapter contains the requirements a facility must comply with to provide rehabilitative services to a resident.

(b) Subchapter BB (relating to Nursing Facility Responsibilities Related to Preadmission Screening and Resident Review (PASRR)) contains the requirements a facility must comply with to provide nursing facility specialized services to a designated resident, as define in §19.2703 of this chapter (relating to Definitions).

 

§19.1301 Provision of Rehabilitative Services

 

(a) If rehabilitative services are required in a resident's comprehensive care plan, 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 chapter (relating to Use of Outside Resources).

(b) A facility must ensure that rehabilitative services:

(1) are provided to a resident under a comprehensive care plan based on a physician's diagnosis and orders; and
(2) are documented in the resident's clinical record.

 

§19.1302 Qualifications

 

A facility must ensure that rehabilitative services are provided by:

(1) an individual who:
(A) is a speech-language pathologist licensed by the Texas Department of Licensing and Regulation; or
(B) meets the educational requirements and has accumulated, or is in the process of accumulating, the supervised professional experience required to be licensed as a speech-language pathologist;
(2) an individual who:
(A) is an audiologist licensed by the Texas Department of Licensing and Regulation; or
(B) meets the educational requirements and has accumulated, or is in the process of accumulating, the supervised professional experience required to be licensed as an audiologist;
(3) an occupational therapist licensed by the Texas Board of Occupational Therapy Examiners;
(4) an occupational therapy assistant licensed by the Texas Board of Occupational Therapy Examiners;
(5) a physical therapist licensed by the Texas Board of Physical Therapy Examiners;
(6) a physical therapist assistant licensed by the Texas State Board of Physical Therapy Examiners; or
(7) a qualified mental health professional – community services.

 

§19.1304 Rehabilitative Services in Medicaid-Certified Facilities

 

(a) Rehabilitative services covered by Medicaid are physical therapy services, occupational therapy services, and speech therapy services.
(b) A facility must ensure that rehabilitative services covered by Medicaid are provided to a resident to evaluate or treat a function that has been impaired by illness or injury. Rehabilitative services must be provided with the expectation that the resident's functioning will improve measurably in 30 days.

 

§19.1306 Fee-for-Service Payment for Rehabilitative Services

 

(a) HHSC pays a facility for rehabilitative services provided to a Medicaid eligible resident based on fees determined in accordance with Title 1, Texas Administrative Code (TAC) §355.313 (relating to Reimbursement Methodology for Rehabilitative and Specialized Services).
(b) A facility must ensure that rehabilitative services provided to a resident eligible for Medicaid are:

(1) ordered by the resident's attending physician; and
(2) except as provided in subsection (c)(1) of this section, pre-certified by DADS.

(c) A session is one physical, occupational, or speech therapy service provided to one resident. HHSC pays for an evaluation at the same rate as a session.

(1) HHSC pays for one evaluation that is not pre-certified by DADS.
(2) To have and additional evaluation pre-certified by DADS, facility must submit documentation by the attending physician that indicates the resident has a new illness or injury, or a substantive change in a pre-existing condition.

(d) A facility must submit a complete and accurate claim for services that is received by DADS within 12 months after the last day services are provided in accordance with a single pre-certification by DADS.
(e) A resident whose request for pre-certification of Medicaid rehabilitative services is denied may request fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).