TITLE 1. ADMINISTRATION

DIVISION 20. PHYSICAL THERAPY [THERAPISTS'] SERVICES

1 TAC §354.1291

The executive commissioner of the Texas Health and Human Services Commission (HHSC) proposes an amendment to §354.1291, concerning Benefits and Limitations.

BACKGROUND AND PURPOSE

The purpose of the proposal is to expand who can prescribe physical therapy (PT) services to a Medicaid recipient. The rule currently provides that physical therapy services must be prescribed by a physician to be reimbursed by Medicaid. This amendment allows a physician, a physician assistant (PA), an advanced practice registered nurse (APRN), including a certified nurse practitioner (CNP) or a clinical nurse specialist (CNS), to prescribe physical therapy services. This amendment clarifies the type of practitioner allowed to prescribe physical therapy services from physician only to physicians and allowed practitioners to align with the rules governing physical therapy as a home health benefit in §354.1031(b)(1)(B) and §354.1039(a)(5)(C). The proposed amendment also updates references, clarifies language, improves accuracy and uniformity to enhance understanding of services under Texas Medicaid.

SECTION-BY-SECTION SUMMARY

The title of Division 20 is currently, "Physical Therapists' Services." It is retitled as "Physical Therapy Services" to specify the name of the service described in the rule.

The proposed amendment to §354.1291, makes the following changes to the rule.

Proposed new subsection (a) adds definitions to provide the meaning of terms used in the rule. Definitions for "allowed practitioner," "physical therapist," "physical therapist assistant," "physical therapy," "physician," and "prescribing provider" are added. The new definition of "prescribing provider" when used in the proposed rule means a physician or an allowed practitioner. "Allowed practitioner" means an individual with a valid and registered prescriptive authority agreement in accordance with Texas Occupations Code, Chapter 157, Subchapter B, and is licensed as a PA or an APRN licensed as a certified nurse practitioner or clinical nurse specialist. The new definition of "physician" is also used in the proposed rule as a person who provides physical therapy services.

Proposed new subsection (b), currently subsection (a), removes the reference to "the Texas Department of Health (department) or its designee" and replaces it with "HHSC" to update an agency name. The amendment also replaces "the Texas Medical Assistance Program" with "Texas Medicaid."

Proposed new subsection (c) sets forth the requirements for physical therapy services to be reimbursable. Proposed new subsection (c)(1) requires physical therapy to be provided by a physician, physical therapist, or a physical therapist assistant under the supervision of the physical therapist. Proposed new subsection (c) uses prescribing provider instead of physician to allow a physician or an allowed practitioner to prescribe physical therapy services.

Current subsection (b) is deleted because its contents have been replaced by proposed new subsection (c).

Proposed new subsection (d), combines current subsections (d) and (e) and sets forth what is not considered reimbursable as physical therapy services under Texas Medicaid. This change is necessary to enhance clarity and group together items that are not reimbursable in a single subsection.

Current subsections (d) and (e) are deleted because their contents have been replaced by proposed new subsection (d).

Proposed new subsection (e), currently subsection (c), sets forth that a provider of physical therapy services must have a treatment plan on file and available for inspection for each Medicaid recipient who is treated. Proposed subsection (e) includes that both a physician and a physical therapist can provide physical therapy services. Proposed subsection (e) allows a treatment plan to be based on a prescribing provider's prescription instead of being established by the attending physician and/or by the therapist. Proposed subsection (e) removes that a prescription must be "written" to allow for electronic prescriptions. Proposed subsection (e) contains some formatting changes for clarity and readability.

The proposed amendment to subsection (f) removes the term "licensed" with respect to physical therapist and clarifies that the therapist may not bill Texas Medicaid for physical therapy services if it would result in duplicate billing. Additionally, a portion of subsection (f) related to the basis and amount of Medicaid reimbursement actually provided is relocated to new subsection (g). This change is necessary to separate the two different topics. Other non-substantive edits are made for clarity.

Proposed new subsection (h), currently subsection (g), clarifies that "services" is referring to "physical therapy services" and clarifies that physical therapy services provided in long-term care facilities must be billed to the Medicaid recipient's nursing facility rather than the Nursing Home Program.

FISCAL NOTE

Trey Wood, HHSC Chief Financial Officer, has determined that for each year of the first five years that the rule will be in effect, enforcing or administering the rule does not have foreseeable implications relating to costs or revenues of state or local governments.

GOVERNMENT GROWTH IMPACT STATEMENT

HHSC has determined that during the first five years that the rule will be in effect:

(1) the proposed rule will not create or eliminate a government program;

(2) implementation of the proposed rule will not affect the number of HHSC employee positions;

(3) implementation of the proposed rule will result in no assumed change in future legislative appropriations;

(4) the proposed rule will not affect fees paid to HHSC;

(5) the proposed rule will create new regulations;

(6) the proposed rule will expand and repeal existing regulations;

(7) the proposed rule will increase the number of individuals subject to the rule;

(8) the proposed rule will not affect the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Trey Wood, HHSC Chief Financial Officer, has also determined that there will be no adverse economic effect on small businesses, micro-businesses, or rural communities because provider participation is optional.

LOCAL EMPLOYMENT IMPACT

The proposed rule will not affect a local economy.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to this rule because the rule does not impose a cost on regulated persons.

PUBLIC BENEFIT AND COSTS

Emily Zalkovsky, State Medicaid Director, has determined that for each year of the first five years the rule is in effect, the public will benefit from a greater number of prescribing providers available to sign all prescriptions, evaluations and treatment plans related to the provision of physical therapy services.

Trey Wood, HHSC Chief Financial Officer, has also determined that for the first five years the rule is in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rule because provider participation in Medicaid physical therapy services is optional.

TAKINGS IMPACT ASSESSMENT

HHSC has determined that the proposal does not restrict or limit an owner's right to the owner's property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC COMMENT

Written comments on the proposal may be submitted to Rules Coordination Office, P.O. Box 13247, Mail Code 4102, Austin, Texas 78711-3247, or street address 4601 West Guadalupe Street, Austin, Texas 78751; or emailed to HHSRulesCoordinationOffice@hhs.texas.gov.

To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register . Comments must be (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rule 25R017" in the subject line.

STATUTORY AUTHORITY

The amendment is authorized by Texas Government Code §524.0151, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies and provides the executive commissioner of HHSC with broad rulemaking authority; and Texas Human Resources Code §32.021, which provides HHSC with the authority to administer the federal medical assistance program in Texas and to adopt rules and standards for program administration.

The amendment implements Texas Government Code §524.0151 and Texas Human Resources Code §32.021.

§ 354.1291. Benefits and Limitations.

(a) The following words and terms when used in this division, have the following meanings, unless the context clearly indicates otherwise.

(1) Allowed practitioner--An individual:

(A) that maintains a valid and registered prescriptive authority agreement in accordance with Texas Occupations Code Chapter 157, Subchapter B; and

(B) is licensed as:

(i) a physician assistant under Texas Occupations Code Chapter 204; or

(ii) an advanced practice registered nurse licensed by the Texas Board of Nursing as a:

(I) certified nurse practitioner; or

(II) clinical nurse specialist.

(2) Physical therapist--An individual licensed under Texas Occupations Code Chapter 453.

(3) Physical therapist assistant--An individual licensed under Texas Occupations Code Chapter 453.

(4) Physical therapy--This term has the meaning assigned in Texas Occupations Code §453.001.

(5) Physician--A Doctor of Medicine or Doctor of Osteopathy legally authorized to practice medicine or osteopathy at the time and place the service is provided.

(6) Prescribing provider--A physician or an allowed practitioner.

(b) [(a)] Subject to the specifications, conditions, requirements, and limitations established by HHSC, [the Texas Department of Health (department) or its designee,] physical therapy services, which include necessary equipment and supplies provided by a licensed physical therapist, are covered by Texas Medicaid. [the Texas Medical Assistance Program.] Covered services also include the services of a physical therapist assistant when the services are provided under the direction of and billed by the licensed physical therapist.

[(b) To be payable, the services must be:]

[(1) within the physical therapist's scope of practice, as defined by state law;]

[(2) reasonable and medically necessary, as determined by the department or its designee;]

[(3) expected to significantly improve the patient's condition in a reasonable and generally predictable period of time, based on the physician's assessment of the patient's restorative potential after any needed consultation with the therapist (benefits are not provided when the patient has reached the maximum level of improvement); and]

[(4) prescribed by a physician (MD or DO), who is licensed in the state in which he practices.]

(c) To be reimbursable, physical therapy services must be:

(1) provided by a physician, physical therapist, or a physical therapist assistant under the supervision of the physical therapist;

(2) reasonable and medically necessary, as determined by HHSC, or its designee;

(3) expected to significantly improve the recipient's condition in a reasonable and generally predictable period of time, based on the prescribing provider's assessment of the recipient's restorative potential after any needed consultation with the physical therapist; and

(4) prescribed by the recipient's prescribing provider.

(d) The following are not reimbursable physical therapy services under Texas Medicaid:

(1) services relating to activities for the general good and welfare of a recipient such as general exercises to promote overall fitness and flexibility;

(2) services relating to activities to provide diversion or general motivation; and

(3) repetitive services designed to maintain a recipient's function after the recipient reaches the maximum level of improvement.

(e) [(c)] The physician or [licensed] physical therapist who provides physical therapy services must have on file and available for inspection for each Medicaid recipient treated:

(1) asigned and dated physical therapy treatment plan [established by the attending physician and/or by the therapist] based on the prescribing provider's [physician's] prescription. The treatment plan [which] addresses:

(A) diagnosis; [,]

(B) modalities, if any;

(C) frequency of treatment; [,]

(D) expected duration of treatment; [,] and

(E) anticipated goals; and

(2)a [written] prescription signed and dated by the recipient's prescribing provider [attending physician] for [the] therapy services.

[(d) Services related to activities for the general good and welfare of patients such as general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation are not considered appropriate therapy services and are not reimbursable under the Texas Medical Assistance Program (TMAP).]

[(e) Repetitive services designed to maintain function once the maximum level of improvement has been reached are not a benefit of the TMAP.]

(f) Physical [Licensed physical] therapists who are employed by or remunerated by a physician, hospital, facility, or other provider may not bill Texas Medicaid [TMAP] directly for physical therapy services if the therapist's [that] billing would result in duplicate payment for the same services. If physical therapy [the] services are covered and reimbursable by Texas Medicaid, [TMAP,] payment may be made to the physician, hospital, or other provider (if approved for participation in Texas Medicaid [TMAP]) who employs or reimburses the licensed physical therapist.

(g) The basis and amount of Medicaid reimbursement depends on the services actually provided, who provided the services, and the reimbursement methodology utilized by Texas Medicaid [TMAP] as appropriate for the services and providers [provider(s)] involved.

(h) [(g)] Physical therapy services[Services] provided by or under the direction of a [licensed] physical therapist in long-term care facilities must be billed to the Medicaid recipient's nursing facility. [Nursing Home Program.]

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on June 20, 2025.

TRD-202502094

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Earliest possible date of adoption: August 3, 2025

For further information, please call: (512) 438-2910

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