Revision 19-1; Effective June 3, 2019

Therapy services provided through the STAR+PLUS Home and Community Based Services (HCBS) program are long term services and do not replace a member’s acute care benefit. Therapy services include the evaluation, examination and treatment of physical, functional, cognitive, speech and hearing disorders and/or limitations. Therapy services include the full range of activities under the direction of a licensed therapist within the scope of her or his state licensure. Therapy services are provided directly by licensed therapists or by assistants under the supervision of licensed therapists in the member's home, or the member may receive the therapy in an outpatient center or clinic. If the therapy is provided outside the member's residence based on the member's choice, the member is responsible for providing her or his own transportation or accessing the Medicaid Medical Transportation Program (MTP).

If the therapy is provided outside the member's residence because of the convenience of the provider, the provider is responsible for providing the member's transportation. If a member resides in an adult foster care (AFC) or an assisted living (AL) setting and therapy is provided in an outpatient center or clinic (see 6112, Service Locations for STAR+PLUS HCBS Program), the AL provider or AFC provider is responsible for arranging for transport or directly transporting the member.

Occupational therapy (OT), physical therapy (PT), speech therapy (ST) and cognitive rehabilitative therapy services are covered by the STAR+PLUS HCBS program only after the member has exhausted her or his therapy benefit under Medicare, Medicaid or other third-party resources (TPRs). Providers contracted with the managed care organization (MCO) must provide the OT, PT, ST and cognitive rehabilitation therapy (CRT) services as identified on the member's individual service plan (ISP). Individuals providing therapy services must be licensed in Texas in their profession or be licensed or certified as assistants and employed directly or through sub-contract or personal service agreements with a provider or through the Consumer Directed Services (CDS) Option.

PT is defined as specialized techniques for evaluation and treatment related to functions of the neuro-musculo-skeletal systems provided by a licensed physical therapist or a licensed PT assistant directly supervised by a licensed physical therapist. PT is the evaluation, examination and utilization of exercises, rehabilitative procedures, massage, manipulations and physical agents (such as mechanical devices, heat, cold, air, light, water, electricity and sound) in the aid of diagnosis or treatment.

OT consists of interventions and procedures to promote or enhance safety and performance in activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, leisure and social participation. It is provided by a licensed occupational therapist or a certified OT assistant directly supervised by a licensed occupational therapist.

ST in the STAR+PLUS HCBS program is defined as evaluation and treatment of impairments, disorders or deficiencies related to an individual's speech and language. The scope of speech, hearing and language therapy services offered to STAR+PLUS HCBS program participants exceeds the state plan as the service in this context is available to adults. It is provided by a speech-language pathologist or a licensed associate in speech-language pathology under the direction of a licensed speech-language pathologist.

6310 Initiation of Assessment and Therapy

Revision 18-2; Effective September 3, 2018

Upon member request or recommendation from the nurse, primary care provider or service coordinator for a therapy assessment, the managed care organization (MCO) service coordinator must work with the member to select a provider for the assessment. The assessment must be submitted by the provider for the MCO to authorize service hours based on physician orders and medical necessity (MN) review.  Any therapy for the management of a chronic condition must be included on the individual service plan (ISP).

6320 Responsibilities of Licensed Therapists in STAR+PLUS HCBS Program

Revision 18-2; Effective September 3, 2018

Responsibilities of the licensed therapists include, but are not limited to, the following:

  • assessing the member's need for therapy, adaptive aids and minor home modifications (MHMs);
  • delivering direct therapy as authorized in the individual service plan (ISP);
  • supervising delivery of therapy rendered by the therapy assistant as authorized in the ISP;
  • informing the physician and other team members of changes in the member's health status requiring a service plan change;
  • training the member’s attendant or caregiver to extend therapeutic interventions;
  • training the member to use adaptive aids; and
  • participating in interdisciplinary team meetings, when appropriate and requested by the managed care organization (MCO).

6330 Cognitive Rehabilitation Therapy

Revision 18-2; Effective September 3, 2018

Cognitive rehabilitation therapy (CRT) is a service that assists a member in learning or relearning cognitive skills lost or altered as a result of damage to brain cells/chemistry in order to enable the member to compensate for the lost cognitive functions. Cognitive rehabilitation therapy is provided when determined to be medically necessary (MN) through an assessment conducted by an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the individual service plan (ISP) developed by the assessor, and includes reinforcing, strengthening or re-establishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems. Qualified providers include:

  • Psychologists licensed under Texas Occupations Code Chapter 501;
  • Speech and language pathologists licensed under Title 3 of the Texas Occupations Code, Subtitle G, Chapter 401; or
  • Occupational therapists licensed under Title 3 of the Texas Occupations Code, Subtitle H, Chapter 454.