1. Program Definition and Services

Skilled Nursing Services in Texas provide medically necessary, clinically supervised interventions delivered by licensed nursing professionals (RNs and LVNs) in the participant’s home or community setting. The program targets individuals with complex, sub-acute, or chronic medical conditions under 1915(c) waivers (HCS, CLASS, TxHmL, DBMD, MDCP). Services include:

• Advanced Clinical Care: Complex wound management, sterile dressing changes, intravenous (IV) therapy, tracheostomy/ventilator care, enteral tube feeding (G-tube/J-tube), and catheterization
• Medication & Health Monitoring: Administration of controlled medications, injections, vital signs diagnostics, health education, and professional nurse delegation

2. Regulations

The program is governed by the following regulations:

• Texas Administrative Code (TAC), Title 26, Part 1, Chapter 558 (HCSSA Licensing Standards)
• Texas Administrative Code (TAC), Title 22, Part 11, Chapter 217 (Texas BON Licensure & Practice Rules)
• Texas Administrative Code (TAC), Title 22, Part 11, Chapters 224 & 225 (RN Nurse Delegation Rules)
• Federal Home and Community-Based Services (HCBS) Final Settings Rule (42 CFR 441.301)

3. Licensing or Certification

Providers must obtain a Home and Community Support Services Agencies (HCSSA) License with either the Licensed Home Health Services (LHHS) or Licensed and Certified Home Health Services (L&CHHS) category code designation. Active credentialing with Texas Medicaid Managed Care Organizations (MCOs) is also required.

4. Responsible State Agency

The Texas Health and Human Services Commission (HHSC) maintains administrative, regulatory, and licensing authority over the HCSSA framework. The Texas Board of Nursing (BON) regulates clinical nursing scopes of practice and nurse delegation frameworks.

5. Application Process

• Register the business entity via the Texas Secretary of State and secure federal EIN/NPI codes
• Submit an initial HCSSA license application through the online Texas Unified Licensure Information Portal (TULIP)
• Enroll the entity via the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment and Management System (PEMS)
• Apply for an open enrollment waiver contract through the HHSC system or individual MCO networks

6. Required Documentation

• Business formation papers, active Federal EIN, and corporate Type 2 NPI
• Active Texas nursing licenses (RN/LVN) and current CPR/BLS certifications for all clinical staff
• Skilled Nursing Services Policy & Procedure Manual (covering specialized clinical protocols, infection control, medication administration [MAR], physician order workflows, and RN nurse delegation)
• Certificates of professional medical malpractice and general liability insurance

7. Timeline for Approval

The combined processing timeline across TULIP HCSSA licensing, initial state surveys, and final TMHP PEMS enrollment typically spans 4 to 6 months, depending on state agency backlogs.

8. Pre-Application Process

Prospective providers must form an LLC or Corporation with the Texas Secretary of State, establish internal business infrastructure, and register a corporate Type 2 National Provider Identifier (NPI) configured with home health or skilled nursing taxonomy codes.

9. Pre-Application Training

Before submitting the initial HCSSA application in TULIP, the designated agency Administrator, Alternate Administrator, Supervising Nurse, and Alternate Supervising Nurse must successfully complete the mandatory HHSC HCSSA Pre-Licensure Computer-Based Training (CBT) modules (Modules 1, 2, and 4) and upload their certificates.

10. Additional Notes

• All services must be backed by a current, signed Physician’s Order (Form 485/Plan of Care) or explicit authorization embedded within the participant's Individual Plan of Care (IPC)
• Registered Nurses (RNs) must strictly evaluate, document, and supervise all nursing tasks delegated to unlicensed personnel or Direct Support Professionals (DSPs) in accordance with TAC Title 22
• Providers must comply with Texas Electronic Visit Verification (EVV) tracking rules for all nursing visits delivered in home or community settings to satisfy state billing requirements
• Complete clinical files, including daily nursing notes, wound logs, and medication records, must undergo internal Quality Assurance (QA) reviews to survive post-payment Medicaid audits

Why Choose Waiver Consulting Group?

Starting or expanding your Medicaid waiver-funded agency can feel overwhelming, but it doesn't have to be. At Waiver Consulting Group, we simplify the process by guiding you through licensing, compliance, provider enrollment, policies & procedures, and regulatory approvals in any state.

With proven expertise, a structured process, and ongoing support, we take the guesswork out of launching your healthcare business. Whether you're a first-time entrepreneur or an established provider looking to expand, our team ensures you stay compliant, competitive, and fully operational.

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