Waiver Consulting Group — Start any program. In any state.

Texas - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Texas Health and Human Services Commission (HHSC) regulates the delivery of in-home RN and LVN services through the Home and Community Support Services Agency (HCSSA) license under the Licensed Home Health Services (LHHS) category. Agencies delivering these physician-ordered assessments, medication administration, and skilled treatments must secure this license through the Texas Unified Licensure Information Portal (TULIP) before applying for Medicaid reimbursement.

Approval to bill Texas Medicaid waivers like STAR+PLUS, STAR Kids, or the Home and Community-based Services (HCS) program requires completing the HHSC Pre-survey Computer-Based Training (CBT), passing an initial licensure survey, and subsequently enrolling through the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment and Management System (PEMS). An applicant cannot initiate TMHP Medicaid enrollment for skilled nursing without first holding an active HCSSA license and obtaining a National Provider Identifier (NPI).

1. Service Definition and Scope

Under Texas Administrative Code (TAC) Title 26, Chapter 558, skilled nursing services include tasks delegated by a physician and performed by a Registered Nurse (RN) or Licensed Vocational Nurse (LVN). These services encompass comprehensive health assessments, medication administration, wound care, and disease management delivered at the client's residence.

Texas Medicaid covers these services through managed care (STAR+PLUS, STAR Kids) and fee-for-service waivers (CLASS, HCS). The scope strictly prohibits unlicensed personnel from performing tasks that require nursing judgment, and all skilled treatments must align with an active physician's plan of care.

2. Regulatory and Oversight Agencies

The Texas Health and Human Services Commission (HHSC) serves as the primary regulatory body, issuing HCSSA licenses and conducting compliance surveys. HHSC's Long-Term Care Regulation (LTCR) division oversees the initial and ongoing unannounced inspections of home health agencies.

The Texas Medicaid & Healthcare Partnership (TMHP) acts as the state's Medicaid claims administrator and handles all provider enrollment. Managed Care Organizations (MCOs) like Superior HealthPlan oversee network contracting and prior authorizations for STAR+PLUS and STAR Kids members.

3. Gatekeeping Prerequisites: Who Can Even Apply

Texas mandates that any entity seeking to provide skilled nursing services must first obtain a Home and Community Support Services Agency (HCSSA) license from HHSC. Medicaid enrollment through TMHP PEMS is structurally blocked until the applicant holds an active HCSSA license with the Licensed Home Health Services (LHHS) category.

Before submitting the TULIP application, the designated Agency Administrator and Alternate Administrator must complete the mandatory HCSSA Pre-survey Computer-Based Training (CBT). For agencies intending to bill Medicare or dual-eligible Medicaid programs, they must apply for the Licensed and Certified Home Health Services (L&CHHS) category and demonstrate intent to meet Medicare Conditions of Participation (CoPs).

4. Licensure and Certification Requirements

Prospective providers submit the initial HCSSA license application through the TULIP system, accompanied by the required fee and corporate documents. The application must designate the specific categories of service, such as Licensed Home Health Services (LHHS).

Upon application approval, HHSC issues an initial license, allowing the agency to admit clients. The agency must then pass an initial on-site health and safety survey conducted by HHSC LTCR surveyors to maintain the license and receive a standard three-year renewal.

5. Medicaid Provider Enrollment

Once the HCSSA license is active, the agency applies for Texas Medicaid through the TMHP Provider Enrollment and Management System (PEMS). The agency must enroll as a Home Health Agency or under specific waiver provider types depending on the target client population.

PEMS requires the submission of the agency's NPI, taxonomy codes, HCSSA license, and ownership disclosures. Providers must also pay the federal Medicaid application fee unless they provide proof of payment to Medicare or another state's Medicaid program.

6. Staffing, Training and Background Checks

Texas HCSSA regulations require a Supervising Nurse (an RN licensed in Texas or a compact state) to oversee all skilled nursing services. Direct care is provided by RNs or Licensed Vocational Nurses (LVNs) operating under the delegation and supervision of the RN.

All staff must undergo criminal history checks through the Texas Department of Public Safety (DPS). Agencies must also verify that employees are not listed on the Texas Employee Misconduct Registry (EMR) or the Nurse Aide Registry (NAR) prior to hire and annually thereafter.

7. Documentation, Policies and Records

26 TAC Chapter 558 mandates comprehensive written policies covering client care, emergency preparedness, and medication administration. Agencies must maintain individualized client records that include physician orders, nursing assessments, and clinical notes for every visit.

The agency must enroll in the HHSC emergency communication system and maintain an active emergency preparedness plan. Client records must be retained for a minimum of five years after the discharge date.

8. Billing, Rates and Claims

Skilled nursing services are billed to Texas Medicaid via TMHP for fee-for-service clients or directly to the respective MCO for STAR+PLUS and STAR Kids members. Claims must utilize standard HCPCS codes or specific waiver procedure codes.

Rates are established by the HHSC Provider Finance Department and published on the HHSC website. Prior authorization is strictly required for most skilled nursing visits, and claims must match the authorized units and physician orders exactly.

9. Approval Sequence and Timeline

The process begins with the Administrator completing the HCSSA Pre-survey CBT, followed by submitting the TULIP application and fee. HHSC typically processes complete initial license applications within 45 to 60 days, issuing an initial license.

After receiving the initial license, the agency enrolls in TMHP PEMS, which can take 60 to 90 days for approval. Concurrently, the agency admits its first client to trigger the HHSC initial on-site survey, which must occur within the first year of operation.

10. Common Denials and Survey Findings

TULIP applications are frequently delayed or denied due to missing corporate documents, failure to complete the Pre-survey CBT, or discrepancies between the Secretary of State filings and the application. TMHP PEMS enrollments are often rejected for mismatched NPI data or failure to pay the application fee.

During HHSC on-site surveys, common citations include failure to follow physician orders, incomplete clinical notes, and lapsed background checks. Agencies also face recoupments if they fail to properly utilize the Electronic Visit Verification (EVV) system.

11. Key Contacts and Resources

Providers should utilize the HHSC and TMHP websites for the most current manuals, fee schedules, and training modules. The TULIP portal is the central hub for all licensure activities, while PEMS handles all Medicaid enrollment tasks.

For specific policy questions, providers can contact the HHSC Long-Term Care Regulation (LTCR) division or the TMHP Contact Center. MCO-specific questions must be directed to the respective health plan's provider relations department.

See all Texas services · Texas Medicaid consulting · book a consultation.