Current through Reg. 49, No. 52; December 27, 2024
(a) Notwithstanding
any other provision of this subchapter, Medicaid services or supplies that are
not medically necessary will not be considered for Medicaid reimbursement. The
following benefit exclusions and limitations are applicable under the Medicaid
program for services provided under this subchapter. They do not apply to
Medicaid services provided through the Texas Health Steps Comprehensive Care
Program. Additional exclusions and limitations are listed in the Texas Medicaid
Provider Procedures Manual. The following benefits are not included in the
Texas Medicaid Program:
(1) services provided
to any individual who is an inmate in a public institution (except as a patient
in a medical institution approved for participation in the Medicaid program),
or is a patient in:
(A) the hospital or
nursing sections of facilities for persons with intellectual and developmental
disabilities; or
(B) an institution
for mental disease if the patient is between the ages of 22 and 64;
(2) special shoes or other
supportive devices for the feet and ambulation aids (except as provided for in
the home health services program);
(3) any services provided by military medical
facilities, except:
(A) those military
hospitals enrolled to provide inpatient emergency services;
(B) Veterans Administration facilities;
or
(C) United States Public Health
Service hospitals;
(4)
care and treatment related to any condition covered by workers' compensation
laws;
(5) care, treatment, or other
services by a doctor of dentistry unless:
(A)
the recipient's dental diagnosis is causally related to a life-threatening
medical condition; or
(B) the
treatment is specifically authorized by the Health and Human Services
Commission (HHSC) or its designee;
(6) any care or services to the extent that a
benefit is paid or payable under Medicare;
(7) any services or supplies provided to an
individual before the effective date of designation by HHSC as an eligible
recipient or after the effective date of denial as an eligible recipient except
orthodontic services that are authorized and initiated while the recipient is
eligible for Medicaid may be continued for 36 months after a recipient is no
longer Medicaid eligible;
(8) any
services or supplies provided in connection with cosmetic surgery except as
required for the prompt repair of accidental injury or for improvement of the
functioning of a malformed body member;
(9) any services provided by an immediate
relative of the eligible recipient or member of the eligible recipient's
household except for personal care services;
(10) custodial care;
(11) any services or supplies provided
outside of the United States, except for Medicare deductible and coinsurance
amounts subject to the limits specified in §354.1143 of this division
(relating to Coordination of Medicaid with Medicare Parts A, B, and
C);
(12) any services or supplies
not provided for in this chapter;
(13) any services or supplies not provided
for in this chapter for:
(A) the treatment of
flat foot conditions and the prescription of supportive devices
therefor;
(B) the treatment of
subluxations of the foot; or
(C)
routine foot care (including the cutting or removal of corns, warts, or
calluses, the trimming of nails, and other routine hygiene care);
(14) any medical and remedial
care, services, and supplies provided to a hospital inpatient after total
hospitalization-related expenditures under the Medicaid Program reach $200,000
per recipient, per 12-month benefit period unless the services are exempted by
subparagraphs (A) - (C) of this paragraph. For the purposes of this limit,
"12-month benefit period" means 12 consecutive months beginning November 1 of
each year and ending October 31 of the next year. The limit applies to
hospitalization-related services while the recipient is a hospital inpatient
regardless of where the services are provided, how soon within the 12-month
period the limit is reached, and how many hospital stays are involved. For the
purposes of this limit, HHSC or its designee processes and pays claims, if
payable, based on the sequential date of service. The services exempted from
the $200,000 limit are:
(A) covered benefits
under §354.1175 of this division (relating to Organ
Transplants);
(B) care, services,
and supplies otherwise authorized by HHSC; and
(C) physician services as allowed by Title
XIX laws and regulations and state law; and
(15) any services or supplies that are
experimental or investigational.
(b) Outpatient Behavioral Health Services.
Benefits to an individual for the diagnosis or treatment of mental disease,
psychoneurotic, and personality disorders while not confined as an inpatient in
a hospital are limited to 30 visits to enrolled practitioners per calendar
year. This utilization control limitation may be exceeded when prior authorized
on a case-by-case-basis.
(c)
Private Room Facilities. Private room facilities are not a benefit unless a
facility submits a physician's certification of medical necessity to HHSC or
its designee certifying that one of the following conditions is met:
(1) the recipient, based on a medical
opinion, has a critical or contagious illness;
(2) the eligible recipient's condition
results in undue disturbance to other patients; or
(3) the need for care is emergent and lower
cost facilities are not immediately available.
(d) Institutional Care. Separate payments are
not made for services and supplies in an institution where the reimbursement
formula and vendor payment include such services or supplies as a part of the
institutional care.
