Current through Reg. 49, No. 38; September 20, 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) immunizations specifically for travel to
or from foreign countries. Immunizations included on the immunization schedule
approved by the Advisory Committee on Immunization Practices (ACIP) are a
benefit unless an immunization is specifically excluded by HHSC;
(10) any services provided by an immediate
relative of the eligible recipient or member of the eligible recipient's
household except for personal care services;
(11) custodial care;
(12) any services or supplies provided
outside of the United States, except for Medicare deductible and coinsurance
amounts subject to the limits specified in §
RSA
354.1143 of this title (relating to
Coordination of Medicaid with Medicare Parts A, B, and C);
(13) any services or supplies not provided
for in this chapter;
(14) 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;
(C) routine foot care
(including the cutting or removal of corns, warts, or calluses, the trimming of
nails, and other routine hygiene care);
(15) 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 §
RSA 354.1175 of
this title (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;
(16) 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.
