Medicaid and CHIP Services Information for Providers

An End of Continuous Medicaid Coverage Ambassador Toolkit is available to help members, providers, health plans, and advocates prepare for the end of continuous Medicaid coverage.

To streamline this page, some older information has been archived. See the Medicaid and CHIP Services COVID-19 Information PDF for this content.

Medicaid CHIP COVID-19 Information Sessions

These sessions are to share information with stakeholders about the implementation of various Medicaid/CHIP flexibilities in response to the COVID-19 pandemic.

June 2, 2022 

Medicaid and CHIP Flexibilities

Any changes to Medicaid and CHIP services will be posted here and sent out through standard communication channels.

Be sure to check health plan provider portals, the TMHP COVID-19 page, and read any emails you get from HHSC.

As noted in the sections below, multiple Medicaid and CHIP flexibilities have been extended through August 31, 2022.

More information will be provided if there are changes.

Testing for COVID-19

Healthcare providers should coordinate with local public health authorities to determine whether a patient needs to be tested for COVID-19.

Coverage

  • Medicaid and CHIP will cover COVID-19 testing for Medicaid and CHIP clients.
  • No prior authorization will be required on the COVID-19 lab test by Medicaid and CHIP health plans or by traditional Medicaid.

For information on the testing and treatment of the uninsured for COVID-19 see the resources section of this page.

Vaccinations for COVID-19

For information on initial vaccine administration procedure codes, see Medicaid and CHIP COVID-19 Information for Providers (PDF).

Additional Vaccine Doses

Effective Aug. 12, 2021, the FDA issued an amended Emergency Use Authorization for the use of an additional dose of the Pfizer-BioNTech and Moderna COVID-19 vaccines in certain immunocompromised individuals.

Read the TMHP bulletin issued on August 24, 2021.

Effective Sept. 22, 2021, the FDA issued an amended Emergency Use Authorization for vaccine administration code 0004A, the booster dose of the Pfizer-BioNTech COVID-19 vaccine.

Read the TMHP bulletin issued on October 15, 2021.

Effective October 20, 2021, the FDA issued amended Emergency Use Authorizations for vaccine administration codes 0034A and 0064A, the booster doses of the Janssen/Johnson & Johnson and Moderna COVID-19 vaccines, respectively.

Read the TMHP bulletin issued on November 15, 2021.

Effective October 29, 2021, vaccine administration procedure codes 0071A and 0072A are benefits of Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program for individuals 5 through 11 years of age.

Read the TMHP bulletin issued on November 18, 2021.

On November 29, 2021, the CDC recommended that everyone age 18 or older should get a booster dose six months after their initial Pfizer-BioNTech or Moderna series or two months after their initial Janssen/Johnson & Johnson vaccine.

Read the TMHP bulletin issued on December 13, 2021.

Effective January 3, 2022, the Pfizer-BioNTech COVID-19 vaccine, COVID-19 vaccine administration code 0004A (the booster dose of the Pfizer-BioNTech COVID-19 vaccine) is now a benefit of Medicaid and CHIP for individuals 12 years of age and older. Read the TMHP bulletin issued on January 25, 2022.

Effective January 3, 2022, COVID-19 vaccine administration code 0073A is a benefit of Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program for the administration of the third (additional) dose of the Pfizer-BioNTech COVID-19 vaccine for children 5 through 11 years of age. Read the TMHP bulletin issued on February 3, 2022.

Beginning February 10, 2022, for dates of service on or after October 29, 2021, COVID-19 vaccine administration add-on procedure code M0201 is a benefit for clients 5 years of age or older for Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program. Read the TMHP bulletin issued on February 22, 2022.

Effective January 3, 2022, COVID-19 vaccine administration codes 0051A, 0052A, 0053A, and 0054A are a benefit of Medicaid, HTW, the Family Planning Program (FPP), and the CSHCN Services Program for the administration of the first, second, third (additional), and booster doses, respectively, of the tris-sucrose formulation of the Pfizer-BioNTech COVID-19 vaccine for individuals 12 years of age and older. Read the TMHP bulletin issued on March 1, 2022.

On May 17, 2022, the FDA amended the Emergency Use Authorization for the Pfizer-BioNTech COVID-19 vaccine single booster dose for individuals 5 years through 11 years of age at least 5 months after completion of the primary series with the Pfizer-BioNTech COVID-19 vaccine. Read the TMHP bulletin issued on May 25, 2022.

On May 13, 2022, HHSC added formulary coverage for a new booster dose-only formulation of the Moderna COVID-19 vaccine for individuals 18 years of age or older. This formulation is authorized under the Emergency Use Authorization. Read the TMHP bulletin issued on May 25, 2022.

Effective March 29, 2022, COVID-19 vaccine administration code 0094A is a benefit of Medicaid, (HTW), the Family Planning Program (FPP), and the Children with Special Health Care Needs (CSHCN) Services Program for the administration of the booster dose of the Moderna COVID-19 vaccine to individuals 18 years of age or older. Read the TMHP bulletin issued on June 2, 2022.

Effective May 17, 2022, COVID-19 vaccine administration code 0074A is a benefit of Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program for the administration of the booster dose of the Pfizer-BioNTech COVID-19 vaccine for individuals five years through 11 years of age. Read the TMHP bulletin issued on June 3, 2022.

Become a COVID-19 Vaccinator

The Department of State Health Services (DSHS) is actively recruiting providers to serve as COVID-19 vaccinators.

Interested providers should visit the Provider Vaccine Information webpage on the DSHS website.

Teleservices

Medicaid and CHIP health plans have flexibility to provide teleservices, including in a member’s home. HHSC has encouraged health plans to take advantage of these options when responding to COVID-19.

No additional enrollment is required to provide telemedicine medical services or telehealth services. For more information read the TMHP bulletin issued on March 16.

Certain Medicaid and CHIP services may soon be delivered using telemedicine, telehealth, and audio-only methods on an ongoing basis. This includes services that have been made available through telemedicine, telehealth, and audio-only methods during the COVID-19 public health emergency (PHE) as well as other services.

With input from advisory committees and other stakeholders, HHSC staff are evaluating services to determine whether this method of delivery is cost-effective and clinically appropriate.

For more information on House Bill 4, see the Medicaid and CHIP Teleservices page.

Interim guidance for physical therapy, occupational therapy and speech therapy services delivered by synchronous audiovisual has been issued, effective February 1, 2022. For more information, read the TMHP bulletin issued January 18, 2022.

Interim guidance and updates for behavioral health services delivered by synchronous audio-visual or telephone (audio-only) have been issued. For more information, read the following:

Rural Health Clinics

Effective April 1, 2022, rural health clinic (RHC) providers performing patient-site telemedicine services may be reimbursed for the facility fee (procedure code Q3014) as an add-on procedure code.

For more information, see the TMHP bulletin posted February 28, 2022.

CLASS Professional and Specialized Therapies

Interim guidance for physical therapy, occupational therapy, speech therapy behavioral support, cognitive rehabilitation therapy, dietary services, music therapy and recreational therapy delivered by telehealth has been released. Read the following for more information:

Nursing Services for CLASS, DBMD, HCS and TxHmL

During the COVID-19 pandemic, flexibilities were put in place to allow nursing assessments to be provided by telehealth (synchronous audio-visual technology). Certain parts of this flexibility are being made permanent effective May 1, 2022. Other parts will end when the COVID-19 Public Health Emergency ends. For more information, see the HHSC alert posted on April 28, 2022.

Hospice Services

Effective November 9, 2021 Medicaid hospice providers must resume face-to-face reassessments, as required in the 40 TAC Section 30.14(e)(1), Certification of Terminal Illness and Record Maintenance.

Read the HHSC IL (PDF) posted on September 13, 2021 for more information.

CHIP Co-Payments

Medical office visit co-payments are waived for all CHIP members for services provided from March 13, 2020 through August 31, 2022. Co-payments are not required for covered services delivered via telemedicine or telehealth to CHIP members.

Provider Reimbursement

The member’s MCO will reimburse the provider the full rate for the service, including what would have been paid by the member through cost-sharing. Providers must attest that the medical office visit co-payment was not collected by using the attestation form and submitting an invoice to the appropriate MCO or by submitting a detailed claim that includes the co-payment amount of each claim transaction for services provided in which co-payments were not collected. MCOs have 30 calendar days to pay an invoice received from a provider.

In-Home Service Delivery

CDS employers can continue to allow service providers, such as personal attendants, to enter their home to provide services. Refer to IL 2021-54 for more information.

Financial Management Services Agencies (FMSAs) can assist to make any necessary CDS budget revisions.

Temporary Change on Living in Same Home Prohibitions

HHSC temporarily lifted the prohibition on service providers of respite and CFC PAS/HAB from living in the same home as the person receiving Home and Community-based Services and Texas Home Living program services.

More information about temporary changes to this policy are available in the bulletin issued on March 26, 2021. This guidance will remain in effect until the end of the PHE.

Appeals and Fair Hearings

Appeals

In response to COVID-19, HHSC requires all MCOs, DMOs and MMPs to extend the timeframes for the number of days members, legally authorized representatives or authorized representatives can request an appeal through August 31, 2022:

  • Normally 60 days to request an MCO internal appeal, now 90 days.

Effective July 1, 2021, MCOs, DMOs and MMPs must enforce the normal, regular and established timeframes that members have to request for continuation of benefits.

HHSC also requires all MCOs, DMOs and MMPs to accept oral requests for appeals without the member having to provide a written request through August 31, 2022.

Fair Hearings

In response to COVID-19, HHSC is also extending the timeframes for the following through August 31, 2022:

  • Number of days members, legally authorized representatives or authorized representatives have to request a fair hearing.
    • Normally 120 days to request a fair hearing after the internal MCO appeal, now 150 days.
      If the timeframe for a member to request a fair hearing would have expired in April 2022, they will have an extra 30 days from that expiration date to request a fair hearing.
  • Number of days HHSC has to make a fair hearing determination.
    • Normally fair hearings determinations are made within 60 - 90 days of the date HHSC receives a request for a fair hearing, now 120 days.

Managed Care: Face to Face Visits

Service coordination visits

Effective immediately MCOs may allow service coordination visits to be completed in person when requested by the member receiving services. Telehealth should be the primary modality for service coordination visits if in-person is not feasible. Beginning September 1, 2021 MCOs must offer service coordination visits in person when requested by the member receiving services.

For all members, including those with levels of care and ISPs that have been extended, MCOs and MMPs must continue to conduct service coordination and service planning telephonic or telehealth visits to ensure members are receiving needed services.

MCOs and MMPs are required to conduct the same number of contractually required annual outreach contacts, at this time. This applies to facility and community members.

All MCOs and MMPs may use telehealth or telephonic processes to:

  • Coordinate discharge planning for members transitioning from hospitals.
  • Conduct joint meetings with Local Intellectual and Developmental Disability Authorities (LIDDAs), Case Management Agencies and Direct Service Agencies.
  • Allow providers to provide mental health targeted case management services.
  • Conduct Screening and Assessment Instruments (SAIs) and Individual Service Plans (ISPs) for STAR Kids members not in the Medically Dependent Children’s Program (MDCP).

Telehealth Assessments

STAR+PLUS HCBS and MDCP interest list releases were suspended beginning in April 2020. STAR+PLUS HCBS interest list releases resumed in February 2021. MDCP interest list releases resumed in October 2021.

Effective immediately MCOs may to conduct initial MDCP and STAR+PLUS HCBS waiver assessments in person when requested by the member. Telehealth should be the primary modality for the assessments if in-person is not feasible. Telephone may only be used as a last resort.

Beginning September 1, 2021 MCOs must offer waiver assessments in person when requested by the member.

This guidance is for the following groups

  • Individuals who were released from STAR+PLUS HCBS or MDCP interest lists prior to the interest list release suspension.
  • STAR+PLUS HCBS releases beginning in February 2021.

MCOs must start conducting level of care reassessments via telehealth for members with ISPs expiring December 30, 2020 and moving forward. Telephone may only be used as a last resort. ISPs that would have expired through December 31, 2020 have been extended for 12 months. Even if the reassessment results in a denial, eligibility for the waiver will be maintained through the length of the pandemic to comply with maintenance of eligibility requirements in H.R. 6201.

MCOs and MMPs will process a change in condition, including submission of a medical necessity level of care (MNLOC) or screening and assessment instrument (SAI), when it is identified there is a change in the member’s service needs.

FMSA Orientations

HHSC directed STAR, STAR Health, STAR Kids, and STAR+PLUS MCOs to allow FMSAs to suspend providing face-to-face orientations for CDS employers through January 31, 2022. Employer orientations scheduled through the end of January 2022 will be virtual or by telephone.

Effective February 1, 2022, FMSAs can permanently conduct new employer orientation virtually (i.e. audio-visual) in addition to allowing in-person orientations, based on member preference.

Upgrades for STAR+PLUS members who left a nursing facility without HCBS in place

HHSC is allowing STAR+PLUS MCOs and MMPs to use the existing process for requesting upgrades to STAR+PLUS HCBS for members who exited a nursing facility (NF) on or after March 18, 2020, due to concerns about COVID-19 or in accordance with local orders during the early stages of the public health emergency, without HCBS in place. MCOs and MMPs are currently identifying and informing eligible members of the option to upgrade and conducting the STAR+PLUS HCBS Program medical necessity/level of care (MN/LOC) assessment for program eligibility.

Providers should direct STAR+PLUS and MMP members who were discharged from a NF on or after March 18, 2020, currently do not reside in a NF, and still have NF Medicaid to their MCOs for more information about the option to upgrade to STAR+PLUS HCBS.

IDD Waivers and Other Services: Face to Face Visits

Service coordination visits

Effective immediately MCOs may allow service coordination visits to be completed in person when requested by the member receiving services for the following groups:

  • Fee-for-service Medicaid 1915(c) waiver case managers and service coordinators for Community Living Assistance and Support Services (CLASS), Texas Home Living (TxHmL), Deaf-Blind with Multiple Disabilities (DBMD) and Home and Community-based Services (HCS)
  • General Revenue service coordinators
  • Community First Choice service coordinators
  • Preadmission Screening and Resident Review (PASRR) habilitation coordinators

Telehealth should be the primary modality for service coordination visits if in-person is not feasible. Beginning September 1, 2021 MCOs must offer service coordination visits in person when requested by the member receiving services.

FMSA Orientations

FMSAs may suspend providing face-to-face orientations for CDS employers through January 31, 2022. Employer orientations scheduled through January 2022 will be virtual or by telephone.

Effective February 1, 2022, FMSAs can permanently conduct new employer orientation virtually (i.e. audio-visual) in addition to allowing in-person orientations, based on member preference.

Provider Enrollment

Revalidation Changes

Effective February 28, 2022, HHSC is ending the flexibility that extended revalidation dates due to the COVID-19 public health emergency.

For more information, read this TMHP bulletin issued on Nov. 1, 2021.

Off-Site Facility Application

In response to the COVID-19 public health emergency, hospitals that have received approval from HHSC via the Health and Human Services COVID-19 Off-Site Facility Application can add alternate physical addresses for temporary off-site facilities.

For more information, read the TMHP bulletin issued on April 20.

Prior Authorizations

Texas Health Steps Comprehensive Care Program

To comply with House Resolution (H.R.) 6201(116th Congress, 2019-2020; Public Law No:116-127), state Medicaid programs cannot terminate or reduce access to benefits available to beneficiaries beginning March 18, 2020, through the end of the public health emergency.

HHSC has directed MCOs and DMOs to ensure members who turn 21 on or after March 18, 2020 continue to have access to Early and Periodic Screening, Diagnosis, and Treatment (EPDST) services through the public health emergency.

Texas Health Steps Checkups

HHSC is allowing remote delivery of certain components of medical checkups for children over 24 months of age (i.e. starting after the “24 month” checkup). Because some of these requirements, like immunizations and physical exams, require an in-person visit, providers must follow-up with their patients to ensure completion of any components within 6 months of the telemedicine visit.

This will remain in effect until the end of the PHE. For details, read the TMHP Bulletin issued on April 27, 2022.

For answers to common questions, read the Texas Health Steps Telemedicine Guidance for Providers (PDF), updated on June 16, 2020.

School and Health Related Services

School and Health Related Services (SHARS) are provided to students with a disability to ensure individuals benefit from special education programs.

Interim guidance has been issued for SHARS Telemedicine or Telehealth Delivered by Synchronous Audio-visual or Telephone (Audio-only) Technology. See TMHP bulletin posted on April 28, 2022 for details.

Past Information Sessions

For older handouts and recordings, email Medicaid CHIP.

Resources

Reimbursement for COVID-19 testing and treatment of the uninsured

On April 22, 2020, the federal Health Resources and Services Administration (HRSA) launched a new COVID-19 uninsured program to support reimbursement to providers and facilities for testing and treatment of the uninsured.

The program includes testing and treatment provided on or after February 4, 2020 and began accepting claims May 6, 2020.

More information is available on the HRSA website.Texas 1135 Request (PDF)