Medicaid and CHIP Services Information for Providers

Medicaid CHIP COVID-19 Information Sessions

To reduce the potential for technical difficulties we will post pre-recorded sessions on this page by 1:00 p.m. CT each Thursday. These sessions will continue to share information with stakeholders about the implementation of various Medicaid/CHIP flexibilities in response to the COVID-19 pandemic.

WHEN:

  • September 17, 2020
    • No stakeholder updates this week.
  • September 24, 2020

Where to go for information on the novel coronavirus (COVID-19)

Visit the Centers for Disease Control (CDC) and Texas Department of State Health Services (DSHS) for information on COVID-19, including:

  • Situational updates.
  • High risk categories.
  • How the virus spreads, symptoms, prevention and treatment.
  • FAQs.

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.

Extensions of Medicaid and CHIP Flexibilities

As noted in the sections below, many Medicaid and CHIP flexibilities have been extended through October 23, 2020. These extensions remain in effect until then unless the U.S. Secretary of Health and Human Services ends the public health emergency earlier. If the public health emergency ends earlier, HHSC will provide additional information.

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.

Billing Codes

The Centers for Medicare & Medicaid Services (CMS) has issued two new HCPCS codes for use by providers who are testing patients for COVID-19. Providers can submit these codes for dates of service on or after Feb. 4, 2020:

  • U0001 – The CDC-developed test kit
  • U0002 – A laboratory test that is not the CDC-developed test kit (any technique)

For more details see the TMHP bulletins issued on March 16 (PDF) and the bulletin issued on June 4 (PDF).

The American Medical Association (AMA) has created a new CPT code for use on or after March 13, 2020:

  • 87635 – A laboratory test that is not the CDC-developed test kit (amplified probe technique)

For more details see the TMHP bulletin issued on June 4 (PDF).

Tests using high-throughput technologies

CMS has issued two new HCPCS codes for lab tests that use high-throughput technologies to test for COVID-19. Providers can submit these codes for dates of service on or after April 14, 2020:

  • U0003 – A laboratory test performed using high-throughput technologies that is not the CDC-developed test kit (amplified probe technique)
  • U0004 – A laboratory test performed using high-throughput technologies that is not the CDC-developed test kit (any technique)

For more details see the TMHP bulletin issued on June 4 (PDF).

Tests for COVID-19 Antibody (serologic)

AMA announced one revised CPT code and two new CPT codes that providers can submit for antibody testing for dates of service on or after April 10, 2020:

  • 86318 – Multiple infectious agents antibody testing performed using a single-step method immunoassay (Revised - see further information in this TMHP bulletin (PDF))
  • 86328 – COVID-19 Antibody testing performed using a single-step method immunoassay
  • 86769 – COVID-19 Antibody testing performed using a multiple-step method

For more details see the TMHP bulletin issued on June 4 (PDF).

Reporting specimen collection

CMS has issued two new HCPCS codes for COVID-19 specimen collection. Laboratories can submit these codes for dates of service on or after March 1, 2020:

  • G2023 - Specimen collection, any specimen source (for use by laboratories only)
  • G2024 - Specimen collection from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source (for use by laboratories only)

For more details see the TMHP bulletin issued on June 4 (PDF)

All other providers may continue to bill for the COVID-19 specimen collection using one of these codes:

  • 99001 - Handling and/or conveyance of specimen
  • 99211 – Established office visit not requiring the presence of a physician

Reimbursement Rates

TMHP has provided reimbursement rate updates for procedure codes related to COVID-19. These rates are effective for the duration of the federal emergency declaration.
For more details, see the TMHP bulletin issued on June 26, 2020 (PDF).

Treatment services

CMS issued a fact sheet for COVID-19 treatment services covered by Medicaid here.

For information on coding related to COVID-19 diagnosis refer to the following TMHP bulletins:

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

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 see the TMHP bulletin issued on March 16.

For details on telehealth services for occupational, physical, and speech therapy see the TMHP bulletin issued on April 24.

Billing for telephone (audio-only) services

For services delivered on March 20, 2020 through October 23, 2020:

  • Providers may bill codes 99201-99205 and 99211-99215 for telephone (audio-only) medical (physician delivered) evaluation and management services delivered. See the TMHP article for full details.
  • Providers may bill to receive Medicaid reimbursement for the following behavioral health services delivered by synchronous audio-visual technologies, including web-based video software, or telephone (audio-only):
    • Psychiatric Diagnostic Evaluation (90791, 90792).
    • Psychotherapy (90832, 90834, 90837, 90846, 90847, 90853).
    • Peer Specialist Services (H0038).
    • Screening, Brief Intervention and Referral to Treatment (H0049, G2011, 99408).
    • Substance Use Disorder Services (H0001, H0004, H0005).
    • Mental Health Rehabilitation services (H0034, H2011, H2012, H2014, H2017).

See the TMHP article for details (PDF).

Providers should use the nationally defined 95 modifier for telemedicine and telehealth service claims to indicate that remote delivery occurred.

Federally Qualified Health Centers

To help ensure continuity of care during the COVID-19 response, HHSC will reimburse Federally Qualified Health Centers (FQHCs) as telemedicine (physician-delivered) and telehealth (non-physician-delivered) service distant site providers. See the TMHP article for full details. This is effective through October 23, 2020.

Rural Health Clinics

Rural Health Clinics (RHCs) may be reimbursed as telemedicine and telehealth distant site providers statewide for service dates from March 24, 2020 through October 23, 2020. For more information see this TMHP bulletin issued on April 24.

Case Management

Case management may be delivered through synchronous audio-visual technologies or telephone (audio-only). Providers should bill procedure code T1017 using the 95 modifier to indicate that remote delivery occurred.

See the TMHP Bulletin from April 24 (PDF) for more information. This is effective through October 23, 2020.

CLASS Professional and Specialized Therapies

Due to COVID-19, certain CLASS professional and specialized therapy services may be provided by telehealth. This is effective through October 23, 2020.

See the HHSC alert posted on June 30 for more information.

Nursing Services for CLASS, DBMD, HCS and TxHmL

Due to COVID-19, HHSC will allow a nursing assessment, including a comprehensive nursing assessment, to be done through telehealth for individuals enrolled in the waiver programs.

See the HHSC alert posted on April 21 for more information.

Hospice Services

Due to COVID-19, face-to-face reassessments may be provided and billed by telemedicine service. 

See HHSC IL (PDF) posted on August 4 for more information. 

CHIP Co-Payments

Medical office visit co-payments for all CHIP members for services provided from March 13, 2020 are waived until further guidance is issued from HHSC. 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.

Electronic Visit Verification Policy Updates

Existing EVV Providers
HHSC is issuing temporary EVV policies (PDF) in response to COVID-19. The temporary policies are effective March 21, 2020 through October 23, 2020 unless noted in the PDF.

Extra Medicine or Supplies

On March 19, 2020, the Texas State Board of Pharmacy authorized pharmacists in Texas to dispense up to a 30-day supply of medication (other than a schedule II-controlled substance) for patients in Texas in the event a prescriber cannot be reached in response to the state of disaster declaration for COVID-19.

Drug Shortages

Visit the Vendor Drug Program website for any temporary changes made to the preferred drug list due to reported drug shortages.

Providers should complete the Drug Shortage Notification (HHS Form 1315) to inform HHSC of potential shortages impacting prescribing choice or pharmacy claim processing.

In-Home Service Delivery

Home health agencies and certified providers of long-term services and supports (LTSS) delivered through either a Medicaid waiver or state plan program are required to have backup plans in place. These plans include provisions for when an in-home care provider cannot work because they are sick.

If a backup plan is not currently in place, providers must work with clients or their legally authorized representatives (LARs) to develop one.

  • Providers in managed care may need to coordinate with members’ service coordinators to ensure backup plans are comprehensive.
  • Providers employed by an individual using the Consumer Directed Services (CDS) option should work with their CDS employer, MCO, program service coordinators or case managers to develop a backup plan.

CDS employers can continue to allow service providers, such as personal attendants, to enter their home to provide services. Refer to IL 2020-08 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 June 30. This guidance is effective through October 23, 2020.

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 and continuation of benefits through October 23, 2020.

  • Normally 60 days to request an MCO internal appeal, now 90 days.
  • Normally 10 days to request continuation of benefits upon receipt of the adverse benefit determination, now 30 days.

HHSC also requires all MCOs, DMOs and MMPs to accept oral requests for appeals without the member having to provide a written request through October 23, 2020.

Fair Hearings

In response to COVID-19, HHSC is also extending the timeframes for the following through October 23, 2020:

  • 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 August 2020, 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

Face to face service coordination visits are suspended through October 23, 2020 for STAR Health, STAR Kids, STAR+PLUS MCOs, and Dual Demonstration Medicare-Medicaid Plans (MMPs).

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).

Extended enrollment MDCP and STAR+PLUS HCBS

To ensure members do not experience a gap in services due to the temporary suspension of face to face service coordination visits for COVID-19, HHSC is extending enrollment in the Medically Dependent Children’s Program (MDCP) and STAR+PLUS Home and Community Based Services (HCBS) for members with individual service plans (ISPs) expiring in September 2020.

This extension also applies to any level of care assessments and service plans that were previously extended in April 2020, and that would have expired in July 2020.

Telehealth Assessments

Interest list releases have been suspended since April 2020. HHSC is allowing MCOs to conduct initial MDCP and STAR+PLUS HCBS waiver assessments via telehealth (audio + visual) for waiver program eligibility as soon as possible, including the following:

  • Individuals in STAR+PLUS who may be eligible for an upgrade to STAR+PLUS HCBS
  • Individuals leaving a nursing facility and entering STAR+PLUS HCBS through money follows the person (MFP)
  • Individuals who were released from STAR+PLUS HCBS or MDCP interest lists prior to the interest list release suspension in April 2020.

To comply with the maintenance of eligibility requirements in H.R. 6201, MCOs may not start conducting level of care reassessments via telehealth for members at this time. When MCOs are able to resume MDCP and STAR+PLUS HCBS reassessments for waiver program eligibility, MCOs may conduct them via telehealth (audio + visual).

MCOs and MMPs may 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. If the MCO suspects the member may lose waiver program eligibility, the MCO must not submit a MNLOC or SAI, but can adjust the member’s ISP as needed.

Nursing facility MDS authorization extensions

HHSC is extending nursing facility minimum data set (MDS) assessment authorizations expiring through October 23, 2020 for 90 days.

For more information, see the TMHP bulletin posted on August 6 (PDF).

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 October 23, 2020. Employer orientations scheduled through the end of October 2020 will be virtual or by telephone. Face-to-face will be required after the suspension.

IDD Waivers and Other Services: Face to Face Visits

Service coordination visits

Face to face service coordination visits are suspended through October 23, 2020 for:

  • 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

Eligibility extensions

To ensure members do not experience a gap in services due to the temporary suspension of face to face service coordination visits for COVID-19, HHSC is extending Intellectual Disability/Related Condition (ID/RC) assessments and individual plans of care (IPC) until further guidance is provided by HHSC for individuals who are enrolled in the following programs:

  • Community Living Assistance and Support (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD)
  • Home and Community-based Services Program (HCS)
  • Texas Home Living (TxHmL)

As a reminder, electronic signatures are allowed in accordance with TAC Chapter 49.305 (j). Additional guidance related to COVID-19 allowances can be found in the information letters below.

For reference:

HCS and TxHmL: IL 2020-11 (PDF)

CLASS and DBMD: IL 2020-12 (PDF)

FMSA Orientations

FMSAs may suspend providing face-to-face orientations for CDS employers through October 23, 2020. Employer orientations scheduled through October 2020 will be virtual or by telephone. Face-to-face will be required after the suspension.

For reference:

IL 2020-08 (PDF)

Supervisory Visits

Community Attendant Services, Family Care, and Primary Home Care providers may suspend face-to-face supervisory visits and instead conduct interdisciplinary team (IDT) meetings by telephone or by video (virtually) if possible.

For reference:

IL 2020-16 (PDF)

Provider Enrollment

Revalidation Changes

Existing providers can find updated information on revalidation extensions related to COVID-19 in the TMHP bulletin issued on May 27 (PDF). This is effective through October 23, 2020.

Expedited Enrollment

The Public Health Emergency Enrollment Application is now available. For more information, see this TMHP bulletin issued on April 1 (PDF).

For pharmacy enrollment information, visit the Vendor Drug Program website.

Fingerprinting Exemptions

All new enrollment, revalidation and re-enrollment applications submitted on or after March 1, 2020, and before the end of the federally-approved public health emergency will be exempt from the requirements to submit proof of fingerprinting and undergo pre-enrollment and post-enrollment site visits (as applicable to the provider type).

For more information, see the TMHP bulletin issued on April 10 (PDF).

Texas Board of Nursing Extension of Licensure Renewal Requirements
In response to the current COVID-19 public health emergency, the Office of the Governor granted a waiver to extend Texas Board of Nursing licensure renewal requirements.

The waived regulations allow the following providers to have a grace period until September 30, 2020 to renew their licenses:

  • Licensed Vocational Nurses (LVNs).
  • Registered Nurses (RNs).
  • Advanced Practice Registered Nurses (APRNs).

For more information, see the TMHP bulletin issued on April 28.

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.

Providers that are not active with TMHP, or those who are not Medicare-enrolled, will need to complete the Public Health Emergency Enrollment Application process to enroll the approved Off-Site Facility location.

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

Prior Authorizations

Extensions to Existing Prior Authorizations

To help ensure continuity of care during the COVID-19 response, HHSC has directed TMHP to extend prior authorizations (PAs) that require recertification until further guidance is provided by HHSC.

This extension does not apply to current authorizations for one-time services or pharmacy PAs. For example, a single non-emergency ambulance trip would not be extended, but a recurrent non-emergency ambulance authorization for dialysis would be extended.

This extension applies to all state plan services requiring recertification, including acute care and long-term services and supports such as personal assistance services, personal care services, community first choice, private duty nursing, physical, occupational and speech therapies, and day activity and health services. This extension also applies to clinician administered drugs (CADs), when clinically appropriate.

See the TMHP bulletin posted on April 9 for more details.

New and Initial Prior Authorizations

HHSC has directed TMHP to move forward with processing new and initial prior authorization (PA) requests, including recertification requests, by relaxing document submission timeframes for providers if they are unable to provide certain required documentation during the COVID-19 emergency.

This guidance applies to all state plan services, including acute care and long-term services and supports such as personal assistance services, personal care services, Community First Choice, private duty nursing, day activity and health services, and durable medical equipment and supplies. Medical necessity-related documentation of clinical records to demonstrate patient status and progress specific to some services is still required.

Providers must submit the appropriate PA forms for requesting services, including the procedure and diagnosis codes, applicable modifiers, dates of service, and numerical quantities for services requested.
See the TMHP bulletin posted on June 30, 2020 (PDF) for more details.

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

To limit exposure to COVID-19 and allow providers to focus on acute care, HHSC encourages medical and dental providers to make decisions on adjusting clinical operations based on professional medical judgement and/or guidance from professional medical and dental societies. This should include considering the risk of exposure to COVID-19 at the local and community

See the TMHP bulletin posted on April 1 (PDF) for more details.

To allow for continued provision of THSteps checkups during the period of social distancing due to COVID-19, 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.

For details, see the TMHP Bulletin issued on May 12 (PDF). This is effective through October 23, 2020.

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

School and Health Related Services

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

During any temporary closure of schools for in-person classroom attendance, schools may continue to provide instruction using alternative methods of delivery. See the TMHP Bulletin posted April 24 (PDF) for more details.

SHARS providers will get the Certification of Funds (COF) letter through email in addition to the mailed letter. See the TMHP Bulletin posted on May 4 (PDF) for details.

If schools are unable to provide instruction using alternative methods of delivery, providers can work with MCOs to ensure clients have access to needed services during this time.

Delivery of Durable Medical Equipment

Guidelines on waiving signature requirements for Durable Medical Equipment (DME) are outlined in this TMHP Bulletin (PDF). This is effective through October 23, 2020.

Past Information Sessions

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.

  • CARES ACT Provider Relief Fund - Medicaid and CHIP Distribution

    The U.S. Department of Health and Human Services (HHS) expects to distribute $15 billion to eligible Medicaid and CHIP providers that have not yet received a payment from the Provider Relief Fund General Distribution allocation. HHS has indicated the payment to each eligible provider will be at least 2 percent of reported gross revenue from patient care. The deadline to apply has been extended to September 13, 2020.

    HHS also plans to allow certain Medicare providers who experienced challenges in the Phase 1 Medicare General Distribution application period a second opportunity to receive funding. This includes Medicare providers who missed the opportunity to apply for additional funding from the $20 billion portion of the $50 billion Phase 1 Medicare General Distribution and Medicare providers and provider practices who experienced a change of ownership in 2020.

    More information is available on the Cares Act Provider Relief Fund webpage.