(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 §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 §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.
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Source Note: The provisions of this §354.1149 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective November 1, 1983, 8 TexReg 4290; amended to be effective October 19, 1984, 9 TexReg 4975; amended to be effective July 1, 1986, 11 TexReg 2757; amended to be effective September 1, 1987, 12 TexReg 2577; amended to be effective April 13, 1988, 13 TexReg 1392; amended to be effective January 4, 1989, 13 TexReg 6292; amended to be effective September 1, 1989, 14 TexReg 3299; amended to be effective February 19, 1990, 15 TexReg 658; amended to be effective July 1, 1991, 16 TexReg 3944; transferred effectiveSeptember 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective November 29, 1993, 18 TexReg 8354; amended to be effective May 19, 1994, 19 TexReg 3487; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective November 15, 2009, 34 TexReg 7777; amended to be effective January 1, 2012, 36 TexReg 9282; amended to be effective October 27, 2013, 38 TexReg 7299; amended to be effective November 25, 2015, 40 TexReg 8200 |