TMPPM 2008 > Texas Medicaid Services > Texas Health Steps (THSteps) > THSteps-Comprehensive Care Program (CCP)

43.4.5.3 Benefits and Limitations

THSteps-CCP benefits are for Medicaid THSteps-eligible clients birth through 20 years of age. THSteps-CCP eligibility ends on the day of the client's 21st birthday. If the client's Medicaid ID states "Emergency Care," "PE," or "QMB," the client is not eligible for THSteps or THSteps-CCP benefits.

DME is defined as medical equipment or an appliance that is manufactured to withstand repeated use, ordered by a physician for use in the home, and is required to correct or ameliorate the client's disability, condition, or illness.

Because there is no single authority (such as a federal agency) that confers the official status of "durable medial equipment" on any device or product, HHSC retains the right to make such determinations with regard to DME covered by Texas Medicaid. DME covered by Texas Medicaid must either have a well-established history of efficacy or, in the case of novel or unique equipment, valid peer-reviewed evidence that the equipment corrects or ameliorates a covered medical condition or functional disability.

Requested DME may be a benefit of the Texas Medicaid Program when it meets the Medicaid definition of DME.

The majority of DME and expendable supplies are covered through Texas Medicaid (Title XIX) Home Health Services.

If a service cannot be provided through Texas Medicaid (Title XIX) Home Health Services, these services may be covered through THSteps-CCP if they are determined to be medically necessary for the child and for which FFP is available.

If a DME provider is unable to deliver an unauthorized piece of equipment, the provider should allow the client the option of obtaining the equipment or supplies from another provider.

Periodic rental payments are made only for the lesser of either the period of time the equipment is medically necessary, or when the total monthly rental payments equal the reasonable purchase cost for the equipment.

DME will be purchased when a purchase is determined to be medically necessary and more cost effective than leasing the device with supplies. Only new, unused equipment will be purchased. When a provider is replacing a piece of rental equipment with purchased equipment, the provider must supply a new piece of equipment to the client.

Purchase is justified when the estimated duration of need multiplied by the rental payments would exceed the reasonable purchase cost of the equipment or it is otherwise more practical to purchase the equipment.

DME repair will be considered based on the age of the item and cost to repair it.

A request for repair of DME must include a statement or medical information from the attending physician substantiating that the medical appliance or equipment continues to serve a specific medical purpose and an itemized estimated cost list from the vendor or DME provider of the repairs. Rental equipment may be provided to replace purchased medical equipment for the period of time it will take to make necessary repairs to purchased medical equipment.

DME that has been delivered to the client's home and then found to be inappropriate for the client's condition will not be eligible for an upgrade within the first six months following purchase unless there had been a significant change in the client's condition, as documented by the physician familiar with the client. All adjustments and modifications within the first six months after delivery are considered part of the purchase price.

Rental reimbursement to the same provider cannot exceed the purchase price, except as addressed in specific policies.

All DME purchased for a client becomes the Medicaid client's property upon receipt of the item. This property includes equipment delivered which will not be prior authorized or reimbursed in the following instances:

•Equipment delivered to the client before the physician signature date on the THSteps-CCP Prior Authorization Form or prescription.

•Equipment delivered more than three business days before obtaining prior authorization from TMHP that meets the criteria for purchase.

As long as the client is eligible for THSteps-CCP services on the date the custom equipment is ordered from the manufacturer, the provider should use the order date as the date of service since custom equipment is client specific and cannot be used for another client.

Providers must use the following TOS codes when providing THSteps-CCP services:

To establish medical necessity of the equipment for the client, the provider must have on file in the client's records current documentation that is signed by a physician (e.g., signed and dated prescription) showing the following:

•A diagnosis relative to each item requested.

•The specific type of supply needed.

•The length of time needed.

A request for authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply.

Prior Authorization and Documentation Requirements

Prior authorization is required. Prior authorization is a condition for reimbursement; it is not a guarantee of payment.

Providers requesting written authorization should complete the "THSteps-CCP Prior Authorization Request Form" and attach documentation to support the request. The documentation must include a current prescription signed and dated by a physician (MD or DO) and then be mailed or faxed to TMHP. For specific policy information not contained in this manual related to the purchase of DME, providers can call TMHP-CCP Customer Service at 1-800-846-7470.