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

43.4.11.4 Benefits and Limitations

Expendable medical supplies and basic medical equipment are available under Texas Medicaid (Title XIX) Home Health Services. Some services may be provided under THSteps-CCP. Clients must be birth through 20 years of age and eligible for THSteps-CCP; the services must be medically necessary and have FFP available for them. 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.

Physician Signature

The physician's signature and date, required on a prescription and the appropriate request form, must be current to the service date of the request.

Physician prescriptions must be specific to the type of service requested.

Example: If requesting incontinent supplies, the prescription must request specific incontinent supplies, not just supplies.

Examples of expendable supplies include incontinent supplies and medical nutritional products for clients birth through 20 years of age.

Refer to: "Physician Signature" for complete information about this requirement.

Incontinence Supplies for Clients Birth Through 3 Years of Age

Incontinence supplies for clients birth through 3 years of age are only available through THSteps-CCP.

Written prior authorization is required for diapers and all other related incontinence supplies (such as diaper wipes and underpads) for clients younger than 4 years of age. Providers must use the appropriate national procedure codes when billing for incontinent supplies for clients birth through 3 years of age.

Supplies that any guardian or caretaker would usually provide during the routine care of the client are not covered under THSteps-CCP. Examples include:

•Nutritional products traditionally used for infant feeding.

•Incontinence supplies, such as diapers (Diapers are considered usual for clients younger than 4 years of age. An exception may be made by written request for prior authorization based on specific medical criteria.).

•Lotions, soaps, powder, or aids for daily living.

Claims may be reduced because the customary limits have been exceeded. Providers may submit a prior authorization request for amounts over the customary limits if there is documentation that supports the medical necessity of such a request. If prior authorization is not given, the provider may appeal the claim.

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

Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.

Medications, Vitamins, and Minerals

VDP reimburses for a large number of prescription and over-the-counter medications. See "Vendor Drug Program" for more information about VDP. Some prescription medications that are not payable through VDP may be paid to enrolled pharmacy providers through THSteps-CCP if the medications are determined to be medically necessary.

Not all medications covered by THSteps-CCP require prior authorization. For those medications that require prior authorization, submit complete documentation with each prior authorization request, including:

•A prescription by the physician with the name of the medication, dosage, frequency, duration, and route of administration.

•Documentation and diagnosis that supports the medical necessity of the requested medications.

Providers must use the appropriate national procedure code when billing for medications and vitamins through THSteps-CCP.