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1.4 Texas Medicaid Program Limitations and Exclusions
Medicaid pays for services on behalf of clients to the provider of service according to the Texas Medicaid Program's limitations and procedures. TMHP does not make Medicaid payments directly to clients.
The following services, supplies, procedures, and expenses are not benefits of the Texas Medicaid Program. This list is not all inclusive.
• Autopsies.
•Biofeedback therapy.
•Bladder stimulators (Pacemaker).
•Breast implants.
•Cardiac rehabilitation programs.
•Care and treatment related to any condition for which benefits are provided or available under Workers' Compensation laws.
•Cellular therapy.
•Chemolase injection (chymodiactin, chymopapain).
•Chemonucleolysis intervertebral disc.
•Custodial care.
•Dentures or endosteal implants for adults.
•Dermabrasion.
•Direct graduate medical education for teaching hospitals.
•DME such as wheelchairs, crutches, and walkers, except when these items are prior authorized as a home health benefit.
•DME (except THSteps-Comprehensive Care Program [CCP] and home health).
•Dressings/supplies billed in physician's office.
•Ergonovine provocation test.
•Excise tax.
•Fabric wrapping of abdominal aneurysms.
•Fetal fibronectin.
•Gastric stapling/bypass.
•Hair analysis.
•Heart-lung monitoring during surgery.
•Histamine therapy-intravenous.
•Hyperthermia.
•Hysteroscopy for infertility.
•Immunizations or vaccines unless they are otherwise covered by the Texas Medicaid Program. (These limitations do not apply to services provided through the THSteps Program).
•Immunotherapy for malignant diseases.
•Inborn errors of metabolism.
•Infertility.
•Inpatient hospital services to a client in an institution for tuberculosis, mental disease, or a nursing section of public institutions for the mentally retarded.
•Inpatient hospital tests that are not specifically ordered by a physician/doctor who is responsible for the diagnosis or treatment of the client's condition.
•Intestinal bypass surgery and gastric stapling for the treatment of morbid obesity.
•Intragastric balloon for obesity.
•Intravenous embolization-cerebral, maxillary, and renal.
•Joint sclerotherapy.
•Keratoprosthesis/refractive keratoplasty.
•Laetrile.
•Mammoplasty for gynecomastia.
•More than $200,000 per client per benefit year (November 1 through October 31) for any medical and remedial care services provided to a hospital inpatient by the hospital. If the $200,000 amount is exceeded because of an admission for an approved organ transplant, the allowed amount for that claim is excluded from the computation. This limitation does not apply to clients eligible for the THSteps-CCP.
•More than 30 days of inpatient hospital stay per spell of illness-each spell of illness must be separated by 60 consecutive days during which the client has not been an inpatient in a hospital.
Important: THSteps-CCP provides medically necessary, federally allowable treatment for Medicaid/THSteps clients birth through 20 years of age. Some medical services that usually would not be covered under Medicaid may be available to CCP-eligible clients. An additional 30-day spell of illness begins with the date of specified covered organ transplant. No spell of illness limitation exists for Medicaid THSteps clients younger than 21 years of age.
Note: Members of the STAR and STAR+PLUS programs are not limited by the spell of illness.
•Obsolete diagnostic tests.
•Oral medications, except when billed by a hospital and given in the emergency room or the inpatient setting (hospital take-home drugs or medications given to the client are not a benefit).
•Orthoptics (except THSteps-CCP).
•Orthotics (except THSteps-CCP).
•Outpatient and nonemergency inpatient services provided by military hospitals.
•Outpatient behavioral health services performed by a licensed chemical dependency counselor (LCDC), psychiatric nurse, mental health worker, social worker, or psychological associate regardless of physician or licensed psychologist supervision.
•Oxygen (except THSteps-CCP and home health).
•Payment for eyeglass materials or supplies regardless of cost if they do not meet Texas Medicaid Program specifications.
•Payment to physicians for supplies is not an allowable charge. All supplies, including anesthetizing agents such as Xylocaine, inhalants, surgical trays, or dressings, are included in the surgical payment.
•Penile prosthesis.
•Podiatry, optometric, and hearing aid services in long term care facilities, unless ordered by the attending physician.
•Private room facilities except when a critical or contagious illness exists that results in disturbance to other patients and is documented as such when it is documented that no other rooms are available for an emergency admission, or when the hospital only has private rooms.
•Procedures and services considered experimental or investigational.
•Prosthetic and orthotic devices.
•Prosthetic eye or facial quarter.
•Psychiatric services:
•Outpatient behavioral health services exceeding 30 visits per calendar year for which no prior authorization has been given.
•Reimbursement is not available for inpatient psychiatric hospital services, including physician fees, delivered to clients between 22 (21 in Texas) and 64 years of age.
•Outpatient behavioral health services in freestanding psychiatric hospitals for Medicaid (except THSteps-CCP and NorthSTAR Program clients in the Dallas Managed Care Service Area).
•Each individual behavioral health practitioner is limited to a combined total of 12 hours of Medicaid reimbursement per day for behavioral health services.
Refer to: "Licensed Marriage and Family Therapist (LMFT)" , "Licensed Clinical Social Worker (LCSW)" , "Licensed Professional Counselor (LPC)" , "Physician" , and "Psychologist" for further information.
•Quest test (infertility).
•Recreational therapy.
•Review of old X-ray films.
•Routine circumcision for clients age one year and older.
•Separate fees for completing or filing a Medicaid claim form. The cost of claims filing is to be incorporated in the provider's usual and customary charges to all clients.
•Services and supplies to any resident or inmate in a public institution.
•Services or supplies for which benefits are available under any other contract, policy, or insurance, or which would have been available in the absence of the Texas Medicaid Program.
•Services or supplies for which claims were not received within the filing deadline.
•Services or supplies not reasonable and necessary for diagnosis or treatment.
•Services or supplies not specifically provided by the Texas Medicaid Program.
•Services or supplies provided in connection with a routine physical examination, except in connection with family planning services, THSteps, or the Medicaid Managed Care programs.
•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, or when prior authorized for specific purposes by TMHP (including removal of keloid scars).
•Services or supplies provided outside of the U.S., except for deductible and coinsurance portions of Medicare benefits as provided for in this manual.
•Services or supplies provided to a client after a finding has been made under utilization review procedures that these services or supplies are not medically necessary.
•Services or supplies provided to a Texas Medicaid client before the effective date of his or her designation as a client, or after the effective date of his or her denial of eligibility.
•Services payable by any health, accident, other insurance coverage, or any private or other governmental benefit system, or any legally liable third party.
•Services provided by an interpreter (except sign language interpreting services requested by a physician).
•Services provided by ineligible, suspended, or excluded providers.
•Services provided by the client's immediate relative or household member.
•Services provided by Veterans Administration facilities or U.S. Public Health Service Hospitals.
•Sex change operations.
•Silicone injections.
•Social and educational counseling except for family planning and genetics education and counseling services.
•Sterilization reversal.
•Sterilizations (including vasectomies) unless the client has given informed consent 30 days before surgery, is mentally competent, and is 21 years of age or older at the time of consent (This policy complies with 42 CFR §441.250, Subpart F).
•Take-home and self-administered drugs except as provided under the vendor drug or family planning pharmacy services.
•Tattooing.
•Telephone calls with clients or pharmacies (except as allowed for case management).
•Thermogram.
•Treatment for obesity.
•Treatment of flatfoot conditions and the prescription of supportive devices (including special shoes), the treatment of subluxations of the foot and routine foot care more than once every six months, including the cutting or removal of corns, warts, or calluses, the trimming of nails, and other routine hygienic care.
•Whole blood or packed red cells when available at no cost to the client.
Refer to: "Organ/Tissue Transplants" .
"Genetic Services" .
"Family Planning Services" for specific coverage.
"Elective Sterilization Services" for sterilization requirements.
"THSteps Medical and Dental Administrative Information" .
"Vendor Drug Program" for information about oral medications.
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