7.5.10 Covered ServicesPCCM clients are entitled to all medically necessary services that are benefits of the Texas Medicaid Program. Except as specified below, primary care providers shall provide (directly or through referrals) all Medicaid-covered services. Refer to: "Referrals" . Spell of Illness Reimbursement to hospitals for adult inpatient services is limited to the patient "spell of illness." The spell of illness is defined as "30 days of inpatient hospital care, which may accrue intermittently or consecutively." After 30 days of inpatient care have been provided, reimbursement for additional inpatient care is not considered until the patient has been out of an acute care facility for 60 consecutive days. Prescriptions As in fee-for-service Medicaid, adult PCCM clients 21 years of age and older are limited to three medicine prescriptions each month. When more than three prescriptions per month are needed, providers may prescribe maintenance medication(s) to cover more than a one month supply. Annual Adult Physical Exams Annual well visit exams are excluded for PCCM adult clients age 21 years of age and older except for well-woman annual exams provided as part of family planning or obstetrics/gynecology (OB/GYN) medical visits. |
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Texas Medicaid & Healthcare Partnership CPT only copyright 2007 American Medical Association. All rights reserved. |
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