TMPPM 2008 > Texas Medicaid Services > Military Hospital > Benefits and Limitations

33.3 Benefits and Limitations

33.3.1 Inpatient Services

Inpatient hospital services include medically necessary items and services ordinarily furnished by a Medicaid hospital or by an approved out-of-state hospital under the direction of a physician for the care and treatment of inpatient clients. Reimbursement to hospitals for inpatient services is limited to the Medicaid "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 client has been out of an acute care facility for 60 consecutive days. Exceptions are made in the following instances:

•Texas Health Steps (THSteps)-eligible clients do not have a 30-day spell of illness limitation, if medically necessary conditions exist (covered under THSteps-CCP).

•Some Medicaid Managed Care clients do not have a 30-day spell of illness limitation.

Refer to: "Managed Care" for more information.

Hospitals may submit information only claims to TMHP when one of the following situations exists:

•The inpatient 30-day spell of illness benefit is exhausted.

•Payment that has been made by a third party resource/other insurance exceeds the Medicaid allowed amount.

For clients older than 21 years of age and not enrolled in Medicaid Managed Care, an inpatient expenditure cap of $200,000 per benefit year (November 1 through October 31) exists. Claims are reviewed retrospectively, and payments exceeding $200,000 will be recouped.

It is appropriate to submit information only claims using TOB 110.

The following hospital services must be medically necessary and are subject to the utilization review requirements of the Texas Medicaid Program. Medicaid reimbursement for services cannot exceed the limitations of the Texas Medicaid Program.

Inpatient hospital services include the following items and services:

•Bed and board in semiprivate accommodations or in an intensive care or coronary care unit, including meals, special diets, and general nursing services; or an allowance for bed and board in private accommodations, including meals, special diets, and general nursing services up to the hospital's charge for its most prevalent semiprivate accommodations. Bed and board in private accommodations are provided in full if required for medical reasons, as certified by the physician. Additionally, the hospital must document the medical necessity for a private room, such as the existence of a critical or contagious illness or a condition that could result in disturbance to other patients. This type of information is included in Block 80 or attached to the claim.

•Whole blood and packed red cells that are reasonable and necessary for treatment of illness or injury, provided they are not available without cost.

•All medically necessary services or supplies ordered by a physician.

Medicaid benefits are not available for take-home or self-administered drugs or personal comfort items, except when received by prescription through the Vendor Drug Program.

Only inpatient claims that have an emergency diagnosis on the claim are considered for reimbursement.