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43.4.1.5 Benefits
Payment is considered for any health-care service that is medically necessary and for which FFP is available. THSteps-CCP benefits are allowable services not currently covered under the Texas Medicaid Program (e.g., speech-language pathology [SLP] services for nonacute conditions, PDN, prosthetics, orthotics, apnea monitors and some durable medical equipment [DME], some specific medical nutritional products, medical nutrition services, inpatient rehabilitation, travel strollers, and special needs car seats). THSteps-CCP benefits also include expanded coverage of current Texas Medicaid Program services where services are subject to limitations (e.g., diagnosis restrictions for TPN or diagnosis restrictions for attendant care services). Requests for services that require a prior authorization (prior authorization is a condition for reimbursement, not a guarantee of payment) must be submitted to the TMHP Medical Director. For information about dental, TPN, respiratory therapy, personal care services (PCS), and vision care benefits, refer to provider-specific sections of this manual.
Medicaid Benefits for Children
The following are Medicaid benefits for clients living with a family (including foster care):
• Medical services (physician, hospital, hearing aids [PACT], and eyeglasses).
•THSteps medical check ups (including immunizations) and dental exams and services.
•Medications through the Texas Medicaid Vendor Drug Program (VDP) (unlimited prescriptions, some over-the-counter with prescription).
•THSteps-CCP (prosthetics, orthotics, PCS, and SLP services for nonacute conditions).
•Texas Medicaid (Title XIX) Home Health Services that may be considered medically necessary (e.g., nursing visits, supplies, DME, and PT and OT for acute conditions provided in the home).
Medicaid benefits for clients living in residential treatment centers include the following:
•Medical services (physician, hospital, hearing aids [PACT], and eyeglasses).
•THSteps medical check ups (including immunizations) and dental exams and services.
•Medications through VDP (unlimited prescriptions, some over-the-counter with prescription).
•THSteps-CCP, excluding outpatient mental health services.
Medicaid benefits for clients living in nursing facilities include the following:
•Medical services (physician, hospital, hearing aids [PACT], and eyeglasses).
•THSteps medical check ups (including immunizations) and dental exams and services.
•Medications through VDP (unlimited prescriptions).
•THSteps-CCP is limited to the following:
•Adaptive strollers.
•Augmentative communication devices.
•Orthotics.
•Prosthetics.
•Texas Medicaid (Title XIX) Home Health Services custom DME.
Medicaid benefits for clients in intermediate care facilities for the mentally retarded (ICF-MR) facilities (not state schools) include the following:
•Medical services (physician, hospital, hearing aids [PACT], and eyeglasses).
•THSteps medical check ups (including immunizations) and dental exams and services.
•Medications through VDP (unlimited prescriptions).
•THSteps-CCP (limited to orthotics and prosthetics).
•DME (covered in the daily rate).
Medicaid Procedure Codes
The following table identifies THSteps-CCP-related Medicaid procedure codes. This list is not all-inclusive but represents the most commonly billed THSteps-CCP procedures that are not listed in specific sections. These codes are not payable for all provider types. Other codes are listed in specific THSteps-CCP sections of this manual, and additional codes can be found in "Texas Medicaid (Title XIX) Home Health Services" . Prices are subject to change.
Limitations
Payment cannot be made for any service, supply, or equipment for which FFP is not available. The following are some examples:
•Vehicle modification, mechanical, and/or structural (such as wheelchair lifts).
•Structural changes to homes, domiciles, or other living arrangements.
•Environmental equipment, supplies, or services, such as room dehumidifiers, air conditioners, filters, space heaters, fans, water purification systems, vacuum cleaners, and treatments for dust mites, rodents, and insects.
•Ancillary power sources and other types of standby equipment (except for technology-dependent clients such as those who are ventilator-dependent for more than six hours per day).
•Educational programs, supplies, or equipment (such as a personal computer or software).
•Equine or hippotherapy.
•Exercise equipment, home spas or gyms, toys, or therapeutic balls.
•Tennis shoes.
•Respite care (relief to caregivers).
•Aids for daily living (toothbrushes, spoons, and foot stools).
•Take-home drugs from hospitals. Eligible hospitals may enroll in and bill VDP. Pharmacies that want to enroll should call 1-512-338-6978.
•Therapy involving any breed of animal.
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