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Update to Texas Medicaid Provider Procedure Manual, Medicaid Managed Care Services Handbook

Last updated on 2/22/2019

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Beginning March 1, 2019, TMHP will add the following breast pump coverage chart to the Texas Medicaid Provider Procedures Manual, Medicaid Managed Care Services Handbook, Section 2.9, “Claims Filing for Managed Care Services.”

Texas Medicaid and the Children’s Health Insurance Program (CHIP) cover breast pumps and equipment when medically necessary after a baby is born.

Coverage in Prenatal Period

Coverage at Delivery

Coverage for Newborn

Breast Pump Coverage & Billing

STAR

STAR

STAR

STAR covers breast pumps when medically necessary for mothers or newborns. Breast pump equipment may be billed under the mother’s Medicaid ID or the newborn’s Medicaid ID.

CHIP Perinatal, with income at or below 198 percent of federal poverty level (FPL)*

Emergency Medicaid

Medicaid Fee-For-Service (FFS) or STAR**

Medicaid FFS and STAR cover breast pumps when medically necessary for newborns when the mother does not have coverage under CHIP. The breast pump must be billed under the newborn’s Medicaid ID.

CHIP Perinatal, with income above 198 percent FPL

CHIP Perinatal

CHIP Perinatal

CHIP covers breast pumps when medically necessary for CHIP Perinatal newborns. Breast pump equipment must be billed under the newborn’s CHIP Perinatal ID.

STAR Kids

STAR Kids

Medicaid FFS

or STAR**

Medicaid FFS, STAR, STAR Kids, and STAR+PLUS cover breast pumps when medically necessary for mothers or newborns. Breast pump equipment may be billed under the mother’s Medicaid ID or the newborn’s Medicaid ID.

STAR+PLUS

STAR+PLUS

Medicaid FFS

or STAR**

STAR Health

STAR Health

STAR Health

STAR Health covers breast pumps when medically necessary for mothers or newborns. Breast pump equipment may be billed under the mother’s Medicaid ID or the newborn’s Medicaid ID.

None, with income at or below 198 percent FPL

Emergency Medicaid

Medicaid FFS or STAR**

Medicaid FFS and STAR cover breast pumps when medically necessary for the newborn when the mother does not have coverage. The breast pump must be billed under the newborn’s Medicaid ID.

*CHIP Perinatal Members with household incomes at or below 198 percent FPL must apply for Emergency Medicaid coverage for labor and delivery services. HHSC mails the pregnant woman an Emergency Medicaid application 30 days before her reported due date. When Emergency Medicaid covers a birth, the newborn is certified for 12 months of Medicaid coverage, beginning on the date of birth.

**These newborns will be enrolled in Fee-For-Service (FFS) Medicaid until they are enrolled with a STAR MCO. Claims should be filed with TMHP using the newborn’s Medicaid ID if the mother does not have coverage.

For more information, call the TMHP Contact Center at 800-925-9126.