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Maintenance Dialysis Benefits for Texas Medicaid Changed on March 1, 2024

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after March 1, 2024, maintenance dialysis benefits changed for Texas Medicaid.

Maintenance Hemodialysis, IPD, CCPD, and CAPD

The number of peritoneal dialysis treatments for continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) in the home is limited to 14 sessions within 31 days. This limit is set regardless of the number of dialysate exchanges that are performed per day.

Any treatment combination of hemodialysis, intermittent peritoneal dialysis (IPD), CAPD, or CCPD is also limited to 14 sessions within 31 days for any provider. If more than 14 sessions are needed, the provider must submit documentation of medical necessity with the claim. Documentation can include but is not limited to medical records, physician notes, and lab results.

The ordering physician must maintain documentation supporting medical necessity in the client’s medical record, including the documentation for any extra sessions that are required.

The Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual (TMPPM), Clinics and Other Outpatient Facility Services Handbook, Section 6.2.2, “Renal Dialysis Facilities – Consolidated Billing,” on April 1, 2024, to reflect the above benefit information.

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