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Rental of Dual-Function Home Ventilators a Benefit of Texas Medicaid Effective April 1, 2025

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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 April 1, 2025, the rental of dual-function home ventilators (procedure code E0468) is a benefit of Texas Medicaid.

Note: The Texas Health and Human Services Commission (HHSC) must present new proposed benefits at a rate hearing to receive public comment on reimbursement rates. After the rate hearing, HHSC must approve the expenditures before Texas Medicaid can adopt the rates. TMHP will notify providers in a future article if a proposed reimbursement rate will change or a procedure code will not be reimbursed because the expenditures were not approved.

Prior Authorization

The client’s treating physician or allowed practitioner must request prior authorization for the rental of a dual-function home ventilator (procedure code E0468). The client must meet the medical necessity criteria for both a mechanical ventilator and a cough augmentation device.

Providers can find more information about medical necessity and prior authorization requirements in the following subsections of the current Texas Medicaid Provider Procedures Manual (TMPPM), Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook:

  • Subsections 2.2.23.9, “Mechanical Ventilation,” and 2.2.23.9.1, “Prior Authorization,” provide information about requirements for mechanical ventilation.
  • Subsection 2.2.23.11.1, “Prior Authorization,” provides information about requirements for a cough augmentation device.

To request prior authorization of procedure code E0468, providers must submit the Home Health Services (Title XIX) DME/Medical Supplies Prescribing Provider Order Form.

Note: Providers may include documentation of medical necessity on the form or submit it as supplemental documentation.

In addition to the Title XIX form, providers may submit the Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices – Initial Request form to document medical necessity for a cough augmentation device.

Related Procedure Codes

Effective for dates of service on or after July 1, 2025, TMHP will deny claims for the following procedure codes if they are submitted by any provider in the same month as procedure code E0468:

Procedure Codes
A4216A4217A4481A4483A4611A4612A4613A4618A7027A7028
A7029A7030A7031A7032A7033A7034A7035A7036A7037A7038
A7039A7046E0465E0466E0470E0471E0472E0482E0561E0562
E0601         

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