Skip to main content

You must have JavaScript enabled in order to access this part of the site. Please enable JavaScript and then reload this page in order to continue.

Spell of Illness Limitation for COVID-19-related Admissions

Last updated on

This article has been updated. To view the updated information, click here.

For inpatient hospital stays related to COVID-19 for which the client was admitted on or after March 13, 2020, Texas Health and Human Services Commission (HHSC) has received federal approval through a disaster 1115 authority to extend the 30-day spell of illness limitation that applies to certain adult Medicaid clients for an additional 30 COVID-19-related days to allow an individual to stay up to 60 days in a hospital.

HHSC is also waiving the $200,000 benefit limitation for COVID-19-related stays, which applies to adults in fee-for-service Medicaid, and for some members who remain in STAR Health after their twenty-first birthday.

For COVID-19-related hospital stays, the provider should include diagnosis code U07.1 on the claim to indicate that the stay is COVID-19-related. HHSC will review cases submitted to HHSC by managed care organizations (MCOs) or, in fee-for-service Medicaid, claims submitted by providers to TMHP and allow for up to 30 COVID-19-related inpatient days beyond the initial 30-day spell of illness limit, if appropriate. Providers should follow regular processes for billing the MCOs (for managed care members) or TMHP (for fee-for-service clients). Providers do not need to submit any information directly to HHSC.

30-day Limitation

  • The 30-day spell of illness limit on inpatient hospital stays applies to fee-for-service clients 21 years of age and older; it also applies to STAR+PLUS, and STAR Health members 21 years of age and older.
  • Payment for up to 30 additional days beyond the initial 30-day spell of illness limit will be allowed if the additional days are for a COVID-19-related stay.
  • Example:
    • A client previously hospitalized for 25 days for a non-COVID-19-related illness, is hospitalized 2 days later with a COVID-19 diagnosis, the non-COVID-19 25 days will remain in the count and the COVID-19 days will begin being counted at day 26. The client can receive an additional 34 COVID-19-related days within the spell.
    • If the client described above is discharged from the COVID-19-related stay on day 50, the client would still have 10 days left for COVID-19-related stays.
    • If the client is discharged from the COVID-related stay on day 50 and 2 days later the client is admitted for a non-COVID-19 illness, the spell of illness limitation would apply because the stay is not COVID-19-related; this means 60 days must pass after the discharge from the COVID-19-related stay before a non-COVID-19 hospital stay would be eligible for payment.

$200,000 Limitation

  • The $200,000 spell of illness limit on inpatient hospital stays normally applies to fee-for-service clients and STAR Health members who are 21 years of age and older.
  • HHSC is waiving the $200,000 limitation on an individual case basis for fee-for-service clients and STAR Health members for COVID-19 related admissions.

The spell of illness limit does not apply to certain approved transplants and children 20 years of age and younger. For STAR+PLUS, the spell of illness limit does not apply to people with serious and persistent mental illness (SPMI). Please refer to the following for further information on the spell of illness:

Texas Medicaid Provider Procedures Manual:

  • Section 3.1.2 of the Inpatient and Outpatient Hospital Services Handbook
  • Sections 3.2.1, 4.2.1, and 5.2.2 of the Medicaid Managed Care Handbook

Uniform Managed Care Manual:

  • Section 16.1.2.10.1

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