Skip to main content

Benefits for Telehealth Services to Change for Texas Medicaid December 1, 2020

Last updated on

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.

Effective for dates of service on or after December 1, 2020, benefits for telehealth (non-physician delivered) services will change for Texas Medicaid.

Refer to: The article titled ”Multiple Medicaid COVID-19 Flexibilities Extended Through November 30, 2020,” which was published on this website October 23, 2020, for information about the COVID-19 telehealth flexibilities that are effective through November 30, 2020.

Overview of Benefit Changes

Major changes to this medical benefit include the following:

  • Reimbursing federally qualified health centers (FQHCs) for distant-site telehealth services
  • Clarification of Texas Medicaid managed care organization (MCO) guidelines for telehealth services

Distant-Site Telehealth Benefits for FQHCs

FQHCs providing distant-site telehealth services may be reimbursed for the following procedure codes:

Procedure Codes

G0466

G0467

G0468

G0469

G0470

T1015

Note: Telehealth services should be billed using modifier 95.

FQHCs may be reimbursed the distant-site provider fee for telehealth services at the Prospective Payment System (PPS) rate or Alternative Prospective Payment System (APPS) rate.

FQHC practitioners may be employees of the FQHC or contracted with the FQHC.

General Guidelines for Texas Medicaid MCOs

Texas Medicaid MCOs are prohibited from denying reimbursement for covered services solely because they are delivered remotely. MCOs must consider reimbursement for all medically necessary Medicaid-covered services provided via telehealth and must consider clinical and cost-effectiveness to determine whether a telehealth visit is appropriate.

Texas Medicaid MCOs must determine whether to reimburse for a telehealth service based on the following considerations:

  • Medical necessity.
  • Clinical effectiveness.
  • The telehealth service provided is cost-effective.
  • The telehealth service is provided in accordance with the law and contract requirements applicable to the provision of the same health-care service provided in person.
  • The use of telehealth promotes and supports patient-centered medical homes.

Texas Medicaid MCOs must consider reimbursement for all services that are currently a Medicaid benefit when provided via telehealth, including the procedure codes that are identified in the table above.

All other medically necessary Medicaid-covered benefits provided via telehealth must also be considered for reimbursement.

Texas Medicaid MCOs cannot deny, limit, or reduce reimbursement for a covered health-care service or procedure provided via telehealth based on the provider's choice of telecommunications platform to provide the service or procedure.

Providers should refer to individual MCO policies for additional coverage information.

Refer to: The current Texas Medicaid Provider Procedures Manual, Telecommunication Services Handbook, subsection 3.3, “Telehealth Services,” for information about the services that are currently a benefit when provided via telehealth.

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