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Update to TMPPM for Respiratory Equipment for Clients Not Meeting Required Criteria

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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 May 1, 2021, TMHP will update the Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsections 2.2.23, “Respiratory Equipment and Supplies,” and 2.2.23.1.2, “Respiratory Equipment for Clients Not Meeting Required Criteria.”

2.2.23 Respiratory Equipment and Supplies

The notes in this subsection will be updated with the following language:

Note: For clients who are 20 years of age and younger, respiratory equipment and supplies that do not meet the criteria under Title XIX Home Health Services may be considered through the Texas Health Steps-Comprehensive Care Program (THSteps-CCP).

Note: For clients who are 21 years of age and older, respiratory equipment and supplies that do not meet the criteria under Title XIX Home Health Services may be considered through the Texas Medicaid Home Health-Durable Medical Equipment (DME) Exceptional Circumstances provision.

2.2.23.1.2 Respiratory Equipment for Clients not Meeting Required Criteria

Clients who are 20 Years of Age and Younger

For clients who are 20 years of age and younger, respiratory equipment and supplies that do not meet the criteria under Title XIX Home Health Services may be considered through the Texas Health Steps-Comprehensive Health Care Program (THSteps-CCP).

Clients who are 21 Years of Age and Older

For clients who are 21 years of age and older, respiratory equipment and supplies that do not meet the criteria under the Title XIX Home Health Services may be considered through the Texas Medicaid Home Health-Durable Medical Equipment (DME) Exceptional Circumstances provision.

Providers may refer to the Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, section 2.2.3, “Home Health DME and Supplies Exceptional Circumstances Provision,” for additional information.

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