Vaccine Services Benefits to Change for Texas Medicaid Effective October 1, 2023

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 October 1, 2023, vaccine services benefits will change for Texas Medicaid.

Vaccine Services to Become Benefits

On June 27, 2023, the Centers for Medicare & Medicaid Services (CMS) issued guidance on Section 11405 of the Inflation Reduction Act (IRA). Beginning October 1, 2023, statutory amendments made by Section 11405 of the IRA require Medicaid coverage and payment for all adult vaccines approved by the U.S. Food and Drug Administration (FDA) and recommended by the Advisory Committee on Immunization Practices (ACIP) and their administration for individuals 19 years of age and older. Occupation and travel will be added to the reasons for vaccinating outside the routine schedule.

The following procedure codes will become benefits of Texas Medicaid and may be reimbursed to physician assistant, nurse practitioner, clinical nurse specialist, and physician providers for services rendered in the office setting and to hospital providers for services rendered in the outpatient hospital setting:

Procedure code 90675 will no longer be diagnosis restricted.

Note: The procedure codes listed above will not be assigned a rate until expenditures are approved and a reimbursement rate is adopted by Texas Medicaid. Providers will be notified of the rate in a future article. Services provided before the rate is assigned will receive the following explanation of benefits (EOB) 02008 notification: “This procedure code has been approved as a benefit pending the approval of expenditures. Providers will be notified of the effective dates of service in a future notification if expenditures are approved.” Once expenditures are approved, TMHP will automatically reprocess the affected claims. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete. 

Respiratory Syncytial Virus (RSV) Vaccines

Procedure codes 90678 and 90679 for RSV vaccines will become benefits of Texas Medicaid and may be reimbursed as follows for clients who are 60 years of age or older:

Note: The procedure codes listed above will not be assigned a rate until expenditures are approved and a reimbursement rate is adopted by Texas Medicaid. Providers will be notified of the rate in a future article. Services provided before the rate is assigned will receive the following explanation of benefits (EOB) 02008 notification: “This procedure code has been approved as a benefit pending the approval of expenditures. Providers will be notified of the effective dates of service in a future notification if expenditures are approved.” Once expenditures are approved, TMHP will automatically reprocess the affected claims. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.

Smallpox/Mpox Vaccines

Smallpox/Mpox vaccines (procedure codes 90611 and 90622) are informational only as these products are provided by the federal government.

Exclusions

Vaccines that are not approved or authorized for emergency use by the U.S. Food and Drug Administration and not recommended by the Advisory Committee on Immunization Practices are not benefits of Texas Medicaid.

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