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 September 11, 2023, per the U.S. Food and Drug Administration’s (FDA’s) amended emergency use authorizations for the Pfizer-BioNTech and Moderna COVID-19 vaccines, COVID-19 vaccine procedure codes 91318, 91319, 91320, 91321, and 91322 and vaccine administration procedure code 90480 are now benefits of Texas Medicaid, the Children with Special Health Care Needs (CSHCN) Services Program, and Texas Health Steps. Effective for dates of service on or after September 11, 2023, COVID-19 vaccine procedure codes 91320 and 91322 and vaccine administration procedure code 90480 are benefits of the Family Planning Program (FPP) and Healthy Texas Women (HTW).
Texas Medicaid and Texas Health Steps Benefits
The following procedure codes are benefits of Texas Medicaid and may be reimbursed as follows:
| Procedure Codes | Age Range |
|---|---|
| 90480 | 6 months of age or older |
| 91318 | 6 months through 4 years of age |
| 91319 | 5 years through 11 years of age |
| 91320 | 12 years of age or older |
| 91321 | 6 months through 11 years of age |
| 91322 | 12 years of age or older |
Vaccine procedure codes 91318, 91319, 91320, 91321, and 91322 and vaccine administration procedure code 90480 are Medicaid benefits that may be reimbursed for the following provider types and places of service:
| Place of Service | Provider Type |
|---|---|
| Office | Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Pharmacist, Certified Nurse Midwife, Registered Nurse, Licensed Midwife, Comprehensive Care Program (CCP), Nephrology (Hemodialysis, Renal Dialysis), Pharmacy |
| Home | Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, CCP Providers, Home Health Agency |
| Outpatient Hospital | Hospital, Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility |
| Other Locations | Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, CCP Providers |
Note: Texas Health Steps providers may be reimbursed for services rendered to clients who are 6 months through 20 years of age in the office, home, outpatient hospital, and other location settings.
CSHCN Services Program Benefits
Procedure codes 91318, 91319, 91320, 91321, 91322, and 90480 are CSHCN Services Program benefits for the following provider types and places of service:
| Place of Service | Provider Type |
|---|---|
| Office | Physician, Physician Assistant, Advanced Practice Registered Nurse, Pharmacist |
| Home | Physician, Physician Assistant, Advanced Practice Registered Nurse |
| Outpatient Hospital | Hospital |
| Other Locations | Physician, Physician Group, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist |
FPP and HTW Benefits
FPP and HTW will implement only procedure codes 90480, 91320, and 91322. These procedure codes will be reimbursed to the same provider types and places of service listed for Texas Medicaid, including family planning clinics.
Other Considerations
As of September 11, 2023, procedure code M0201 (COVID-19 vaccine administration inside a patient’s home) may be billed in the home setting with procedure code 90480.
Immunization counseling is included in procedure code 90480. Procedure code G0315 cannot be billed on the same day by the same provider as procedure code 90480.
Vaccines administered to individuals eligible for the Vaccines for Children (VFC) program should come from VFC-provided stocks. COVID-19 vaccine products submitted for reimbursement will be processed as informational-only when administered to individuals who are 6 months through 18 years of age.
Note: Procedure codes 91318, 91319, 91320, 91321, 91322, and 90480 will be assigned interim rates until expenditures are approved and permanent rates are adopted by Texas Medicaid. We will notify providers of the permanent rates in a future article. Services provided before the interim rates are 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, we 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. When the claims are reprocessed, providers may receive additional payment, which will be reflected on the Remittance and Status (R&S) Report.
As a reminder, Texas Medicaid, CSHCN, FPP, and HTW do not cover vaccines that are not authorized or approved by the FDA.
For more information, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.