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Update to Smallpox and Mpox Vaccine Reimbursement for Texas Medicaid

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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 August 1, 2024, for dates of service on or after May 1, 2024, the smallpox and mpox vaccine (procedure code 90611) may be reimbursed for the following provider types and places of service for clients who are 18 years of age or older:

Place of ServiceProvider Type
OfficePhysicians, physician assistants, nurse practitioners, clinical nurse specialists
Outpatient hospitalHospital providers

Procedure code 90611 was previously processed as “informational only” because this vaccine was distributed by the federal government. Effective August 1, 2024, for dates of service on or after May 1, 2024, procedure code 90611 will be processed with a payable rate.

Note: New benefits that are adopted by Texas Medicaid must be presented at a rate hearing to receive public comment on proposed Texas Medicaid reimbursement rates. After the rate hearing, expenditures must be approved before the rates are adopted by Texas Medicaid. Providers will be notified in a future article if a proposed reimbursement rate will change or a procedure code will not be reimbursed because the expenditures are not approved.

Claims that were submitted before August 1, 2024, with dates of service on or after May 1, 2024, will be reprocessed. Providers may receive additional payment when the claims are reprocessed.

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