Per House Bill 1575, 88th Legislature, Regular Session, 2023, Texas Medicaid is creating a doula and a community health worker (CHW) provider type that will be available in December 2024. Upon enrollment, these new provider types will be authorized to provide case management services for the Children and Pregnant Women (CPW) program.
Establishing a separate provider type for doulas and CHWs will allow providers to enroll and bill for Medicaid CPW services. The national taxonomy identifiers for doula (374J00000X) and CHW (172V00000X) will be used and are new to the CPW Medicaid program.
The required designations that will be used at enrollment are still being developed. More information will be published as soon as it is finalized.
Case Manager Responsibilities
The new doula and CHW providers will be providing case management services that include conducting initial, comprehensive, and follow-up visits to determine eligibility and service needs for members qualifying for services from the CPW program.
Case Management Training Courses
Prior to enrollment, CPW providers must complete the required standardized Texas Health and Human Services Commission (HHSC) case management training courses. The core case management training includes two half-day virtual sessions that are instructor-led.
The 2024 summer course details are as follows:
- August 21, 2024, and August 22, 2024: 9:00 a.m.–12:30 p.m. Central time
To register for the summer course, email ASKCM@hhs.texas.gov.
CHW Requirements
CHWs must be 18 years of age or older and will need the following to enroll as one of the new provider types:
- An HHSC approval letter.
- A CHW certification number and expiration date.
- Health Insurance Portability and Accountability Act (HIPAA) training.
Doula Requirements
Doulas must be 18 years of age or older.
Doulas that are planning to enroll with the experience pathway will need:
- An HHSC approval letter.
- Five years of doula-related experience.
- Attendance in at least three births.
- Three professional letters of recommendation.
- HIPAA training.
Doulas that are planning to enroll with the training pathway but do not have five years of experience will need:
- An HHSC approval letter.
- Training that meets the following core competency requirements:
- Childbirth education.
- Lactation support or proof of lactation counselor (CLC) or international lactation consultant (IBCLC) certification.
- Nonmedical comfort measures, prenatal support, and labor support techniques.
- Chronic and acute health conditions during the perinatal period.
- Cultural competency.
- Attendance in at least three births.
- Three professional letters of recommendation.
- HIPAA training.
All attestation and maintenance of the required documents for the enrollment of the new provider types will be managed by HHSC through the Texas Medicaid & Healthcare Partnership (TMHP) using the Provider Enrollment and Management System.
Managed Care Requirements
Providers must contract and be credentialed with a managed care organization (MCO) to provide services to members enrolled in Medicaid managed care. In a managed care model:
- Provider reimbursement rates are negotiated between the provider and the MCO. An MCO’s provider reimbursement rate may differ from the Medicaid fee-for-service fee schedule. Providers should discuss rates with MCOs during the contracting and credentialing process.
- Providers must obtain professional liability insurance to participate in the MCO’s provider network.
- If an MCO determines there is no duplication of services, an MCO may allow the Member to receive CPW Services by a CPW provider with a previously established relationship.
- MCOs are required to share non-medical needs screening results with CPW providers within 30 days of approving a referral to a CPW provider.
If providers choose not to contract with MCOs in the service area, the providers will not be part of the MCO’s provider network.
For MCO contact information and more detail on the contracting and credentialing process, reference the Medicaid Managed Care Provider Contracting and Credentialing Resources guide.
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.
CPW Case Management Procedure Codes
Case Management for CPW providers currently bill for services using procedure code G9012. The new CHW and doula provider types will also use G9012 to receive reimbursement.
More details will be published later this year, closer to the implementation of these updates.
Providers may refer to the current Texas Medicaid Provider Procedures Manual, Volume 2, Behavioral Health and Case Management Services Handbook, section 3, “Case Management for Children and Pregnant Women,” for additional information.
For more information, call the TMHP Contact Center at 800-925-9126.