Skip to main content

Reminder: Eligible Provider Types Can Request a Medicare Waiver for Medicare Participation

Last updated on

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.

Reminder: Under federal law, Medicaid is the payer of last resort, so Medicare-covered services must first be billed to and paid by Medicare.

Some provider types may apply for a waiver of the Medicare certification requirement in the application process if they do not serve Medicare-eligible individuals.

The following provider types are eligible to apply for this waiver:

  • Audiologist
  • Dentist (D.D.S. or D.M.D.)
  • Licensed clinical social workers (LCSWs)
  • Licensed professional counselors (LPCs)
  • Licensed marriage and family therapists (LMFTs)
  • Nurse practitioner/clinical nurse specialist (NP/CNS)
  • Optometrist (OD)
  • Orthotist
  • Physician (DO)
  • Physician (MD)
  • Physician assistant (PA)
  • Prosthetist

Performing providers cannot request a Medicare waiver when they join a group that is enrolled as a Medicaid provider.

Requesting a Medicare Waiver in PEMS

Within the practice location’s program-specific questions, you will be asked, “Are you using a Medicare Certification Number for this location?” If you select No and your enrollment type has Medicare as a prerequisite, you must select one of the following options to request a waiver for the Medicare prerequisites:

  • Select this option if you provide pediatric services for individuals birth through 20 years of age:

“I certify my practice is limited to individuals’ birth through 20 years of age. I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information. Performing providers cannot request a Medicare Waiver when joining a group that is Medicare enrolled."

  • Select this option if you provide services for clients of all ages:

“I certify that the service(s) I render is/are not recognized by Medicare for reimbursement. I further certify the claims for these services will not be billed to Medicare (this includes Medicare crossover claims). I understand if Medicare certification is obtained during or after the completion of the Texas State Health-Care Programs enrollment application, I will be required to submit a new enrollment application listing this Medicare certification information.”

In the text box below the checkboxes, you must provide an explanation to justify your reasons for making a Medicare Waiver Request.

Providers may refer to the Texas Medicaid Provider Procedures Manual (TMPPM), Section 1: “Provider Enrollment and Responsibilities,” section 1.1.9, “Required Enrollment Forms,” subsection 1.1.9.10, “Medicare Participation” for additional information.

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