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Rental of Dual-Function Home Ventilators Will Be a Benefit for CSHCN Services Program Effective October 1, 2025

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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 for dates of service on or after October 1, 2025, the rental of dual-function home ventilators (procedure code E0468) will be a benefit for the Children with Special Health Care Needs (CSHCN) Services Program.

Prior Authorization

A dual-function respiratory device home ventilator (procedure code E0468) may be prior authorized for rental for an initial three months for clients who require mechanical ventilation. The prior authorization request must be submitted with documentation that establishes the medical necessity of a cough augmentation device.

Providers can find more information about medical necessity and prior authorization requirements in the following subsections of the current Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, Respiratory Equipment and Supplies:

  • Subsection 36.2, “Benefits, Limitations, and Authorization Requirements”
  • Subsection 36.2.4.1, "Cough Augmentation Device (Insufflation Devices or Cough Assist Machine)”
  • Subsection 36.2.12, “Home Ventilators (any type) with or without Invasive Interface”

To request prior authorization of procedure code E0468, providers must submit the CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) Form and Instructions with documentation of medical necessity.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.