Home Health DME and Supplies Exceptional Circumstances Provision for Medicaid Members 21 years of age and older

Attention: DME Providers Effectvie Date: June 1, 2020Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.Call to action: Texas Children’s Health Plan aligns with the Texas Medicaid and Healthcare Partnership (TMHP) new guidance for Durable Medical equipment (DME) and supplies under exceptional circumstances. Effective June 1, 2020 Texas Medicaid’s Home Health Durable Medical Equipment (DME) and Supplies Exceptional Circumstances provision for Medicaid clients 21 years of age and older became available. The details are as follows:

• Texas Medicaid’s obligation to consider coverage of medically necessary DME and supplies not otherwise covered as a Texas Medicaid benefit for clients 21 years of age and older is known as the Home Health Durable Medical Equipment (DME) and Supplies Exceptional Circumstances provision. This includes items listed as non-covered services in the Texas Medicaid Provider Procedures Manual (TMPPM) or any item of DME and supplies that is not considered a benefit of Medicaid. TMPPM criteria, 2.2.3 can be found at this link on page 19, Home Health DME and Supplies Exceptional Circumstances Provision.
• Home Health DME and Supplies Exceptional Circumstances requests must be pre-authorized.
• Requests for medically necessary DME and supplies not covered as a benefit under Texas Medicaid should be submitted through the Home Health DME and Supplies Exceptional Circumstances process.
• This process is limited to DME and supplies for which Federal Financial Participation is available.

How this impacts providers: Requesting Use of the Home Health DME and Supplies Exceptional Circumstances Provision:

• Providers may request to use the Home Health DME and Supplies Exceptional Circumstances provision by providing a written notice to TCHP if the written notice meets all the conditions outlined below. The notice must include:
  • A completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form or other required form (e.g. Special Medical Prior Authorization [SMPA], Oxygen Therapy Devices and Supply Form, Wound Care Equipment and Supplies, etc.) signed and dated by the prescribing physician along with a cover letter indicating use of the Home Health DME and Supplies Exceptional Circumstances provision
  • The client's diagnosis and identification of specific medical needs that can only be met by the requested equipment or supply
  • A clear, concise description of the DME or supply requested
  • Letters of Medical Necessity (LOMN) from the client's prescribing physician and other clinical professionals, as appropriate, documenting alternative measures and alternative DME or supplies that have been tried and failed to meet the client's medical need(s), or have been ruled out, and an explanation of why it failed or was ruled out
  • Submission of either the manufacturer's suggested retail pricing (MSRP) for the DME or supply requested, or an invoice documenting the provider's cost

References: Home Health DME and Supplies Exceptional Circumstances Provision for Medicaid Clients 21 Years of Age and OlderCorrection to ‘Home Health DME and Supplies Exceptional Circumstances Provision for Medicaid Clients 21 Years of Age and Older’ posted May 15. 2020   Next steps for providers: Providers should request the use of home health DME supplies according to the outlined procedure and follow the authorization guidelines. For reimbursement and billing, DME and supplies allowed under the Home Health DME and Supplies Exceptional Circumstances provision must be requested by providers using the most appropriate procedure code available and must be authorized by TCHP in order to be considered for payment. If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers