Vaccine Services Benefits Changes for Texas Medicaid

Date: November 6, 2023

Attention: All Providers

Effective: October 1, 2023

Call to Action: Texas Children Health Plan (TCHP) would like to let providers know that effective for dates of service on or after October 1, 2023, vaccine services benefits have changed for Texas Medicaid.

On June 27, 2023, the Centers for Medicare & Medicaid Services (CMS) issued guidance on Section 11405 of the Inflation Reduction Act (IRA). Beginning October 1, 2023, statutory amendments made by Section 11405 of the IRA require Medicaid coverage and payment for all adult vaccines approved by the U.S. Food and Drug Administration (FDA) and recommended by the Advisory Committee on Immunization Practices (ACIP) and their administration for individuals 19 years of age and older. Occupation and travel will be added to the reasons for vaccinating outside the routine schedule.

This expanded vaccine coverage will allow adults who are traveling to areas around the world that are affected by endemic infectious diseases to be vaccinated prior to travel. This also allows adults who work in affected areas or specialized fields (laboratories, research, etc.) to be vaccinated due to their occupation.

The following procedure codes will become benefits of Texas Medicaid and may be reimbursed to physician assistant, nurse practitioner, clinical nurse specialist, and physician providers for services rendered in the office setting and to hospital providers for services rendered in the outpatient hospital setting:

Procedure Code	Age Range	Number of Recognized Components
90476	19–50 years	1
90477	19–50 years	1
90581	19–65 years	1
90625	19–64 years	1
90626	19 years of age or older	1
90627	19 years of age or older	1
90690	19 years of age or older	1
90691	19 years of age or older	1
90717	19 years of age or older	1
90738	19 years of age or older	1

Procedure code 90675 (Rabies Toxoid) will no longer be diagnosis restricted.

Travel related infections include Yellow Fever, Typhoid, Japanese Encephalitis, Cholera, and Tick-Borne Encephalitis. Occupational related infections include Adenovirus Type 4 and 7, Anthrax, and Typhoid.

Respiratory Syncytial Virus (RSV) Vaccines

Procedure codes 90678 and 90679 for RSV vaccines will become benefits of Texas Medicaid and may be reimbursed as follows for patients who are 60 years of age or older.

Smallpox/Mpox Vaccines

Smallpox/Mpox vaccines (procedure codes 90611 and 90622) are informational only as these products are provided by the federal government.

Exclusions

Vaccines that are not approved or authorized for emergency use by the FDA and not recommended by the Advisory Committee on Immunization Practices are not benefits of Texas Medicaid.

Next Steps for Providers: Providers are not required to appeal the claims unless they are denied for additional reasons after the claims reprocessing is complete. Providers may bill TCHP retroactively for vaccine procedure codes and related vaccine administration procedure codes.

Additional information regarding recommendations for routine adult vaccines and adult preventive care services can be found at:

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

For access to all Provider Alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.