Date: May 23, 2025
Attention: All Providers
Effective date: September 1, 2025
Call to action: Effective September 1, 2025, Rider 32 will be implemented. Rider 32 went into law during the 86th Texas Legislative Session.
What is Rider 32? Rider 32 transitions dually eligible individuals enrolled in Medicaid managed care from a fee-for-service (FFS) model to a Medicaid-only managed care service delivery system.
- Starting September 1, 2025, providers will be required to bill Managed Care Organizations (MCOs) like Texas Children’s Health Plan (TCHP) directly for the Medicaid-only acute care services provided to dually eligible members that MCOs/TCHP cover for members who do not have Medicare.
- TCHP, like other MCOs must cover, Medicaid wrap-around services for their dually eligible members; Medicaid-only acute care services that are one of the following.
- Are not covered by Medicare; and
- MCOs/TCHP cover for members who do not have Medicare
Health Care Coverage for Dual-eligible Members on September 1, 2025
Examples of Medicaid-only acute care services in Rider 32. This is not a complete list of acute care services. Click here for the complete Procedure Code list.
- Targeted case management and mental health rehabilitation
- Substance use disorder treatment services provided in a chemical dependency treatment facility
- Routine podiatry
- Hearing aids and fitting exams
- Most disposable medical supplies such as those for incontinence and tube feeding
- Vision services
Rider 32 does NOT change:
- How providers bill for Medicare services provided to dual-eligible individuals;
- Which services are covered by Medicare for dual eligible individuals; or
- Which services are covered by Medicaid MCOs for non-dual-eligible members.
Claims Information: Rider 32 claims are administered like all others. Providers should reference TCHP’s claims processing requirements and claims processing overview policies for guidance.
Claims Processing Requirements Policy
Claims Processing Overview Policy
Ongoing communication as we approach September 1, 2025: We understand providers may have questions about how Rider 32 will impact their practice. Additional details, including relevant CPT codes, and billing guidance will be shared in the coming months. Please check back for additional updates and guidance on our provider alerts webpage at www.texaschildrenshealthplan.org/provideralerts.
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts,log into:
www.texaschildrenshealthplan.org/provideralerts.
