Texas Medicaid Now Participates in the Cell and Gene Therapy Access Model

Date: September 10, 2025

Attention: Hematologists

Effective date: September 1, 2025

Call to action: Texas Children’s Health Plan (TCHP) would like inform providers that on September 1, 2025, Texas Medicaid began to use the Cell and Gene Therapy (CGT) Access Model that was implemented by the Centers for Medicare & Medicaid Services (CMS) Innovation Center.

The CGT Access Model focuses on the following gene therapies for sickle cell disease:

• Lyfgenia by bluebird bio
• Casgevy by Vertex Pharmaceuticals

These therapies require chemotherapy, which may affect a client’s fertility. Under this model, clients can receive fertility preservation services that are not normally covered by Texas Medicaid. The cost of these fertility preservation services will not be billed to Medicaid or providers – drug manufacturers (bluebird bio and Vertex Pharmaceuticals) will cover the full cost.

Billing process for gene therapies:

• Providers must be enrolled with the CMS Designated Registry through the Center for International Blood and Marrow Transplant Research (CIBMTR) before administering the therapy.
• Providers must also participate in the CMS study linked to the model (details provided directly from CIBMTR).
• Claims must follow the billing requirements in the Texas Medicaid Provider Procedures Manual (TMPPM), including “Separate Reimbursement of Certain Inpatient HCCADs” and “HCCADS Claims Processing Requirements.”
• Providers must submit the invoice of the actual acquisition cost of the drug.

Next steps: Providers can find more information about gene therapies, eligibility, claims submission, and related services on the Texas Vendor Drug Program website. Please share this information with your staff.

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.