Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

Other Services

Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Texas (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes		Specified services		Prospective cost based rate per episode of care using Medicare payment rates as ceiling	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes		Specified services		Prospective cost based rate per episode of care	CN & MN
Federally Qualified Health Center Services
Yes		Specified services		Prospective cost based rate/visit	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes		Admissions for specified procedures	$200,000/year, LOS limited to 30 days in a 90-day period	Prospective payment/discharge using DRG and peer groups	CN & M
Outpatient Hospital Services
Yes		Specified services		Cost based payment, prospective payment with surgical procedures grouped using Medicare methodology	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes			Limited to persons with severe or persistent mental health disorders	Cost based payment	CN & MN
Rural Health Clinic Services
Yes		Specified services		Prospective cost based rate/visit	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes				Fee for service at 92% of physician fee	CN & MN
Chiropractor Services
Yes			12 visits/year	Fee for service	CN & MN
Dental Services
Yes		Specified surgical procedures	Adult coverage lfor other than ICF/MR residents limited to trauma or cancer-related care	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes		Specified surgical procedures and services	Adult coverage lfor other than ICF/MR residents limited to trauma or cancer-related care	Fee for service	CN & MN
Nurse Midwife Services
Yes				Fee for service, some services paid 92% of physician fee	CN & MN
Nurse Practitioner Services
Yes		Yes		Fee for service, some services paid 92% of physician fee	CN & MN
Optometrist Services
Yes			1 refractive exam/2 years	Fee for service	CN & MN
Physician Services
Yes		Specified services		Fee for service	CN & MN
Podiatrist Services
Yes				Fee for service	CN & MN
Psychologist Services
Yes			30 visits/year	Fee for service	CN & MN
Prescription Drugs
Prescription Drugs
Yes			3 Rxs/month	Lower of AWP-15% or WAC+12% for independent pharmacies, AWP-18% for chain stores, plus $5.14 dispensing fee	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
Yes		Yes	180 days of treatment/year for acute or exaxcerbation of chronic condition	Fee for service	CN & MN
Services for Speech, Hearing and Language Disorders
No
Products and Devices
Dentures
Yes		Specified services	Adult coverage limited to ICF/MR residents	Fee for service	CN & MN
Eyeglasses
Yes		Yes	1 pair eyeglasses/2 years if minimum diopter correction criteria met	Fee for service	CN & MN
Hearing Aids
Yes		Repairs	45 degree hearing loss in better ear required, 1 hearing aid/6 years, repairs not covered	Fee for service	CN & MN
Medical Equipment and Supplies
Yes		Specified items		Fee for service	CN & MN
Prosthetic and Orthotic Devices
Yes			Adult coverage limited to NF and ICF/MR residents	Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes				Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes		Specified services		See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes			Limited to specified screenings only	Fee for service	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes		Specified services		Fee for service	CN & MN
Targeted Case Management
Yes		Yes		Cost based payment	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Services for the following populations: 2, 4, 6 & 8 - See service-specific FN	Prospective rates by service	CN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	Yes		Cost based payment for visits, med equipment and supplies paid fee for service	CN
Hospice Care
Yes		One 6-month period with additional periods as necessary	Prospective rates based on Medicare methodology	CN
Personal Care Services
Yes		Functional limitation criteria must be met, care limited to 50 hours/week	Fee for service using quarter hour or hourly rates	CN
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
Yes		See service-specific FN	Capitated payment	CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
No
Inpatient Psychiatric Services, under age 21
Yes		Services in private residential treatment facility not covered	Prospective cost based per diem	CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes		Unlimited therapeutic leave episodes up to 3 days and one therapeutic leave episode up to 10 days/year	Private facilities paid acuity adjusted cost based per diem that varies by facility size, cost based per diem for public facilities	CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes	Admission	3 consecutive therapeutic leave days	Prospective per diem based on cost and acuity adjusted, higher rates for heavy care residents	CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group are required to pay an income-based monthly premium.