Fee-For-Service

Pharmacies must be contracted with VDP to provide LHHS to clients in fee-for-service Medicaid, KHC, or CSHCN.  Enrollment as a durable medical equipment (DME) provider is not required. Pharmacies already enrolled as a Medicaid DME provider have the choice to submit LHHS claims as either a medical or pharmacy benefit. 

The LHHS products are classified as a Title XIX (Medicaid) home health benefit as Durable Medical Equipment or Medical Supplies. Reimbursement rates are based on the Texas Medicaid Fee Schedule. Pharmacies will not be paid a dispensing fee or delivery fee for providing these LHHS. Quantity guidelines are based on the Medicaid DME and Medical Supplies policies.

Please refer to the LHHS Pharmacy Benefit Chart (PDF) for covered products, reimbursement rates, and quantity guidelines.  Please refer to Chapter 5 (Limited Home Health Supplies) of the Pharmacy Provider Procedure Manual to learn more.

Managed Care

Pharmacies must be contracted with VDP and with the health plan’s pharmacy benefit manager (PBM) to provide LHHS to clients enrolled in Medicaid Managed Care or CHIP.  Pharmacy staff must work with the MCO/PBM in their service area to determine the billing requirements, reimbursements rates, and coverage limitations for these products.  Health plans have the ability to designate certain LHHS products as preferred.  Please contact the appropriate health plan for specific requirements.

Pharmacy Benefit Information

These LHHS are classified as a Title XIX (Medicaid) home health benefit as Durable Medical Equipment or Medical Supplies. Reimbursement rates are based on the Texas Medicaid Fee Schedule. Pharmacies will not be paid a dispensing fee or delivery fee for providing these LHHS. Quantity guidelines are based on the Medicaid DME and Medical Supplies policies. Please refer to the LHHS Pharmacy Benefit Chart (PDF) for covered products, reimbursement rates, and quantity guidelines.

Claim Submission for Medicaid FFS, KHC, and CSHCN

Please keep the following in mind when submitting a LHHS claim:

  • Claims must be submitted in accordance with the most current NCPDP pharmacy billing standard
  • Prescriptions for diabetic test trips, lancets, and diabetic disposable monitor and test strips kit are all limited to a max of 5 refills.
  • Claims must include the specific NDC for each product.
  • The only products available to clients in the Kidney Health Care Program are: diabetic insulin syringe with needle 1cc or less, diabetic insulin needles, diabetic blood glucose test strips, and diabetic lancets. 
  • If the prescribed quantity exceeds the quantity guidelines, the claim will reject.
  • If it is medically necessary for the prescribed quantity to exceed the maximum unit per filling a pharmacy will be required to submit additional information for the claims for blood glucose test strips, blood glucose test strips with disposable monitor, diabetic lancets, aerosol holding chamber, spring powered device for lancet, and blood glucose monitor (talking) to be accepted.
    • The pharmacy must attest that the submitted quantity is the actual quantity prescribed in accordance with the directions for use specified on the prescription by resubmitting the claim with “2” in “Submission Clarification Code” (Field 42Ø-DK).

    Please refer to Chapter 5 (Limited Home Health Supplies) of the Pharmacy Provider Procedure Manual to learn more.