HHSC provides specific home health supply products as a pharmacy benefit to clients enrolled in Medicaid, CHIP, the CSHCN Services Program, and KHC Program. The covered products include the following:
- Aerosol Holding Chamber
- Diabetic Lancets
- Diabetic Monitor (talking)
- Diabetic Test Strips
- Hypertonic Salines
- Insulin Needles
- Insulin Syringes
- Oral Electrolyte Replacement Fluid
- Spring Powered Device for Lancet
CMS classifies these products as a Title XIX (Medicaid) home health benefit as either durable medical equipment (DME) or medical supplies.
Pharmacies are not required to enroll as a Medicaid durable medical equipment (DME) provider to supply these products. Pharmacies already enrolled as Medicaid DME providers can submit claims as either a pharmacy benefit or medical benefit. Contact the Texas Medicaid and Healthcare Partnership (TMHP) for instructions about submitting medical claims.
A physician must prescribe all DME and home health supplies. Advanced practice registered nurses and physician assistants cannot prescribe these products to clients enrolled in Medicaid or CHIP.
A list of products is available through the Formulary search (txvendordrug.com/formulary/formulary-search). You can search by product name, the 11-digit NDC, or select the product from the HCPCS Description dropdown. Additional filters are available to find products payable by each program. Products not included in the search are only available through the Medicaid medical benefit.
A prescription is required for HHSC to process pharmacy claims for clients enrolled in fee-for-service Medicaid, the CSHCN Services Program, and KHC Program. HHSC does not require the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form (TMHP Form F00030) for products dispensed by a pharmacy.
The claim system will reject products submitted as part of a multi-ingredient compound claim with NCPDP error code 70 ("Product/Service Not Covered") and include the message "LHHS products are not covered in a compound claim" in the "Additional Message Information" field (526-FQ).
The claim system will reject claims if the submitted quantity exceeds the maximum unit per filling with NCPDP error code 9G ("Product/Service Not Covered"). If the quantity submitted exceeds the maximum unit per month, the claim system will reject claims with NCPDP error code 76 ("Plan Limitation Exceeded").
If the claim exceeds quantity limits, pharmacy staff must attest the submitted quantity is the actual quantity prescribed based on medical necessity by submitting the following values:
|Field Name||Field Number||Value|
|Submission Clarification Code||420-DK||2 (Other override)|
|Prescriber ID||411-DB||10-digit National Provider Identifier|
Refer to the NCPDP B1 Transaction Payer Sheet for submission requirements.
Refer to the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook chapter of the Texas Medicaid Provider Procedures Manual (tmhp.com/resources/provider-manuals/tmppm) for quantity guideline criteria. Refer to the table below for limitations impacting claims paid by HHSC.
|Aerosol Holding Chamber (for use with a metered-dose inhaler)||
|Blood Glucose Monitor (Talking)||
|Blood Glucose Strips (for monitor)||
|Blood Glucose Test Strips with Disposable Monitor||
|Hypertonic Saline Solution 3%||
|Hypertonic Saline Solution 7%||
|Insulin Syringes (1 cc or less)||
|Nasal Saline Spray||
|Oral Electrolyte Replacement Fluid||
|Spring-powered Device for Lancets||
Claims for Medicaid do not count towards a client's three prescription-per-month limit. Claims for KHC will count towards a client's four prescription-per-month limit.
HHSC bases its reimbursement rates on the "Home Health DME" Provider Type in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule and does not reimburse pharmacies a dispensing fee or delivery incentive. Refer to the Static Fee Schedules (public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx) page for the individual reimbursement rates.
HHSC does not require the TMHP DME Certification and Receipt Form (Form F00018) for pharmacy claims.
Pharmacies submit claims for clients enrolled in Medicaid managed care and CHIP to the client's MCO. MCOs have the flexibility to manage a preferred home health supplies list for the limited home health supplies. Contact the MCO to determine billing requirements, reimbursement rates, and coverage limitations.