9. Home Health Supplies

1. Home Health Supplies

Certain home health supply products are a covered Texas Medicaid benefit and available from pharmacies enrolled in the Vendor Drug Program (VDP). These products are classified as a Title XIX (Medicaid) home health benefit and as durable medical equipment or medical supplies. These products are available to people enrolled in Medicaid, the Children’s Health Insurance Program (CHIP), the Children with Special Health Care Needs (CSHCN) Services Program, and the Kidney Health Care (KHC) Program.

Pharmacies are not required to enroll as a Durable Medical Equipment (DME) provider to provide access to supplies. Pharmacies already enrolled as a Medicaid DME provider have the option to submit claims for these products either as a pharmacy benefit or as a medical benefit through the Texas Medicaid Healthcare Partnership (TMHP).

A physician must prescribe all DME and home health supplies. Advanced practice registered nurses and physician assistants are prohibited from prescribing DME and home health supplies to people enrolled in Medicaid or CHIP.

Refer to 42 C.F.R. 440.70: Home Health Services for more information.

2. Pharmacy Benefit

The content in Appendix A contains:

2.1 Formulary Search

The VDP website formulary search is used to find home health supplies. Users enter either the brand or generic name of the product, the 11-digit national drug code (NDC), or type of supply. Additional filters are available to find products payable by each program. Refer to the product search.

3. Pharmacy Claims

3.1 Fee for service

Claims for Medicaid, the CSHCN Services Program, and the KHC program are submitted to the Vendor Drug Program.

3.1.1 Prescription Guidelines

A written, faxed, or electronic prescription is required with the following information:

  • Person’s name
  • Description of the home health supply 
  • Quantity to dispense (quantity per day or month)

The "Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form" is not required for home health supplies dispensed through a pharmacy.

3.1.2 Claim Submission

Claims must include the specific national drug code (NDC) for the product. Multiingredient compound claims submitted with home health supplies will reject.

3.1.3 Excessive Quantity

Claims will reject if the submitted quantity exceeds the maximum unit per filling.  If the prescribed quantity is medically necessary, then pharmacy staff must attest the submitted quantity is the actual quantity prescribed by resubmitting the claim with a value of “2” ("Other override") in the “Submission Clarification Code” field (42ØDK).  Refer to Appendix A for quantity limits and refill limitations. This applies to claims for blood glucose test strips, blood glucose test strips with a disposable monitor, diabetic lancets, aerosol holding chamber, spring-powered device for lancet, and blood glucose monitor (talking).

3.1.4 Prescription Limits

  • Claims for traditional Medicaid do not count towards a person’s three prescription-per-month limit.
  • Claims for KHC will count towards a person’s four prescription-per-month limit.

3.1.5 Reimbursement 

  • Pharmacies are not paid a dispensing fee or delivery incentive.

3.1.6 Signature

  • Pharmacies requiring signatures to pick up prescriptions should require a signature for people picking up home health supplies.
  • The "DME Certification and Receipt Form" is not required.

3.2 Managed Care

Pharmacy claims for people enrolled in Medicaid managed care or CHIP are submitted to the managed care organization (MCO).  Pharmacy staff must work with the MCO's pharmacy benefit manager to determine the billing requirements, reimbursement rates, and coverage limitations for these products.  MCOs can also designate certain home health supplies as preferred. 

Refer to the Pharmacy MCO Assistance Chart (PDF) for the pharmacy call center phone numbers for each MCO, or refer to the Managed Care section in the Contact chapter of this manual to contact the appropriate MCO in your area.

Appendix A. Home Health Products

Description HCPCS Unit Unit Price Max Billable Units per Filling Quantity Guidelines Limited to 5 Refills? Covered Programs
Insulin Syringes (1 cc or less) A4206 EA $0.23000 100 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN, KHC
Insulin Needles A4215 EA $0.18000 100 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN, KHC
Blood Glucose Strips (for monitor) A4253 EA $0.56560 100 Maximum: 100 units every calendar month. Limited to a 30-day supply.

A person must use 100% of the product before refills are allowed.
Yes Medicaid, CHIP, CSHCN, KHC
Blood Glucose Test Strips with Disposable Monitor A9275 EA $0.56560 100 Maximum: 100 units every calendar month. Limited to a 30-day supply.

A person must use 100% of the product before refills are allowed.
Yes Medicaid, CHIP, CSHCN
Blood Glucose Monitor (Talking) E2100 EA $312.80000 1 Maximum: 1 unit per three rolling years. Only available for people with visual impairment. No Medicaid, CHIP, CSHCN
Lancets A4259 EA $0.11100 100 Maximum: 100 units every calendar month. Limited to a 30-day supply.

A person must use 100% of the product before refills are allowed.
Yes Medicaid, CHIP, CSHCN, KHC
Spring-powered Device for Lancets A4258 EA $14.65000 1 Maximum: 2 units per rolling year. No Medicaid, CHIP, CSHCN
Aerosol Holding Chamber (for use with a metered-dose inhaler) A4627 EA $27.60000 1 Maximum: 1 unit every 180 days. No Medicaid, CHIP, CSHCN
Oral Electrolyte Replacement Fluid B4103 ML $4.51000 per 500 ML or $0.00902 per ML 2000 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN
Hypertonic Saline Solution 7% T1999 ML (AWP-10.5%) - 8% 1800 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN
Hypertonic Saline Solution 3% T1999 ML (AWP-10.5%) - 8% 1800 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN
Nasal Saline Spray T1999 ML (AWP-10.5%) - 8% 1800 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN