SECTION 354.1149. Exclusions and Limitations

(a) Notwithstanding any other provision of this subchapter, Medicaid services or supplies that are not medically necessary will not be considered for Medicaid reimbursement. The following benefit exclusions and limitations are applicable under the Medicaid program for services provided under this subchapter. They do not apply to Medicaid services provided through the Texas Health Steps Comprehensive Care Program. Additional exclusions and limitations are listed in the Texas Medicaid Provider Procedures Manual. The following benefits are not included in the Texas Medicaid Program:

(1) services provided to any individual who is an inmate in a public institution (except as a patient in a medical institution approved for participation in the Medicaid program), or is a patient in:

(A) the hospital or nursing sections of facilities for persons with intellectual and developmental disabilities; or

(B) an institution for mental disease if the patient is between the ages of 22 and 64;

(2) special shoes or other supportive devices for the feet and ambulation aids (except as provided for in the home health services program);

(3) any services provided by military medical facilities, except:

(A) those military hospitals enrolled to provide inpatient emergency services;

(B) Veterans Administration facilities; or

(C) United States Public Health Service hospitals;

(4) care and treatment related to any condition covered by workers' compensation laws;

(5) care, treatment, or other services by a doctor of dentistry unless:

(A) the recipient's dental diagnosis is causally related to a life-threatening medical condition; or

(B) the treatment is specifically authorized by the Health and Human Services Commission (HHSC) or its designee;

(6) any care or services to the extent that a benefit is paid or payable under Medicare;

(7) any services or supplies provided to an individual before the effective date of designation by HHSC as an eligible recipient or after the effective date of denial as an eligible recipient except orthodontic services that are authorized and initiated while the recipient is eligible for Medicaid may be continued for 36 months after a recipient is no longer Medicaid eligible;

(8) any services or supplies provided in connection with cosmetic surgery except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member;

(9) immunizations specifically for travel to or from foreign countries. Immunizations included on the immunization schedule approved by the Advisory Committee on Immunization Practices (ACIP) are a benefit unless an immunization is specifically excluded by HHSC;

(10) any services provided by an immediate relative of the eligible recipient or member of the eligible recipient's household except for personal care services;

(11) custodial care;

(12) any services or supplies provided outside of the United States, except for Medicare deductible and coinsurance amounts subject to the limits specified in §354.1143 of this title (relating to Coordination of Medicaid with Medicare Parts A, B, and C);

(13) any services or supplies not provided for in this chapter;

(14) any services or supplies not provided for in this chapter for:

(A) the treatment of flat foot conditions and the prescription of supportive devices therefor;

(B) the treatment of subluxations of the foot;

(C) routine foot care (including the cutting or removal of corns, warts, or calluses, the trimming of nails, and other routine hygiene care);

(15) any medical and remedial care, services, and supplies provided to a hospital inpatient after total hospitalization-related expenditures under the Medicaid Program reach $200,000 per recipient, per 12-month benefit period unless the services are exempted by subparagraphs (A) - (C) of this paragraph. For the purposes of this limit, "12-month benefit period" means 12 consecutive months beginning November 1 of each year and ending October 31 of the next year. The limit applies to hospitalization-related services while the recipient is a hospital inpatient regardless of where the services are provided, how soon within the 12-month period the limit is reached, and how many hospital stays are involved. For the purposes of this limit, HHSC or its designee processes and pays claims, if payable, based on the sequential date of service. The services exempted from the $200,000 limit are:

(A) covered benefits under §354.1175 of this title (relating to Organ Transplants);

(B) care, services, and supplies otherwise authorized by HHSC; and

(C) physician services as allowed by Title XIX laws and regulations and state law;

(16) any services or supplies that are experimental or investigational.

(b) Outpatient Behavioral Health Services. Benefits to an individual for the diagnosis or treatment of mental disease, psychoneurotic, and personality disorders while not confined as an inpatient in a hospital are limited to 30 visits to enrolled practitioners per calendar year. This utilization control limitation may be exceeded when prior authorized on a case-by-case-basis.

(c) Private Room Facilities. Private room facilities are not a benefit unless a facility submits a physician's certification of medical necessity to HHSC or its designee certifying that one of the following conditions is met:

(1) the recipient, based on a medical opinion, has a critical or contagious illness;

(2) the eligible recipient's condition results in undue disturbance to other patients; or

(3) the need for care is emergent and lower cost facilities are not immediately available.

(d) Institutional Care. Separate payments are not made for services and supplies in an institution where the reimbursement formula and vendor payment include such services or supplies as a part of the institutional care.

Source Note: The provisions of this §354.1149 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective November 1, 1983, 8 TexReg 4290; amended to be effective October 19, 1984, 9 TexReg 4975; amended to be effective July 1, 1986, 11 TexReg 2757; amended to be effective September 1, 1987, 12 TexReg 2577; amended to be effective April 13, 1988, 13 TexReg 1392; amended to be effective January 4, 1989, 13 TexReg 6292; amended to be effective September 1, 1989, 14 TexReg 3299; amended to be effective February 19, 1990, 15 TexReg 658; amended to be effective July 1, 1991, 16 TexReg 3944; transferred effectiveSeptember 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective November 29, 1993, 18 TexReg 8354; amended to be effective May 19, 1994, 19 TexReg 3487; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective November 15, 2009, 34 TexReg 7777; amended to be effective January 1, 2012, 36 TexReg 9282; amended to be effective October 27, 2013, 38 TexReg 7299; amended to be effective November 25, 2015, 40 TexReg 8200