11/29/2023

What’s New

For dates of service on or after October 1, 2023, Texas Medicaid vaccine services benefits have changed. The Centers for Medicare & Medicaid Services (CMS) issued guidance on Section 11405 of the Inflation Reduction Act (IRA) back on June 27, 2023. Statutory amendments made by Section 11405 of the IRA required Medicaid coverage and payment for all adult vaccines approved by the U.S. Food and Drug Administration (FDA) and recommended by the Advisory Committee on Immunization Practices (ACIP) and their administration for individuals 19 years of age and older.

Two Reasons for vaccinating outside the routine schedule would include occupation and travel.

The following procedure codes will become benefits of participating Texas Medicaid providers and may be reimbursed to physician assistant, nurse practitioner, clinical nurse specialist, and physician providers for services rendered in the office setting and to hospital providers for services rendered in the outpatient hospital setting:

Vaccine claims submission information:

REMINDERS:

• Rabies Vaccine                                                                                        Procedure code 90675 is no longer restricted by diagnosis.
• Smallpox/Mpox Vaccines:                                                                              Smallpox/Mpox Vaccines procedure codes 90611 and 90622 are informational only as these products are provided by the federal government.
• Respiratory Syncytial Virus (RSV) Vaccines:                                        Procedure code 90678 and 90679 for RSV vaccines will become benefits of Texas Medicaid and may be reimbursed as follows for patients 60 years of age or older:
  • Office: Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Pharmacist, Certified Nurse Midwife, Registered Nurse, Licensed Midwife, Comprehensive Care Program (CCP) and Pharmay
  • Home: Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Comprehensive Care Program Provider
  •  Outpatient Hospitals: Hospital Providers
  • Other Locations: Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Comprehensive Care Program Provider 

EXCLUSIONS

Vaccines that are not approved or authorized for emergency use by the U.S. Food and Drug Administration and not recommended by the Advisory Committee on Immunization Practices are not benefits of Texas Medicaid.

CLAIMS REPROCESSING

Claims with these procedure codes listed above with dates of service on or after October 1, 2023, must be reprocessed for appropriate payment. Blue Cross and Blue Shield of Texas does not require providers to submit an appeal unless they are denied for other reasons after the claims reprocessing is complete.

QUESTIONS

Providers, for questions or additional information, please:

• Contact your BCBSTX Medicaid Network team at 1-855-212-1615
• Submit via email Texas Medicaid Network Department

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to other third-party sources or organizations are not a representation, warranty, or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations, and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.