CurrentDell Children's Health PlanPolicy N/A

Vaccine Services Benefits to Change for Texas Medicaid

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This policy governs coverage, reimbursement, provider settings, and claim handling for vaccine services under Texas Medicaid, including adult, RSV, smallpox, and mpox vaccines.

Policy Summary

PayerDell Children's Health Plan

PolicyVaccine Services Benefits to Change for Texas Medicaid

Policy CodePolicy N/A

Change TypeCoverage and reimbursement update

Effective DateOctober 1, 2023

Next Review DateN/A

Key ActionSubmit eligible adult vaccine services and related administration services when the vaccine is FDA approved, ACIP recommended, and the client meets applicable age requirements.

SourceLink

POLICY UPDATE CHANGES

Adult vaccines approved by the FDA and recommended by ACIP, along with their administration, become Texas Medicaid benefits for individuals age 19 and older.

RSV vaccine procedure codes 90678 and 90679 become Texas Medicaid benefits for clients age 60 and older.

Procedure code 90675 is no longer diagnosis restricted.

Smallpox and mpox vaccine procedure codes 90611 and 90622 are informational only because the products are supplied by the federal government.

Vaccines lacking FDA approval or emergency-use authorization and ACIP recommendation are not Texas Medicaid benefits.

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CurrentDell Children's Health PlanPolicy N/A

Vaccine Services Benefits to Change for Texas Medicaid

Customize your policy alerts

Sign up for all dellchildrenshealthplan policy alerts

Know when dellchildrenshealthplan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs coverage, reimbursement, provider settings, and claim handling for vaccine services under Texas Medicaid, including adult, RSV, smallpox, and mpox vaccines.

Policy Summary

PayerDell Children's Health Plan

PolicyVaccine Services Benefits to Change for Texas Medicaid

Policy CodePolicy N/A

Change TypeCoverage and reimbursement update

Effective DateOctober 1, 2023

Next Review DateN/A

Key ActionSubmit eligible adult vaccine services and related administration services when the vaccine is FDA approved, ACIP recommended, and the client meets applicable age requirements.

SourceLink

POLICY UPDATE CHANGES

Adult vaccines approved by the FDA and recommended by ACIP, along with their administration, become Texas Medicaid benefits for individuals age 19 and older.

RSV vaccine procedure codes 90678 and 90679 become Texas Medicaid benefits for clients age 60 and older.

Procedure code 90675 is no longer diagnosis restricted.

Smallpox and mpox vaccine procedure codes 90611 and 90622 are informational only because the products are supplied by the federal government.

Vaccines lacking FDA approval or emergency-use authorization and ACIP recommendation are not Texas Medicaid benefits.

Vaccine Service Coverage Criteria

Covered vaccine services

A vaccine service may be covered when the product and client meet the applicable federal, age, provider, and place-of-service requirements.

ALL of the following

All of the following
- ALL of the following
  - Vaccine is approved by the U.S. Food and Drug Administration (FDA) or authorized for emergency use.
  - Vaccine is recommended by the Advisory Committee on Immunization Practices (ACIP).
- One of the following coverage pathways
  - General adult vaccine services
    Client is 19 years of age or older.
    Service is rendered by an eligible provider in the office setting or by a hospital provider in the outpatient hospital setting.
  - RSV vaccine services (procedure codes 90678 or 90679)
    Client is 60 years of age or older.60 years and older
    Service is rendered through an eligible provider and place-of-service combination.

Excluded or informational vaccine services

The following products or circumstances are excluded from ordinary Texas Medicaid vaccine benefits.

Any of the following applies

Vaccine is not approved by the U.S. Food and Drug Administration (FDA) and is not authorized for emergency use.
Vaccine is not recommended by the Advisory Committee on Immunization Practices (ACIP).
Product is a smallpox or mpox vaccine supplied by the federal government and reported under procedure code 90611 or 90622; these codes are informational only.

Covered and Informational Vaccine Codes

Adult vaccine services becoming Texas Medicaid benefitsCPTCovered

90476	Adult vaccine procedure; recognized component count 1; age range 19-50 years
90477	Adult vaccine procedure; recognized component count 1; age range 19-50 years
90581	Adult vaccine procedure; recognized component count 1; age range 19-65 years
90625	Adult vaccine procedure; recognized component count 1; age range 19-64 years
90626	Adult vaccine procedure; recognized component count 1; age 19 years or older
90627	Adult vaccine procedure; recognized component count 1; age 19 years or older
90690	Adult vaccine procedure; recognized component count 1; age 19 years or older
90691	Adult vaccine procedure; recognized component count 1; age 19 years or older
90717	Adult vaccine procedure; recognized component count 1; age 19 years or older
90738	Adult vaccine procedure; recognized component count 1; age 19 years or older

RSV vaccine servicesCPTCovered

90678	RSV vaccine; covered for clients age 60 or older subject to place-of-service and provider-type rules
90679	RSV vaccine; covered for clients age 60 or older subject to place-of-service and provider-type rules

Diagnosis restriction changeCPTCovered

90675

Vaccine procedure code no longer subject to diagnosis restriction

Smallpox and mpox vaccinesCPT

90611	Smallpox/mpox vaccine product supplied by the federal government; informational only
90622	Smallpox/mpox vaccine product supplied by the federal government; informational only

General adult vaccine age requirement

Minimum client age19 years and older

Codes 90476 and 90477 age range

Eligible procedure codes90476 and 90477

Client age range19-50 years

Code 90581 age range

Procedure code90581

Billing and Claim Handling

Billing Rule

Bill newly covered adult vaccine services

Submit eligible adult vaccine services and related administration services for reimbursement when the vaccine is FDA approved or authorized for emergency use, recommended by ACIP, and the client meets the applicable age requirements.

Covered adult vaccine procedure codes include 90476, 90477, 90581, 90625, 90626, 90627, 90690, 90691, 90717, and 90738.
Services are reimbursable for eligible providers in the office setting and hospital providers in the outpatient hospital setting.

Billing Rule

Bill covered RSV vaccines

Submit RSV vaccine procedure codes 90678 and 90679 for clients who are 60 years of age or older only when the provider type and place of service are eligible.

Eligible combinations include physician offices; homes for specified practitioners and the Comprehensive Care Program; outpatient hospitals for hospital providers; and other locations for specified practitioners and the Comprehensive Care Program.