Texas

Last updated 12/17/2024

Consent Requirements

A parent or legal guardian must provide written or verbal consent to the distant site provider to allow any other individual, other than the health professional as required by Texas Government Code §531.0217(c-4)(4) for school-based telemedicine, to be physically present in the distant or patient site environment during a telehealth or telemedicine service with a child.

An adult client must also provide written or verbal consent to the distant site provider to allow any other individual to be physically present in the distant or patient site environment during a telehealth or telemedicine service.

Documentation of the written or verbal consent must be maintained in the client’s medical record. (In CSHCN Manual only).

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 4-5  (Dec. 2024) &  TX Medicaid CSHCN Services Program Provider Manual Telecommunication Services (Nov. 2024), p. 4. [language varies] (Accessed Dec. 2024).

The commission shall ensure that Medicaid reimbursement is provided to a physician for a telemedicine medical service provided by the physician, even if the physician is not the patient’s primary care physician or provider, if:

• the physician is an authorized health care provider under Medicaid;
• the patient is a child who receives the service in a primary or secondary school-based setting; and
• the parent or legal guardian of the patient provides consent before the service is provided.

SOURCE: TX Govt. Code Sec. 531.0217., [repealed eff. Apr. 1, 2025],(Accessed Dec. 2024).

Provider must obtain informed consent from the client, client’s parent, or the client’s legally authorized representative prior to rendering a behavioral health service through a synchronous audio-only technology platform; except when doing so is not feasible or could result in death or injury to the client. Verbal consent is permissible and must be documented in the client’s medical record.

The distant site provider must obtain informed consent to treatment from the patient, patient’s parent, or the patient’s guardian prior to rendering a telemedicine medical service.

The distant site provider must obtain informed consent to treatment from the patient, patient’s parent or the patient’s legal guardian prior to rendering a telehealth service.

If a patient has a primary care provider who is not the distant site provider and the patient or their parent or legal guardian provides consent to a release of information, a distant site provider must provide the patient’s primary care provider with the following information:

• A medical record or report with an explanation of the treatment provided by the distant site provider
• The distant site provider’s evaluation, analysis, or diagnosis of the patient

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6, 8, 11, 12  (Dec. 2024). (Accessed Dec. 2024).

School-Based Setting

The parent or legal guardian of the client provides consent before the service is provided.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 10  (Dec. 2024). (Accessed Dec. 2024).

If a patient receiving a telemedicine medical service has a primary care physician or provider and consents or, if appropriate, the patient’s parent or legal guardian consents to the notification, the commission shall require that the primary care physician or provider be notified of the telemedicine medical service for the purpose of sharing medical information. In the case of a service provided to a child in a school-based setting as described by Subsection (c-4), the notification, if any, must include a summary of the service, including exam findings, prescribed or administered medications, and patient instructions.

If a patient receiving a telemedicine medical service in a school-based setting as described by Subsection (c-4) does not have a primary care physician or provider, the commission shall require that the patient’s parent or legal guardian receive:

• The notification required under Subsection (g); and
• A list of primary care physicians or providers from which the patient may select the patient’s primary care physician or provider.

SOURCE: TX Govt. Code Sec. 531.0217., [repealed eff. Apr. 1, 2025],(Accessed Dec. 2024).

Conditions for telemedicine medical services provided in a primary or secondary school-based setting.

For a child receiving telemedicine medical services in a primary or secondary school-based setting, advance parent or legal guardian consent for a telemedicine medical service must be obtained.

The patient’s primary care physician or provider must be notified of a telemedicine medical service, unless the patient does not have a primary care physician or provider.

• The patient receiving the telemedicine medical service, or the patient’s parent or legal guardian, must consent to the notification.
• For a telemedicine medical service provided to a child in a primary or secondary school-based setting, the notification must include a summary of the service, including:
  • exam findings;
  • prescribed or administered medications; and
  • patient instructions.

If a child receiving a telemedicine medical service in a primary or secondary school-based setting does not have a primary care physician or provider, the child’s parent or legal guardian must be offered:

• the information in subparagraph (B)(ii) of this paragraph; and
• a list of primary care physicians or providers from which to select the child’s primary care physician or provider.

Telemedicine medical services provided in a school-based setting by a physician, even if the physician is not the patient’s primary care physician or provider, are reimbursed if:

• the physician is enrolled as a Medicaid provider;
• the patient is a child who receives the service in a primary or secondary school-based setting; and
• the parent or legal guardian of the patient provides consent before the service is provided.

SOURCE: TX Admin Code, Title 1, Part 15, Sec. 354.1432, (Accessed Dec. 2024).

Physical Therapy, Occupational Therapy, and Speech Therapy

The provider should obtain informed consent for treatment from the patient, patient’s parent, or the patient’s legal guardian prior to rendering a telehealth service. Verbal consent is permissible and should be documented in the client’s medical record.

SOURCE: TX Medicaid Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook pg. 9 (Dec. 2024). (Accessed Dec. 2024).

Managed Care (also applies to START Kids and STAR Health)

When an MCO conducts a change in condition assessment using audio-visual communication, verbal consent must be obtained and documented, and a HIPAA-compliant audio-visual communication product must be used.

If verbal consent for audio-visual communication is not received, the MCO must use in-person communication.

The MCO must inform members who utilize audio-visual communication for change in condition assessments that the member’s services will be subject to the following:

• The MCO must monitor services for fraud, waste, and abuse.
• The MCO must determine whether additional social services or supports are needed.
• The MCO must ensure that verbal consent to use telecommunications is documented in writing.

See rules Sec. 1604-1506 for additional requirements for each program.

SOURCE: Title 1, Part 15, Sec. 353.1503, (Accessed Dec. 2024).

Last updated 12/17/2024

Definitions

Teledentistry

“Teledentistry dental service” means a health care service delivered by a dentist, or a health professional acting under the delegation and supervision of a dentist, acting within the scope of the dentist’s or health professional’s license or certification to a patient at a different physical location than the dentist or health professional using telecommunications or information technology.

SOURCE: Insurance Code Title 8, Subtitle F, Ch. 1455.001 refers to Occupations Code, Sec. 111.001. (Accessed Dec. 2024).

“Telehealth service” means a health service, other than a telemedicine medical service or a teledentistry dental service, delivered by a health professional licensed, certified, or otherwise entitled to practice in this state and acting within the scope of the health professional’s license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.

“Telemedicine medical service” means a health care service delivered by a physician licensed in this state, or a health professional acting under the delegation and supervision of a physician licensed in this state, and acting within the scope of the physician’s or health professional’s license to a patient at a different physical location than the physician or health professional using telecommunications or information technology.

SOURCE: TX Admin. Code, Title 1 Sec. 354.1430, & TX Government Code, Sec. 531.001  & TX Admin Code, Part 1, Ch. 97,  Ch. 157, Sec. 157.2, refers to Occupations Code, Sec. 111.001. (Accessed Dec. 2024).

Synchronous audiovisual technology – An interactive, two-way audio and video telecommunications platform that meets the privacy requirements of the Health Insurance Portability and Accountability Act.

Standards of Care in Crisis Stabilization Units 

Telehealth service–A health-care service, other than telemedicine medical services, delivered by a health professional licensed, certified or otherwise entitled to practice in Texas and acting within the scope of the health professional’s license, certification or entitlement to an individual at a different physical location other than the health professional using telecommunications or information technology, in accordance with Texas Occupation Code §111.001(3).

Telemedicine medical service–A health-care service delivered to an individual at a different physical location using telecommunications or information technology by:

• a physician licensed in Texas; or
• a health professional who acts under the delegation and supervision of a physician licensed in Texas and within the scope of the health professional’s license in Texas.

SOURCE: TX Admin Code, Title 26, Part 1, Ch. 306, Subchapter B, Sec. 306.45, (Accessed Dec. 2024).

SOURCE: TX Admin Code Sec. 133.182, (Accessed Dec. 2024).

Children with Special Health Care Needs (CSHCN) Program

Telemedicine is defined as a health-care service that is either initiated by a physician who is licensed to practice medicine in Texas or provided by a health professional who is acting under physician delegation and supervision.

SOURCE:  TX Medicaid CSHCN Services Program Provider Manual: Telecommunication Services (Nov. 2024), p. 4.  (Accessed Dec. 2024).

Last updated 12/17/2024

Email, Phone & Fax

Telemedicine medical services and telehealth services are authorized service delivery methods for Texas Medicaid covered services as provided in this section. All telemedicine medical services and telehealth services are subject to the specifications, conditions, limitations, and requirements established by the Texas Health and Human Services Commission (HHSC) or its designee.

• A client must not be required to receive a covered service as a telemedicine medical service or telehealth service except in the event of an active declaration of state of disaster and at the direction of HHSC.
• In the event of a declaration of state of disaster, HHSC may issue direction to providers regarding the use of telemedicine medical services and telehealth services, including the use of an audio-only platform, to provide covered services to clients who reside in the area subject to the declaration of state of disaster.
• HHSC considers the following criteria when determining whether a covered service may be delivered as telemedicine medical service or telehealth service, including via an audio-only platform:
  • Clinical effectiveness;
  • Cost effectiveness;
  • Health and safety;
  • Patient choice and access to care; and
  • Other criteria specific to the service.

Conditions for reimbursement applicable to behavioral health services provided through an audio-only platform are described in this section.

• The provider must be enrolled in Texas Medicaid.
• The provider must obtain informed consent from the client, client’s parent, or the client’s legally authorized representative prior to rendering a behavioral health service via an audio-only platform; except when doing so is not feasible or could result in death or injury to the client. Verbal consent is permissible and must be documented in the client’s medical record.
• The covered services must be provided in compliance with the standards established by the respective licensing or certifying board of the professional providing the audio-only telemedicine medical service or audio-only telehealth service.
• Behavioral health services provided via audio-only platform must be designated for reimbursement by HHSC. Behavioral health services provided via an audio-only platform designated for reimbursement are those that are clinically effective and cost-effective, as determined by HHSC and in accordance with §354.1432(3) of this subchapter (relating to Telemedicine and Telehealth Benefits and Limitations). Behavioral health services that HHSC has determined are clinically effective and cost-effective when provided via an audio-only platform can be found in the Texas Medicaid Provider Procedures Manual (TMPPM).

SOURCE: TX Admin Code Title 1, Sec. 354.1435, (Accessed Dec. 2024).

• Synchronous audio-only technology between the distant site provider and the client in another location

A Texas Medicaid Managed Care organization (MCO) is not required to provide reimbursement for telemedicine services [or telehealth service] that are provided through the following methods:

• A text-only email message
• A facsimile transmission

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6, 9, 12-13 (Dec. 2024). (Accessed Dec. 2024).

Conditions for reimbursement applicable to telemedicine and telehealth provided using a synchronous audiovisual technology platform, or using store and forward technology in conjunction with synchronous audio-only are those that meet the following conditions:

• Must be designated for reimbursement by HHSC.
• Must be clinically effective and cost-effective, as determined and published in the benefit language by HHSC.
• May not be denied solely because an in-person medical service between a provider and client did not occur.
• May not be limited by requiring the provider to use a particular synchronous audiovisual technology platform to receive reimbursement for the service.

Other conditions for reimbursement applicable to services may vary by service type. Providers may refer to the appropriate TMPPM handbook for additional information on synchronous audiovisual technology platform coverage conditions.

Note: : Telemedicine and telehealth services that HHSC has determined are clinically effective and cost-effective when provided via a synchronous audiovisual technology platform or using store and forward technology in conjunction with synchronous audio-only technology can be found in the appropriate TMPPM handbooks.

Conditions for reimbursement applicable to behavioral health services provided using a synchronous audio-only technology platform are those that meet the following conditions:

• Must be designated for reimbursement by HHSC.
• Provider must obtain informed consent from the client, client’s parent, or the client’s legally authorized representative prior to rendering a behavioral health service through a synchronous audio-only technology platform; except when doing so is not feasible or could result in death or injury to the client. Verbal consent is permissible and must be documented in the client’s medical record.
• Must be clinically effective and cost-effective, as determined and published in the benefit language by HHSC.
• May not be denied solely because an in-person medical service between a provider and client did not occur.
• May not be limited by requiring the provider to use a particular synchronous audio-only technology platform to receive reimbursement for the service.
• Other conditions for reimbursement applicable to behavioral health services may vary by service type. Providers may refer to the appropriate TMPPM handbook for additional information on audio-only coverage conditions.

Conditions for reimbursement applicable to non-behavioral health services provided using a synchronous audio-only technology platform:

• Must be designated for reimbursement by HHSC.
• Clinically effective and cost-effective, as determined and published by HHSC.
• May not be denied solely because an in-person medical service between a provider and client did not occur.
• May not be limited by requiring the provider to use a particular synchronous audio-only technology platform to receive reimbursement for the service.

Note: Behavioral or non-behavioral health services that HHSC has determined are clinically effective and cost-effective when provided via a synchronous audio-only technology platform can be found in the appropriate TMPPM handbooks.

Telemedicine and telehealth services are reimbursed in accordance with 1 TAC §355.

In the event of a Declaration of State of Disaster, HHSC will issue direction to providers regarding the use of telemedicine or telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law.

Declaration of State of Disaster is when to an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Texas Government Code §418.014.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6-7 (Dec. 2024). (Accessed Dec. 2024).

Procedure codes that are reimbursed to distant site providers when billed with the 93 modifier (audio-only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the 93 modifier.

Behavioral health procedure codes that are reimbursed to distant site providers when billed with the FQ modifier (audio-only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the FQ modifier.

See manual for codes MCOs must reimburse when delivered via telemedicine services.

Texas Medicaid MCOs may optionally provide reimbursement for telemedicine services that are provided through asynchronous audio-only technology, such as voice mail technology. Distant site providers should contact each MCO to determine whether an MCO provides reimbursement for a specified modality.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 8-9, Dec. 2024 (Accessed Dec. 2024).

Telemedicine medical services used for the treatment of chronic pain with scheduled drugs via audio-only is prohibited, unless a patient:

• Is an established chronic pain patient of the physician or health professional issuing the prescription;
• Is receiving a prescription that is identical to a prescription issued at the previous visit; and
• Has been seen by the prescribing physician or health professional defined under Section 111.001(1) of Texas Occupations Code, in the last 90 days either in-person or via telemedicine using audiovisual communication.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 10 (Dec. 2024). (Accessed Dec. 2024).

Case Management for Children and Pregnant Women

Case Management for Children and Pregnant Women services are limited to one contact per day per person. Additional provider contacts on the same day are denied as part of another service rendered on the same day. Prior authorization is not required for case management services.

Procedure code G9012, with required modifiers, may be reimbursed for Case Management for Children and Pregnant Women (CPW) services. Modifiers are used to identify which service component is provided.

CPW services may be provided using synchronous audiovisual technologies if clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on policy restrictions for services delivered by synchronous telephone (audio-only) technologies. Services delivered using audio-only technologies must be billed using the 93 modifier.

During a Declaration of State Disaster, HHSC may issue direction to providers regarding the use of a telemedicine or telehealth service to include the use of synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

A follow-up visit may be completed in-person or through the use of synchronous audiovisual technology, or synchronous telephone (audio-only) technology. Follow-up visits completed using synchronous audiovisual technology or synchronous telephone (audio-only) technology should only be provided if agreed to by the client, parent, or legal guardian.

Intellectual and Developmental Disabilities Service Coordination

Supportive Encounter (Type B):  A face-to-face, telephone, or telemedicine contact with a person or with a collateral on the person’s behalf to provide service coordination.

Outpatient Mental Health Services

The following MHR services may be provided by synchronous telephone (audio-only) technology to persons with whom the billing provider has an existing clinical relationship and if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services or LAR. In addition, except for crisis intervention services, approval to deliver the services by synchronous telephone (audio-only) technology must be documented in the plan of care of the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers of MHR services must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. MHR services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.

• Medication training and support
• Skills training and development
• Psychosocial rehabilitation services
• Crisis intervention services
  • Synchronous telephone (audio-only) technology may only be used for crisis intervention services as a back-up mode of delivery only, meaning if the person who is in crisis, not the billing provider, is unwilling or has limited technological capabilities that prevent them from using a synchronous audiovisual platform at the time the crisis intervention services are delivered. Also, the existing clinical relationship requirement is waived.
  • Documented approval of the use of synchronous telephone (audio-only) technology in the plan of care is not required prior to the delivery of crisis intervention services. However, providers must document the justification for using synchronous telephone (audio-only) technology to deliver crisis intervention services in the medical record.

An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual MHR, MHTCM, or peer specialist service from the same billing provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology. The six-month requirement for at least one in-person or synchronous MHR, MHTCM, or peer specialist audiovisual service by the same billing provider prior to the initial synchronous telephone (audio-only) service may not be waived.

Note:  “Same billing provider” refers to providers that are within the same entity, as identified by the entity’s NPI number or numbers, if the entity has multiple locations (i.e., the same LMHA/LBHA or same non-LMHA/private provider).

Note:  The required in-person or synchronous audiovisual-delivered MHTCM, MHR, or peer specialist service may be delivered by another authorized professional or paraprofessional of the same LMHA/LBHA or the same non-LMHA as the professional or paraprofessional who delivers the service by synchronous telephone (audio-only) technology.

The billing provider is required to conduct at least one in-person or synchronous audiovisual MHR, MHTCM, or peer specialist service every rolling 12 months from the date of the initial service delivered by synchronous telephone (audio-only) technology unless the person receiving services and the billing provider agree that an in-person or synchronous audiovisual service is clinically contraindicated, or the risks or burdens of an in-person or synchronous audiovisual service outweigh the benefits. The decision to waive the 12-month requirement applies to that particular rolling 12-month period and the basis for the decision must be documented in the person’s medical record. Examples of when a synchronous telephone (audio-only) service may be more clinically appropriate or beneficial than an in-person or synchronous audiovisual service include, but are not limited to, the following:

• The person receiving services is located at a qualifying originating site in an eligible geographic area, e.g., a practitioner office in a rural Health Professional Shortage Area.
• An in-person or synchronous audiovisual service is likely to cause disruption in service delivery or has the potential to worsen the person’s condition(s).

Note: The required in-person or synchronous audiovisual-delivered MHTCM, MHR, or peer specialist service may be delivered by another authorized professional or paraprofessional of the same LMHA/LBHA or the same non-LMHA as the professional or paraprofessional who delivers the service by synchronous telephone (audio-only) technology.

Peer Specialist Services

Peer specialist services may be provided by synchronous telephone (audio-only) technology to persons with whom the billing provider has an existing clinical relationship and if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. In addition, approval to deliver the services by synchronous telephone (audio-only) technology must be documented in the person-centered recovery plan of the person receiving services.

Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers of peer specialist services must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. Peer specialist services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.

An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual peer specialist, MHTCM, or MHR service from the same billing provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology. The six-month requirement for at least one in-person or synchronous audiovisual peer specialist, MHTCM, or MHR service from the same billing provider prior to the initial synchronous telephone (audio-only) service may not be waived.

Note: “Same billing provider” refers to providers that are within the same entity or organization, as identified by the entity’s or organization’s NPI number or numbers, if the entity or organization has multiple locations (i.e., the same LMHA/LBHA, comprehensive provider agency of mental health targeted case management or rehabilitative services, clinic/group practice, FQHC, rural health clinic, or chemical dependency treatment facility, or opioid treatment provider) presuming all other applicable state and federal laws and regulations are followed.

Note: The required in-person or synchronous audiovisual delivered peer specialist, MHTCM, or MHR service may be delivered by another authorized professional or paraprofessional of the same billing provider as the professional or paraprofessional who delivers the service by synchronous telephone (audio-only) technology.

The billing provider is required to conduct at least one in-person or synchronous audiovisual peer specialist, MHTCM, or MHR service every rolling 12 months from the date of the initial service delivered by synchronous telephone (audio-only) technology unless the person receiving services and the billing provider agree that an in-person or synchronous audiovisual service is clinically contraindicated, or the risks or burdens of an in-person or synchronous audiovisual service outweigh the benefits.  The decision to waive the 12-month requirement applies to that particular rolling 12-month period and the basis for the decision must be documented in the person’s medical record. Examples of when a synchronous telephone (audio-only) service may be more clinically appropriate or beneficial than an in-person or synchronous audiovisual service include, but are not limited to, the following:

• The person receiving services is located at a qualifying originating site in an eligible geographic area, e.g., a practitioner office in a rural Health Professional Shortage Area.
• An in-person or synchronous audiovisual service is likely to cause disruption in service delivery or has the potential to worsen the person’s condition.

Note:  The required in-person or synchronous audiovisual delivered peer specialist, MHTCM, or MHR service may be delivered by another authorized professional or paraprofessional of the same billing provider as the professional or paraprofessional who delivers the service by synchronous telephone (audio-only) technology.

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

SBIRT services may be provided by synchronous telephone (audio-only) technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. SBIRT services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.  See manual for additional information.

Medication Assisted Treatment Services

The following SUD services may be provided by synchronous telephone (audio-only) technology to persons with whom the billing provider has an existing clinical relationship and if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers of SUD services must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. SUD services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.

• Comprehensive assessment (procedure code H0001) – Only during certain public health emergencies or natural disasters; to the extent allowed by federal law (assessments for withdrawal management services are excluded); and the existing clinical relationship requirement is waived.
• Individual and group counseling (procedure codes H0004 and H0005)

An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual SUD service (comprehensive assessment, individual or group counseling, MAT, outpatient or residential withdrawal management, or residential treatment services) from the same provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology. The six-month requirement for at least one in-person or synchronous audiovisual service by the same billing provider prior to the initial synchronous telephone (audio-only) service may not be waived.

Note: “Same billing provider” refers to providers within the same entity or organization, as identified by the entity’s or organization’s NPI number or numbers, if the entity or organization has multiple locations (i.e., CDTF, OTP or clinic, or group practice).

Note: The required in-person or synchronous audiovisual-delivered SUD service (comprehensive assessment, individual or group counseling, MAT, outpatient or residential withdrawal management, or residential treatment services) may be delivered by another authorized professional or paraprofessional of the same billing provider as the professional or paraprofessional who delivers the service by synchronous telephone (audio-only) technology, presuming all other applicable state and federal laws and regulations are followed.

The billing provider is required to conduct at least 1 in-person or synchronous audiovisual SUD service (comprehensive assessment, individual or group counseling, MAT, outpatient or residential withdrawal management, or residential treatment services) every rolling 12 months from the date of the initial service delivered by synchronous telephone (audio-only) technology unless the person receiving services and the billing provider agree that an in-person or synchronous audiovisual service is clinically contraindicated, or the risks or burdens of an in-person or synchronous audiovisual service outweigh the benefits. The decision to waive the 12-month requirement applies to that particular rolling 12-month period and the basis for the decision must be documented in the person’s medical record. Examples of when a synchronous telephone (audio-only) service may be more clinically appropriate or beneficial than an in-person or synchronous audiovisual service include, but are not limited to, the following:

• The person receiving services is located at a qualifying originating site in an eligible geographic area, e.g., a practitioner office in a rural Health Professional Shortage Area.
• An in-person or synchronous audiovisual service is likely to cause disruption in service delivery or has the potential to worsen the person’s condition(s).

Note: The required in-person or synchronous audiovisual-delivered SUD service (comprehensive assessment, individual or group counseling, MAT, outpatient or residential withdrawal management, or residential treatment services) may be delivered by another authorized professional, or paraprofessional, of the same billing provider as the professional, or paraprofessional, who delivers the service by synchronous telephone (audio-only) technology, presuming all other applicable state and federal laws and regulations are followed.

SOURCE: TX Medicaid Behavioral Health and Case Management Services Handbook, (Dec. 2024). (Accessed Dec. 2024).

A cardiac rehabilitation program in which the cardiac monitoring is done using telephonically transmitted electrocardiograms (ECGs) to a remote site is not a benefit of Texas Medicaid.

SOURCE: TX Medicaid Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, (Aug. 2024), pg. 66 (Accessed Aug. 2024).

For the diagnosis, evaluation and treatment of a mental health or substance use condition, as well as non-behavioral health conditions, the following office and other outpatient services may be provided by synchronous telephone (audio-only) technology if clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology for telemedicine and telehealth services. Therefore, providers must document in the client’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. Established patient services for mental health or substance use conditions provided by synchronous telephone (audio-only) technology must be billed using modifier FQ. Established patient services for non-behavioral health conditions provided by synchronous telephone (audio-only) technology must be billed using modifier 93.

Procedure code 99211 may be delivered by synchronous telephone (audio-only) technology during certain public health emergencies only.

See manual for more details on procedure codes.

SOURCE: TX Medicaid Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, (Dec. 2024), pg. 179 (Accessed Dec. 2024).

CSHCN – Physicians

Non-face-to-face specialist or subspecialist telephone consultations (procedure code 99499 with modifier U9) are a benefit for a specialist or subspecialist when the clinician providing the medical home contacts the specialist for advice or a referral and the consultation is at least 15 minutes in duration.

Telephone consultations are defined by the CSHCN Services Program as the process where the specialist or subspecialist receives a telephone call from the clinician providing the medical home. During the telephone call, the specialist or subspecialist assesses and manages the client’s condition by providing advice or referral to a more appropriate provider.

Specifically, non-face-to-face clinician supervision of the development or revision of a client’s care plan (care plan oversight services) may include the following activities.

These services do not have to be contiguous:

• Review of charts, reports, treatment plans, or lab or study results, except for the initial interpretation or review of lab or study results ordered during or associated with a face-to-face encounter
• Telephone calls with other clinicians (not employed in the same practice), including specialists or subspecialists involved in the care of the client
• Telephone or face-to-face discussions with a pharmacist about pharmacological therapies (not just ordering a prescription)
• Medical decision making
• Activities to coordinate services (if the coordination activities require the skill of a clinician)
• Documentation of the services provided, including writing a note in the client chart describing services provided, decision making performed, and amount of time spent performing the countable services, including time spent by the physician working on the care plan after the nurse has conveyed pertinent information from agencies or facilities to the physician, including the start and stop times

See manual or activities not covered as non-face-to-face oversight/supervision of the development or revision of the client’s care plan.

Non-face-to-face specialist or subspecialist telephone consultations may be billed with procedure code 99499 and modifier U9.

A specialist or subspecialist telephone consultation is limited to two every 6 months by the same provider.

The specialist or subspecialist must maintain documentation of the telephone consultation using the CSHCN Services Program Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services Form or similar clinical record documentation. These records are subject to retrospective review.

Non-face-to-face specialist or subspecialist telephone consultations do not require authorization.

Preventive care medical checkups are not a benefit of a telemedicine or telehealth service.

SOURCE: TX Medicaid CSHCN Services Program Manual – Physician, (Nov. 2024), (Accessed Dec. 2024).

To the extent permitted by state and federal law and to the extent it is cost-effective and clinically effective, as determined by the commission, the executive commissioner by rule shall develop and implement a system that ensures behavioral health services may be provided using an audio-only platform consistent with Section 111.008, Occupations Code, to a Medicaid recipient, a child health plan program enrollee, or another individual receiving those services under another public benefits program administered by the commission or a health and human services agency.

If the executive commissioner determines that providing services other than behavioral health services is appropriate using an audio-only platform under a public benefits program administered by the commission or a health and human services agency, in accordance with applicable federal and state law, the executive commissioner may by rule authorize the provision of those services under the applicable program using the audio-only platform. In determining whether the use of an audio-only platform in a program is appropriate under this subsection, the executive commissioner shall consider whether using the platform would be cost-effective and clinically effective.

SOURCE: TX Government Code Title 4, Subtitle I, Chapter 531, Subchapter A, Sec. 531.02161. [Repealed eff. Apr. 1, 2025], (Accessed Dec. 2024).

Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telehealth services.

Providers must defer to the needs of the client receiving services, allowing the mode of service delivery to be accessible, person- and family-centered, and primarily driven by the client in service’s choice and not provider convenience.

Services delivered by synchronous audiovisual technology will require participation of a parent or caregiver to assist with the treatment.

Therapy assistants may deliver services and receive supervision using synchronous audiovisual technology in accordance with each discipline’s rules. Providers should refer to state practice rules and national guidelines regarding supervision requirements for each discipline.

See manual for applicable codes.

Telehealth Exclusions

See manual for procedure codes that are in-person only and will not be reimbursed if provided through telehealth delivery.

Any PT, OT, ST, and SST services delivered through synchronous telephone (audio-only) technology is not a benefit.

During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of a telehealth service to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

See Children’s Services Handbook for a list of procedure codes that are in-person only and will not be reimbursed if provided through telehealth delivery.

Targeted Case Management (TCM)

TCM services (procedure code T1017) may also be delivered using a synchronous telephone (audioonly) platform. TCM services delivered using a synchronous telephone (audio-only) platform are subject to the restrictions outlined in the Telecommunication Services Handbook (Vol. 2, Provider Handbooks).

Health and Behavior Assessment and Intervention

HBAI services may be provided by synchronous telephone (audio-only) technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. HBAI services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ. See manual for eligible services and additional requirements.

Medical Nutrition Counseling Services (CCP)

Certain telehealth services may be provided for medical nutrition therapy and nutrition counseling services clients if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interactions, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telehealth services. Therefore, providers must document in the person’s medical record the reason(s) that services were delivered by synchronous telephone (audio-only) technology.  See chart in manual for services are authorized for telehealth delivery using synchronous audiovisual and synchronous telephone (audio-only) technologies.

The procedure codes in the table above may be delivered by synchronous telephone (audio-only) technology only during certain PHE or natural disasters.

Medical nutrition counseling services (procedure code S9470) are authorized for telehealth delivery using synchronous audiovisual and synchronous telephone (audio-only) technologies, when noted.

Medical nutrition counseling services (procedure code S9470) may be delivered by synchronous telephone (audio-only) technology only during certain PHE or natural disasters. Services provided by synchronous audio-visual technology must be billed using modifier 95. Services delivered using audio-only technologies must be billed using modifier 93. Documentation requirements for a telehealth service are the same as for an in-person visit and must accurately reflect the services rendered. Documentation must identify the means of delivery when provided.

During a Declaration of State of Disaster, the Texas Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

SOURCE: TX Medicaid Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook pg. 10, (Dec. 2024). (Accessed Dec. 2024).

Healthy Texas Women (HTW) Program/HTW Plus

Certain telemedicine and telehealth services may be provided for HTW clients if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interactions, such as an in-person visit, as well as the use of synchronous audio-visual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. See manual for codes.

See manual for synchronous telephone (audio-only) technology services that are eligible only during certain PHE or natural disasters.

Established client services for behavioral health or substance use conditions provided by synchronous telephone (audio-only) technology must be billed using modifier FQ. Established patient services for non-behavioral health conditions provided by synchronous telephone (audio-only) technology must be billed using modifier 93.  See manual for codes.

Behavioral health services delivered using synchronous telephone (audio-only) technologies must be billed using the FQ modifier. Non-behavioral health services delivered using synchronous telephone (audio-only) technologies must be billed using the 93 modifier.

HTW Plus: Procedure code H0001 is authorized for delivery by synchronous telephone (audio-only) technology only during certain public health emergencies or natural disasters; to the extent allowed by federal law (assessments for withdrawal management services are excluded); and the ‘existing clinical relationship’ requirement is waived.

FQHCs and RHCs may be reimbursed for telemedicine and telehealth in the following manner:

• The distant site provider fee is reimbursable as a prospective payment system (PPS), alternative prospective payment system (APPS), or AIR (All Inclusive Rate) PPS.
• The facility fee (procedure code Q3014) is an add-on procedure code that should not be included in any cost reporting that is used to calculate a FQHC PPS, APPS, or the RHC AIR (All Inclusive Rate) PPS per visit encounter rate.

Last updated 12/17/2024

Live Video

POLICY

Synchronous audiovisual technology – An interactive, two-way audio and video telecommunications platform that meets the privacy requirements of the Health Insurance Portability and Accountability Act.

Telemedicine/Telehealth Service Delivery:  The following delivery methods may be used to provide telemedicine within fee-for-service (FFS) Medicaid:

• Synchronous audiovisual technology between the distant site provider and the client in another location …

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 5 & 9 (Dec. 2024), (Accessed Dec. 2024).

The executive commissioner by rule shall develop and implement a system to reimburse providers of services under Medicaid for services performed using telemedicine medical services, teledentistry dental services, or telehealth services.

SOURCE: TX Govt. Code Sec. 531.0216. [repealed eff. April 1, 2025], (Accessed Dec. 2024).

The executive commissioner by rule shall require each health and human services agency that administers a part of Medicaid to provide Medicaid reimbursement for a telemedicine medical service initiated or provided by a physician.

The commission shall ensure that reimbursement is provided only for a telemedicine medical service initiated or provided by a physician.

The commission shall ensure that Medicaid reimbursement is provided to a physician for a telemedicine medical service provided by the physician, even if the physician is not the patient’s primary care physician or provider, if:

• The physician is an authorized health care provider under Medicaid;
• The patient is a child who receives the services in a primary or secondary school-based setting; and
• The parent or legal guardian of the patient provides consent before the services is provided.

The commission shall require reimbursement for a telemedicine medical service at the same rate as Medicaid reimburses for the same in-person medical service. A request for reimbursement may not be denied solely because an in-person medical service between a physician and a patient did not occur. The commission may not limit a physician’s choice of platform for providing a telemedicine medical service or telehealth service by requiring that the physician use a particular platform to receive reimbursement for the service.

SOURCE: TX Govt. Code Sec. 531.0217(d), [repealed eff. April 1, 2025 (Accessed Dec. 2024).

Telemedicine and telehealth services are reimbursed in accordance with 1 TAC §355.

In the event of a Declaration of State of Disaster, HHSC will issue direction to providers regarding the use of telemedicine or telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law.

Declaration of State of Disaster is when to an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Texas Government Code §418.014.

A valid practitioner-patient relationship must exist between the distant site provider and the patient. A valid practitioner-patient relationship exists between the distant site provider and the patient if:

• The distant site provider meets the same standard of care required for and in-person service.
• The relationship can be established through:
  • A prior in-person service.

SOURCE: TX Medicaid Telecommunication Services Handbook, Jan. 2024, p. 5, 7 and 8, (Aug. 2024) (Accessed Aug. 2024).

The following delivery methods may be used to provide telemedicine [telehealth] within fee-for-service (FFS) Medicaid:

• Synchronous audiovisual technology between the distant site provider and the client in another location
• Synchronous audio-only technology between the distant site provider and the client in another location
• Store and forward technology in conjunction with synchronous audio-only technology between the distant site provider and the client in another location. The distant site provider must use one of the following:
  • Clinically relevant photographic or video images, including diagnostic images
  • The client’s relevant medical records, such as medical history, laboratory and pathology results, and prescriptive histories

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 9, & 13-14, (Aug. 2024). (Accessed Aug. 2024).

Eligible distant site providers are reimbursed in the same manner as their other professional services.  See administrative code for each provider type and the reference for the code under which TX Medicaid pays in the same manner of.

SOURCE: TX Admin. Code, Title 1 Sec. 355.7001, (Accessed Dec. 2024).

CSHCN Program

Authorization is not required for telemedicine or telehealth services, however prior authorization may be required for the individual procedure codes billed.

Telemedicine and telehealth services must be provided in compliance with standards established by the respective licensing or certifying board of the professional providing the services.

Only those services that involve direct face-to-face interactive video communication between the client and the distant-site provider constitute a telemedicine or telehealth service. No separate reimbursement will be made for the cost of telemedicine and telehealth hardware or equipment, electronic documentation, and transmissions. Telephone conversations, chart reviews, electronic mail messages, and fax transmissions alone do not constitute a telemedicine or telehealth interactive video service and will not be reimbursed as telemedicine or telehealth services.

Telecommunication services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

SOURCE: TX Medicaid CSHCN Services Program Provider Manual: Telecommunication Services (Nov. 2024), p. 3., 13  (Accessed Dec. 2024).

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ELIGIBLE SERVICES/SPECIALTIES

Telemedicine medical services and telehealth services are authorized service delivery methods for Texas Medicaid covered services as provided in this section. All telemedicine medical services and telehealth services are subject to the specifications, conditions, limitations, and requirements established by the Texas Health and Human Services Commission (HHSC) or its designee.

• A client must not be required to receive a covered service as a telemedicine medical service or telehealth service except in the event of an active declaration of state of disaster and at the direction of HHSC.
• In the event of a declaration of state of disaster, HHSC may issue direction to providers regarding the use of telemedicine medical services and telehealth services, including the use of an audio-only platform, to provide covered services to clients who reside in the area subject to the declaration of state of disaster.
• HHSC considers the following criteria when determining whether a covered service may be delivered as telemedicine medical service or telehealth service, including via an audio-only platform:
  • Clinical effectiveness;
  • Cost effectiveness;
  • Health and safety;
  • Patient choice and access to care; and
  • Other criteria specific to the service.

Conditions for reimbursement applicable to telemedicine medical services.

• The provider must be enrolled in Texas Medicaid.
• The covered services must be provided in compliance with Texas Occupations Code Chapter 111 and Title 22 Texas Administrative Code Chapter 174 (relating to Telemedicine).
• A telemedicine medical service must be designated for reimbursement by HHSC. Telemedicine medical services designated for reimbursement are those that are clinically effective and cost-effective, as determined by HHSC and in accordance with paragraph (3) of this section. Covered services that HHSC has determined are clinically effective and cost-effective when provided as a telemedicine medical service can be found in the Texas Medicaid Provider Procedures Manual (TMPPM).

*See regulations for eligible sites topic for conditions for school-based settings.

Conditions for reimbursement applicable to telehealth services.

• The provider must be enrolled in Texas Medicaid.
• The covered services must be provided in compliance with Texas Occupations Code Chapter 111 and standards established by the respective licensing or certifying board of the professional providing the telehealth service.
• Telehealth services must be designated for reimbursement by HHSC. Telehealth services designated for reimbursement are those that are clinically effective and cost-effective, as determined by HHSC and in accordance with paragraph (3) of this section. Covered services that HHSC has determined are clinically effective and cost-effective when provided as a telehealth service can be found in the TMPPM.

Telemedicine & Telehealth

Not all Medicaid-covered services are authorized by HHSC for telemedicine or telehealth delivery in fee-for-service. Providers must always ensure the covered service is allowable by HHSC for telemedicine or telehealth services delivery.

Note: For example, if a service is authorized for telemedicine or telehealth delivery only when using synchronous audiovisual technology, that service may not be delivered using store and forward technology, store and forward technology in conjunction with synchronous audio-only technology, synchronous audio-only technology, or asynchronous audio-only technology.

Telemedicine or telehealth may be provided if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6, Dec. 2024, (Accessed Dec. 2024).

Telemedicine and telehealth services must be provided in compliance with standards established by the respective licensing or certifying board of the professional providing the services.

The use of telemedicine and telehealth services within intermediate care facilities for individuals with intellectual disabilities (ICD-IID) and State Supported Living Centers is subject to the policies established by the Health and Human Services Commission (HHSC).

More than one medically necessary telemedicine service or telehealth service may be reimbursed for the same date and same place of service if the services are billed by providers of different specialties.

Telemedicine medical services, also known as telemedicine, are allowable for Texas Medicaid. Telemedicine has the meaning assigned by Texas Occupations Code §111.001. Telemedicine services are defined as health-care services delivered by a physician licensed in Texas or a health professional who acts under the delegation and supervision of a health professional licensed in Texas and within the scope of the health professional’s license to a client at a different physical location using telecommunications or information technology. Telemedicine excludes teledentistry services.

Telehealth services, also known as telehealth, are allowable for Texas Medicaid. Telehealth has the meaning assigned by Texas Occupations Code §111.001. Telehealth services are defined as health-care services, other than telemedicine medical services or a teledentistry service, delivered by a health professional licensed, certified or otherwise entitled to practice in Texas and acting within the scope of the health professional’s license, certification or entitlement to a patient at a different physical location other than the health professional using telecommunications or information technology.

Telehealth services are reimbursed in accordance with 1 TAC §355.

Procedure codes that are reimbursed to distant site providers when billed with the 95 modifier (synchronous audiovisual technology) are included in the individual TMPPM handbooks. Procedure codes that indicate remote (telemedicine/telehealth) delivery in the description do not need to be billed with the 95 modifier.

Behavioral health procedure codes that are reimbursed to distant site providers when billed with the FQ modifier (audio-only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the FQ modifier.

See manual for codes MCOs must reimburse when delivered via telehealth.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 4, 7, 8-9 12 (Dec. 2024). (Accessed Dec. 2024).

Conditions for reimbursement applicable to telemedicine and telehealth provided using a synchronous audiovisual technology platform, or using store and forward technology in conjunction with synchronous audio-only are those that meet the following conditions:

• Must be designated for reimbursement by HHSC.
• Must be clinically effective and cost-effective, as determined and published in the benefit language by HHSC.
• May not be denied solely because an in-person medical service between a provider and client did not occur.
• May not be limited by requiring the provider to use a particular synchronous audiovisual technology platform to receive reimbursement for the service.

Other conditions for reimbursement applicable to services may vary by service type. Providers may refer to the appropriate TMPPM handbook for additional information on synchronous audiovisual technology platform coverage conditions.

Note: Telemedicine and telehealth services that HHSC has determined are clinically effective and cost-effective when provided via a synchronous audiovisual technology platform or using store and forward technology in conjunction with synchronous audio-only technology can be found in the appropriate TMPPM handbooks.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 6. (Dec. 2024). (Accessed Dec. 2024).

To the extent permitted by federal law and to the extent it is cost-effective and clinically effective, as determined by the commission, the commission shall ensure that Medicaid recipients, child health plan program enrollees, and other individuals receiving benefits under a public benefits program administered by the commission or a health and human services agency, regardless of whether receiving benefits through a managed care delivery model or another delivery model, have the option to receive services as telemedicine medical services, telehealth services, or otherwise using telecommunications or information technology, including the following services:

• preventive health and wellness services;
• case management services, including targeted case management services;
• subject to Subsection (c), behavioral health services;
•  occupational, physical, and speech therapy services;
• nutritional counseling services; and
• assessment services, including nursing assessments under the following Section 1915(c) waiver programs:
  • the community living assistance and support services (CLASS) waiver program;
  • the deaf-blind with multiple disabilities (DBMD) waiver program;
  • the home and community-based services (HCS) waiver program; and
  • the Texas home living (TxHmL) waiver program.

SOURCE:  TX Statute Sec. 531.02161, [repealed eff. April 1, 2025] (Accessed Dec. 2024).

Providers must defer to the needs of the person receiving services, allowing the mode of service delivery to be accessible, person- and family-centered, and primarily driven by the person’s choice and not provider convenience.

Providers must provide outpatient mental health services to Medicaid eligible persons in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1659. In addition, providers must deliver, to include delivery by telemedicine or telehealth, outpatient mental health services in full accordance with all applicable licensure and certification requirements.

During a Declaration of State of Disaster, the Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of a telemedicine or telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

Outpatient Mental Health Services

The following outpatient mental health services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. Outpatient mental health services provided by synchronous audiovisual technology must be billed using modifier 95.

The following SUD services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. SUD services provided by synchronous audiovisual technology must be billed using modifier 95.

• Comprehensive assessment
• Individual and group counseling
• MAT services – Prescribing of certain MAT medications may be done via telemedicine presuming all other applicable state and federal laws and regulations are followed.

Case Management for Children and Pregnant Women (CPW)

CPW services may be provided using synchronous audiovisual technologies if clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on policy restrictions for services delivered by synchronous telephone (audio-only) technologies. Services delivered using audio-only technologies must be billed using
the 93 modifier.

A follow-up visit may be completed in-person or through the use of synchronous audiovisual technology, or synchronous telephone (audio-only) technology. Follow-up visits completed using synchronous audiovisual technology or synchronous telephone (audio-only) technology should only be provided if agreed to by the client, parent, or legal guardian.

SOURCE: TX Medicaid Behavioral Health and Case Management Services Handbook, (Dec. 2024). (Accessed Dec. 2024).

Children’s Services

Telehealth services may be provided using synchronous audiovisual technologies if clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telehealth services.

Providers must defer to the needs of the client receiving services, allowing the mode of service delivery to be accessible, person- and family-centered, and primarily driven by the client in service’s choice and not provider convenience.

Services delivered by synchronous audiovisual technology will require participation of a parent or caregiver to assist with the treatment.

Therapy assistants may deliver services and receive supervision using synchronous audiovisual technology in accordance with each discipline’s rules. Providers should refer to state practice rules and national guidelines regarding supervision requirements for each discipline

The following procedure codes may be provided through telehealth delivery using synchronous audiovisual technology:

• Specialized skills training (SST)
• Targeted case management (TCM)
• Physical therapy (PT) evaluations and reevaluations
• Occupational therapy (OT) evaluations and reevaluations
• PT and OT treatments

Health and Behavior Assessment and Intervention

HBAI services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. HBAI services provided by synchronous audiovisual technology must be billed using modifier 95. See manual for eligible services.

Medical Nutrition Counseling Services (CCP)

Certain telehealth services may be provided for medical nutrition therapy and nutrition counseling services clients if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interactions, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telehealth services. Therefore, providers must document in the person’s medical record the reason(s) that services were delivered by synchronous telephone (audio-only) technology.  See chart in manual for services are authorized for telehealth delivery using synchronous audiovisual and synchronous telephone (audio-only) technologies.

The procedure codes in the table above may be delivered by synchronous telephone (audio-only) technology only during certain PHE or natural disasters.

Medical nutrition counseling services (procedure code S9470) are authorized for telehealth delivery using synchronous audiovisual and synchronous telephone (audio-only) technologies, when noted.

Medical nutrition counseling services (procedure code S9470) may be delivered by synchronous telephone (audio-only) technology only during certain PHE or natural disasters. Services provided by synchronous audio-visual technology must be billed using modifier 95. Services delivered using audio-only technologies must be billed using modifier 93. Documentation requirements for a telehealth service are the same as for an in-person visit and must accurately reflect the services rendered. Documentation must identify the means of delivery when provided.

During a Declaration of State of Disaster, the Texas Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on restrictions for services delivered by synchronous telephone (audio-only) technologies.

Medical Checkups During a Declaration of State Disaster

The following limitations apply to all THSteps preventive medical checkups and exception-to-periodicity checkups during a Declaration of State Disaster when HHSC issues direction regarding the use of synchronous audiovisual and synchronous telephone (audio-only) technologies:

• Clients who are 2 years through 20 years of age may receive a THSteps medical checkup or exception-to-periodicity checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies.
• Clients from birth through 2 years of age may not receive a THSteps checkup or exception-to-periodicity checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies.
• Clients from birth through 24 months of age must receive in-person checkups.

A medical checkup provided using synchronous audiovisual or synchronous telephone (audio-only) technologies must be completed according to the age-specific checkup requirements listed on the THSteps Periodicity Schedule.

Synchronous audiovisual delivery for medical checkups is preferred over synchronous telephone (audio-only) delivery.

An in-person THSteps follow-up visit must be completed within six months of the synchronous audiovisual or synchronous telephone (audio-only) checkup in order for the checkup to be considered a complete THSteps checkup.

When HHSC issues direction, the following THSteps medical checkup services are authorized for delivery using synchronous audiovisual or synchronous telephone (audio-only) technologies during a Declaration of State Disaster (see manual).

Medical checkups and exception-to-periodicity checkups provided using synchronous audiovisual or synchronous telephone (audio-only) technologies are limited to checkups for clients who are over 24 months of age for the following procedure codes (see manual).

Medical checkups for clients who are 2 years of age or younger must be completed in-person and may not be completed using synchronous audiovisual or synchronous telephone (audio-only) technologies (procedure codes 99381, 99382, 99391 and 99392).

THSteps providers should use their clinical judgement regarding which checkup components may be appropriate for completion using synchronous audiovisual or synchronous telephone (audio-only) technologies.

THSteps providers are encouraged to ensure that clients receiving a medical checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies receive age-appropriate vaccines and laboratory screenings in a timely manner.

Medical checkup services using synchronous audiovisual or synchronous telephone (audio-only) technologies should only be provided if agreed to by the client or parent/guardian.

See Children’s Services Handbook for additional information and a list of procedure codes.

SOURCE:  TX Medicaid Children’s Services Handbook, (Dec. 2024), (Accessed Dec. 2024).

Telemedicine medical services used for the treatment of chronic pain with scheduled drugs via audio-only is prohibited, except in certain circumstances (see audio-only section for more info).

Treatment of a client for acute pain with scheduled drugs using telemedicine is permitted, as provided by 22 TAC §174.5(e). Acute pain is defined by 22 TAC §170.2(2).

All physicians must comply by 22 TAC §174.5 when issuing prescriptions through a telemedicine service.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 10, (Dec. 2024). (Accessed Dec. 2024).

See manual for additional details for synchronous audio visual technology and telemedicine services.

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, (Dec. 2024). (Accessed Dec. 2024).

In addition to the service requirements in this division, a child or adolescent must receive additional assessments, including a developmental assessment and history of trauma assessment, performed by an LPHA with appropriate training and experience in the assessment and treatment of children in a crisis setting. The assessments must:

• be administered in person or through telehealth or telemedicine medical services; and
• include the individual’s parents, LAR, or adult caregiver, as applicable and as clinically appropriate according to the child’s or adolescent’s age, functioning, and current living situation.

SOURCE: TX Admin Code, Title 26, Part 1 Ch. 306, Sec. 306.67, (Accessed Dec. 2024).

In providing covered benefits to a child with special health care needs, a health plan provider must permit benefits to be provided through telemedicine medical services, teledentistry dental services, and telehealth services in accordance with policies developed by the commission.  See statute for additional requirements.

SOURCE: TX Statute 62.157 (Accessed Dec. 2024).

Federally Qualified Health Center Services Reimbursement

A visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, visiting nurse, a qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exist:

• after the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or
• the FQHC patient has a medical visit and an “other” health visit, as defined in paragraph (13) of this subsection.

A medical visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, or visiting nurse. An “other” health visit includes, but is not limited to, a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a Texas Health Steps Medical Screen.

SOURCE: TX Admin Code, Title 1, Part 15, Ch. 355 Subchapter J, 355. 8261. (Accessed Dec. 2024).

Physical Therapy, Occupational Therapy, and Speech Therapy

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ELIGIBLE PROVIDERS

The information in this handbook is intended for home health agencies, hospitals, nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM), licensed professional counselors (LPC), licensed marriage and family therapists (LMFT), licensed clinical social workers (LCSW), physicians, physician assistants (PA), psychologists, licensed psychological associates, provisionally licensed psychologists, and licensed dieticians.

Providers may provide telecommunication services for Texas Medicaid clients under the provider’s National Provider Identifier (NPI). No additional enrollment is required to provide telemedicine medical service or telehealth services.

Telemedicine Services

A distant site is the location of the provider rendering the service. Distant-site telemedicine benefits include services that are performed by the following providers, who must be enrolled as a Texas Medicaid provider:

• Physician
• Clinical Nurse Specialist (CNS)
• Nurse Practitioner (NP)
• Physician Assistant (PA)
• Certified Nurse Midwife (CNM)
• Federally Qualified Health Center (FQHC) (in manual only)

A distant site provider is the physician, or PA, NP, CNM, FQHC, Rural Health Clinic (RHC), or CNS who is supervised by and has delegated authority from a licensed Texas physician, who uses telemedicine to provide health-care services to a client in Texas.

Distant site providers must be licensed in Texas.

An out-of-state physician who is a distant site provider may provide episodic telemedicine without a Texas medical license as outlined in Texas Occupations Code §151.056 and Title 22 Texas Administrative Code (TAC) §172.2(g)(4) and 172.12(f).

Distant site providers that provide mental health services must be appropriately licensed or certified in Texas, or be a qualified mental health professional-community services (QMHP-CS), as defined in 26 TAC §301.303(48).

School Based Services: Telemedicine services provided in a school-based setting are also a benefit if the physician delegates provision of services to a nurse practitioner, clinical nurse specialist, or physician assistant, as long as the nurse practitioner, clinical nurse specialist, or physician assistant is working within the scope of their professional license and within the scope of their delegation agreement with the physician.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 7-8, 10 (Dec. 2024) (Accessed Dec. 2024).

Telehealth Services

A distant site is the location of the provider rendering the service. A distant site provider is the health professional licensed, certified, or otherwise entitled to practice in Texas who uses telehealth services to provide health care services to a patient in Texas.

Licensed psychological associates (LPAs), provisionally licensed psychologists (PLPs), post-doctoral psychology fellows, and pre-doctoral psychology interns under psychologist supervision may also deliver telehealth services. All requirements outlined in the Outpatient Mental Health Services benefit language must be met.

Distant site providers who provide mental health services must be appropriately licensed or certified in Texas or be a QMHP-CS as defined in 26 Texas Administrative Code §301.303(48).

A distant-site provider that is located outside of state lines while rendering services is considered an out-of-state provider.

The distant site provider must obtain informed consent to treatment from the patient, patient’s parent or the patient’s legal guardian prior to rendering a telehealth service.

Distant site providers should meet all other telehealth service requirements specified in Texas Occupations Code §111.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 12 (Dec. 2024) (Accessed Dec. 2024).

The executive commissioner by rule shall ensure that a rural health clinic as defined by 42 U.S.C. Section 1396d(l)(1) and a federally-qualified health center as defined by 42 U.S.C. Section 1396d(l)(2)(B) may be reimbursed for the originating site facility fee or the distant site practitioner fee or both, as appropriate, for a covered telemedicine medical service, teledentistry dental service, or telehealth service delivered by a health care provider to a Medicaid recipient. The commission is required to implement this subsection only if the legislature appropriates money specifically for that purpose. If the legislature does not appropriate money specifically for that purpose, the commission may, but is not required to, implement this subsection using other money available to the commission for that purpose.

SOURCE: TX Statute Sec. 531.0216, [repealed eff. April 1, 2025], (Accessed Dec. 2024).

The Health and Human Services Commission (HHSC) reimburses eligible distant site professionals providing telemedicine medical services as follows:

• Physicians
• Physician assistants
• Advanced Practice Registered Nurses (APRNs)
• Certified nurse midwives

HHSC reimburses eligible distant site professionals providing telehealth services as follows:

• Licensed professional counselors, including licensed marriage and family therapists, and licensed clinical social workers (including Comprehensive Care Program social workers) are reimbursed for their Medicaid telehealth services in the same manner as their other professional services in accordance with §355.8091 of this title (relating to Reimbursement to Licensed Professional Counselors, Licensed Clinical Social Workers, and Licensed Marriage and Family Therapists).
• Licensed psychologists (including licensed psychological associates) and psychology groups are reimbursed for their Medicaid telehealth services in the same manner as their other professional services in accordance with §355.8085 of this title.
• Durable medical equipment suppliers are reimbursed for their Medicaid telehealth services in the same manner as their other professional services in accordance with §355.8023 of this title (relating to Reimbursement Methodology for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)).

Telemedicine medical services provided in a school-based setting by a physician, even if the physician is not the patient’s primary care physician, will be reimbursed in accordance with the applicable methodologies described in subsection (b)(1) of this section and §355.8443 of this title (relating to Reimbursement Methodology for School Health and Related Services (SHARS)) if the following conditions are met:

•  the physician is an authorized health care provider under Medicaid;
•  the patient is a child who receives the service in a primary or secondary school-based setting;
•  the parent or legal guardian of the patient provides consent before the service is provided; and
•  a health professional as defined by Government Code §531.0217(a)(1) is present with the patient during the treatment.

Fees for telemedicine, telehealth, and home telemonitoring services are adjusted within available funding as described in §355.201 of this title (relating to Establishment and Adjustment of Reimbursement Rates by the Health and Human Services Commission).

SOURCE:  TX Admin Code. Title 1, Sec. 355.7001 (Accessed Dec. 2024).

School Health and Related Services (SHARS)

See manual for specific requirements.

LEAs that participate in the SHARS program may be reimbursed for telehealth occupational therapy (OT), physical therapy (PT), speech therapy (ST), counseling, and psychological services.

All other reimbursement and billing guidelines that are applicable to in-person services will also apply when OT, PT, ST, counseling, and psychological services are delivered as telehealth services.

See manual for procedure codes and requirements that may be provided to children eligible through SHARS as telehealth services via synchronous audiovisual technology if clinically appropriate (as determined by the treating provider), safe and agreed to by the student receiving services.

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, (Dec. 2024). (Accessed Dec. 2024).

School-based telemedicine medical services. If a telemedicine medical service provided by an out-of-network physician to a member in a primary or secondary school-based setting meets the conditions for reimbursement in § 354.1432 of this title (relating to Telemedicine and Telehealth Benefits and Limitations), a health care MCO must reimburse the out-of-network physician without prior authorization, even if the physician is not the member’s primary care provider. The MCO must use the reasonable reimbursement methodology described in subsection (f)(2) of this section to reimburse an out-of-network physician.

SOURCE: TX Admin Code Title 1, Sec. 353.4, (Accessed Dec. 2024).

FQHCS

FQHCs may be reimbursed the distant-site provider fee for telemedicine services at the Prospective Payment System (PPS) rate or Alternative Prospective Payment System (APPS) rate.

FQHC practitioners may be employees of the FQHC or contracted with the FQHC.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 10 & 12 (Dec. 2024). (Accessed Dec. 2024).

The executive commissioner by rule shall ensure that a rural health clinic as defined by 42 U.S.C. Section 1396d(l)(1) and a federally-qualified health center as defined by 42 U.S.C. Section 1396d(l)(2)(B) may be reimbursed for the originating site facility fee or the distant site practitioner fee or both, as appropriate, for a covered telemedicine medical service, teledentistry dental service, or telehealth service delivered by a health care provider to a Medicaid recipient. The commission is required to implement this subsection only if the legislature appropriates money specifically for that purpose. If the legislature does not appropriate money specifically for that purpose, the commission may, but is not required to, implement this subsection using other money available to the commission for that purpose.

SOURCE: TX Statute Sec. 531.0216, [repealed eff. Apr. 1, 2025], (Accessed Dec. 2024).

A visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, visiting nurse, a qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exist:

• After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or
• The FQHC patient has a medical visit and an “other” health visit, as defined in paragraph (13) of this subsection.

A medical visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, or visiting nurse. An “other” health visit includes, but is not limited to, a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a Texas Health Steps Medical Screen.

SOURCE:  Texas Admin Code Title 1, Sec. 355.8261, (Accessed Dec. 2024).

The commission by rule shall require each health and human services agency that administers a part of the Medicaid program to provide Medicaid reimbursement for teledentistry dental services provided by a dentist licensed to practice dentistry in this state.

The commission shall require reimbursement for a teledentistry dental service at the same rate as the Medicaid program reimburses for the same in-person dental service. A request for reimbursement may not be denied solely because an in-person dental service between a dentist and a patient did not occur. The commission may not limit a dentist’s choice of platform for providing a teledentistry dental service by requiring that the dentist use a particular platform to receive reimbursement for the service.

SOURCE: TX Govt. Code Sec. 531.02172, [repealed Apr. 1, 2025], (Accessed Dec. 2024)

Rural Health Clinics

RHCs may be reimbursed the distant-site provider fee for telemedicine services at the PPS rate. RHC practitioners may be employees of the RHC or contracted with the RHC.

The facility fee (procedure code Q3014) may be reimbursed as an add-on procedure code that should not be included in any cost reporting that is used to calculate the RHC AIR (All Inclusive Rate) PPS per visit encounter rate.

To receive reimbursement for more than one facility fee for the same client on the same date of service, an RHC must submit documentation of medical necessity that the client needed multiple distant-site provider consultations. An RHC can use a signed letter from the client’s treating health care provider at the RHC documenting that the client suffered an illness or injury requiring additional diagnosis or treatment by a distant site provider. This will suffice to document the client’s medical need for purposes of receiving additional facility fee payments for the same client on the same date of service. The letter must state that the client suffered an illness or injury that required additional diagnosis or treatment by a distant-site provider.

If an RHC is eligible for payment of both an encounter fee and a facility fee for the same client on the same date of service, the RHC must submit a claim for the facility fee separate from the claim submitted for the encounter.

The facility fee should not be included in any cost reporting that is used to calculate the RHC All Inclusive Rate (AIR) prospective payment system (PPS) per-visit encounter rate.

Note: Telemedicine and telehealth services must be billed with modifier 95. Procedure codes that indicate remote delivery (telemedicine medical services or telehealth services) in the description do not need to be billed with modifier 95.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 11 (Dec. 2024). (Accessed Dec. 2024).

A medical visit is a face-to-face or telemedicine medical service encounter between an RHC patient and a physician, physician assistant, advanced nurse practitioner, certified nurse-midwife, visiting nurse, or clinical nurse practitioner. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exists:

• after the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or
• the RHC patient has a medical visit and an “other” health visit as defined in subsection (n) of this section.

An “other” health visit includes, but is not limited to, a face-to-face or telehealth service encounter between an RHC patient and a clinical social worker.

SOURCE: 15 TAC Sec. 355.8101.  (Accessed Dec. 2024).

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ELIGIBLE SITES

The physical environments of the client and the distant site provider must ensure that the client’s protected health information remains confidential. A parent or legal guardian may be physically located in the patient site or distant site environment during a telehealth or telemedicine service with a child.

A patient site is the place where the client is physically located. A client’s home may be the patient site for telemedicine.

A patient site is the place where the client is physically located while the service is rendered. Patient-site providers that are enrolled in Texas Medicaid may only be reimbursed for the facility fee using procedure code Q3014. Charges for other services that are performed at the patient site may be submitted separately.

A client’s home may be the patient site for telehealth. Procedure code Q3014 is not a benefit if the patient site is the client’s home.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 4, 10, 13-13 (Dec. 2024), (Accessed Dec. 2024).

School-Based Setting

See Administrative Code Section for more details.

SOURCE: TX Admin Code Title 1, Sec. 354.1432, (Accessed Dec. 2024).

Telemedicine provided in a school-based setting by a physician, even if the physician is not the client’s primary care physician or provider, are benefits if all of the following criteria are met:

• The physician is an authorized health-care provider enrolled in Texas Medicaid.
• The client is a child who is receiving the service in a primary or secondary school-based setting.
• The parent or legal guardian of the client provides consent before the service is provided.

Telemedicine services provided in a school-based setting are also a benefit if the physician delegates provision of services to a nurse practitioner, clinical nurse specialist, or physician assistant, as long as the nurse practitioner, clinical nurse specialist, or physician assistant is working within the scope of their professional license and within the scope of their delegation agreement with the physician.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 10 (Dec. 2024), (Accessed Dec. 2024).

• The physician is an authorized health care provider under Medicaid;
• The patient is a child who receives the service in a primary or secondary school-based setting;
• the parent or legal guardian of the patient provides consent before the service is provided; and
• a health professional as defined by Government Code §531.0217(a)(1) is present with the patient during the treatment.

SOURCE: TX Admin. Code, Title 1, Sec. 355.7001(f). (Accessed Dec. 2024).

School Health and Related Services (SHARS)

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, (Dec. 2024). (Accessed Dec. 2024).

CSHCN Program

A patient site is where the client is physically located while the service is rendered. The patient-site must be one of the following:

• Established medical site – A location where clients will present to seek medical care. There must be a patient-site presenter and sufficient technology and medical equipment to allow for an adequate physical evaluation, as appropriate for the client’s presenting complaint. A defined physician-client relationship is required. A client’s private home is not considered an established medical site.
• Established health site – A location where clients will present to seek a health service. There must be a patient-site presenter and sufficient technology and medical equipment to allow for an adequate physical evaluation or assessment, as appropriate for the client’s presenting complaint. A defined health provider-client relationship is required. A client’s private home is not considered an established health site.

SOURCE: TX Medicaid CSHCN Services Program Provider Manual (Nov. 2024), p. 6, 8-9.  (Dec. 2024).

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GEOGRAPHIC LIMITS

No Reference Found

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FACILITY/TRANSMISSION FEE

SOURCE: TX Admin. Code, Title 1 Sec. 355.7001(d), (Accessed Dec. 2024).

Last updated 12/17/2024

Miscellaneous

The commission in coordination with the department and single source continuum contractors shall establish guidelines in the STAR Health program to improve the use of telehealth services to provide and enhance mental health and behavioral health care for children placed in the managing conservatorship of the state.

SOURCE: Human Resources Code Title 2, Section D, Chapter 42, 42.260. (Accessed Dec. 2024).

Children’s Health Insurance Program

The executive commissioner by rule shall establish policies that permit reimbursement under Medicaid and the child health plan program for services provided through telemedicine medical services, teledentistry dental services, and telehealth services to children with special health care needs.

SOURCE: TX Govt. Code Sec. 531.02162, [repealed eff. Apr. 1, 2025], (Accessed Dec. 2024).

Procedure codes that are benefits for distant site providers when billed with the 95 modifier (synchronous audiovisual technology) are included in the individual TMPPM handbooks. Procedure codes that indicate remote (telehealth/telemedicine service) delivery in the description do not need to be billed with the 95 modifier.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 8, 12 (Aug. 2024). (Accessed Aug. 2024).

Providers of telehealth or telemedicine must maintain the confidentiality of protected health information (PHI) as required by Federal Register 42, Code of Federal Regulations (CFR) Part 2, 45 CFR Parts 160 and 164, Chapters 111 and 159 of the Texas Occupations Code, and other applicable federal and state law.

See provider manual for other information security and documentation requirements.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 5. (Dec. 2024). (Accessed Dec. 2024).

Fees for telemedicine, telehealth, and home telemonitoring services are adjusted within available funding as described in §355.201 of this title (relating to Establishment and Adjustment of Reimbursement Rates by the Health and Human Services Commission).

SOURCE: TX Admin Code. 355.7001(g). (Accessed Dec. 2024).

A valid practitioner-patient relationship must exist between the distant site provider and the patient. A valid practitioner-patient relationship exists between the distant site provider and the patient if:

• The distant site provider meets the same standard of care required for and in-person service.
  
• The relationship can be established through:
  
  • A prior in-person service.
    
  • A prior telemedicine service that meets the delivery method requirements specified in Texas Occupations Code §111.005(a)(3).
    
  • The current telemedicine service that meets the delivery method requirements specified in Texas Occupations Code §111.005(a)(3).

A call coverage agreement established in accordance with Texas Medical Board (TMB) administrative rules in 22 TAC §177.20.

The distant site provider must obtain informed consent to treatment from the patient, patient’s parent, or the patient’s guardian prior to rendering a telemedicine medical service.

Distant site providers that communicate with clients using electronic communication methods other than phone or facsimile must provide clients with written notification of the physician’s privacy practices prior to evaluation and treatment. A good faith effort must be made to obtain the client’s written acknowledgment of the notice, including by email response.

A distant site provider should provide patients who receive a telemedicine service with guidance on the appropriate follow-up care.

Prescriptions Generated from a Telemedicine Medical Service

A distant site provider may issue a valid prescription as part of a telemedicine service. An electronic prescription (e-script) may be used as permitted by applicable federal and state statues and rules.

The same standards that apply for the issuance of a prescription during an in-person setting apply to prescriptions issued by a distant site provider..

The prescription must be issued for a legitimate medical purpose by the distant site provider as part of a valid practitioner-patient relationship.

The prescribing physician must be licensed in Texas. If the prescription is for a controlled substance, the prescribing physician must have a current valid U.S. Drug Enforcement Administration (DEA) registration number.

A licensed health professional acting under the delegation and supervision of a physician licensed in Texas may also issue a valid prescription. Prescribing must be in accordance with the required prescriptive authority agreement or other forms of delegation.

If the prescription is for a controlled substance, the health professional must have a current valid DEA registration number. If the prescription is for a schedule II controlled substance, the health professional must comply with DEA regulations regarding the use of electronic prescriptions. The health professional may also use the official prescription forms issued with their name, address, phone number, DEA registration number, delegating physician’s name, and delegating physician’s DEA registration number.

As applicable, all drug prescriptions must meet the requirements of the Texas Controlled Substance Act (Texas Health and Safety Code §481), the Texas Dangerous Drug Act (Texas Health and Safety Code §483), and any other federal or state statutes or rules.

Telemedicine medical services used for the treatment of chronic pain with scheduled drugs via audio-only is prohibited, unless a patient:

• Is an established chronic pain patient of the physician or health professional issuing the prescription;
• Is receiving a prescription that is identical to a prescription issued at the previous visit; and
• Has been seen by the prescribing physician or health professional defined under Section 111.001(1) of Texas Occupations Code, in the last 90 days either in-person or via telemedicine using audiovisual communication.

Treatment of a client for acute pain with scheduled drugs using telemedicine is permitted, as provided by 22 TAC §174.5(e). Acute pain is defined by 22 TAC §170.2(2).

All physicians must comply by 22 TAC §174.5 when issuing prescriptions through a telemedicine service.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 8-10 (Dec. 2024). (Accessed Dec. 2024).

All client health information generated or utilized during a telehealth or telemedicine service must be stored by the distant site provider in a client health record. If the distant site provider stores the patient health information in an electronic health record, the provider should use software that complies with Health Insurance Portability and Accountability Act (HIPAA) confidentiality and data encryption requirements, as well as with the United States Department of Health and Human Services (HHS) rules implementing HIPAA.

Medical records must be maintained for all telemedicine services.

Documentation for a service provided via telemedicine must be the same as for a comparable in-person service.

If a patient has a primary care provider who is not the distant site provider and the patient or their parent or legal guardian provides consent to a release of information, a distant site provider must provide the patient’s primary care provider with the following information:

• A medical record or report with an explanation of the treatment provided by the distant site provider
• The distant site provider’s evaluation, analysis, or diagnosis of the patient

Unless the telemedicine services are rendered to a child in a school-based setting, distant site providers of mental health services are not required to provide the patient’s primary care provider with a treatment summary.

For telemedicine provided to a child in a school-based setting, a notification provided by the telemedicine physician to the child’s primary care provider must include a summary of the service, exam findings, prescribed or administered medications, and patient instructions.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 5 & 11. (Dec. 2024). (Accessed Dec. 2024).

Screening activities for crisis stabilization units, including triage and determining if the individual’s need is urgent can be conducted in person or through telehealth.

SOURCE: TX Admin Code, Title 26, Part 1, Ch. 306, Subchapter B, Sec. 306.45, (Accessed Dec. 2024).

A patient can be admitted on a voluntary admission only if a physician has conducted or consulted with a physician who has conducted, either in person or through telemedicine medical services, an admission examination within 72 hours before or 24 hours after admission.

SOURCE: TX Admin Code, Title 26, Part 1, Ch. 568, Subchapter B, Sec. 568.22, (Accessed Dec. 2024).

The commission shall establish policies and procedures to improve access to care under the Medicaid managed care program by encouraging the use of telehealth services, telemedicine medical services, home telemonitoring services, and other telecommunications or information technology under the program.

To the extent permitted by federal law, the executive commissioner by rule shall establish policies and procedures that allow a Medicaid managed care organization to conduct assessments and provide care coordination services using telecommunications or information technology.  See rule for details.

SOURCE: TX Statute Sec. 533.039, [repealed eff. Apr. 1, 2025], (Accessed Dec. 2024).

In the event of a state of disaster declared pursuant to Texas Government Code §418.014 for statewide disasters or limited areas subject to the declaration, the flexibilities listed under subsection (c) of this section will be available until the state of disaster is terminated.

Telehealth and telemedicine have the same meaning as the terms telehealth services and telemedicine medical services defined in §111.001 of the Texas Occupations Code (relating to Definitions).

See rule for additional details.

SOURCE: TX Admin Code Title 26, Part 1, Ch. 306, Subchapter X, 306.1251. (Accessed Dec. 2024).

SOURCE: TX Admin Code Sec. 133.185, (Accessed Dec. 2024).

A limited services rural hospital’s (LSRH’s) governing body shall address and is fully responsible, either directly or by appropriate professional delegation, for the operation and performance of the LSRH.

The governing body’s responsibilities shall include:…

• ensuring that when telemedicine services are furnished to the LSRH’s patients through an agreement with a distant-site hospital, the agreement meets the requirements of 42 CFR §485.510; and
• ensuring that when telemedicine services are furnished the services meet all federal and state laws, rules, and regulations.

SOURCE: TX Admin Code Sec. 511.42, (Accessed Dec. 2024).

Emergency Medical Services Trauma Systems

The ED must have physicians with special competence in the care of critically injured patients, designated as members of the trauma team, and physically present in the ED 24-hours per day. Neither a facility’s telemedical capabilities nor the physical presence of advanced practice providers (APPs) satisfies this requirement.

APPs who participate in trauma patient resuscitations and telemedicine-support physicians who participate in the care of major, severe, or critical trauma patients must be credentialed by the facility to participate in the resuscitation and treatment of trauma patients and must maintain:

• board-certification or board-eligibility in specialty, or current ATLS or an equivalent department-approved ATLS course;
• nine hours of trauma-related continuing medical education per year;
• compliance with trauma management guidelines; and
• participation in the trauma PIPS program.

Physicians with special competence in the care of critically injured patients, designated as members of the trauma team and on-call (if not in-house 24/7) must be promptly available within 30 minutes of request from inside or outside the facility. Neither a facility’s telemedicine medical service capabilities nor the physical presence of APPs satisfy this requirement with the exception of the following:

• A health care facility located in a county with a population of less than 30,000 may satisfy a Level IV trauma facility designation requirement relating to physicians through the use of telemedicine medical service in which an on-call physician who has special competence in the care of critically injured patients provides patient assessment, diagnosis, consultation, or treatment, or transfers medical data to a physician, advanced practice registered nurse, or physician assistants located at the facility; and
• APPs and telemedicine-support physicians who participate in the care of major, severe, or critical trauma patients must be credentialed by the facility to participate in the resuscitation and treatment of trauma patients, to include requirements such as current board-certification or board-eligibility in surgery or emergency medicine, nine hours of trauma-related continuing medical education per year, compliance with trauma management guidelines, and participation in the trauma PIPS program.

Rural Level IV trauma facilities in a county with a population less than 30,000 may utilize telemedicine resources with an Advanced Practice Provider (APP) available to respond to the trauma patient’s bedside within 30 minutes of notification, with written resuscitation and trauma management guidelines monitored through the trauma performance improvement and patient safety processes.

The facility must have a documented telemedicine physician credentialing process.

All assessments, physician orders, and interventions initiated through telemedicine must be documented in the patient’s medical record.

Telemedicine in trauma facilities in a county with a population of 30,000 or more, if utilized, must have a documented physician credentialing process, written trauma protocols for utilization of telemedicine including physician response times, and measures to ensure the trauma management guidelines and evidence-based practice are monitored through the trauma performance improvement and patient safety processes.

• Telemedicine cannot replace the requirement for the trauma on-call physician to respond to the trauma activations in-person, to conduct inpatient rounds, or to respond to emergency requests from the inpatient units, when requested.
• All telemedicine assessments, physician orders, and interventions initiated through telemedicine must be documented in the patient’s medical record.
• Telemedicine services or the telemedicine physician may be requested to assist in trauma performance improvement committee reviews.

SOURCE:  TX Admin Code, Title 25, art 1, Ch. 97, Subch, G, Emergency medical services trauma systems, (Accessed Dec. 2024).

Last updated 12/17/2024

Out of State Providers

Distant site providers must be licensed in Texas.

An out-of-state physician who is a distant site provider may provide episodic telemedicine without a Texas medical license as outlined in Texas Occupations Code §151.056 and Title 22 Texas Administrative Code (TAC) §172.2(g)(4) and 172.12(f).

Distant site providers that provide mental health services must be appropriately licensed or certified in Texas, or be a qualified mental health professional-community services (QMHP-CS), as defined in 26 TAC §301.303(48).

Distant site providers that provide mental health services must be appropriately licensed or certified in Texas or be a QMHP-CS as defined in 26 Texas Administrative Code §301.303(48).

A distant-site provider that is located outside of state lines while rendering services is considered an out-of-state provider.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 8, 12 (Dec. 2024). (Accessed Dec. 2024).

CSHCN

To enroll in the CSHCN Services Program, telecommunication providers must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Out-of-state providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border, and be approved by the Department of State Health Services (DSHS).

SOURCE: TX Medicaid Telecommunication Services (CSHCN Services Program Provider Manual), (Nov. 2024), p. 3.  (Accessed Dec. 2024).

Last updated 12/17/2024

Overview

Texas Medicaid reimburses for live video, and store-and-forward in some circumstances. Home telemonitoring is reimbursable for some conditions when a provider is approved to deliver those services.  Texas Medicaid has two telehealth manuals (which they title “telecommunications services”), one for the general Medicaid program and one specifically for Children with Special Health Care Needs (CSHCN) as well as specific telehealth sections in a variety of other program provider manuals.

Audio-only service deliver is also allowed for behavioral health services under certain circumstances.

 

Last updated 12/17/2024

Remote Patient Monitoring

POLICY

“Home telemonitoring service” means a health service that requires scheduled remote monitoring of data related to a patient’s health and transmission of the data to a licensed home and community support services agency, a federally qualified health center, a rural health clinic, or a hospital, as those terms are defined by Section 531.02164(a). The term is synonymous with “remote patient monitoring.”

SOURCE: TX Government Code, Sec. 531.001(4-a) (Accessed Dec. 2024).

HHSC reimburses eligible providers performing home telemonitoring services in the same manner as their other professional services described in §355.8021 of this title (relating to Reimbursement Methodology for Home Health Services).

SOURCE: TX Admin Code, Title 1, Sec. 355.7001(e). (Accessed Dec. 2024).

Home telemonitoring services, also known as remote patient monitoring, is a benefit of Texas Medicaid. Home telemonitoring is a health service that requires scheduled remote monitoring of data related to a client’s health, and transmission of the data from the client’s home to a licensed home health agency, hospital, FQHC, or RHC. Data and information collected remotely will be transmitted from the client’s home to the home health agency, hospital, FQHC, or RHC. The data transmission must comply with standards set by HIPAA.

Home telemonitoring providers must establish a plan of care (POC) with outcome measures based on the physician or requesting provider’s order for each client, and the POC and outcome measures must be reviewed by the client’s physician.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 14-16 (Dec. 2024), (Accessed Dec. 2024).

CSHCN Program

Home telemonitoring services are a benefit of the CSHCN Services Program.

Home telemonitoring is a health service that requires scheduled remote monitoring of data related to a client’s health, and transmission of the data from the client’s home to a licensed home health agency or a hospital. The data transmission must comply with standards set by the Health Insurance Portability and Accountability Act (HIPAA).

Data parameters are established as ordered by a physician’s plan of care. Data must be reviewed by a registered nurse (RN), APRN, or PA, who is responsible for reporting data to the prescribing physician in the event of a measurement outside the established parameters.

Procedure code S9110 (with modifier U1) is limited to once per episode of care even if monitoring parameters are added after initial setup and installation. A claim for a subsequent set up and installation will not be reimbursed unless there is a documented new episode of care or documentation of the occurrence of extenuating circumstances.

Home monitoring (procedure code S9110 with the appropriate modifier) is a benefit when services are provided by a home health agency or an outpatient hospital. Hospital providers must submit revenue code 780 with procedure code S9110 and the appropriate modifier for monthly home monitoring. Refer to table below for the appropriate modifier.

Providers must bill the appropriate modifier to indicate the number of days that transmissions of data were received and reviewed for the client within a rolling month.

Providers are not required to submit modifiers U2, U3, U4, U7, U8, or U9 for telemonitoring on the prior authorization request, but are required to submit the appropriate modifier on the claim for reimbursement based on the number of days as outlined in the table.

Procedure code S9110 with or without modifier U1 requires prior authorization. Telemonitoring services may be requested and approved for up to 90 days per prior authorization request. The initial setup and installation (procedure code S9110 with modifier U1) may be prior authorized once per episode of care, unless the provider submits documentation of extenuating circumstances that require another installation of telemonitoring equipment. If additional home telemonitoring services are needed, the home health agency or hospital must request prior authorization before the current prior authorization period ends.

Telecommunication services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

See manual for prior authorization requirements.

SOURCE:  TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Nov. 2024), p. 9-13. (Accessed Dec. 2024).

Concurrent services for telemonitoring are allowed for distinctly different medical reasons. Duplication of services by any provider will not be prior authorized.

SOURCE: TX Medicaid CSHCN Services Program Manual – Home Health Services, (Nov. 2024), pg. 7 (Accessed Dec. 2024).

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CONDITIONS

Home telemonitoring is a benefit for clients who have been diagnosed with either diabetes or hypertension or both.

Home telemonitoring services are also a benefit for clients who are 20 years of age and younger, with one or more of the following conditions:

• End-stage solid organ disease
• Organ transplant recipient
• Requiring mechanical ventilation

The physician or requesting provider who orders home telemonitoring services has a responsibility to ensure the following:

• The client has a choice of home telemonitoring providers.
• The client has the right to discontinue home telemonitoring services at any time.

Note: A nurse practitioner (NP), clinical nurse specialist (CNS) or physician assistant (PA) are considered requesting providers and may request home telemonitoring and sign prior authorization forms.
Although Texas Medicaid supports the use of home telemonitoring, clients are not required to use this service.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 14-15 (Dec. 2024). (Accessed Dec. 2024).

Home telemonitoring services are available only to Texas Medicaid clients who:

• are diagnosed with diabetes, hypertension, or any other conditions allowed by Texas Government Code §531.02164 and determined by HHSC to be cost effective and feasible; and
• exhibit two or more of the following risk factors:
  • Two or more hospitalizations in the previous 12-month period
  • Frequent or recurrent emergency department visits
  • A documented history of poor adherence to ordered medication regime
  • A documented history of falls in the previous 6-month period
  • Limited or absent informal support systems
  • Living alone or being home alone for extended periods of time
  • A documented history of care access challenges

Home telemonitoring services are reimbursed in accordance with Chapter 355 of this title (relating to Reimbursement Rates).

Home telemonitoring services are available to Texas Medicaid clients who are 20 years of age and younger, with one or more of the following conditions [prior authorization applies according to telecommunications manual]:

• end-stage solid organ disease;
• organ transplant recipient; or
• requiring mechanical ventilation.

SOURCE: TX Admin Code. Title 1, Sec. 354.1434, (Accessed Dec. 2024).

The executive commissioner shall adopt rules for the provision and reimbursement of home telemonitoring services under Medicaid as provided under this section.  See sections below for additional details.

For purposes of adopting rules under this section, the commissioner shall:

• Identify and provide home telemonitoring services to persons diagnosed with conditions for which the commission determines the provision of home telemonitoring services would be cost-effective and clinically effective;
• consider providing home telemonitoring services under Subdivision (1) to Medicaid recipients who:
  • Are diagnosed with one or more of the following conditions:
    • pregnancy;
    • diabetes;
    • heart disease;
    • cancer;
    • chronic obstructive pulmonary disease;
    • hypertension;
    • congestive heart failure;
    • mental illness or serious emotional disturbance;
    • asthma;
    • myocardial infarction;
    • stroke;
    • end stage renal disease; or
    • a condition that requires renal dialysis treatment; and
  • Exhibit at least one of the following risk factors
    • two or more hospitalizations in the prior 12-month period;
    • frequent or recurrent emergency room admissions;
    • a documented history of poor adherence to ordered medication regimens;
    • a documented risk of falls; and
    • a documented history of care access challenges
• Ensure that clinical information gathered by the following providers while providing home telemonitoring services is shared with the recipient ’s physician:
  • a home and community support services agency;
  • a federally qualified health center;
  • a rural health clinic; or
  • a hospital
• Ensure that the home telemonitoring provided under this section do not duplicate disease management program services provided under 32.057, Human Resources Code; and require providers to:
  • establish a plan of care that includes outcome measures for each recipient who receives home telemonitoring services under this section; and
  • share the plan and outcome measures with the recipient ’s physician.

Not withstanding any other provision of this section, the commission shall ensure that home telemonitoring services are available to pediatric persons who:

• are diagnosed with end-stage solid organ disease;
• have received an organ transplant; or
• require mechanical ventilation.

In addition to determining whether to provide home telemonitoring services to Medicaid recipients with the conditions described under Subsection (c)(2), the commission shall determine whether high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective. If the commission determines that high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective:

• the commission shall, to the extent permitted by state and federal law, provide recipients experiencing a high-risk pregnancy with clinically appropriate home telemonitoring services equipment for temporary use in the recipient ’s home; and
• the executive commissioner by rule shall:
  • establish criteria to identify recipients experiencing a high-risk pregnancy who would benefit from access to home telemonitoring services equipment;
  • ensure that, if cost-effective, feasible, and clinically appropriate, the home telemonitoring services equipment provided includes uterine remote monitoring services equipment and pregnancy-induced hypertension remote monitoring services equipment;
  • subject to Subsection (c-3), require that a provider obtain:
    • prior authorization from the commission before providing home telemonitoring services equipment to a recipient during the first month the equipment is provided to the recipient; and
    • an extension of the authorization under Subparagraph (i) from the commission before providing the equipment in a subsequent month based on the ongoing medical need of the recipient; and
  • prohibit payment or reimbursement for home telemonitoring services equipment during any period that the equipment was not in use because the recipient was hospitalized or away from the recipient ’s home regardless of whether the equipment remained in the recipient ’s home while the recipient was hospitalized or away.

For purposes of Subsection (c-2), the commission shall require that:

• a request for prior authorization under Subsection (c-2)(2)(C)(i) be based on an in-person assessment of the recipient; and
• documentation of the recipient ’s ongoing medical need for the equipment is provided to the commission before the commission grants an extension under Subsection (c-2)(2)(C)(ii).

If, after implementation, the commission determines that a condition for which the commission has authorized the provision and reimbursement of home telemonitoring services under Medicaid under this section is not cost-effective and clinically effective, the commission may discontinue the availability of home telemonitoring services for that condition and stop providing reimbursement under Medicaid for home telemonitoring services for that condition, notwithstanding Section 531.0216 or any other law.

The commission shall determine whether the provision of home telemonitoring services to persons who are eligible to receive benefits under both Medicaid and the Medicare program achieves cost savings for the Medicare program.

To comply with state and federal requirements to provide access to medically necessary services under Medicaid, including the Medicaid managed care program, and if the commission determines it is cost-effective and clinically effective, the commission or a Medicaid managed care organization, as applicable, may reimburse providers for home telemonitoring services provided to persons who have conditions and exhibit risk factors other than those expressly authorized by this section.

SOURCE: TX Government Code Sec. 531.02164 (Accessed Dec. 2024).

CSHCN Program

Home telemonitoring services are a benefit only for clients who are diagnosed with one or more of the following conditions:

• Diabetes
• Hypertension
• Congestive heart failure
• End-stage solid organ disease
• Organ transplant recipient
• Requiring mechanical ventilation

Clients with diabetes or hypertension must exhibit two or more of the following risk factors for approval of telemonitoring services:

• Two or more hospitalizations in the previous 12-month period
• Frequent or recurrent emergency department visits
• A documented history of poor adherence to ordered medication regimens
• Documented history of falls in the previous six-month period
• Limited or absent informal support systems
• Living alone or being home alone for extended periods of time
• A documented history of care access challenges

SOURCE: TX Medicaid CSHCN Services Program Provider Manual Telecommunications Services (Nov. 2024), p. 11.  (Accessed Dec. 2024).

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PROVIDER LIMITATIONS

The RN, NP, CNS, or PA in a licensed home health agency, hospital, FQHC, or RHC is responsible for reporting data to the physician or requesting provider. Telemonitoring providers must be available 24 hours a day, 7 days a week. Although transmissions are generally at scheduled times, they can occur any time of the day or any day of the week, according to the client’s plan of care.

Scheduled periodic reporting of the client data to the physician or requesting provider is required in the event of a measurement outside the parameters established in the physician’s orders, or at least once per month when there have been no readings outside the established parameters.

Collection and interpretation of a client’s data for home telemonitoring services (procedure code 99091) is a benefit in the office or hospital setting when services are provided by a physician or other qualified health care professional. Procedure code 99091 is limited to once in a 30-day period to the physician or provider ordering the services.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 14-15 (Dec. 2024). (Accessed Dec. 2024).

Home telemonitoring service providers must:

• Comply with all applicable federal, state and local laws and regulations;
• Be enrolled and approved as home telemonitoring services providers;
• Bill for the services covered under the Texas Medicaid Program in the manner and format prescribed by HHSC;
• Share clinical information gathered while providing home telemonitoring services with the patient’s physician; and
• not duplicate disease management program services provided under Human Resources Code §32.057 and further described in Division 32 of this subchapter (relating to Texas Medicaid Wellness Program).

See specific documentation requirements for telemonitoring providers in manual.

SOURCE: TX Admin Code. Title 1, Sec. 354.1434(c). (Accessed Dec. 2024).

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OTHER RESTRICTIONS

Facility Services: The provision and maintenance of home telemonitoring equipment is the responsibility of the home health agency, hospital, FQHC, or RHC. Procedure code S9110 with modifier U1 is reimbursed one time to a home health agency or hospital for the initial setup and installation in the client’s home. A claim for a subsequent set up and installation will not be reimbursed unless there is a documented new episode of care. There will not be reimbursement for the addition of monitoring parameters during the current episode of care. Monthly home telemonitoring services (procedure code S9110 with the appropriate modifier) are a benefit when services are provided by a home health agency or hospital. Home health agency and hospital providers must submit revenue code 780 with procedure code S9110 and one of the appropriate modifiers listed in the table within this section.

Use one of the modifiers [listed in the manual] with monthly home telemonitoring services procedure code S9110 to indicate the number of days per month data is transmitted from the client’s home to the home telemonitoring provider.

Providers are not required to submit modifiers U2, U3, U4, U7, U8, or U9 for telemonitoring on the prior authorization request, but are required to submit the appropriate modifier on the claim for reimbursement based on the number of days as outlined in the table.

Documentation supporting medical necessity for home telemonitoring services must be maintained in the client’s medical record by the entity providing the service (home health agency, hospital, FQHC, or RHC) and is subject to retrospective review. All paid home telemonitoring services not supported by documentation of medical necessity are subject to recoupment.

FQHCs/RHCs:  FQHC and RHC providers may be reimbursed outside the encounter rate for the provision of home telemonitoring services if the services follow all requirements as outlined in this section and in the following subsections 3.7.1, “Prior Authorization of Telemonitoring Services,” and 3.8.1, “Documentation Requirements.”

Procedure code G0511 may be reimbursed to an FQHC or RHC for the provision of home telemonitoring services.

Initial equipment set up, patient education on use of equipment, monthly collection and transmission of physiologic data, and physician or requesting provider services must be billed by one provider
under procedure code G0511.

Procedure code G0511 is reimbursed once per month, per client. The place of service code reported on the claim must reflect the physical location of the client. At least 16 days of data collection per month are required for reimbursement.

See manual for more on prior authorization requirements.

Home telemonitoring providers, the home health agency, hospital, FQHC, or RHC must maintain all documentation in the client’s medical record (see manual for more details).

SOURCE: TX Medicaid Telecommunication Services Handbook, (Dec. 2024). (Accessed Dec. 2024).

CSHCN Program

The CSHCN Program has certain requirements around equipment, prior authorization, and billing instructions similar to the main Telecommunication Services manual above.  Please refer to manual for specifics.

SOURCE: TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Nov. 2024), p. 9-13 (Accessed Dec. 2024).

A cardiac rehabilitation program in which the cardiac monitoring is done using telephonically transmitted electrocardiograms to a remote site is not covered by Texas Medicaid.

Cardiac rehabilitation must be provided in a facility that has the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment (i.e. oxygen, cardiopulmonary resuscitation equipment, or defibrillator) available for immediate use. If no clinically significant arrhythmia is documented during the first three weeks of the program, the provider may have the client complete the remaining portion without telemetry monitoring by the physician’s order.

SOURCE: TX Medicaid Inpatient and Outpatient Hospital Services Handbook, p. 54 (Dec. 2024). (Accessed Dec. 2024).

DME and Supplies

CGMs are devices that measure glucose levels taken from interstitial fluid continuously throughout the day and night, providing real-time data to the client or physician. See manual for complete description.

There are no devices on the United States market that function as stand-alone adjunctive CGM devices. Current technology for adjunctive CGM devices operates in conjunction with an insulin pump.

See manual for non-adjunctive CGM device procedure codes and related supplies that are a benefit when provided by medical supplier durable medical equipment (DME) providers in the home setting.

Prior authorization requirements apply.  See manual.

Non-Covered Services (CGM)

CGM devices (procedure code A9278) and supplies (procedure codes A9276 and A9277) for use with non-durable medical equipment are informational only. DME is defined as:

• Medical equipment or appliances that are manufactured to withstand repeated use, ordered by a physician or allowed practitioner for use in the home, and required to correct or ameliorate a client’s disability, condition, or illness.

The following services are not benefits of Texas Medicaid:

• Rental of adjunct CGM devices
• Smart devices (smart phones, tablets, personal computers, etc.) used as GCM monitors
• Medical supplies used with non-covered equipment

SOURCE: TX Medicaid DME and Supplies Handbook, p. 52-53 (Dec. 2024). (Accessed Dec. 2024).

Last updated 12/17/2024

Store and Forward

POLICY

The following delivery methods may be used to provide telehealth/telemedicine within fee-for-service (FFS) Medicaid:

• Synchronous audiovisual technology between the distant site provider and the client in another location
• Synchronous audio-only technology between the distant site provider and the client in another location
• Store and forward technology in conjunction with synchronous audio-only technology between the distant site provider and the client in another location. The distant site provider must use one of the following:
  • Clinically relevant photographic or video images, including diagnostic images
  • The client’s relevant medical records, such as medical history, laboratory and pathology results, and prescriptive histories

A Texas Medicaid managed care organization (MCO) is not required to provide reimbursement for telemedicine services that are provided through the following methods:

• A text-only email message
• A facsimile transmission

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 5, 6, 9, & 13 (Dec. 2024). (Accessed Dec. 2024).

Reimbursement to eligible providers must be made in the same manner as in-person services.

SOURCE: TX Admin. Code, Title 1 Sec. 355.7001. (Accessed Dec. 2024).

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ELIGIBLE SERVICES

Not all Medicaid-covered services are authorized by HHSC for telemedicine or telehealth delivery in fee-for-service. Providers must always ensure the covered service is allowable by HHSC for telemedicine or telehealth services delivery.

Note: For example, if a service is authorized for telemedicine or telehealth delivery only when using synchronous audiovisual technology, that service may not be delivered using store and forward technology, store and forward technology in conjunction with synchronous audio-only technology, synchronous audio-only technology, or asynchronous audio-only technology.

Telemedicine or telehealth may be provided if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

Conditions for reimbursement applicable to telemedicine and telehealth provided using a synchronous audiovisual technology platform, or using store and forward technology in conjunction with synchronous audio-only are those that meet the following conditions:

• Must be designated for reimbursement by HHSC.
• Must be clinically effective and cost-effective, as determined and published in the benefit language by HHSC.
• May not be denied solely because an in-person medical service between a provider and client did not occur.
• May not be limited by requiring the provider to use a particular synchronous audiovisual technology platform to receive reimbursement for the service.

Other conditions for reimbursement applicable to services may vary by service type. Providers may refer to the appropriate TMPPM handbook for additional information on synchronous audiovisual technology platform coverage conditions.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 6. (Dec. 2024). (Accessed Dec. 2024).

To the extent permitted by federal law and to the extent it is cost-effective and clinically effective, as determined by the commission, the commission shall ensure that Medicaid recipients, child health plan program enrollees, and other individuals receiving benefits under a public benefits program administered by the commission or a health and human services agency, regardless of whether receiving benefits through a managed care delivery model or another delivery model, have the option to receive services as telemedicine medical services, telehealth services, or otherwise using telecommunications or information technology, including the following services:

• preventive health and wellness services;
• case management services, including targeted case management services;
• subject to Subsection (c), behavioral health services;
•  occupational, physical, and speech therapy services;
• nutritional counseling services; and
• assessment services, including nursing assessments under the following Section 1915(c) waiver programs:
  • the community living assistance and support services (CLASS) waiver program;
  • the deaf-blind with multiple disabilities (DBMD) waiver program;
  • the home and community-based services (HCS) waiver program; and
  • the Texas home living (TxHmL) waiver program.

SOURCE:  TX Statute Sec. 531.02161, [repealed eff. Apr. 1, 2025], (Accessed Dec. 2024).

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GEOGRAPHIC LIMITS

No Reference Found

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TRANSMISSION FEE

No Reference Found