Important Updates on State Legislation, Rules and Medicaid

February 2013

17-Hydroxyprogesterone Caproate Benefit Updated
Effective for dates of service on or after February 1, 2013, 17-hydroxyprogesterone caproate benefit criteria will be updated for Texas Medicaid.

17-hydroxyprogesterone caproate is administered intramuscularly at a dose of 250 mg once a week (every 7 days) and is indicated when all of the following criteria are met:

  • The client’s treatment is initiated between 16 weeks, 0 days and 20 weeks, 6 days gestation.
  • The client’s treatment may continue, as medically indicated, through 36 weeks, 6 days gestation or delivery, whichever occurs first.
  • The client has a singleton pregnancy.
  • The client has had a prior, singleton, spontaneous, preterm delivery before 37 weeks gestation.
  • Use of a trademarked version of 17-hydroxyprogesterone caproate for injection (such as Makena), which must be prior authorized, will be indicated if one of the following additional criteria is met:
  • The provider lacks access to the compounded product.
  • Compounded 17-hydroxyprogesterone caproate for injection is contraindicated, for example, because of allergy to the compounded product.
  • The Medical Director reviews supporting documentation and finds that trademarked 17-hydroxyprogesterone caproate for injection is medically necessary. 

For more information, call the TMHP Contact Center at 1-800-925-9126.

January 2013

New State Rules You Should Know

Medicaid Reimbursement for Licensed Midwives Starts January 1
Effective January 1, 2013 Texas Medicaid will implement newly adopted rules that allow licensed midwives to be reimbursed by Medicaid. The Affordable Care Act (ACA) requires states to provide Medicaid reimbursement to all provider types defined as birth attendants by state law. Texas defines birth attendant as a “physician, certified nurse midwife (CNM), or licensed midwife (LM).” LMs are licensed in Texas by the Department of State Health Services. ACOG District XI joined several other groups in submitting a letter addressing concerns about this new rule and suggesting a stronger referral arrangement.

The proposed fees for LMs are based on 70 percent of the rate for the same professional service provided by a physician. The proposed fees can be found here

Any licensed midwife or certified nurse midwife who enrolls in Medicaid must provide the name and license number of a physician with whom they have an arrangement for referral and consultation in the event of medical complications. Upon initial enrollment or revalidation, the CNM or LM must complete and submit to TMHP, along with the Texas Medicaid Provider Enrollment Application, the Physician’s Letter of Agreement form that affirms the CNM’s supervising physician arrangement or the LM’s referring or consulting physician arrangement. A separate letter of agreement must be submitted for each physician or group of physicians with whom an arrangement is made. This agreement must be signed by the CNM or LM and the physician. A new letter of agreement must be completed and submitted to TMHP within 10 business days when a new arrangement or changes to an existing arrangement are made. TMHP must be notified within 10 business days if an existing agreement is cancelled. Details are available on the TMHP Website at or the TMHP Contact Center at 1-800-925-9126.


New Texas Women’s Health Program Starts January 1
(from HHSC)
January 1, 2013, marks the start of the Texas Women’s Health Program. This fully state-funded program replaces the Medicaid Women’s Health Program. Here are some things you need to know about the Texas Women’s Health Program:

New client application: This new application is similar to the previous Women’s Health Program application, but without references to Medicaid. The new application is posted on the website Women can use either the new or existing application to apply for benefits.

Providers who would like to order large quantities of the new application can do so online:

1. Go to
2. Click Providers and Vendors in the left menu.
3. Click Texas Women’s Health Program.
4. Click Online Order Form in the box at the top right of the page.
5. Fill out the form and Submit. The new applications should arrive in one to two weeks.

Providers can also order new Texas Women’s Health Program brochures to share with clients who might be interested in the services.

New ID cards: Women who enroll in the program will get Your Texas Benefits cards, featuring “TWHP” in bold letters on the top right of the card.

Same services: The Texas Women’s Health Program will continue to provide low-income women with family planning services and annual exams. Women who currently get healthcare services from the program will continue to get those same services, as well as treatment for certain sexually transmitted diseases found during a family planning visit.

Same eligibility requirements for clients: Eligibility requirements are unchanged from the previous program.

Same provider billing process: Providers can continue to submit claims and be reimbursed for services the way they do now.

Same provider certification process: Women’s Health Program providers that certified for the program between March and December 31, 2012, are certified for the full 2013 calendar year. Providers that have not certified can find information and the certification form on the TMHP website on the Texas Women’s Health Program web page or can call TMHP Provider Enrollment at 1-800-925-9126, Option 2. Women who need help finding a certified Texas Women’s Health Program provider can search online at or can call 1-800-335-8957 for assistance.


Medicaid to Match Medicare Rate for Dual Eligible Providers
(from HHSC)
HHSC has received approval from state leadership to resume paying 100 percent of the Medicare rate for claims for dual eligible clients until the client reaches the Medicare deductible limit. The change is effective Jan. 1.

Some clients, known as dual eligibles, qualify for both Medicare and Medicaid. For those clients, Medicaid pays their health-care costs that aren’t covered by Medicare. That includes the clients’ coinsurance and deductibles. Last session, the Legislature directed HHSC to limit payments for services to dual eligible clients to the Medicaid rate. For example, if the Medicare rate for a service was $100, and the Medicaid rate was $75, the doctor would get $75 from Medicaid during the deductible period. Under the revised policy, Medicaid will pay the full $100 Medicare rate for that service until the client meets their deductible. For 2013, the Medicare deductible is $147. HHSC will take comments on the policy change at a public hearing at 1:30 p.m. Jan. 11 in Austin. 


Additional Reporting Requirements for Abortions
On December 21, 2012, amendments to Title 25 Texas Administrative Code, Chapter 139, Abortion Facility Reporting and Licensing Rules, were published in the Texas Register with an effective date of December 31, 2012. Amendments to these rules concern Sections 139.4 Annual Reporting Requirements for All Abortions Performed; and 139.5 Additional Reporting Requirements for Physicians.

The amendment to §139.4(a)-(e) requires additional data to be reported annually to the department. As such, the Induced Abortion Report form has been revised and is available on the DSHS web site.

Section 139.5(3) amends the reporting requirements concerning abortion complications by adding the Abortion Complications Reporting form the physician must submit to the Department within 20 days from discovering a complication. The Abortion Complication Reporting form can be found here. The rules can be found here

For questions or concerns related to facility licensing and regulations, please submit an email to or contact Ellen Cooper, Health Facilities Licensing Group Manager, at (512) 834-6639.


Medicaid Primary Care Rates Increased
HHSC is working to finalize a primary rate increase now that states have received federal guidance on the Affordable Care Act provision.

The higher rates, including those for certain physician visits and vaccine administration, will be retroactive to Jan. 1. Federal regulations for the rate increases came Nov. 1, leaving HHSC inadequate time to develop a state plan for the increases and get federal approval by the Jan. 1 target date. Once the state plan is approved and the rates are increased, HHSC will make retroactive payments to cover the increase for services that qualify under the federal regulations. More information can be found here

December 2012

Update on Postpartum Coding Change

On December 17, 2012, TMA, ACOG District XI, TAOG and TAFP met with Dr. Brendle Glomb, Medical Director of Texas Medicaid and CHIP Programs. We called the meeting because Medicaid had issued a clarification that they would only pay the postpartum visit code 59430 once ( Clarification on Postpartum Visits.pdf). This was a change from past practice when this code was paid twice.

HHSC staff reported that the Medicaid clarification was issued in response to the ACA requirement for "correct coding.”  In the AMA CPT manual, the code 59430 does not limit the number of postpartum visits so, for example, a patient with a Cesarean delivery may have two visits, and the single code 59430 covers both of them. The ACOG/TAOG representatives pointed out that the national RVU amount for this code was 5.32 for 2012 and has been increased to 5.6 for 2013. In Texas, our reimbursement is set at 3.39 RVU. Dr. Glomb voiced that he was unaware Texas was reimbursing at such a low level and this could have been related to the prior to July 2012 change when more than one visit was being paid for. With only one visit allowed now, we are being reimbursed not even near the national level. He advised he was going to check with other state Medicaid directors on this issue.

It is possible for a provider to use E&M coding to be reimbursed for a postpartum visit when the patient has a complication such as hypertension, but the Medicaid manual is very unclear about how and when this can be used. The Medicaid HHSC staff advised to bill the 59430 code only for routine, normal post-partum visit. If the patient has any other identifiable ICD-9 diagnosis for which she needs follow-up in the post-partum visit, then bill this as an E&M visit and not a post-partum visit.  The ACOG/TAOG representatives voiced concern if this would be paid.

Another billing/reimbursement issue was identified: some providers have been billing for deliveries using 59410 (vaginal) and 59515 (cesarean).  These codes include payment for both the delivery and the postpartum visit.  There is significant confusion regarding what "postpartum care" is included in these codes, with many physicians thinking it was the postpartum care in the hospital.  This is not the case and the postpartum care refers to the subsequent outpatient visit.

We asked for:

1) clarification on the use of E&M codes for billing for postpartum visits.
HHSC says this may be done in as short as three weeks (but with the holidays, likely longer)

2) review of the RVU and the conversion factor to get this changed to adequately pay providers for the postpartum visits at recommended national RVU values.(Dr. Glomb promised to look at this, but an increase in payment will need LBB review).

3) evaluation of payment for obstetric codes for delivery 59409, 59410.  At the present, it is believed that the payment for these codes is the same--thus the provider is not receiving any payment for postpartum care if they select the delivery plus PPcare code.

4) suspension of the rule changes.  Dr. Glomb said he would investigate this possibility.

Updates on this issue will be posted on the DXI website.

October 2012

Final Rules for Texas Women's Health Program

The Texas Health & Human Services Commission has finalized the rules for the Texas Women's Health Program with the following revisions:

  • Amends rules to prevent disqualification of a provider who may work with a physician in a group practice or someone associated with a medical school or hospital that performs or "promotes" elective abortions

  • Amends definition of elective abortion to include medical emergency exceptions: (1) continued pregnancy would place mother at risk of death or substantial impairment of major bodily function, (2) fetus has severe abnormality

  • Amends definition of "promote" -- provider may provide neutral information about abortion, if asked by patient, as well as referral information (name, address, phone number)

  • Added severability clause that states the TWHP will end if Planned Parenthood prevails in pending lawsuit before the 5th Circuit Court

More information can be found at regarding the revisions and
for provider information. The adopted rules will be published in the Texas Register on Friday, October 26th.  I encourage you to review the revised rules when deciding about participation in the new program.

August 2012

Texas Babies Deserve a Healthy Beginning

Texas Health Steps Online Provider Education announces a newly released training module, Reducing Non-Medically Necessary Deliveries Before 39 Weeks. The goal of this module is to educate health-care providers and others who care for women of childbearing age about the new Texas Medicaid reimbursement criteria for delivery of infants at less than 39 weeks of gestation.

The module is designed to educate providers about collaborating with hospitals to create procedures to reduce pre-39 week non-medically indicated deliveries. It will increase provider comprehension of why the new Medicaid reimbursement criteria were implemented. It also guides providers to develop processes to determine and document the medical necessity of deliveries at less than 39 weeks. Providers will be able to recognize the clinical implications of non-medically necessary delivery by induction or cesarean at less than 39 weeks of gestation and more effectively educate their patients.

To view this new course and more than 40 more courses online, visit Courses are available online 24/7. All Online Provider Education courses are accredited for Continuing Medical Education (CME) and Continuing Nursing Education (CNE).

All courses accredited by the Texas Medical Association, American Nurses Credentialing Center, National Commission for Health Education Credentialing, and the Texas State Board of Social Worker Examiner. Select courses are accredited by the Accreditation Council of Pharmacy Education, UTHSCSA Dental School Office of Continuing Dental Education, Texas Dietetic Association, Texas Academy of Audiology, and International Board of Lactation Consultant Examiners. Continuing Education for multiple disciplines will be provided for these events.

July 2011

Changes to Medicaid -- 39 Weeks

Texas Medicaid announced it will delay changes to coding for obstetrical services until October 1, 2011.  Please click here for the full update from the Texas Medicaid & Healthcare Partnership. Starting October 1, Texas Medicaid is changing its benefit criteria for deliveries, and will deny claims for any induction or cesearean delivery before 39 weeks gestation if not medically necessary and properly documented.

If your practice and/or hospital would like training on the most recent research and how to develop policy guidelines to properly document medically-indicated labor inductions or ceseareans, please contact  Several of our members have recently received training on how to talk to fellow physicians about the research behind this initiative and are available to assist you and your hospital with best practices, so as to avoid problems with Medicaid reimbursement.  As you will recall, HB 1983 allows hospitals to develop policies at the local level.

A sample talk on how to present this to physicians, administrators and nurses and can be found here.  Additional tools will be posted soon.  To have any of these documents emailed to you, please contact

March of Dimes also has some valuable information as well as a downloadable toolkit. Click here for more information. If you have access to the Green Journal, you can also review this recently published article: Timing of Indicated Late-Preterm and Early-Term Birth Spong, Catherine Y.; Mercer, Brian M.; D'Alton, Mary; Kilpatrick, Sarah; Blackwell, Sean; Saade, George Obstetrics & Gynecology. 118(2, Part 1):323-333, August 2011.


Sarah Rayburn

ACOG District XI: