CHIP $20,000 CAP for Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies Now Active

Date: August 22, 2023

Attention: CHIP Providers

Effective date: May 23, 2023

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that in accordance with the Uniform Managed Care Manual, for CHIP Members, there is a $20,000 12-month period limit for DME, prosthetics, devices and disposable medical supplies limitation (diabetic supplies and equipment are not counted against this cap). Covered services require prior authorization and physician prescription when in excess of benefit limitations for members 20 years of age and under. A co-payment is not required.

Resource:https://www.texaschildrenshealthplan.org/for-providers/prior-authorization-information

How this impacts providers: Covered services include DME (equipment that can withstand repeated use and is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of Illness, Injury, or Disability, and is appropriate for use in the home), including devices and supplies that are medically necessary and necessary for one or more activities of daily living and appropriate to assist in the treatment of a medical condition, including but not limited to:

• Orthotic braces and orthotics
• Dental Devices
• Prosthetic devices such as artificial eyes, limbs, braces, and external breast prostheses
• Prosthetic eyeglasses and contact lenses for the management of severe ophthalmologic disease
• Other artificial aids including surgical implants
• Hearing aids
• Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit.
• Diagnosis-specific disposable medical supplies, including diagnosis-specific prescribed specialty formula and dietary supplements.

Next step for Providers: Providers should adhere to this guidance and submit prior authorization requests when applicable.

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.