AUTHORITY AND SCOPE OF PROGRAM; ELIGIBILITY

(a) The commission shall provide medical assistance to all persons who receive financial assistance from the state under Chapter 31 and to other related groups of persons if the provision of medical assistance to those persons is required by federal law and rules as a condition for obtaining federal matching funds for the support of the medical assistance program.

(b) The commission may provide medical assistance to other persons who are financially unable to meet the cost of medical services if federal matching funds are available for that purpose. The executive commissioner shall adopt rules governing the eligibility of those persons for the services.

(c) The executive commissioner shall establish standards governing the amount, duration, and scope of services provided under the medical assistance program. The standards may not be lower than the minimum standards required by federal law and rule as a condition for obtaining federal matching funds for support of the program.

(c-1) The commission shall ensure that money spent for purposes of the demonstration project for women's health care services under former Section 32.0248 or a similar successor program is not used to perform or promote elective abortions, or to contract with entities that perform or promote elective abortions or affiliate with entities that perform or promote elective abortions.

(d) The executive commissioner may establish standards that increase the amount, duration, and scope of the services provided only if federal matching funds are available for the optional services and payments and if the executive commissioner determines that the increase is feasible and within the limits of appropriated funds. The executive commissioner may establish and maintain priorities for the provision of the optional medical services.

(e) The commission may not authorize the provision of any service to any person under the program unless federal matching funds are available to pay the cost of the service.

(f) The executive commissioner shall set the income eligibility cap for persons qualifying for nursing facility care at an amount that is not less than $1,104 and that does not exceed the highest income for which federal matching funds are payable. The executive commissioner shall set the cap at a higher amount than the minimum provided by this subsection if appropriations made by the legislature for a fiscal year will finance benefits at the higher cap for at least the same number of recipients of the benefits during that year as were served during the preceding fiscal year, as estimated by the commission. In setting an income eligibility cap under this subsection, the executive commissioner shall consider the cost of the adjustment required by Subsection (g).

(g) During a fiscal year for which the cap described by Subsection (f) has been set, the executive commissioner shall adjust the cap in accordance with any percentage change in the amount of benefits being paid to social security recipients during the year.

(i) The executive commissioner in adopting rules may establish a medically needy program that serves pregnant women, children, and caretakers who have high medical expenses, subject to the availability of appropriated funds.

(j) Repealed by Acts 2015, 84th Leg., R.S., Ch. 1, Sec. 4.465(a)(36), eff. April 2, 2015.

(k) Repealed by Acts 2015, 84th Leg., R.S., Ch. 1, Sec. 4.465(a)(36), eff. April 2, 2015.

(l) The executive commissioner shall set the income eligibility cap for medical assistance for pregnant women and infants up to age one at not less than 130 percent of the federal poverty guidelines.

(l-1) The commission shall continue to provide medical assistance to a woman who is eligible for medical assistance for pregnant women for a period of not less than:

(1) six months following the date the woman delivers or experiences an involuntary miscarriage; and

(2) 12 months that begins on the last day of the woman's pregnancy and ends on the last day of the month in which the 12-month period ends in accordance with Section 1902(e)(16), Social Security Act (42 U.S.C. Section 1396a(e)(16)).

(m) Repealed by Acts 2015, 84th Leg., R.S., Ch. 1, Sec. 4.465(a)(36), eff. April 2, 2015.

(n) The executive commissioner, in the adoption of rules and standards governing the scope of hospital and long-term services, shall authorize the providing of respite care by hospitals.

(o) The executive commissioner, in the rules and standards governing the scope of hospital and long-term services, shall establish a swing bed program in accordance with federal regulations to provide reimbursement for skilled nursing patients who are served in hospital settings provided that the length of stay is limited to 30 days per year and the hospital is located in a county with a population of 100,000 or less. If the swing beds are used for more than one 30-day length of stay per year, per patient, the hospital must comply with the minimum licensing standards as mandated by Chapter 242 , Health and Safety Code, and the Medicaid standards for nursing facility certification, as promulgated by the executive commissioner.

(p) The commission shall provide home respiratory therapy services for ventilator-dependent persons to the extent permitted by federal law.

(q) The commission shall provide physical therapy services.

(r) The commission, from funds otherwise appropriated to the commission for the early and periodic screening, diagnosis, and treatment program, shall provide to a child who is 14 years of age or younger, permanent molar sealants as dental service under that program as follows:

(1) sealant shall be applied only to the occlusal buccal and lingual pits and fissures of a permanent molar within four years of its eruption;

(2) teeth to be sealed must be free of proximal caries and free of previous restorations on the surface to be sealed;

(3) if a second molar is the prime tooth to be sealed, a non-restored first molar may be sealed at the same sitting, if the fee for the first molar sealing is no more than half the usual sealant fee;

(4) the sealing of premolars and primary molars will not be reimbursed; and

(5) replacement sealants will not be reimbursed.

(s) The executive commissioner, in the rules governing the early and periodic screening, diagnosis, and treatment program, shall:

(1) revise the periodicity schedule to allow for periodic visits at least as often as the frequency recommended by the American Academy of Pediatrics and allow for interperiodic screens without prior approval when there are indications that it is medically necessary; and

(2) require, as a condition for eligibility for reimbursement under the program for the cost of services provided at a visit or screening, that a child younger than 15 years of age be accompanied at the visit or screening by:

(A) the child's parent or guardian; or

(B) another adult, including an adult related to the child, authorized by the child's parent or guardian to accompany the child.

(s-1) Subsection (s)(2) does not apply to services provided by a school health clinic, Head Start program, or child-care facility, as defined by Section 42.002 , if the clinic, program, or facility:

(1) obtains written consent to the services from the child's parent or guardian within the one-year period preceding the date on which the services are provided, and that consent has not been revoked; and

(2) encourages parental involvement in and management of the health care of children receiving services from the clinic, program, or facility.

(t) The executive commissioner by rule shall require a physician, nursing facility, health care provider, or other responsible party to obtain authorization from the commission or a person authorized to act on behalf of the commission on the same day or the next business day following the day of transport when an ambulance is used to transport a recipient of medical assistance under this chapter in circumstances not involving an emergency and the request is for the authorization of the provision of transportation for only one day. If the request is for authorization of the provision of transportation on more than one day, the executive commissioner by rule shall require a physician, nursing facility, health care provider, or other responsible party to obtain a single authorization before an ambulance is used to transport a recipient of medical assistance under this chapter in circumstances not involving an emergency. The rules must provide that:

(1) except as provided by Subdivision (3), a request for authorization must be evaluated based on the recipient's medical needs and may be granted for a length of time appropriate to the recipient's medical condition;

(2) except as provided by Subdivision (3), a response to a request for authorization must be made not later than 48 hours after receipt of the request;

(3) a request for authorization must be immediately granted and must be effective for a period of not more than 180 days from the date of issuance if the request includes a written statement from a physician that:

(A) states that alternative means of transporting the recipient are contraindicated; and

(B) is dated not earlier than the 60th day before the date on which the request for authorization is made;

(4) a person denied payment for ambulance services rendered is entitled to payment from the nursing facility, health care provider, or other responsible party that requested the services if:

(A) payment under the medical assistance program is denied because of lack of prior authorization; and

(B) the person provides the nursing facility, health care provider, or other responsible party with a copy of the bill for which payment was denied;

(5) a person denied payment for services rendered because of failure to obtain prior authorization or because a request for prior authorization was denied is entitled to appeal the denial of payment to the commission; and

(6) the commission or a person authorized to act on behalf of the commission must be available to evaluate requests for authorization under this subsection not less than 12 hours each day, excluding weekends and state holidays.

(t-1) The executive commissioner, in the rules governing the medical transportation program, may not prohibit a recipient of medical assistance from receiving transportation services through the program to obtain renal dialysis treatment on the basis that the recipient resides in a nursing facility.

(u) The executive commissioner by rule shall require a health care provider who arranges for durable medical equipment for a child who receives medical assistance under this chapter to:

(1) ensure that the child receives the equipment prescribed, the equipment fits properly, if applicable, and the child or the child's parent or guardian, as appropriate considering the age of the child, receives instruction regarding the equipment's use; and

(2) maintain a record of compliance with the requirements of Subdivision (1) in an appropriate location.

(v) The executive commissioner by rule shall provide a screening test for hearing loss in accordance with Chapter 47 , Health and Safety Code, and any necessary diagnostic follow-up care related to the screening test to a child younger than 30 days old who receives medical assistance.

(w) The executive commissioner shall set a personal needs allowance of not less than $75 a month for a resident of a convalescent or nursing facility or related institution licensed under Chapter 242 , Health and Safety Code, assisted living facility, ICF-IID facility, or other similar long-term care facility who receives medical assistance. The commission may send the personal needs allowance directly to a resident who receives Supplemental Security Income (SSI) (42 U.S.C. Section 1381 et seq.). This subsection does not apply to a resident who is participating in a medical assistance waiver program administered by the commission.

(x) The commission shall provide dental services annually to a resident of a nursing facility who is a recipient of medical assistance under this chapter. The dental services must include:

(1) a dental examination by a licensed dentist;

(2) a prophylaxis by a licensed dentist or licensed dental hygienist, if practical considering the health of the resident; and

(3) diagnostic dental x-rays, if possible.

(y) The commission shall provide medical assistance to a person in need of treatment for breast or cervical cancer who is eligible for that assistance under the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Pub. L. No. 106-354) for a continuous period during which the person requires that treatment. The executive commissioner shall simplify the provider enrollment process for a provider of that medical assistance and shall adopt rules to provide for certification of presumptive eligibility of a person for that assistance. In determining a person's eligibility for medical assistance under this subsection, the executive commissioner, to the extent allowed by federal law, may not require a personal interview.

(y-1) A woman who receives a breast or cervical cancer screening service under Title XV of the Public Health Service Act (42 U.S.C. Section 300k et seq.) and who otherwise meets the eligibility requirements for medical assistance for treatment of breast or cervical cancer as provided by Subsection (y) is eligible for medical assistance under that subsection, regardless of whether federal Medicaid matching funds are available for that medical assistance. A screening service of a type that is within the scope of screening services under that title is considered to be provided under that title regardless of whether the service was provided by a provider who receives or uses funds under that title.

(z) In the executive commissioner's rules and standards governing the vendor drug program, the executive commissioner, to the extent allowed by federal law and if the executive commissioner determines the policy to be cost-effective, may ensure that a recipient of prescription drug benefits under the medical assistance program does not, unless authorized by the commission in consultation with the recipient's attending physician or advanced practice nurse, receive under the medical assistance program:

(1) more than four different outpatient brand-name prescription drugs during a month; or

(2) more than a 34-day supply of a brand-name prescription drug at any one time.

(z-1) Subsection (z) does not affect any other limit on prescription medications otherwise prescribed by commission rule.

(z-2) The limits on prescription drugs and medications under the medical assistance program provided by Subsections (z) and (z-1) do not apply to a prescription for an opioid for the treatment of acute pain under Section 481.07636 , Health and Safety Code.

(aa) The commission shall incorporate physician-oriented instruction on the appropriate procedures for authorizing ambulance service into current medical education courses.

(bb) The commission may not provide an erectile dysfunction medication under the Medicaid vendor drug program to a person required to register as a sex offender under Chapter 62 , Code of Criminal Procedure, to the maximum extent federal law allows the commission to deny that medication.

(cc) In this subsection, "deaf" and "hard of hearing" have the meanings assigned by Section 81.001 . Subject to the availability of funds, the commission shall provide interpreter services as requested during the receipt of medical assistance under this chapter to:

(1) a person receiving that assistance who is deaf or hard of hearing; or

(2) a parent or guardian of a person receiving that assistance if the parent or guardian is deaf or hard of hearing.

(dd) Nothwithstanding any other law, an inmate released on medically recommended intensive supervision under Section 508.146 , Government Code, who otherwise meets the eligibility requirements for the medical assistance program is not ineligible for the program solely on the basis of the conviction or adjudication for which the inmate was sentenced to confinement.

(ff) The executive commissioner shall establish a separate provider type for prosthetic and orthotic providers for purposes of enrollment as a provider of and reimbursement under the medical assistance program. The executive commissioner may not classify prosthetic and orthotic providers under the durable medical equipment provider type.

(gg) Notwithstanding any other law, including Sections 843.312 and 1301.052 , Insurance Code, the commission shall ensure that advanced practice registered nurses and physician assistants may be selected by and assigned to recipients of medical assistance as the primary care providers of those recipients regardless of whether the physician supervising the advanced practice registered nurse is included in any directory of providers of medical assistance maintained by the commission. This subsection may not be construed as authorizing the commission to supervise or control the practice of medicine as prohibited by Subtitle B, Title 3, Occupations Code. The commission must require that advanced practice registered nurses and physician assistants be treated in the same manner as primary care physicians with regard to:

(1) selection and assignment as primary care providers; and

(2) inclusion as primary care providers in any directory of providers of medical assistance maintained by the commission.

(ii) The commission shall provide medical assistance reimbursement to a pharmacist who is licensed to practice pharmacy in this state, is authorized to administer immunizations in accordance with rules adopted by the Texas State Board of Pharmacy, and administers an immunization to a recipient of medical assistance to the same extent the commission provides reimbursement to a physician or other health care provider participating in the medical assistance program for the administration of that immunization.

(jj) The executive commissioner shall establish a separate provider type for prescribed pediatric extended care centers licensed under Chapter 248A , Health and Safety Code, for purposes of enrollment as a provider for and reimbursement under the medical assistance program.

(kk) The commission in its rules and standards governing the scope of services provided under the medical assistance program shall include peer services provided by certified peer specialists to the extent permitted by federal law.

(ll) The executive commissioner shall establish a separate provider type for a local public health entity for purposes of enrollment as a provider for and reimbursement under the medical assistance program.

(mm) The commission shall provide medical assistance reimbursement to an authorized wound care education and training services provider and establish outcome measures for evaluating the physical health care outcomes of recipients who receive wound care education and training services from an authorized wound care education and training services provider.

(oo) The commission shall provide medical assistance reimbursement to a treating health care provider who participates in Medicaid for the provision to a child or adult medical assistance recipient of behavioral health services that are classified by a Current Procedural Terminology code as collaborative care management services.

(pp) For purposes of enrollment as a provider and reimbursement under the medical assistance program, the commission shall establish a separate provider type for a community health worker who provides case management services under the case management for children and pregnant women program under Section 531.653(4), Government Code.

(qq) For purposes of enrollment as a provider and reimbursement under the medical assistance program, the commission shall establish a separate provider type for a doula who:

(1) is certified by a recognized national doula certification program approved by the commission; and

(2) provides case management services under the case management for children and pregnant women program under Section 531.653(5), Government Code.

(rr) The medical assistance program may not provide coverage for services prohibited by Section 161.702 , Health and Safety Code, that are intended to transition a child's biological sex as determined by the child's sex organs, chromosomes, and endogenous profiles. Text of Subsection (kk) effective on June 15, 2017, but only if a specific appropriation is provided as described by Acts 2017, 85th Leg., R.S., Ch. 1015 (H.B. 1486 ), Sec. 5(b), which states: This Act takes effect only if the 85th Legislature appropriates money specifically for the purpose of implementing this Act. If the legislature does not appropriate money specifically for that purpose, this Act does not take effect. Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1989, 71st Leg., ch. 1027, Sec. 11, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1085, Sec. 3, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1107, Sec. 1, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1219, Sec. 1, eff. Sept. 1, 1989; Acts 1990, 71st Leg., 6th C.S., ch. 12, Sec. 2(11) to (13), eff. Sept. 6, 1990; Acts 1991, 72nd Leg., ch. 690, Sec. 1, eff. Aug. 26, 1991; Acts 1995, 74th Leg., ch. 6, Sec. 3, eff. March 23, 1995; Acts 1997, 75th Leg., ch. 1153, Sec. 2.01(a), 2.02(a), eff. June 20, 1997; Acts 1999, 76th Leg., ch. 766, Sec. 1, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1333, Sec. 1, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1347, Sec. 3, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1505, Sec. 1.06, eff. Sept. 1, 1999; Acts 2001, 77th Leg., ch. 220, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 348, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 974, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 1420, Sec. 21.001(81), eff. Sept. 1, 2001; Acts 2003, 78th Leg., ch. 198, Sec. 2.96, 2.97(a), 2.207(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 215, Sec. 1, eff. June 18, 2003; Acts 2003, 78th Leg., ch. 1251, Sec. 6, eff. June 20, 2003; Acts 2003, 78th Leg., ch. 1275, Sec. 2(97), eff. Sept. 1, 2003. Amended by: Acts 2005, 79th Leg., Ch. 349 (S.B. 1188 ), Sec. 22, eff. September 1, 2005. Acts 2005, 79th Leg., Ch. 728 (H.B. 2018 ), Sec. 23.001(57), eff. September 1, 2005. Acts 2005, 79th Leg., Ch. 1314 (H.B. 3235 ), Sec. 1, eff. September 1, 2005. Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10 ), Sec. 16, eff. September 1, 2007. Acts 2007, 80th Leg., R.S., Ch. 442 (H.B. 52 ), Sec. 1, eff. September 1, 2007. Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167 ), Sec. 17.001(50), eff. September 1, 2007. Acts 2007, 80th Leg., R.S., Ch. 1308 (S.B. 909 ), Sec. 45, eff. June 15, 2007. Acts 2009, 81st Leg., R.S., Ch. 745 (S.B. 531 ), Sec. 2, eff. September 1, 2009. Acts 2009, 81st Leg., R.S., Ch. 858 (S.B. 2424 ), Sec. 1, eff. June 19, 2009. Acts 2011, 82nd Leg., R.S., Ch. 35 (S.B. 874 ), Sec. 1, eff. May 9, 2011. Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7 ), Sec. 1.19(b), eff. September 28, 2011. Acts 2013, 83rd Leg., R.S., Ch. 418 (S.B. 406 ), Sec. 25, eff. November 1, 2013. Acts 2013, 83rd Leg., R.S., Ch. 1168 (S.B. 492 ), Sec. 6, eff. September 1, 2013. Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219 ), Sec. 4.080, eff. April 2, 2015. Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219 ), Sec. 4.081, eff. April 2, 2015. Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219 ), Sec. 4.465(a)(36), eff. April 2, 2015. Acts 2017, 85th Leg., R.S., Ch. 302 (S.B. 654 ), Sec. 3, eff. September 1, 2017. Acts 2017, 85th Leg., R.S., Ch. 1015 (H.B. 1486 ), Sec. 2, eff. June 15, 2017. Acts 2019, 86th Leg., R.S., Ch. 1105 (H.B. 2174 ), Sec. 12, eff. September 1, 2019. Acts 2021, 87th Leg., R.S., Ch. 370 (S.B. 672 ), Sec. 1, eff. September 1, 2021. Acts 2021, 87th Leg., R.S., Ch. 535 (S.B. 73 ), Sec. 2, eff. September 1, 2021. Acts 2021, 87th Leg., R.S., Ch. 629 (H.B. 133 ), Sec. 3, eff. September 1, 2021. Acts 2021, 87th Leg., R.S., Ch. 966 (S.B. 1921 ), Sec. 2, eff. September 1, 2022. Acts 2023, 88th Leg., R.S., Ch. 316 (H.B. 1575 ), Sec. 4, eff. September 1, 2023. Acts 2023, 88th Leg., R.S., Ch. 335 (S.B. 14 ), Sec. 3, eff. September 1, 2023. Acts 2023, 88th Leg., R.S., Ch. 658 (H.B. 54 ), Sec. 1, eff. September 1, 2023. Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595 ), Sec. 24.001(25), eff. September 1, 2023. Acts 2023, 88th Leg., R.S., Ch. 996 (H.B. 12 ), Sec. 2, eff. June 18, 2023. Acts 2025, 89th Leg., R.S., Ch. 204 (H.B. 1620 ), Sec. 22.001(25), eff. September 1, 2025.