Relating to Medicaid coverage and reimbursement for lactation consultation services.

Contracts

• Managed Care Agreements: Legal teams must review upcoming amendments from Medicaid MCOs (STAR, STAR+PLUS, CHIP) to ensure the new fee schedule is incorporated.
• Employment Agreements: Revise contracts for employed lactation consultants. Shift language from general support staff to revenue-generating providers. Clauses must be added mandating maintenance of HHSC-approved certifications as a condition of employment.
• Vendor Agreements: Third-party billing vendors must be contractually obligated to update practice management software to recognize the new provider taxonomy by Q2 2026.

Hiring/Training

• Provider Enrollment: Lactation consultants must obtain individual National Provider Identifiers (NPIs) and enroll directly with Texas Medicaid (TMHP). They can no longer bill solely under a supervising physician’s NPI for these specific codes.
• Credentialing: Practices must add lactation consultants to their credentialing rosters immediately upon the opening of the specific provider type application.

Reporting & Record-Keeping

• Primary Source Verification: You must maintain proof of the specific certification (e.g., IBCLC, CLC) required by HHSC rules to survive future OIG audits.
• Medical Necessity: Documentation workflows must be updated to link services to a specific diagnosis (e.g., feeding difficulties, failure to thrive) for the mother or infant to justify the claim.

Fees & Costs

• Revenue Impact: The Legislative Budget Board projects a reimbursement rate of approximately $54.20 per session.
• Administrative Cost: Budget for administrative hours in FY2026 to process new provider applications and re-credentialing for all lactation staff.