Relating to Medicaid and child health plan program coverage and reimbursement for childhood cranial remolding orthosis.

Contracts

• Managed Care Organizations (MCOs): Expect contract amendments or provider manual updates from Texas Medicaid MCOs (e.g., Superior, Amerigroup, Texas Children’s) to include this benefit.
• Vendor Negotiations: The state estimates a reimbursement rate of $1,864 per utilizer. You must immediately audit your fabrication vendor contracts. If your cost of goods sold (COGS) plus clinical labor exceeds this margin, renegotiate fabrication rates or adjust internal manufacturing processes before the 2026 go-live.

Hiring/Training

• Clinical Staff: Orthotists must be trained to document specific anthropometric measurements (in millimeters) rather than qualitative assessments. "Visible flattening" is insufficient; the chart must reflect asymmetry >6mm or a cephalic index >2 SD from the mean.
• Intake Coordinators: Staff must be retrained to screen referrals for the statutory age window (3 to 18 months). Referrals for children outside this window must be flagged immediately as non-reimbursable.

Reporting & Record-Keeping

• Evidence of Failed Therapy: You must implement a document intake process that secures proof of two months of failed conservative therapy (repositioning/PT) prior to the helmet prescription. Without this paper trail from the referring pediatrician or therapist, the claim will be denied or recouped.
• Audit-Proofing: Patient files must explicitly link the diagnosis code (e.g., Plagiocephaly) with the specific statutory measurement criteria.

Fees & Costs

• Revenue Impact: This is a reimbursement expansion, not a fee increase.
• Cash Flow Warning: Expect initial claims denials in late 2026 as MCO adjudication systems adjust to the new logic. Maintain sufficient cash reserves to cover the lag in receivables.