Texas Medicaid Requires Providers to Enroll in Medicare Before Medicaid Enrollment

The Texas Health and Human Services Commission (HHSC) reminds providers that any healthcare professional enrolling in Texas Medicaid must also be registered with Medicare if they serve Medicare beneficiaries. This rule applies to all new enrollments, revalidations, and updates completed through the Provider Enrollment and Management System (PEMS).

PEMS System Update

In the updated PEMS system, providers who answer “No” to the question “Are you using a Medicare certification number for this location?” will now receive an on-screen warning. The message refers to the Texas Administrative Code, Title 1, Part 15, Section 352.13, Medicare Certification or Enrollment in Medicare, where the providers are required to be enrolled or certified in Medicare before submitting their Medicaid applications.

HHSC also states that, in accordance with Section Texas Administrative Code, Title 1, Part 15, Section 371.1703(c)(4), the enrollment contract of a provider can be rejected or canceled under the condition of providing false information in the application procedure. If a provider selects no and later provides Medicare services without prior Medicare will face reprimands such as termination in Texas Medicaid as stated in 42 CFR Section 455.416(g)(1).

Action Required

Providers should confirm their Medicare enrollment status before they make Medicaid enrollment applications in PEMS. The individuals who work with Medicare beneficiaries need to get a valid Medicare ID and make sure that PEMS records are updated accordingly.

To have a step-wise instruction, the providers may access the TMHP Provider Enrollment webpage or call the TMHP Contact Center, 800-925-9126.