How To Change Medicaid Plans In Texas


Executive Commissioner’s Commitment To Improving Member And Provider Experience In Medicaid Managed Care

‘Fundamentally change healthcare’: Group of Texas Republicans join Democrats to expand Medicaid

Executive Commissioner Chris Traylor held stakeholder meetings in 2015 to gather input on ways to improve the managed care landscape, from both the member and provider perspective. According to Executive Commissioner Traylor, the purpose was to improve provider experience in managed care and ultimately to ensure the 4.5 million people relying on the Medicaid and Children’s Health Insurance Program programs have appropriate access to services to enable them to live strong, productive lives. He also shared thoughts that it is important as Texas evolves from fee-for-service to managed care, to project future needs to create the best system possible.

HHSC responses were shared directly with stakeholder groups in February 2016, updates were posted to the website on April 11, 2016, and July 22, 2016, and biannual updates on items in progress or under discussion will continue to be shared on the website. Items that are closed as of the last update will be provided in a separate file as there will be no further update. Items were closed either as complete, no action to be taken, or other . In each update, changes to previous responses are noted with red strikethrough for language that is being removed in order to provide an update, and new language is provided in red.

Questions about this project can sent to .

Star Medicaid Managed Care Program

Most people who have Medicaid in Texas get their coverage through the STAR managed care program. STAR covers low-income children, pregnant women and families. STAR members get their services through health plans they choose.

If you’re new to STAR, you’ll choose a health plan from the ones available in your service area . Learn more about how to choose or change your health plan.

What Is A Managed Care Organization

HHSC contracts with managed care organizations, licensed by the Texas Department of Insurance, and pays them a monthly amount to coordinate health services for Medicaid clients enrolled in their health plan. The health plans contract directly with doctors and other health care providers to create provider networks their members can use. The health plans are required to provide all covered medically necessary services to their members.

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Can I Use My Medicaid Coverage In Any State

In most cases, Medicaid will not cover services that you receive outside of the state where you live. Although Medicaid is a joint federal and state program, each state administers its own Medicaid program. As a result, eligibility and benefits vary widely by state. Each state also has its own network of providers. If you are temporarily out of state, Medicaid will generally only cover services if you encounter a medical emergency that is life-threatening and requires immediate care.

Are There Copays With Medicaid

Texas Medicaid 101

States can impose copayments, coinsurance, deductibles, and other similar charges on most Medicaid-covered benefits, both inpatient and outpatient services, and the amounts that can be charged vary with income. In addition, Medicaid enrollees may be denied services for nonpayment of alternative copayments.

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Health Insurance Premium Payment

The Health Insurance Premium Payment program is a Medicaid program that helps families pay for private health insurance. This program is for families who have:

  • A parent or a spouse with private health insurance
  • A child or a spouse with Medicaid

Medicaid will pay the family’s private health insurance if the total cost of that insurance is less than the total cost of care with Medicaid. The total cost of the private insurance includes the premium, coinsurance and deductibles.

If approved, Medicaid may pay the private health insurance costs for the entire family and not just for the family members who get Medicaid. The family will get services through the private health insurance plan.

To learn more or to apply, visit the Get HIPP Texas website or call us toll-free at 800-440-0493. You also can ask us to send you an application. Write to:

Texas Health and Human Services CommissionTMHP-HIPP

Is There A Penalty For Cancelling Health Insurance

Yes, usually you can cancel your health insurance without a penalty. However, if you reside in a state that has its own coverage mandate, you may face a tax penalty. Your cancellation may take effect beginning the day you cancel, or you may set a date in the future, such as when your new coverage will start.

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Compare The Quality Ratings On The Health Plan Score Cards

The Texas HHS website includes reviews, also known as score cards, for all health plans in Texas. These reviews a wide range of items that are important to people who need care for themselves and their children.

You can learn more and see the score cards online.

The Medicaid STAR Adult Report Card shows scores for 10 different areas.

Parkland Community Health Plan rates especially high in the overall Experience of Care category. We are the only health plan to have a rating for Doctors listen carefully, explain clearly and spend enough time with people.

We also scored high for New mothers get checkups after giving birth.

See the entire STAR Adult Report Card here.

The CHIP Report Card measures healthcare services for infants, children, teens and pregnant women.

See the entire CHIP Report Card here.

Parkland Community Health Plan is the only health plan to earn five out of five stars in Overall Health Plan Quality, Parents give high ratings to their childs personal doctor and Children see the doctor for ADHD.

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Texas Medicaid Wellness Program

Texas HHS STAR PLUS – Medicaid for Breast and Cervical Cancer – 17V0028

The Texas Medicaid Wellness Program is a special health program for people who get Medicaid and have long-lasting or serious health conditions. These conditions can include asthma, diabetes, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease , and others.

People in this program can get help any time of day or night with:

  • Getting an answer to a health question.
  • Finding a main doctor.
  • Managing their health between doctor visits.
  • Learning more about their health conditions.
  • Knowing how to take their medicines.
  • Picking the best medical care for their health.

Learn more about the Wellness Program.

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How Will Hhsc Verify Individuals With Complex Conditions Are Getting The Care They Need In A Managed Care Setting

HHSC has a contract with all Texas Medicaid managed care health plans. The contract lists requirements the health plans must meet to get paid. For example, health plans must provide members with medically necessary services in a timely manner and appropriate setting. When a health plan does not meet its requirements, HHSC will address the issue and ensure the member’s needs are met.

Texas Health Steps Program

Through outreach,Texas Health Steps staff, or contractors encourage STAR Members to use Texas Health Steps preventive medical checkup services when they first become eligible for Medicaid/Texas Health Steps and when they are periodically due for their yearly medical checkup in their birthday month.

On request by the client, the Medical Transportation Program assists the client with scheduling transportation. Refer to the MTP section on page 23 of this Provider Manual for more detailed information.

Texas Health Steps medical providers must perform medical checkups on any client who is currently enrolled in Medicaid and who are ages of birth through 20 years of age. Providers also are encouraged to notify the client when he or she is due for the next medical checkup according to the Texas Health Steps Periodicity Schedule.

Note: Newly enrolled STAR Members must receive a Texas Health Steps medical checkup within 60 days from enrollment.

Provider Training Schedule

To register for training sessions, please call 358-6030 or email .

Free online provider education is available, and many include Continuing Education credits. Check out the online options offered by Texas Health and Human Services Commission .

For additional information visit Health & Human Services.

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Apply For Medicaid In Texas

You can enroll through or the state Medicaid website. You can enroll by phone at 800-318-2596.

Eligibility: The aged, blind, and disabled. Also, parents with dependent children are eligible with household incomes up to 15% of FPL. Children are eligible for Medicaid or CHIP with household incomes up to 201% of FPL, and pregnant women are eligible with household incomes up to 198% of FPL.

Are Medicaid Benefits The Same From State To State

Texas Medicaid 101

Each state administers its own Medicaid benefits, but federal rules require all states to provide certain mandatory services. Examples of mandatory benefits include inpatient and outpatient hospital services, doctor visits, lab and X-rays, home health services and nursing facility services for adults, among other mandatory services. States are also required to cover a more comprehensive set of services for children under age 21.

States can choose to cover additional optional benefits that are not required by federal law. For example, federal rules do not require states to cover prescription drugs, but all state Medicaid programs offer prescription drug benefits. Other common optional benefits include dental care, vision services, hearing aids and personal care services for older adults and people with disabilities.

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What Is A Provider Network

Provider networks are organizations of health care providers that deliver services within managed care health plans. Managed care enrollees are expected to use network providers.

In Texas, there are four types of Medicaid: STAR, STAR+PLUS, STAR Health, and traditional Medicaid. The type of Medicaid coverage a person gets depends on where the person lives and what kind of health issues the person has.

Which Is The Best Medicaid Plan

NCQA Health Insurance Plan Ratings 2019-2020 Summary Report Rating Plan Name 3.5 Coventry Health Care of Florida, Inc. d/b/a Aetna Better Health of Florida 3.5 Humana Medical Plan, Inc. 3.5 Molina Healthcare of Florida, Inc. Special Project: Managed Medical Assistance 3.5 Simply Healthcare Plans, Inc.

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Reasons Why You Would Switch Healthcare Plans

Switching between healthcare plans with other plans is now a common thing nowadays. Gone were the days where people are still naive about these healthcare plans, assuming that the one they got is permanent until the very last of their lives.

However, as you grow older, your healthcare needs will change therefore, you will look for a better healthcare plan that covers your needs. Therefore, here are some of the reasons why you would switch your healthcare plan:

According to a study, the reasons why most people change plans aside from consumer preference are the following:

  • A change in employment

How To Change Pcp On A Texas Medicaid Card

State changes for Medically Dependent Children concern families

If you have Medicaid in Texas, then you have the option to choose your PCP, or Primary Care Provider. Your PCP is the health-care provider you see most often, such as your family doctor. Medicaid policy in Texas does not cover office visits to a provider who is not your PCP, unless your PCP is closed at the time that you need medical care. If you are not satisfied with your PCP in Texas, you may request a PCP change up to four times a year.

Research health-care providers in your area. Texas has a searchable database of health-care providers that accept Medicaid at the website of the Texas Medicaid and Healthcare Partnership. Find a provider that is close to your home or work. Make sure to call the provider and confirm that they are accepting new patients.

Confirm that your medical records were sent to your new PCP. This is usually automatically done by your old PCP, upon Medicaid informing the PCP that they no longer may claim you as a primary Medicaid patient. Inform your new PCP of any medication that has been prescribed for you or that you are taking, including over-the-counter medicines.


  • Texas Medicaid will cover emergency medical care such as ambulatory care or Emergency Room visits, even if not provided by your PCP. Texas Medicaid policies also cover visits to specialists if referred to by your PCP.



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Will There Be A Limit On Prescription Drugs

  • If a member is enrolled in a Medicaid health plan and not Medicare, there is no limit on the medicines they can fill each month.
  • If an individual is enrolled in Medicaid and Medicare Part D, the individual’s Part D health plan will cover most medicines. Medicare Part B also covers certain medicines. Medicaid covers a limited number of medicines that are not covered by Medicare.
  • If an adult is transitioning from fee-for-service Medicaid, which currently has a limit on medicines, into managed care, they will receive unlimited prescriptions once they are enrolled in managed care.

What Services Does Star Cover

Community provides its Medicaid Members with access to comprehensive medical care, including services such as hospital care, surgery, X-rays, physical/speech/occupational therapies, prescription drugs, emergency services, transplants, regular health checkups, and immunizations.

Members receive unlimited medically necessary prescriptions through the Medicaid/CHIP Vendor Drug Formulary.

Demographic Information Updates with TMHP

To Providers: Please update your enrollment and demographic information with TMHP . TMHP is HHSCs provider enrollment administrator and serves as the authoritative source for HHSC Providers enrollment and demographic information. Once you update your enrollment and demographic information with TMHP, your data will be reconciled with the demographic information on file with the MCOs.

To make updates to your current enrollment , please access the web page titled Provider Enrollment and click on Enroll Today at the following URL: Provider Enrollment | TMHP.

For instructions on how to make demographic changes to your current enrollment, please access the web page titled Provider Enrollment and Management System : A Step-by-Step Guide at the following URL: Provider Enrollment and Management System | TMHP.

Otherwise, you can contact TMHP directly at 800-925-9126 for assistance.

Behavioral Health Providers

Facility/Hospital-Based Providers, Group/Practice Providers and Individually-Contracted Clinicians

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Unitedhealthcare Connected For Mycare Ohio

UnitedHealthcare Connected® for MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. If you have any problem reading or understanding this or any other UnitedHealthcare Connected® for MyCare Ohio information, please contact our Member Services at from 7 a.m. to 8 p.m. Monday through Friday for help at no cost to you.

Si tiene problemas para leer o comprender esta o cualquier otra documentación de UnitedHealthcare Connected® de MyCare Ohio , comuníquese con nuestro Departamento de Servicio al Cliente para obtener información adicional sin costo para usted al de lunes a viernes de 7 a.m. a 8 p.m. .

How To Apply For Medicaid In Texas

Texas Medicaid 101

You can apply online for benefits. You will need to be prepared to answer questions about the following for each family member:

  • Social Security number and birth date
  • Citizenship or immigration status
  • Money from jobs and other sources
  • The value of cars and other property
  • Costs you pay for bills

You can also call 211 if you are in Texas. Alternatively, you can dial 1-877-541-7905 Monday to Friday, 8 a.m. to 6 p.m.

You can also visit a community partner in person. Printing and mailing a copy to HHS is also an option

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How Will Hhsc Provide Consumer Direction In A Managed Care Model

Medicaid managed care includes consumer-directed services that allow individuals who receive certain services to hire and manage the people who provide their services. The following services are available for self-direction:

  • Personal assistance services
  • Professional therapies
  • Respite
  • Supported employment
  • Employment assistance
  • Cognitive rehabilitation therapy

Consumer-directed services will continue to be an option in the STAR+PLUS model as it is in traditional Medicaid. In addition, the STAR+PLUS health plans are required to submit quarterly consumer directed services utilization reports to HHSC for review.

How To Report A Change To Medicaid In Texas

Medicaid is a federal health care program that is offered and operated individually by each state. This means that although the federal government authorizes and offers the program, each state uses federal funding to operate its program, set its own budget and program restrictions for use of the funds. In Texas, Medicaid is offered primarily to low-income children under age 19, but some low-income adults may also qualify. If you or a member of your household receives Texas Medicaid, you must report changes to your living or financial situation within 10 days of the change.

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Consider The Open Enrollment

What do you mean when you say open enrollment in a healthcare plan? Well, open enrollment is the time on which you can make changes to your healthcare plan or you can enroll in a new health insurance plan. Hence, the dates for an open enrollment varies depending on where you reside. Usually, open enrollment runs from October to December every year.

However, open enrollment does NOT include Medicaid or the Childrens Health Insurance Program . It does not limit enrollment through Open Enrollment because if you are qualified to sign up, you can do it any time of the year.

In short, it is only applicable for Medicare members, those who have individual insurance, or people who get healthcare plans through the Affordable Care Act . For Medicare recipients, open enrollment runs from October 15 to December 7 and for ACA members, open enrollment happens between November 1 to December 15.

However, some states have their own open enrollment period such as the following:

Rhode Island

For people who got their insurance plans through their employer, you may check with your employer since open enrollment for business varies because they are the ones who decide for that matter.

During the open enrollment, here are the health care insurance options you can do:

  • Buy a short-term health plan
  • Renew your current policy
  • Make changes to your current plan

Who is Eligible for Special Enrollment

1. Change in Household Size


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