Overview of the managed care medicaid chip programs in texas
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Overview of the Managed Care Medicaid & CHIP Programs in Texas. What is Managed Care?. Managed care organizes health care through a network of doctors, hospitals and other health care providers who are responsible for managing and delivering quality, cost-effective care.

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Overview of the Managed Care Medicaid & CHIP Programs in Texas

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Overview of the Managed Care Medicaid & CHIP Programs in Texas

What is Managed Care?

  • Managed care organizes health care through a network of doctors, hospitals and other health care providers who are responsible for managing and delivering quality, cost-effective care.

  • The state pays a managed care organization a capped rate for each client enrolled, rather than paying for each unit of service provided.

Goals of Managed Care

  • Emphasize preventative care

  • Improve access to care

  • Ensure appropriate utilization of services

  • Improve client and provider satisfaction

  • Establish a medical home for Medicaid clients through a primary care provider (PCP)

  • Improve health outcomes, quality of care and cost effectiveness

STAR (State of Texas Access Reform)


STAR Health



Managed Care Programs in Texas

Number of Clients Enrolled in Managed Care

As of March 2013:

  • 3,317,287 people are enrolled in Medicaid

    • 88 percent are enrolled in managed care

      • 2,919,004 are enrolled in

        • STAR,

        • STAR Health, or

        • STAR+PLUS

Page 5

STAR Program

The STAR program operates under a federal waiver and provides acute care services for:

People receiving Temporary Assistance for Needy Families (TANF)

Non-disabled pregnant women


Low income families and children

Each STAR member is enrolled in a managed care organization (MCO) and has a primary care provider (PCP).

The PCP serves as the medical home and coordinates the member’s care.

Statewide service areas: Bexar, Dallas, El Paso, Harris, Hidalgo, Jefferson, Lubbock, Medicaid Rural Service Area (MRSA), Nueces, Tarrant, and Travis.

Geographic Distribution of Managed Care Delivery Models


Mandatory Populations Enrolled in STAR

TANF recipients

Pregnant women


Children receiving Medicaid assistance only

Medicaid Rural Service Area (MRSA):

Adults (age 21 and older) receiving Supplemental Security Income (SSI) without Medicare

Adults (age 21 and older) in a DADS 1915(c) waiver program

Voluntary Populations Enrolled in STAR

Children residing in the Medicaid RSA and receiving SSI benefits but not Medicare.

Some children enrolled in the DADS 1915 (c) waiver program that are not receiving SSI or Medicare

Populations Excluded from STAR

  • Medicaid recipients who reside in institutions

  • Medically needy

  • Children in foster care

  • Refugees

  • Dual-eligible Medicaid recipients (clients with both Medicaid and Medicare)

Adult STAR Benefits

Traditional Medicaid package

Primary care provider (PCP)

Unlimited prescriptions

Unlimited necessary days in hospital

Health education classes

Value-added services

Children’s STAR Benefits

Children’s Medicaid benefits


Health education classes

Value-added services

Children in traditional Medicaid receive unlimited prescriptions and unlimited necessary days in a hospital.


STAR Health is a statewide program that provides comprehensive and coordinated health services to children in foster care and kinship care.

The Health and Human Services Commission (HHSC) contracted with Superior HealthPlan Network (Superior) to provide an array of health services.

Eligible Populations for STAR Health

  • Children and youth in state conservatorship.

  • Young adults up to 22 years of age with a voluntary foster care placement agreement.

  • Young adults under 21 years of age who were previously in foster care and receiving transitional Medicaid services.

  • Young adults age 21 through the month of their 23rd birthday who are enrolled in an institute of higher education.

Excluded from STAR Health

  • Youth adjudicated in Texas Juvenile Justice Department (TJJD) facilities.

  • Youth from other states placed in Texas, or youth from Texas who were placed in other states.

  • Youth residing in Medicaid-paid facilities such as nursing homes, state supported living centers, or Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF-IID).

Excluded from STAR Health

Dual eligible clients (enrolled in Medicare & Medicaid).

Youth who have been adopted or have a signed adoption placement agreement.

Youth who have been on runaway status for longer than 60 days.

Youth who are in a hospice program.

Youth who have been declared manifestly dangerous and placed in Vernon State Hospital.

STAR Health Benefits

Primary Care Provider and Medical Home

Service Coordination

Service Management

Medical Services

Dental Services

Vision Services

Behavioral Health Services

Health Passport

STAR Health Features & Enhancements

  • Nurse Helpline

    • Trained staff available 24 hours a day, 7 days a week

  • Behavioral Health Helpline

    • Trained staff available 24 hours a day, 7 days a week

  • Service Team to provide service coordination and service management

    • Service Managers and Service Coordinators

STAR Health Features & Enhancements

  • Health Passport

    • Provides statewide electronic access to a child’s medical and administrative information.

  • Behavioral Health

    • No referral requirement.

  • Medical Home

    • Health care coordinated through a primary care provider.


STAR+PLUS is a Texas Medicaid managed care program designed to provide health care, acute care, long-term services and support (LTSS) and pharmacy benefits through a managed care system.

Main feature - service coordination.

A specialized care management service that is performed by a service coordinator

Each member is enrolled in an MCO.

Service Areas: Bexar, Dallas, El Paso, Harris, Hidalgo, Jefferson, Lubbock, Nueces, Tarrant, and Travis.

STAR+PLUS Managed Care Service Areas


Mandatoryfor STAR+PLUS

People who have a physical or mental disability and qualify for Supplemental Security Income (SSI) benefits or for Medicaid because of low income.

People who qualify for Community-Based Alternative 1915(c) waiver services.

People age 21 or older who can receive Medicaid, because they are in a Social Security Exclusion program and meet financial criteria for 1915(c) waiver services.

People age 21 or older who receive SSI.

Voluntary for STAR+PLUS

Children under age 21 receiving SSI or SSI-related services living in a STAR+PLUS service area may choose to enroll in STAR+PLUS or choose to be placed in traditional Medicaid.

Adult STAR+PLUS Benefits

Medicaid Only

Traditional Medicaid benefits


Community-based LTSS

Service Coordinator

Unlimited prescriptions

Dual Eligibles – Individuals who qualify for both Medicare benefits and Medicaid assistance. These individuals receive their Acute Care though Medicare and their LTSS through the STAR+Plus Program.

Children’s STAR+PLUS Benefits

Children’s Medicaid package

Primary Care Physician (PCP)

Community-based LTSS

Service Coordinator

Unlimited necessary hospital days

Medicaid Rural Service Area (MRSA) Expansion


  • Expands STAR+PLUS into the Medicaid Rural Service Areas.

  • Projected expansion date: September 1, 2014

  • Service Areas: Central, Northeast and West Texas

Page 26

Children’s Health Insurance Program (CHIP)

The Balanced Budget Act (BBA) of 1997 (P.L. 105-33) created the State Children’s Health Insurance Program (SCHIP) under Title XXI of the Social Security Act.

The Texas program become operational in 2000.

CHIP is offered statewide and covers children in families who have too much income or too many assets to qualify for Medicaid, but cannot afford to buy private insurance.

CHIP Eligibility

In CHIP, children are eligible from birth through the month of their 19th birthday if they reside in families with incomes at or below 200 percent of the Federal poverty level (FPL), provided that they are not eligible for Medicaid.

CHIP-eligible children must enroll in a CHIP MCO.

CHIP Benefits

  • The CHIP benefit package includes a basic set

    of health care benefits that is cost effective and

    focuses on primary health care needs.

  • These benefits are subject to certain limitations and exclusions.

CHIP Cost Sharing

Based on the families income, most families in CHIP pay an annual enrollment fee, to cover all children in the family.

CHIP families also pay co-payments for doctor visits, prescription drugs, inpatient hospital care, and non-emergent care provided in an emergency room setting.

American Indians and Alaska Natives are exempt from all CHIP cost sharing obligations.

CHIP Delivery Network

CHIP services are delivered by private MCOs selected by the state through a competitive procurement.

Enrollees residing in a CHIP service area receive services through one of the CHIP MCOs.

Enrollees residing in rural counties that are not included in a CHIP service area receive their services through one of two MCOs that provide comprehensive health care services for enrollees throughout the rural counties (CHIP RSA).

CHIP Service Areas


CHIP Dental Services

Each CHIP member is enrolled in a dental maintenance organization (DMO) and has a dental home.

The main dental home assesses dental needs and coordinates members’ care with specialty providers.

CHIP Dental Benefits

  • CHIP members get up to $564 in dental services per 12 month enrollment period for all dental procedures unless an exception applies.

  • Exceptions after the $564 is reached:

    • Preventative services in the American Academy of Pediatric Dentistry periodicity schedule.

    • Some medically necessary services subject to prior authorization by the dental plan.

CHIP Medically Necessary Dental Services

  • Diagnostic and preventative services

  • Restorative

  • Endodontic

  • Periodontal

  • Prosthodontic

  • Oral and maxillofacial surgery services

  • Orthodontic benefits (limited to pre and post surgical orthodontic services to treat craniofacial anomalies requiring surgical intervention).

Children’s Medicaid Dental Services

  • Children’s Medicaid Dental operates under an 1115 waiver and provides primary and preventive dental services in a managed care environment.

  • Each member is enrolled in a dental maintenance organization (DMO) and has a main dental home.

  • The main dental home assesses dental needs and coordinates member’s care with specialty providers.

  • Most Medicaid children birth through age 20 who receive Medicaid.

Children’s Medicaid Dental Medically Necessary Covered Benefits

Diagnostic and preventative services





Prosthodontic (removable and fixed)

Implant and oral and maxillofacial surgery services

Orthodontic services

Adjunctive general services

Excluded from Children’s Medicaid Dental Services

  • Medicaid recipients age 21 and over.

    • Medicaid recipients under age 21 who reside in institutions receive their dental services through traditional Medicaid.

  • STAR Health Program recipients.

Proposed Changes from 83rd Legislative Session

  • Integrate Nursing Facilities into Managed Care

  • Integrate Behavioral Health into Managed Care

  • Integrate Children with disabilities into Managed Care

  • Pilot Program for Long Term Services and Support

  • STAR+PLUS Expansion State Wide

  • Medical Transportation

Community First Choice (CFC)

What it is: A new Medicaid state plan option that provides a 6% increase in federal Medicaid matching funds for services to help keep Medicaid beneficiaries with disabilities out of nursing homes and institutional settings.

What this means for Texas: Implementation of CFC in Texas is projected to provide long-term services and supports to an additional 12,000 clients, many of whom are on interest lists waiting to receive waiver services.

Note: In order to qualify for the service an individual must earn 74% of FPL or less. 

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