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
STAR (State of Texas Access Reform)
Managed Care Programs in Texas
As of March 2013:
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.
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
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
Traditional Medicaid package
Primary care provider (PCP)
Unlimited necessary days in hospital
Health education classes
Children’s Medicaid benefits
Health education classes
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.
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.
Primary Care Provider and Medical Home
Behavioral Health Services
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.
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.
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.
Traditional Medicaid benefits
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 Medicaid package
Primary Care Physician (PCP)
Unlimited necessary hospital days
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.
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.
of health care benefits that is cost effective and
focuses on primary health care needs.
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 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).
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.
Diagnostic and preventative services
Prosthodontic (removable and fixed)
Implant and oral and maxillofacial surgery services
Adjunctive general services
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.
Questions and Answers