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Texas Medicaid. Medical and Dental Information Series. Version 1.2 (6/22/2010). 2/22/2013. Medicaid Curriculum Overview. Module 1: General Structure of the Texas Medicaid System Module 2: Understanding Medicaid Clients and Health Literacy Module 3: Texas Health Steps

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Texas medicaid

Module 1

Texas Medicaid

Medical and Dental Information Series

Version 1.2 (6/22/2010)


Medicaid curriculum overview

Module 1

Medicaid Curriculum Overview

  • Module 1: General Structure of the Texas Medicaid System

  • Module 2: Understanding Medicaid Clients and Health Literacy

  • Module 3: Texas Health Steps

  • Module 4: Navigating Insurance and Managed Care

  • Module 5: Interfacing with Medicaid as a Provider

  • Module 6: Special Medicaid Programs

  • Module 7: Special Medical Issues

  • Module 8: Special Dental Issues

Module 1

Module 1

General Structure of the Texas Medicaid Program

Module 1 objectives after completing this module you should be able to

Module 1

Module 1: ObjectivesAfter completing this module, you should be able to:

  • Describe the purpose and background of Medicaid

  • Identify who benefits from services supported by Texas Medicaid

  • Contrast Medicaid with other major health programs

  • Describe the organization of Medicaid in Texas

  • List features of Medicaid Managed Care

  • Identify examples of Texas Medicaid programs

  • Outline advantages to serving as a Medicaid provider

  • Find Medicaid resources

True or false test your knowledge about texas medicaid

Module 1

True or False?Test Your Knowledge about Texas Medicaid:

  • Medicaid is funded solely by the federal government.

  • Medicaid is an entitlement program based solely on age.

  • Medicaid benefits include many optional services that a state can choose to provide.

  • Non-disabled children account for more than half of Texas Medicaid spending.

  • Physician visits, inpatient services, and pharmacy costs are all examples of acute health care costs that Medicaid covers.

What is medicaid

Module 1

What is Medicaid?

  • Medicaid is a federal health care program that is jointly funded by federal and state money. Medicaid is jointly funded by the state and federal governments:

    • About one-third funded by the State of Texas

    • About two-thirds funded by the Federal Government

  • In December 2011, about 1 in 7 Texans relied on Medicaid for health insurance or long-term services (3.7 million of the 25.9 million).

  • Medicaid was created through Title XIX of the 1965 Social Security Act, and established in Texas in 1967.

  • In Texas, Medicaid is administered by the Texas Health and Human Services Commission (HHSC).

  • Medicaid is an entitlement program, which means:

    • The number of eligible people who can enroll cannot be limited.

    • Any services covered under the program must be paid.

What does medicaid cover

Module 1

What Does Medicaid Cover?

  • Long-term services for elderly and disabled clients

  • Mental health and substance abuse treatment

  • Acute and preventive health care for all ages

    • Physician visits

    • Inpatient and outpatient services

    • Pharmacy, lab, and radiology costs

  • Dental Services (for patients under the age of 21)

    • Preventive

    • Therapeutic

Basic principles of medicaid social security act

Module 1

Basic Principles of MedicaidSocial Security Act

Amount, Duration and Scope

Freedom of Choice

  • States must cover each service in an amount, duration, and scope that is “reasonably sufficient” and may impose limits on services for adult clients. A state may not arbitrarily limit services for any specific illness or condition.


  • With certain exceptions, including for managed care, the States must allow Medicaid recipients freedom of choice among participating providers of health care services.


  • The same level of services must be available to all clients or patients (e.g., those with similar disabilities).

  • All services must be available statewide.

Medicaid benefits

Module 1

Medicaid Benefits

  • The Social Security Act specifies…

Required Benefits

Optional Benefits

States may define their own amount, duration, and scope

of (or limitations on) Medicaid benefits

Example: Limitations on prescription drugs

Limits on coverage, for both required and optional services, may not be imposed for children under 21 if there is a medical necessity.

Mandated services covered by texas medicaid 2013

Module 1

Mandated ServicesCovered by Texas Medicaid, 2013

  • EPSDT (Texas Health Steps) medical and dental check-ups and treatments for persons under 21

  • Physician services

  • Dental services

  • Family planningservices

  • Inpatient & outpatient hospital

  • Lab and radiology

  • Nursing facility care

  • Home health care

  • Services by:

    • Federally Qualified Health Centers

    • Rural Health Clinics

    • Certified Nurse Midwives

    • Clinical nurse specialists and nurse practitioners

Examples of optional services covered by texas medicaid 2013

Hospice services

Maternity service clinics

Prescription drugs


Optometry, including glasses

Hearing instruments

Renal dialysis

Rehabilitation services

Medical or remedial care provided by:

Physician extenders

Mental health providers


Physical therapists

Occupational therapists

Speech therapists

Module 1

Examples of Optional Services Covered by Texas Medicaid, 2013

All services are required for children under 21 years of age if medically necessary; restrictions apply for many services to adults.

  • Rehabilitative services for mental illness

  • In-home respiratory care

  • Attendant services

  • Program for All-Inclusive Care for the Elderly (PACE)

Who is eligible for medicaid benefits

Module 1

Who is Eligible for Medicaid Benefits?

  • Medicaid primarily serves:

    • Low-income families

    • Foster children

    • Pregnant women

    • The elderly

  • People with disabilities

  • Babies born to mothers receiving benefits at time of delivery

    (Services available for one year)

Who is eligible to deliver medicaid funded services

Module 1

Who is Eligible to Deliver Medicaid Funded Services?

  • Individual Health Care Providers

    • Doctors, dentists, advanced practice registered nurses, physician assistants, physical therapists, optometrists, and psychologists

  • Outpatient Facilities

    • Rural health clinics, federally qualified health centers, school clinics, family planning agencies, and mental health centers

  • Inpatient Facilities

    • Hospitals and skilled nursing facilities

  • Providers of Goods & Services

    • Durable medical equipment, ambulance, pharmacies, radiology, and labs

Choosing a provider patient options

Module 1

Choosing a Provider:Patient Options

  • Although the Social Security Act requires freedom of choice in selecting Medicaid providers, it also allows states to set specific guidelines, especially for managed care organizations

  • Medicaid fee-for-service patients may choose any Medicaid provider

  • Patients enrolled in Health Maintenance Organizations (HMOs) have a primary care provider (or PCP) in a medical home

    • Patients in an HMO may choose any Medicaid primary care provider or specialist within the HMO network

    • In most cases, a referral for specialty care from the PCP is required for HMO patients

Medicaid vs medicare what is the difference

Texas Medicaid


Module 1

Medicaid vs. MedicareWhat is the difference?

Authorized by Social Security Act of 1965

Established in Texas – 1967

Jointly Funded by State and Federal Government, administered by State & regulated by CMS

Funded by Federal Government & administered by CMS

Entitlement program

based on income

Entitlement program

based on age or disability

Low income families, children, pregnant women, disabled, elderly

People 65 years or older, or people with disabilities

CMS: Centers for Medicare and Medicaid, US federal agency that administers Medicare, Medicaid, and the Children's Health Insurance Program.

Eligibility and enrollment in both programs concurrently is possible

Medicaid vs chip what is the difference

Texas Medicaid

Children’s Health Insurance Program(CHIP)

Module 1

Medicaid vs. CHIPWhat is the difference?

Authorized by Social Security Act

of 1965

Authorized by Balance Budget Act

of 1997

Jointly Funded by State and Federal Government

Entitlement program based on income, assets and/or disability

Enrollment based on income

(not an entitlement program)

Low income families, children, pregnant women, disabled, elderly

Children in families with too much income or too many assets to qualify for Medicaid and who meet the CHIP income requirements

Who can receive full medicaid benefits categories of eligibility

Module 1

Who can receive FullMedicaid Benefits?Categories of Eligibility

  • Low income families, pregnant women, and children

    • Based on income level, age, caring for a related Medicaid eligible dependent child or pregnancy

  • Cash assistance recipients

    • Based on receipt of Supplemental Security Income (SSI)

  • People age 65 and older and those with disabilities

    • Based on income level, age, and physical or mental disability

Who can receive limited medicaid benefits categories of eligibility

Module 1

Who can receive LimitedMedicaid Benefits?Categories of Eligibility

  • Medicare Beneficiaries

    • Based on income level and age

  • Non-Citizens

    • Legal permanent residents and undocumented persons who are not eligible for Medicaid based on citizenship status may receive emergency services.

How many people does texas medicaid serve

Module 1

How Many People DoesTexas Medicaid Serve?

At any one time, how many individuals are enrolled in Medicaid? About 3.54 million

How many people does texas medicaid serve1

Module 1

How Many People DoesTexas Medicaid Serve?

How many individual Texans received Medicaid-funded services at some point in the year? About 4.57 million

Distribution of medicaid enrollees

Module 1

Distribution of Medicaid Enrollees

State Total = 3,098,169

As of: August 2010

Texas medicaid recipients state fiscal year 2011

Module 1

Texas Medicaid Recipients State Fiscal Year 2011

Unduplicated Clients

SFY 2011 = 4,567,077












How does texas enroll medicaid participants

Module 1

How does Texas enroll Medicaid participants?

Managed Care

Fee for Service

  • Structured clinical, financial, and organizational activities designed to improve continuity and access to health care services, promote appropriate use of services, and contain costs.

  • Traditional arrangement in which a provider is paid for each individual service that a patient receives

  • MCO: Managed Care Organization, a health organization that finances and delivers health care through a specific provider network and defined services and products

The medical home key feature of medicaid managed care

Module 1

The Medical HomeKey Feature of Medicaid Managed Care

  • Serves as a source for continuity of care from a primary care provider (PCPs)

  • Provides comprehensive preventive and primary acute care

  • Provides specialty referrals and other services offered by a managed care organization and coordinates all levels of patient care

  • Texas Medicaid PCPs:

    • Family physicians

    • Pediatricians

    • General internists

    • Obstetricians/gynecologists

    • Physicians’ assistants

    • Advanced practice registered nurses

    • Community clinics including federally qualified health centers (FQHCs) and rural health centers

Medicaid managed care in texas overview of plans

Module 1

Medicaid Managed Carein TexasOverview of Plans

  • STAR (Originally an acronym for State of Texas Access Reform)

    A statewide managed care program in which HHSC contracts with MCOs to provide, arrange for, and coordinate preventative, primary, and acute care covered services


    Provides integrated acute and long-term services and supports to people with disabilities and the elderly

  • NorthSTAR

    A capitated program in Dallas and surrounding counties that provides behavioral health (mental health and substance abuse) services to Medicaid and medically indigent patients

  • STAR Health

    A statewide program to provide coordinated care to children and youth in foster and kinship care

Percentage of medicaid clients by delivery type state fiscal year 2011

Module 1

Percentage of Medicaid Clients by Delivery Type, State Fiscal Year 2011

What are examples of texas medicaid programs

Module 1

What are Examples of Texas Medicaid Programs?

Texas Health Steps

  • Provides medical prevention and dental preventive/treatment services to eligible children

Programs for Women and Children

  • Programs for family planning and pregnant women, Medicaid Buy-In for Children, and women’s cancers

Prescription Drugs

  • Prescription medications through local pharmacies

Behavioral Health Services

  • Mental, emotional, and chemical dependency treatment for eligible patients

Long-Term Services and Supports

  • Programs for those with physical, intellectual and developmental disabilities

Texas health steps

Module 1

Texas Health Steps

  • Perhaps the best known of Texas Medicaid programs is THSteps, which provides medial and dental preventive care and screening to eligible children.

  • THSteps is the name for the federally-required Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services in Texas.

Module 3 will focus specifically on Texas Health Steps.

Components of thsteps medical checkups

Module 1

Components of THStepsMedical Checkups

  • Medical history

  • A complete physical examination

  • Screening of nutritional, developmental, and mental-health needs

  • Age appropriate laboratory tests (including lead screening)

  • Routine immunizations

  • Health education

  • Vision and hearing screening

  • Oral health screening and referral to a dental home

  • Referrals to other health care providers as needed

Components of thsteps dental checkups and services

Module 1

Components of THStepsDental Checkups and Services

  • Preventive services

    • Dental examinations, cleanings, oral health education, topical fluoride applications, application of sealants, maintenance of space

  • Treatment services

    • Restorations (fillings and crowns), endodontic treatment, periodontic treatment, prosthodontics, oral surgery, implant services and maxillofacial prosthetics

  • Emergency treatment

    • Procedures to control and treat bleeding, pain, acute infection, immediate tooth loss, and injury to teeth or supporting structures

  • Health Related Orthodontic Services (prior authorization needed)

    • Correction of cleft palate, crossbite therapy, treatment of severe malocclusion, and treatment of facial accidents involving severe traumatic deviation

The medicaid team

Module 1

The Medicaid Team

Providers: Medical, Dental and Other Services

HHSC:Single State Agency charged with the administration & supervision of the Medicaid plan

MCOs: Managed Care Organizations

TMHP: Claims Administrator



MAXIMUS: Medicaid and

CHIP Enrollment Broker


ICHP: Quality Monitor

Texas medicaid operating departments

Module 1

Texas MedicaidOperating Departments

Medicaid functions

Module 1

Medicaid Functions

  • Operates as the single state agency responsible for Medicaid

  • Serves as primary contact point for the federal government

  • Administers the state Medicaid plan

  • Contracts with other state agencies to carryout certain Medicaid functions

  • Determines Medicaid eligibility

  • Operates the state’s acute care, prescription drug, and most managed care programs

  • Develops Medicaid policies, rules, and reimbursement rates

  • Organizes and coordinates initiatives to maximize federal funding

  • Manages the Medical Care Advisory Committee (MCAC)

Medicaid functions1

Module 1

Medicaid Functions

  • Texas Health Steps

  • Case Management for pregnant women and children

  • Newborn metabolic screening, newborn hearing screening

  • Family planning

  • Targeted case management and rehabilitation

  • Services for people diagnosed with a mental health condition

  • NorthSTAR Administrator

  • YES Waiver program for children with severe emotional disturbance

Medicaid functions2

Module 1

Medicaid Functions

  • Early childhood intervention

  • Targeted case management for Blind Children’s Vocational Discover and Developmental Program (BCVDDP)

Medicaid functions3

Module 1

Medicaid Functions

  • Nursing facility programs and services

  • Long-term care licensing and certification

  • Program of All-Inclusive Care for the Elderly (PACE)

  • Hospice

  • Nursing home Preadmission Screening and Resident Review (PASRR)

  • Intermediate Care Facilities and Mental Retardation Facilities, including State Supported Living Centers.

  • Targeted case management for people with intellectual disabilities

  • Home and community-based services for people with developmental disabilities and those who would otherwise require nursing facility level of care

Module 1

  • TMHP acts as the state's Medicaid fiscal agent and is responsible for paying acute care claims, while the state of Texas is responsible for covering the cost of claims.

  • Affiliated Computer Services, Inc. (ACS) meets consolidated contractual Medicaid responsibilities with a team of subcontractors under the name of TMHP (Texas Medicaid & Healthcare Partnership).


  • Administers fee-for-service Medicaid claims

  • Manages policy development

  • Collects HMO encounter data

  • Enrolls providers

  • Supplies provider relations representatives to enrolled providers

What does medicaid cost

Module 1

What Does Medicaid Cost?

  • In 1967, Texas Medicaid served fewer than 1 million people at a cost of less than $200 million

  • In 2011, Texas Medicaid served more than 3 million people at a cost of $29.4 billion, representing about 26% of the total state budget

Federal funds are based on the Federal Medicaid Assistance Percentage (FMAP) the matching rate that changes annually.

For federal fiscal year (FFY) 2011, the Texas FMAP was 66.46%.

Federal medical assistance percentages fmap fiscal year 2011

Module 1

Federal Medical Assistance Percentages (FMAP), Fiscal Year 2011



*Note: Percentages do not reflect temporary increases in FMAP provided by the American Recovery and Reinvestment Act of 2009.

Texas medicaid spending the big picture

Module 1

Texas Medicaid SpendingThe Big Picture

By Services Type, State Fiscal Year 2010

Texas medicaid spending the major categories

Module 1

Texas Medicaid SpendingThe Major Categories

By Services Type, State Fiscal Year 2011

Average monthly medicaid spending by type of eligibility state fiscal year 2011

Module 1

Average Monthly Medicaid Spendingby Type of Eligibility, State Fiscal Year 2011

Federal health care reform and texas medicaid

Module 1

Federal Health Care Reform and Texas Medicaid

  • The federal health care reform Affordable Care Act (ACA) will impact Texas Medicaid, the Texas HHSC and other agencies. Examples of ACA changes include:

  • Benefit changes:

    • Concurrent hospice care and treatment services for children enrolled in Medicaid and CHIP

    • Birthing centers as a Medicaid provider

    • Expanded Medicaid formulary

  • New provisions to address fraud and abuse

    • Increased use of the National Provider Identifier (NPI) on claims and applications

    • Requiring face-to-face encounters with patients for the certification of home health services and durable medical equipment

Aca medicaid eligibility expansion

Module 1

ACA Medicaid Eligibility Expansion

  • Effective January 1, 2014, ACA expands Medicaid to the following groups:

    • Former foster care youth through age 25

    • Children ages 6-18 whose families have an income 100%-133% of the FPL; this is the population of children currently eligible for CHIP

  • The “individual mandate” for health insurance could lead to the enrollment of about 130,000 people who are currently eligible for Medicaid or CHIP, but are not currently enrolled

If a Medicaid expansion is pursued by the state, income eligibility could be expanded to adults ages 19 to 64 who are not currently eligible for Medicaid, and have incomes ≤133% of the FPL.

With this option Texas could expect to experience a caseload growth in 2014 of approximately 340,976.

Texas healthcare transformation and quality improvement program 1115 waiver

Module 1

Texas Healthcare Transformationand Quality Improvement Program 1115 Waiver

  • In December 2011, Texas was granted a waiver of certain federal Medicaid requirements under Section 1115 of the Social Security Act; the waiver:

    • Expands Medicaid managed care to the entire state, including managed care for dental and prescription drug services

    • Creates 2 new funding pools, one to reimburse

      hospitals for Uncompensated Care (UC) for

      Medicaid and uninsured patients and one for

      Delivery System Reform Incentive Payment

      (DSRIP) to provide financial incentives to

      encourage hospitals and other providers to

      achieve quality health outcomes

  • What is being “waived”?

    • Certain aspects of the Statewideness,

      Comparabilityof Services and Freedom of

      Choice requirements of the Social Security Act

Regional Healthcare

Partnership Regions

The face of medicaid the patient s perspective

Module 1

The Face of Medicaid:The Patient’s Perspective

  • Amy and her husband Josh have

    a 4-year old son, Ian, and another

    child due in 6 months.

  • Josh’s work hours at a local

    lumberyard have recently been

    reduced. Amy is a full-time

    cosmetology student and

    does not currently work.

  • The family income is currently about $1,900 per month, which is less than 120% of the current federal poverty level for a family of 3.

  • What services and support can Amy’s family expect from Texas Medicaid this year?

How can texas medicaid help amy s family

Module 1

How Can Texas Medicaid HelpAmy’s Family?

  • Medicaid for Ian and the new baby (when it is born)

    • Medicaid: Treatment and prescriptions for any of the children's acute illnesses or chronic conditions that are medically necessary

    • THSteps

      • Medical check-ups, including routine immunizations, physical examinations, and anticipatory guidance/health education

      • Dental check-ups, including preventive services and treatment

  • Amy

    • Medicaid: Pre-natal and pregnancy services for Amy, including the delivery of her baby, and post-partum care

    • Women’s Health Program: Family planning after the baby is born

The face of medicaid the provider s perspective

Module 1

The Face of Medicaid:The Provider’s Perspective

  • Lauren will graduate from dental school in

    Texas this year, and she plans to establish

    a general practice in her hometown in the

    Texas Panhandle, in a county considered

    to be “dental lagging.”

  • She’s looking forward to building

    a practice and taking care of a wide range

    of patients, including those with Medicaid.

  • What services and support can Lauren expect from Texas Medicaid when she enrolls as a Texas Health Steps Provider?

How can texas medicaid help lauren build her practice

Module 1

How Can Texas Medicaid Help Lauren Build Her Practice?

  • Payment to establish a dental home for her patients as young as 6 months of age. The first dental home visit can include (but is not limited to) an oral exam, oral hygiene instruction, dental prophylaxis, topical fluoride application, and caries risk assessment.

  • Payment for dental services for her child patients, 6 months to 21 years, to cover dental visits every 6 months for diagnostic, preventive, and routine therapeutic care.

How does texas medicaid remain dynamic progressive

Module 1

How Does Texas Medicaid Remain Dynamic & Progressive?

  • Medicaid adjusts and grows to meet Texas’ changing health care needs of its recipients and providers:

    • Legislation has led to expanded services and populations covered

    • Professional organizations provide feedback, medical recommendations, and suggestions about practice guidelines

    • Provider feedback is actively sought


The Interactive Medicaid Provider Voice System allows providers to submit concerns & suggestions to share with the HHSC Medicaid Staff

Common medicaid myths

Module 1

Common Medicaid Myths

  • Medicaid is designed with minimum federal standards, which require states to cover certain populations and provide certain benefits to key populations.

  • In many ways it is a system that operates as 50 separate state coverage programs, with states having the choice to cover populations and services beyond minimum standards.

  • Myth

    • Medicaid is a rigid, one-size-fits-all program.

  • Fact

    • States have taken advantage of Medicaid’s flexibility to customize their programs—about 2/3 of Medicaid spending is for “optional” services or populations.

Common medicaid myths1

Module 1

Common Medicaid Myths

  • Research supports Medicaid’s role in improving access to care for the people it serves.

  • Medicaid beneficiaries value their coverage, are grateful for the assistance it provides, and often report satisfaction with their coverage at the same levels as those with commercial insurance coverage.

  • Myth

    • Medicaid is a poor-quality program that has little impact on access to care or health and Medicaid patients dislike the program.

  • Fact

    • Medicaid offers access to primary and preventive health care for its patients that is comparable to that of commercial coverage and greatly exceeds that of the uninsured.

Test your knowledge about texas medicaid true or false

Module 1

Test Your Knowledge about Texas Medicaid: True or False?

  • Medicaid is funded by the federal government.

    • FALSE: Medicaid is jointly funded by the federal and state governments. In 2011, the state funded more than 33% of Medicaid costs.

  • Medicaid is an entitlement program based on age.

    • FALSE: Medicaid is an entitlement program, but one based on income, assets, and disability/age.

  • Medicaid benefits include many optional services that a state can choose to provide.

    • TRUE: About 2/3 of the services provided under Texas Medicaid are considered optional for adults, rather than mandatory. Optional benefits in Texas include durable medical equipment, optometry, and prescription drugs. All federally allowable and medically necessary services are provided to children under 21 years of age.

Test your knowledge about texas medicaid true or false1

Module 1

Test Your Knowledge about Texas Medicaid: True or False?

  • Non-disabled children account for more than half of Texas Medicaid spending.

    • FALSE: Although non-disabled children account for about 66% of the Medicaid caseload, they account for only about 33% of the costs

  • Physician visits, inpatient services, and pharmacy costs are all examples of acute health care costs that Medicaid covers.

    • TRUE: Medicaid covers all such acute care costs.

Tmhp provider manual

Module 1

TMHP Provider Manual


Providers > Reference Manual

Medicaid resources

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Medicaid Resources

Texas Health & Human Services Commissionwww.hhsc.state.tx.us/medicaid

Texas Medicaid & Healthcare Partnershipwww.tmhp.com

Texas Health Stepswww.dshs.state.tx.us/thsteps/providers.shtmwww.dshs.state.tx.us/dental/thsteps_dental.shtmwww.dshs.state.tx.us/thsteps/default.shtm

CHIP/Children’s Medicaidwww.chipmedicaid.org

This texas medicaid curriculum was prepared by

Module 1

This Texas Medicaid curriculumwas prepared by

Betsy Goebel Jones, EdDProject Director

Tim Hayes, MAMProject Designer

Authors: Module 1 Betsy Goebel Jones, EdD

David Trotter, MA

Department of Family & Community Medicine