Medicaid HMO Expansion: South Texas FAQs

Updated: January 2012 

Background  |  Patient Eligibility  |  South Texas Service Area and Health Plans  |  Physician Participation/Credentialing  |  Reimbursement Issues and Utilization Management  |  HMO Benefits and Services  |  Appeals/Complaints  

Background 

Q: Why is the Texas Medicaid program replacing the Primary Care Case Management Model (PCCM) with HMOs? 

A: The Texas legislature directed the Health and Human Services Commission (HHSC) to implement the changes as part of a broad package of Medicaid cost-containment initiatives adopted during the 2011 legislative session. Medicaid HMOs already operate in most of Texas’ metropolitan communities. The legislature directed that the model be implemented in all remaining Texas counties and extended to additional services, including dental and pharmacy services. The Medicaid HMO expansion is projected to save the state $385 million over the next two year plus generate $240 million in new health premium taxes.

Q: I thought that Medicaid HMOs were prohibited in South Texas? 

A: The 82nd legislature repealed the prohibition against Medicaid HMOs in Cameron, Hidalgo, and Maverick counties.

Q: When will the HMOs begin operating?  

A: The Medicaid HMOs will begin operations on March 1, 2012 (though the date is subject to change). Prior to implementation, health plans must undergo a “readiness review” to demonstrate to the state that they can comply with their contractual obligations, including having in place an adequate physician and provider network, an efficient and timely claims processing system, and a system to respond quickly to patient and physician complaints. HMOs that do not successfully pass their readiness review will be issued a corrective action plan, which may include suspension of participation or even termination.

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Patient Eligibility 

Q: Are patients required to enroll in an HMO? 

A: The vast majority of Medicaid patients will be required to obtain their health care services through one of the participating Medicaid HMOs.

Pregnant women, low-income parents, and most children must select a STAR HMO. (Children in foster care are required to enroll in STAR Health while children with disabilities may enroll in STAR+PLUS or remain in Medicaid fee-for-service.) Additionally, patients must also select a primary care physician or provider within the HMO network to furnish and coordinate their care.

Adult patients with disabilities receiving Supplemental Security Income (SSI) must enroll in a STAR+PLUS HMO. They too must select a PCP.

Patients who are dually-eligible for Medicare and Medicaid and classified as an “MQMB”, meaning they are eligible for full Medicaid benefits in addition to Medicare, also must select a STAR+PLUS plan for any needed long-term care services or supports. However, acute care services for MQMBs will continue to be provided through Medicare. Physicians do not need to enroll in a STAR+PLUS Medicaid HMO to continue providing acute care services for MQMBs. However, be aware that these patients may be enrolled in a Medicare Advantage Plan (MAP) for their Medicare benefits.

Patients residing in nursing homes or other institutions are excluded from the HMO model as are patients classified as Medicaid spend down or who are refugees.

South Texas Service Area and Health Plans 

Q: Which HMOs will operate in the Hidalgo service area? 

A: Four STAR HMOs will serve the Hidalgo service area:

Driscoll Children’s Health Plan
Melinda Lopez
361-694-6551
melinda.lopez@dchstx.org 

Donald Well
361-694-4349
donald.well@dchstx.org 

Molina Healthcare of Texas
RosCet Varner
888-562-5442, ext.204059
roscet.varner@molinahealthcare.com 

Superior Healthplan Network
Will Rodriguez
800-783-5386, ext. 22765
gurodriguez@centene.com 

Network Development
866-615-9399, ext. 22534
shp-networkdevelopment@centene.com 

United Healthcare Community Plan
Pamela Cobb
713-596-2676
pamela_h_cobb@uhc.ocm 

For STAR+PLUS, there will be three HMOs:    

Health Spring
Jeff Allen
817-554-5666
jeff.allen@healthspring.com 

Benjy Green
817-554-5618
benjy.green@healthspring.com   

Molina Healthcare of Texas
See above   

Superior Healthplan Network
See above   

There will be no changes to either the CHIP or STAR Health (foster care) plans. 

Q: How did the state select the Medicaid HMOs? 

A: In May 2011, the state issued a “Request for Proposal” inviting qualified health plans to submit proposals for consideration.  The state evaluated each proposal for how well the plan responded to the RFP, the strength of the plan’s proposed provider network, and “value added” services the plan proposed offering for patients and providers.  HMOs were issued tentative contract awards in August pending contract negotiations with the state.  Plans must also undergo a readiness review several months prior to the HMO start date to ensure the plan is capable of fulfilling its contractual obligations.   

Q: How frequently can patients change HMOs? 

 A: Currently, patients can change their HMO anytime.  However, the state, at the direction of the legislature, is evaluating limiting how many times a patient may change to only one time after the first 90 days of enrollment unless the patient has good cause.  

Q: How will patients select an HMO? 

A: Patients were sent enrollment packets in mid-December.  Enrollment packets were printed in both English and Spanish. The packets included an overview of each Medicai


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