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A: The 82nd legislature repealed the prohibition against Medicaid HMOs in Cameron, Hidalgo, and Maverick counties.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 Medicaid HMO doing business within the service area, a directory of network physicians/providers for each plan, the value-added benefits offered by each of plan, and a member handbook. 

Patients will be required to select an HMO and a PCP by mid February. Selections can be made in person, fax, or phone. Patients who do not select a plan and/or PCP will be assigned to one by Maximus, but may change plan and/or PCP if dissatisfied with the assignment.    

Physicians may inform patients about which HMOs they are contracted, such as by posting a sign in the waiting room, but cannot steer patients to a particular plan. If a patient arrives at your office ready to select a plan or wanting to change plans, then the patient may call Maximus, from your office but the patient must actually speak to the enrollment broker.  Physicians cannot act on the patient’s behalf.  The patient enrollment number is (800) 964-2777.   

Patients may also mail their enrollment packet or contact Maximus by phone.   

Maximus will begin conducting training for patients on November 1.  For a list of patient training events in your area, go to www.txmedicaidevents.org.    

Q: How will I know which plan a patient has selected? How do I know the patient’s primary care physician? 

 A: Each Medicaid HMO patient will receive an identification card from their health plan.  This card will be in addition to the Medicaid eligibility card provided by the state.  Listed on the card will be: 

• Plan name 
• Plan type (e.g. STAR, STAR+PLUS) 
• Name of patient’s primary care physician or provider and phone number 
• Toll-free number for member services and behavioral services 
• Plans may list other information on the cards, such as PCP address 

Physicians should continue to verify Medicaid and HMO eligibility before providing services.  Eligibility can be verified via the health plan’s eligibility system, TexMedConnect, the TMHP telephone eligibility verification system (800-925-9126), or at www.yourtexasbenefits.com.   

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Physician Participation/Credentialing 

Q: Will my practice be required to participate in the Medicaid HMO networks? 

 A: Participation in a Medicaid HMO is voluntary.  Physicians should evaluate each Medicaid HMO contract carefully to determine which plan(s) best meets the needs of the practice and the patients it serves, though TMA does recommend that practices sign up with all plans initially in order to better assess each plan’s real world performance. 

The vast majority of Medicaid patients will be required to enroll in a Medicaid HMO.  Choosing not to participate in any of the Medicaid HMO networks will affect the ability of the practice to continue to care for most Medicaid patients.  For out-of-network/in-area services, the Medicaid HMOs are required to pay the out-of-network physician, provider or hospital the Medicaid fee-for-service rates, less a five percent discount unless the HMO and provider agree on a different rate. 

Q: What specialties will be considered as primary care? 

 A: As in the PCCM model, primary care physicians include pediatricians, family physicians, general internists, and obstetricians/gynecologists. Patients may also select a Federally Qualified Health Center or Rural Health Clinic as their primary care provider. Specialists caring for patients with chronic conditions or who have other special health care needs may also serve as a PCP if they agree to serve as the patient’s medical home and meet all other contractual requirements for PCPs.  

 Texas also allows patients to select an advanced practice nurse or physician assistant as a PCP (when practicing under the supervision of a physician specializing in Family Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology who also qualifies as a PCP under this contract).               

PCPs must agree to serve as the patient’s medical home, provide preventive and primary care services, as well as coordinate and arrange specialty and other services according to the patient’s medical needs.  

Patients may change their PCP up to four times per year by contacting the health plan (though additional changes may be authorized by the health plan for good cause). 

Q: I am an OBGyn.  Can patients select me as their PCP? 

A: Yes.  OBGyns may serve as a PCP if they agree to meet all PCP requirements.  Women may self refer to their OBGyn for pregnancy related care, well woman services, or other services within an OBGyn’s scope of services.   

Q: The PCCM model does not require specialists to be credentialed and contracted to participate in the network.  Will the HMOs have the same process?   

A: Specialists wishing to participate in the HMO networks must be credentialed by the health plans. Participation in a Medicaid HMO is voluntary. Physicians should evaluate each Medicaid HMO contract to determine which plan(s) best meets the needs of the practice and the patients it serves. However, the vast majority of Medicaid patients will be required to enroll in a Medicaid HMO. 

Choosing not to participate in any of the Medicaid HMO networks will affect the ability of the practice to continue to care for most Medicaid patients.  For out-of-network/in-area services, the Medicaid HMOs are required to pay the out-of-network physician or hospital the Medicaid fee-for-service rates, less a five percent discount unless the HMO and provider agree on a different rate. 

Q: Do the HMOs have to offer me a contract? 

A: During the first three years of operation in a service area, the HMOs must contract with “significant traditional providers (STPs)”, which are primary care physicians who care for a significant number of Medicaid patients.  The STP must meet the HMO’s credentialing requirements and agree to the HMOs contract.  HHSC creates a list of STPs by service area.  The list of STPs by area is posted on the TMA website.   

Q: May I limit the number of Medicaid HMO patients I accept? 

 A: Yes, but carefully read the health plan contract for any requirements relating to setting patient limits.  Plans usually require that practices provide at least 30 days notice before establishing patient limits.  Plans may also set additional requirements. 

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Reimbursement Issues and Utilization Management 

Q: Will the Medicaid HMOs use the same fee schedule as PCCM/fee-for-service? 

A: Each Medicaid HMOs determines its own Medicaid fee schedule for physicians, hospitals, and other Medicaid providers. Generally, the Medicaid HMOs adhere to the Medicaid fee-for-service physician fee schedule, but they are not required to do so.   

Q: I am a primary care physician.  Will the Medicaid HMOs continue to pay a monthly case management fee like I received under PCCM?  

A: Each Medicaid HMO will determine its own physician fee schedule, including any incentive fees.  The state does not determine what the plans pay. Check with the HMOs regarding any incentive fees that will be offered. 

Q: Where do I send my claims? 

 A: Physicians can submit claims directly to the patient’s HMO. As in Medicaid fee-for-service, claims must be submitted within 95 days of the date of service.  HMOs have up to 30 days to process claims, though in practice most plans pay clean claims within 8 to 14 days. 

HHSC also recently announced a single claims portal option for electronic Medicaid fee-for-service and HMO claims.  The new portal will become effective on March 1.Physicians will be able to submit electronic HMO and FFS claims to the Texas Medicaid and Healthcare Partnership (TMHP).  TMHP will forward HMO claims to the plan in which the patient is enrolled.  HMO prior authorization requests must continue to be obtained directly from the plan.  More detailed information about this option can be found on the TMHP website: www.tmhp.com. 

Q: Will Medicaid HMOs require a referral for specialty care? 

 A: As in the PCCM model, a referral from the patient’s primary care physician/provider will be necessary for most specialty services, but a PCP referral to an in-network specialist is not required for some services, including obstetrical/gynecological care, mental health, Texas Health Steps, or routine (non-surgical) vision care.   

Patients may self refer for family planning services to any family planning provider, even if the provider is out of network.   

Please refer to the HMO provider manuals for details about which specialty services require referrals.   

Q: Will Medicaid HMOs require prior authorization for services? 

A: As in the PCCM and fee-for-service Medicaid, the HMOs will require that some services be prior approved.  The services requiring prior authorization will vary by HMO, by typically include inpatient admissions, advanced imaging, such as MRIs and CT scans, and home health, among others.  Pior approval is not needed for some services, including emergency services, prenatal care, well woman exams, well-child visits (Texas Health Steps) mental health (with exceptions) and family planning. Please refer to the HMO provider manuals for complete details. 

During the first 3 months after Medicaid HMO implementation, the HMOs must honor previous prior authorizations issued by TMHP through the earlier of 1) the first 90 days or 2) the prior approval expires. 

Q: May I refer patients to physicians who are not in the patient’s HMO network? 

A: Patients should be referred to in-network physicians, providers, or facilities.  If a medically-necessary service is not available within the HMO’s network, then upon request of the patient’s physician, the HMO must approve an out-of-network referral provided appropriate documentation is provided supporting the need for the referral.  The out-of-network physician or provider, if within the HMO’s service area, will be paid the Medicaid fee schedule, less five percent, or a rate negotiated between the physician/provider and health plan.   

Emergency services provided out-of-network do not need prior approval. 

For out-of-network OBGyns, if an HMO enrollee is pregnant and past the 24^th week of pregnancy, then the HMO must allow the patient to continue under the physician’s care through the post-partum visit even if the physician is out-of-network.  As outlined above, the HMO will pay the Medicaid fee schedule, less 5 percent, unless the HMO and OBGyn negotiate a different rate.   

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HMO Benefits and Services   

Q: What benefits will the HMOs cover? 

A: The Medicaid HMOs must cover the same medically necessary benefits provided under the Medicaid fee-for-service/Primary Care Case Management program. Adults enrolled in Medicaid HMOs also are exempted from the 3-prescription limit and 30 day spell of illness imposed under Medicaid fee-for-service/PCCM.   

HMOs may also offer their enrollees “value added” services that are designed to improve health outcomes and quality of care.  Examples of value-added services include 24-hour nurse hotlines, sports physicals, programs to help high-risk pregnant women stay healthy, or weight loss programs.  Value-added benefits will vary by plan, so check the HMO provider manuals for a list of benefits. The state must approve any value-added services offered by the plans.   

Q: Will prescription drug coverage be administered by the HMOs? 

A: Beginning in March 2012, prescription drug benefits will be administered by the HMOs instead of the Texas Medicaid Vendor Drug Program, a change mandated by the Texas legislature. However, to minimize administrative complexity, the Medicaid HMOs will be required to adhere to a statewide drug formulary, prior authorization and preferred drug list criteria developed by the Texas Health and Human Services Commission (HHSC), though each plan’s PBM will manage the prior authorization process. 

HMOs will be contracting with pharmacies to provide Medicaid prescription drug services.  HMO enrollees will be required to fill prescriptions at an in-network pharmacy.  HMOs may also contract with select pharmacies for specialty drugs.   

Q: Will children continue to receive dental benefits through Medicaid fee-for-service? 

A: Beginning in March 2012, Medicaid dental benefits for children will be provided through one of three dental HMOs.  Families will be required to select a dental HMO and choose a network dentist for their children’s dental needs.  The dental HMOs are Delta Dental Insurance Company, DentaQuest USA Insurance Company, Inc. and MCNA Insurance Company. These plans also will provider coverage for CHIP enrollees. 

Physicians making referrals for dental care will need to refer patients to a dentist enrolled in one of the three plans.   

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Appeals/Complaints 

Q: If a Medicaid HMO denies coverage or a claim, how do I appeal? 

 A: Each HMO must maintain an appeal mechanism for denials of claims or coverage.  Additionally, HMOs must maintain a system to track and resolve complaints made by physicians, providers, and patients.  This includes complaints related to claims payment or medical necessity determinations.  Complaints must be resolved within 30 days. If an HMO does not resolve 98 percent of physician/provider complaints within 30 days, the plan is subject to corrective action, including liquidated damages. 

In the case of denials relating to medical necessity, the HMO must contract with a non-network physician to review and resolve cases unresolved after the first provider appeal.  The determination of the reviewing physician is binding on the HMO and network physician. The physician conducting the review must be in the same or similar specialty as the appealing physician/provider and located in the same service area where the care was provided.  

Each HMO must also maintain a system to track and resolve complaints made by enrollees or their authorized representative (a physician may serve as an authorized representative).  HMOs also must resolve member complaints within 30 days. 

HMOs must also offer an expedited appeal mechanism in cases where the patient, or the patient’s physician or provider indicates that taking time for standard resolution could seriously jeopardize the patient’s life or health. A request for expedited appeal may be made in writing or verbally. The HMO must notify the patient of the outcome of the Expedited Appeal within three (3) Business Days, except that the MCO must complete investigation and resolution of an Appeal relating to an ongoing emergency or denial of continued Hospitalization: (1) in  accordance with the medical or dental immediacy of the case; and (2) not later than one  (1) Business Day after receiving the Member’s request for Expedited Appeal. 

The Medicaid HMO provider manuals contain instructions for submitting a complaint or appeal. 

Q: If I have a complaint about a Medicaid HMO, who do I contact? 

 A: The initial point of contact is the Medicaid HMO.  Each HMO is required to maintain a provider hotline for physicians and providers to submit concerns and complaints.  If the HMO is not responsive, practices are encouraged to submit a complaint to the TMA Hassle Factor Log (HFL) program.    

If the HMO does not address the complaint, practices may also submit written complaints to HHSC at hpm_complaints@hhsc.state.tx.us.    

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