Medicaid HMO Expansion: Are You Ready?

On March 12, Texas will complete statewide expansion of the Medicaid HMO model by requiring most patients living in rural and South Texas counties to obtain their health care services from physicians and providers participating in one of the Medicaid HMO networks. Patients were sent English and Spanish versions of enrollment packets on Dec. 15. Patients must select an HMO and a primary care physician by Feb. 12 or be assigned to an HMO and/or primary care provider (PCP) by the state's enrollment broker, Maximus. Patients who are assigned to a plan and/or PCP can subsequently change it.

Practices that haven't done so already should inform their patients about the Medicaid HMOs with which they are contracted (by posting a sign in the waiting room, sending patients a letter, or the like); however, physicians should not steer patients to a particular plan.

If a contracted physician is not listed in the HMO's provider directory, the patient may still select the physician as his or her PCP so long as Maximus has the information on file. To ensure that your practice location and contact information are listed accurately in the HMO directories, check that the practice's name, phone number, and address are accurately listed on the Texas Medicaid & Healthcare Partnership provider portal. Maximus and the HMOs use the information to populate the provider directories.

If a patient arrives at your office ready to select a plan or wanting to change plans, the patient may call Maximus from your office, but he or she must actually speak to a company representative directly. Physicians cannot act on the patient's behalf. The Maximus patient enrollment number is (800) 964-2777.

To avoid administrative and claims snafus when the HMOs become operational and to better assess how well each plan will work for a practice, TMA encourages physicians to sign up with all the health plans in your area, at least initially. 

HMOs will discount out-of-network (in-area) physicians' fees by 5 percent (or a rate negotiated with the plan).

Action, Jan. 17, 2012

Last Updated On

May 13, 2016