Medicaid HMO Expansion Begins March 1

On March 1, 2012, the Medicaid HMO model will replace the Primary Care Case Management model in South Texas and rural Texas. The majority of Medicaid patients in these counties will be required to obtain their health care services through one of the Medicaid HMOs approved by the state to operate in their community (see chart for a description of the HMO models and impacted patient populations by service area).

To ensure your practice is prepared for the change, here are some last-minute reminders and tips:

  • Remember to verify Medicaid and health plan eligibility via TexMedConnect, the Texas Medicaid & Healthcare Partnership (TMHP) telephone eligibility verification system at (800) 925-9126,, or the HMO's eligibility system.

  • HMO enrollees must select a primary care physician or provider (PCP) to manage and coordinate their care. Patients may change their PCP by contacting the HMO in which they are enrolled. HMOs typically make the PCP change effective immediately or will authorize the new PCP to provide services until the change becomes official.

  • Patients may alter the HMO in which they are enrolled by calling Maximus, the HMO enrollment broker, at (800) 964-2777. Patients may call from their physician's office, but the patient must speak to Maximus directly. HMO change requests submitted prior to the 15th of the month will be effective the first day of the following month (e.g., change requested March 5th; new HMO effective date will be April 1). If the request is made after the 15th of the month, the new HMO will be effective the first day of the month after the following month (e.g., change requested March 20; new HMO effective date will be May 1).

  • Physicians may submit Medicaid HMO claims directly to the health plan or use the TMHP claims portal for both HMO and fee-for-service claims. TMHP will route HMO claims it receives to the patient's health plan. Check here for instructions on how to use the TMHP single claims portal [PDF].

  • Prescription drug benefits will be administered by the HMOs, but each HMO will adhere to a statewide formulary and preferred drug list. Patients must obtain prescription drugs from a pharmacy within their HMO's network. The legislature required the change, but to help minimize the impact of the new requirement, it also specified that the HMOs must adhere to a statewide prescription drug formulary and preferred drug list instead of each plan developing its own. Prior authorization requests, such as those for nonpreferred drugs, will be handled by each plan's pharmacy benefits manager (PBM). PBMs must answer prior approval requests within 24 hours if submitted electronically or by fax and immediately if submitted by phone. For a list of PBMs and contact information for each, check here [PDF]. Patients will be required to obtain prescription drugs from a pharmacy within their health plan's network. For a list of in-network pharmacies, refer to the Medicaid or Children's Health Insurance Program HMO provider directories. The Texas Medicaid Vendor Drug program will continue to administer the prescription drug benefit for Medicaid fee-for-service patients. For additional information, visit the Texas Health and Human Services Commission website. HMOs must honor previous prior authorizations issued by TMHP through the earlier of the first 90 days following enrollment or the date the prior approval expires.

  • HMOs must ensure continuity of care with an out-of-network physician for patients receiving treatment for an acute condition, pregnant women in the second or third trimester, or patients who are terminally ill. However, the HMOs must pay out-of-network (in-area) physicians/providers less 5 percent from the Medicaid fee-for-service fee schedule unless another rate is negotiated.

  • If you have a complaint with the HMO, contact the HMO first. 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. To submit a Hassle Factor Log, visit the TMA website for a copy of the form and instructions. If the HMO does not address the complaint, practices may submit urgent issues to the Health and Human Services Commission command center at The command center will operate at least through April 30, 2012. Physicians also may submit complaints to



Action, March 1, 2012