190.014 Medicaid Managed Care Guiding Principles


Medicaid Managed Care Guiding Principles: In restructuring the current Medicaid program, the Texas Medical Association supports a pluralistic health delivery system which promotes high quality, cost effective patient care. As Medicaid is delivered increasingly through managed care, the following guidelines should be applied:

(1) Medicaid patients must be assured choice of physicians and type of health plan.

(2) Physicians currently serving Medicaid patients must be included in any network developed or which may develop to deliver care to Medicaid patients in a community or locality of the state.

(a) The managed care organization must establish fair and equitable physician enrollment criteria and credentialing standards. Board certification and/or residency training should not be essential criteria for physicians to participate in networks.

(b) Managed care organizations or networks should provide for network practicing physicians to develop and direct peer review and quality management/utilization review programs.

(c ) There should be an appropriate due process mechanism for physicians not accepted or deselected from networks which provides full information as to the reason for deselection, a grievance or peer review appeals panel of at least three network practicing physicians to reconsider deselection, and an opportunity for corrective action before deselection from the network.

(3) There should be sufficient time built into the restructuring to account for community differences in resources and health care delivery systems to progressively implement change over a reasonable time. This would allow community-based delivery systems to more fully develop to meet the demands for delivery of care.

(4) Physician reimbursement should account for cost-of-living increases, incentives to provide preventive and primary care/medical home concept, and should allow physician networks the opportunity to fairly negotiate reimbursements.

(5) The physician community, both statewide and local, should be given ample opportunity to participate in development and implementation of health care delivery systems which address patient access, physician participation, and quality and utilization of care.

(6) Mid-level practitioners: TMA supports physician assistants and nurse practitioners in the shared goal of addressing the health care needs of all Texans. Physician assistants and nurse practitioners should work collaboratively under the supervision of a physician for the benefit of the patient. This model currently exists in Texas and is working effectively. There is no evidence that expanding the scope of practice of physician assistants and advanced nurse practitioners will provide additional benefits to the people of Texas.

(7) The Medicaid program shall assure that any policies or programs developed for Medicaid managed care be reviewed and approved by some advisory body such as the Texas Department of State Health Services Medical Care Advisory Committee (Council on Socioeconomics, p 111, A-95; reaffirmed CSE Rep. 1-A-05; amended CSE Rep. 1-A-15).

Last Updated On

October 07, 2016