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Overview of the Managed Care Medicaid & CHIP Programs in Texas
Page 2
What is Managed Care?
• Managed care organizes health care through a network of doctors, hospitals and other health care providers who are responsible for managing and delivering quality, cost-effective care.
• The state pays a managed care organization a capped rate for each client enrolled, rather than paying for each unit of service provided.
Page 3
Goals of Managed Care
• Emphasize preventative care• Improve access to care• Ensure appropriate utilization of services• Improve client and provider satisfaction• Establish a medical home for Medicaid clients
through a primary care provider (PCP)• Improve health outcomes, quality of care and cost
effectiveness
Page 4
• STAR (State of Texas Access Reform)• STAR+PLUS• STAR Health• CHIP • Dental
Managed Care Programs in Texas
Page 5
Number of Clients Enrolled in Managed Care
As of March 2013: •3,317,287 people are enrolled in Medicaid
• 88 percent are enrolled in managed care• 2,919,004 are enrolled in
• STAR, • STAR Health, or • STAR+PLUS
Page 5
Page 6
STAR Program• The STAR program operates under a federal waiver and provides acute care services for:
• People receiving Temporary Assistance for Needy Families (TANF)• Non-disabled pregnant women • Newborns• Low income families and children
• Each STAR member is enrolled in a managed care organization (MCO) and has a primary care provider (PCP).
• The PCP serves as the medical home and coordinates the member’s care.
• Statewide service areas: Bexar, Dallas, El Paso, Harris, Hidalgo, Jefferson, Lubbock, Medicaid Rural Service Area (MRSA), Nueces, Tarrant, and Travis.
Page 7Page 7
Geographic Distribution of Managed Care Delivery Models
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
KendallComal
Gillespie
Llano
Travis
Hays
Caldwell
BurnetWilliamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
CampMorris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Bexar
Lubbock
Harris
El Paso
Dallas *
HHSC, Health Plan OperationsSeptember 2010
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Travis
Orange
Sabine
Newton
Colorado
Houston
Tarrant *
Nacogdoches
San Jacinto
Jasper
Nueces
Washington
JeffersonChambersHarris
Hidalgo
Jefferson
HoodHoward
PresidioVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
KendallComal
Gillespie
Llano
Travis
Hays
Caldwell
BurnetWilliamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
CampMorris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Bexar
Lubbock
Harris
El Paso
STAR and Medicaid Rural Service Areas
(effective March 1, 2012)
Dallas
HHSC, Health Plan OperationsJune 2011
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Travis
Orange
Sabine
Newton
Colorado
Houston
Tarrant
Nacogdoches
San Jacinto
Jasper
Nueces
Washington
JeffersonChambersHarris
Hidalgo
Jefferson
Medicaid Rural Service Area (MRSA)
Brewster
HoodHoward
PresidioVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
KendallComal
Gillespie
Llano
Travis
Hays
Caldwell
BurnetWilliamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
CampMorris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
BexarAetna, Amerigroup, Community First, Superior
LubbockAmerigroup, FirstCare, Superior
HarrisAmerigroup, Community Health Choice,
Molina, Texas Children’s, United
El PasoEl Paso First, Molina, Superior
STAR Service Areas
DallasAmerigroup, Molina, Parkland
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
TravisBlue Cross and Blue Shield of Texas, Sendero, Seton, Superior
Orange
Sabine
Newton
Colorado
Houston
TarrantAetna, Amerigroup, Cook Children’s
Nacogdoches
San Jacinto
Jasper
NuecesChristus, Driscoll Children’s, Superior
Washington
JeffersonChambersHarris
HidalgoDriscoll Children’s, Molina, Superior, UnitedHealthCare
JeffersonAmerigroup, Community Health Choice,
Molina, Texas Children’s, United
Medicaid Rural Service Area
Medicaid (MRSA)
Brewster
Page 8
Mandatory Populations Enrolled in STAR
• TANF recipients• Pregnant women• Newborns• Children receiving Medicaid assistance only• Medicaid Rural Service Area (MRSA):
• Adults (age 21 and older) receiving Supplemental Security Income (SSI) without Medicare
• Adults (age 21 and older) in a DADS 1915(c) waiver program
Page 9
Voluntary Populations Enrolled in STAR
• Children residing in the Medicaid RSA and receiving SSI benefits but not Medicare.
• Some children enrolled in the DADS 1915 (c) waiver program that are not receiving SSI or Medicare
Page 10
Populations Excluded from STAR
• Medicaid recipients who reside in institutions• Medically needy• Children in foster care• Refugees• Dual-eligible Medicaid recipients (clients with
both Medicaid and Medicare)
Page 11
Adult STAR Benefits
• Traditional Medicaid package• Primary care provider (PCP)• Unlimited prescriptions• Unlimited necessary days in hospital• Health education classes• Value-added services
Page 12
Children’s STAR Benefits
• Children’s Medicaid benefits• PCP• Health education classes• Value-added services
Children in traditional Medicaid receive unlimited prescriptions and unlimited necessary days in a hospital.
Page 13
STAR Health
• STAR Health is a statewide program that provides comprehensive and coordinated health services to children in foster care and kinship care.
• The Health and Human Services Commission (HHSC) contracted with Superior HealthPlan Network (Superior) to provide an array of health services.
Page 14
Eligible Populations for STAR Health
• Children and youth in state conservatorship.• Young adults up to 22 years of age with a
voluntary foster care placement agreement.• Young adults under 21 years of age who were
previously in foster care and receiving transitional Medicaid services.
• Young adults age 21 through the month of their 23rd birthday who are enrolled in an institute of higher education.
Page 15
Excluded from STAR Health
• Youth adjudicated in Texas Juvenile Justice Department (TJJD) facilities.
• Youth from other states placed in Texas, or youth from Texas who were placed in other states.
• Youth residing in Medicaid-paid facilities such as nursing homes, state supported living centers, or Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF-IID).
Page 16
Excluded from STAR Health
• Dual eligible clients (enrolled in Medicare & Medicaid).
• Youth who have been adopted or have a signed adoption placement agreement.
• Youth who have been on runaway status for longer than 60 days.
• Youth who are in a hospice program.• Youth who have been declared manifestly
dangerous and placed in Vernon State Hospital.
Page 17
STAR Health Benefits
• Primary Care Provider and Medical Home• Service Coordination• Service Management• Medical Services• Dental Services• Vision Services• Behavioral Health Services• Health Passport
Page 18
STAR Health Features & Enhancements
• Nurse Helpline
• Trained staff available 24 hours a day, 7 days a week
• Behavioral Health Helpline
• Trained staff available 24 hours a day, 7 days a week
• Service Team to provide service coordination and service management
• Service Managers and Service Coordinators
Page 19
STAR Health Features & Enhancements
• Health Passport• Provides statewide electronic access to a child’s
medical and administrative information.• Behavioral Health
• No referral requirement.• Medical Home
• Health care coordinated through a primary care provider.
Page 20
STAR + PLUS• STAR+PLUS is a Texas Medicaid managed care
program designed to provide health care, acute care, long-term services and support (LTSS) and pharmacy benefits through a managed care system.
• Main feature - service coordination.
• A specialized care management service that is performed by a service coordinator
• Each member is enrolled in an MCO.
• Service Areas: Bexar, Dallas, El Paso, Harris, Hidalgo, Jefferson, Lubbock, Nueces, Tarrant, and Travis.
Page 2121
STAR+PLUS Managed Care Service Areas
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
KendallComal
Gillespie
Llano
Travis
Hays
Caldwell
BurnetWilliamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
CampMorris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Bexar
Lubbock
Harris
El Paso
Dallas *
HHSC, Health Plan OperationsSeptember 2010
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Travis
Orange
Sabine
Newton
Colorado
Houston
Tarrant *
Nacogdoches
San Jacinto
Jasper
Nueces
Washington
JeffersonChambersHarris
Hidalgo
Jefferson
HoodHoward
PresidioVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
KendallComal
Gillespie
Llano
Travis
Hays
Caldwell
BurnetWilliamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
CampMorris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
BexarAmerigroup, Molina, Superior
LubbockAmerigroup, Superior
HarrisAmerigroup, Molina, United
El PasoAmerigroup, Molina
STAR+PLUS Service Areas
DallasMolina, Superior
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
TravisAmerigroup, United
Orange
Sabine
Newton
Colorado
Houston
TarrantAmerigroup, HealthSpring
Nacogdoches
San Jacinto
Jasper
NuecesSuperior, United
Washington
JeffersonChambersHarris
HidalgoHealthSpring, Molina, Superior
JeffersonAmerigroup, Molina, United
Brewster
Page 22
Mandatory for STAR+PLUS• People who have a physical or mental disability and
qualify for Supplemental Security Income (SSI) benefits or for Medicaid because of low income.
• People who qualify for Community-Based Alternative 1915(c) waiver services.
• People age 21 or older who can receive Medicaid, because they are in a Social Security Exclusion program and meet financial criteria for 1915(c) waiver services.
• People age 21 or older who receive SSI.
Page 23
Voluntary for STAR+PLUS
• Children under age 21 receiving SSI or SSI-related services living in a STAR+PLUS service area may choose to enroll in STAR+PLUS or choose to be placed in traditional Medicaid.
Page 24
Adult STAR+PLUS Benefits
Medicaid Only• Traditional Medicaid benefits• PCP• Community-based LTSS• Service Coordinator• Unlimited prescriptions
Dual Eligibles – Individuals who qualify for both Medicare benefits and Medicaid assistance. These individuals receive their Acute Care though Medicare and their LTSS through the STAR+Plus Program.
Page 25
Children’s STAR+PLUS Benefits
• Children’s Medicaid package• Primary Care Physician (PCP)• Community-based LTSS• Service Coordinator• Unlimited necessary hospital days
Page 26
Medicaid Rural Service Area (MRSA) Expansion
• Expands STAR+PLUS into the Medicaid Rural Service Areas.
• Projected expansion date: September 1, 2014
• Service Areas: Central, Northeast and West Texas
Page 26
.
Page 27
HoodHoward
PresidioVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
KendallComal
Gillespie
Llano
Travis
Hays
Caldwell
BurnetWilliamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
Rains Wood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
CampMorris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Medicaid Rural Service Area Medicaid (RSA) Regions
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Orange
Sabine
Newton
Colorado
Houston
Nacogdoches
San Jacinto
Jasper
Washington
JeffersonChambersHarris
West TexasSTAR - Amerigroup, FirstCare, Superior
STAR+PLUS TBD
Brewster
Central TexasSTAR - Amerigroup, Scott & White, Superior
STAR+PLUS - TBD
Northeast TexasSTAR - Amerigroup, Superior
STAR+PLUS -TBD
Page 28
Children’s Health Insurance Program (CHIP)
• The Balanced Budget Act (BBA) of 1997 (P.L. 105-33) created the State Children’s Health Insurance Program (SCHIP) under Title XXI of the Social Security Act.
• The Texas program become operational in 2000.• CHIP is offered statewide and covers children in
families who have too much income or too many assets to qualify for Medicaid, but cannot afford to buy private insurance.
Page 29
CHIP Eligibility
• In CHIP, children are eligible from birth through the month of their 19th birthday if they reside in families with incomes at or below 200 percent of the Federal poverty level (FPL), provided that they are not eligible for Medicaid.
• CHIP-eligible children must enroll in a CHIP MCO.
Page 30
CHIP Benefits
• The CHIP benefit package includes a basic setof health care benefits that is cost effective and focuses on primary health care needs.
• These benefits are subject to certain limitations and exclusions.
Page 31
CHIP Cost Sharing
• Based on the families income, most families in CHIP pay an annual enrollment fee, to cover all children in the family.
• CHIP families also pay co-payments for doctor visits, prescription drugs, inpatient hospital care, and non-emergent care provided in an emergency room setting.
• American Indians and Alaska Natives are exempt from all CHIP cost sharing obligations.
Page 32
CHIP Delivery Network
• CHIP services are delivered by private MCOs selected by the state through a competitive procurement.
• Enrollees residing in a CHIP service area receive services through one of the CHIP MCOs.
• Enrollees residing in rural counties that are not included in a CHIP service area receive their services through one of two MCOs that provide comprehensive health care services for enrollees throughout the rural counties (CHIP RSA).
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CHIP Service Areas
Page 33
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
KendallComal
Gillespie
Llano
Travis
Hays
Caldwell
BurnetWilliamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
CampMorris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Bexar
Lubbock
Harris
El Paso
CHIPReprocurement Service Areas
Dallas
HHSC, Health Plan OperationsSeptember 2010
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Travis
Orange
Sabine
Newton
Colorado
Houston
Tarrant
Nacogdoches
San Jacinto
Jasper
Nueces
Washington
JeffersonChambersHarris Jefferson
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
KendallComal
Gillespie
Llano
Travis
Hays
Caldwell
BurnetWilliamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
CampMorris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
BexarAetna, Amerigroup Community First, Superior
LubbockFirstCare, Superior
HarrisAmerigroup, Community Health Choice,
Molina, Texas Children’s, United
El PasoEl Paso First, Superior
CHIP Service Areas(effective March 1, 2012)
DallasAmerigroup, Molina, Parkland
HHSC, Managed Care OperationsSeptember 2011
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
TravisBlue Cross and Blue Shield of Texas, Sendero, Seton, Superior
Orange
Sabine
Newton
Colorado
Houston
TarrantAetna, Amerigroup, Cook Children’s
Nacogdoches
San Jacinto
Jasper
NuecesChristus, Driscoll Children’s, Superior
Washington
JeffersonChambersHarris
JeffersonAmerigroup, Community Health Choice,
Molina, Texas Children’s, United
CHIP Rural Service Area (RSA)Molina, Superior
Page 34
CHIP Dental Services
• Each CHIP member is enrolled in a dental maintenance organization (DMO) and has a dental home.
• The main dental home assesses dental needs and coordinates members’ care with specialty providers.
Page 35
CHIP Dental Benefits
• CHIP members get up to $564 in dental services per 12 month enrollment period for all dental procedures unless an exception applies.
• Exceptions after the $564 is reached:
• Preventative services in the American Academy of Pediatric Dentistry periodicity schedule.
• Some medically necessary services subject to prior authorization by the dental plan.
Page 36
CHIP Medically Necessary Dental Services
• Diagnostic and preventative services• Restorative• Endodontic• Periodontal• Prosthodontic• Oral and maxillofacial surgery services• Orthodontic benefits (limited to pre and post surgical
orthodontic services to treat craniofacial anomalies requiring surgical intervention).
Page 37
Children’s Medicaid Dental Services • Children’s Medicaid Dental operates under an 1115 waiver
and provides primary and preventive dental services in a managed care environment.
• Each member is enrolled in a dental maintenance organization (DMO) and has a main dental home.
• The main dental home assesses dental needs and coordinates member’s care with specialty providers.
• Most Medicaid children birth through age 20 who receive Medicaid.
Page 38
Children’s Medicaid Dental Medically Necessary Covered Benefits
• Diagnostic and preventative services• Therapeutic• Restorative• Endodontic• Periodontal• Prosthodontic (removable and fixed)• Implant and oral and maxillofacial surgery services• Orthodontic services• Adjunctive general services
Page 39
Excluded from Children’s Medicaid Dental Services
• Medicaid recipients age 21 and over.• Medicaid recipients under age 21 who reside in
institutions receive their dental services through traditional Medicaid.
• STAR Health Program recipients.
Proposed Changes from 83rd Legislative Session
• Integrate Nursing Facilities into Managed Care• Integrate Behavioral Health into Managed Care• Integrate Children with disabilities into Managed
Care• Pilot Program for Long Term Services and
Support• STAR+PLUS Expansion State Wide• Medical Transportation
Page 40
Community First Choice (CFC)
What it is: A new Medicaid state plan option that provides a 6% increase in federal Medicaid matching funds for services to help keep Medicaid beneficiaries with disabilities out of nursing homes and institutional settings.
What this means for Texas: Implementation of CFC in Texas is projected to provide long-term services and supports to an additional 12,000 clients, many of whom are on interest lists waiting to receive waiver services.
Note: In order to qualify for the service an individual must earn 74% of FPL or less.
Page 41
Questions and Answers
Page 42
