TMPPM 2008 > Provider Information > Managed Care > Medicaid Managed Care

7.1.1 Overview

Originally, the Texas Medicaid Managed Care Program was called the State of Texas Access Reform (STAR) Program. The STAR Program was established to explore different methods of building a framework of managed care around segments of the Texas Medicaid Program. In 1995, the Texas Legislature adopted Senate Bill (S.B.) 10 and related legislation that authorized HHSC to undertake a comprehensive restructuring of the Texas Medicaid Program to incorporate managed care delivery systems statewide.

Currently, the Medicaid Managed Care Program consists of two types of health-care delivery systems: health maintenance organizations (HMOs) and Primary Care Case Management (PCCM). HMOs provide services in the metropolitan areas, including Nueces. PCCM provides services in the remaining 202 rural counties. (See page 7-23 for a listing of PCCM counties and page 7-20 for a listing of HMO service areas [SAs].)

The principal objectives of Medicaid Managed Care are to emphasize early intervention and to promote improved access to quality care, thereby significantly improving health outcomes for the target population, with a special focus on prenatal and well-child care.

Clients enrolled in any of the Medicaid Managed Care programs may reside in metropolitan or rural areas. These programs include:

•The STAR Program operates under a 1915(b) waiver and provides acute care medical assistance in a Medicaid Managed Care environment for clients who reside in the Bexar, Dallas, El Paso, Harris, Harris Expansion, Lubbock, Nueces, Tarrant, and Travis metropolitan SAs (see "STAR Program" ).

•The STAR+PLUS Program operates under a 1915(b) waiver and 1915(c) waiver and provides integrated acute and long term services and supports in a Medicaid Managed Care environment for clients who reside in the Bexar, Travis, Nueces, Harris, and Harris Expansion SAs (see "STAR+PLUS Program" ).

•The NorthSTAR Program, administered by the Department of State Health Services (DSHS), operates under a 1915 (b) waiver and provides integrated behavioral health services under contract with a behavioral health organization (BHO) for clients who reside in the Dallas SA (see "NorthSTAR Program" ).

•The PCCM Program, administered by TMHP, operates under a state plan amendment for clients who reside in the 202 rural Texas counties (see "PCCM" ).

The goals of Medicaid Managed Care are to:

•Improve the access to care for clients enrolled in the programs.

•Increase quality and continuity of care for clients.

•Decrease inappropriate usage of the health-care delivery system, such as emergency rooms (ERs) for nonemergencies.

•Achieve cost-effectiveness and efficiency for the state.

•Promote provider and client satisfaction.

Additional goals for the STAR+PLUS Program include:

•Integrating acute and long term services and supports.

•Coordinating Medicare services for clients who are dual eligible.

Higher use of medical services by traditional Medicaid clients occurs when clients obtain care through ERs or access duplicative services for the same medical condition. In Medicaid Managed Care, clients assume a responsible role in achieving their personal health care by choosing a primary care provider, then actively participating with their primary care provider to access preventive, primary care services. This collaborative approach to health-care delivery usually achieves cost savings for the Texas Medicaid Program by reducing duplicative services and unnecessary emergency and inpatient care.

Although many of the Medicaid Managed Care requirements are similar, each program has established specific objectives, eligibility and enrollment requirements, and claims filing processes, which are detailed in this section.