TMPPM 2008 >7.1.4.1 Managed Care Eligibility and Effective Date

Providers must validate a client's eligibility and membership within an identified plan. Providers must then pursue any prior authorization or administration requirements specific to that plan.

Benefits under the STAR and STAR+PLUS programs usually begin on the first day of the next month following selection of a primary care provider and plan. NorthSTAR has retroactive enrollment and does not require a primary care provider (see "Client Enrollment" ).

Benefits under the PCCM and ICM programs usually begin on the first day of the next month following Medicaid eligibility. For example, a client who has become eligible for Medicaid benefits for the first time, may be certified and begin to receive benefits under Texas Medicaid on the same day. If the client is also determined to be eligible for managed care, a second and separate enrollment process takes place.

The client does not begin to receive services under Medicaid managed care until the first day of the following month (providing enrollment takes place before the cut-off date for the following month). Enrollments and disenrollments become effective on the first day of the month (refer to example 1).


STAR and STAR+PLUS Example 1
Client certified for Texas Medicaid	January 1
Medicaid benefits begin	January 1
Client selects health plan and primary care provider	January 1
Managed care benefits begin	February 1

If a client selects a plan and primary care provider after the cut-off date (approximately the 15th of the month) they will not be enrolled in managed care nor appear on a primary care provider's patient list until the second month after their enrollment effective date (refer to example 2).


STAR and STAR+PLUS Example 2
Client certified for Texas Medicaid	January 1
Medicaid benefits begin	January 1
Client selects health plan and primary care provider	January 20
Managed care benefits begin	March 1

Clients may receive services under Texas Medicaid fee-for-service from the first date of eligibility. Claims for these services are billed to TMHP. Once managed care enrollment is in effect, the provider must bill the client's managed care organization for all capitated services or PCCM. Providers continue to bill noncapitated services to TMHP.

Note: All claims for Supplemental Security Income (SSI) clients in STAR are billed to TMHP.

When a client in the PCCM area is determined Medicaid-eligible and is a mandatory enrollee, the client is automatically enrolled in PCCM. Enrollment into PCCM is prospective.


Example
Client certified for Texas Medicaid	January 2
Medicaid benefits begin	January 1
PCCM benefits begin (automatic enrollment)	February 1

When a client is determined Medicaid eligible and is eligible for the ICM program, the client enrollment into the ICM program occurs prior to the cutoff date and the benefits begin on the first day of the following month.


Example
Client certified for Medicaid	January 1
Enrollment in ICM occurs prior to January Cutoff
ICM benefits begin	February 1

ICM clients do not select a health plan for ICM (there is only one) and do not have to select a primary care provider for their benefits to begin. Babies born to ICM clients receive benefits through Texas Medicaid fee-for-service retroactive to their DOB; they will not be ICM members.