TMPPM 2009 > Provider Information > Managed Care > STAR+PLUS Program

7.3.1.4 Dual Eligible Clients

Many STAR+PLUS clients are eligible for Medicaid and Medicare. STAR+PLUS HMOs are not at risk for the delivery of acute care services needed by these clients.

Most STAR+PLUS clients with Medicare and Medicaid are Medicaid Qualified Medicare Beneficiaries (MQMBs). MQMBs receive Medicare benefits through a Medicare risk product (HMO) or Medicare fee-for-service insurance program. To reduce confusion, HHSC has mandated that STAR+PLUS MQMBs continue to receive all their acute care services as they do today, with Medicare being the primary payor and Texas Medicaid fee-for-service, through TMHP, the secondary payor. Providers are to continue billing for Medicare acute care services through the client's Medicare HMO or fee-for-service insurer following the rules of the Medicare insurer. If the client is in both a Medicare and Medicaid HMO, the client uses the Medicare primary care provider, and providers follow the Medicare HMO's medical management rules for authorization, concurrent review, etc. MQMBs choose a Medicaid HMO but do not choose a Medicaid primary care provider.

Refer to: Sections on MQMBs in this manual for further instructions.

"Claims Filing Information" for MQMB reimbursement requirements.

Dual eligible adults continue to be limited to three prescriptions unless they have joined the Medicare HMO also offered by their STAR+PLUS plan. With the implementation of the Medicare prescription benefit in January 2006, dual eligible clients no longer receive any prescription benefit through Medicaid.