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8.1.6.1 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 administrative requirements specific to that plan.
A Client determined eligible for Medicaid benefits may be certified and begin to receive benefits under Texas Medicaid fee-for-service on the same day. Claims for these services are billed to TMHP. If the client is also determined to be eligible for managed care, a second and separate enrollment process takes place. Once managed care enrollment is effective, the provider must bill the HMO for all capitated services for clients enrolled in an HMO or TMHP for clients enrolled in PCCM. Providers continue to bill noncapitated services to TMHP.
Note: All claims for SSI clients in STAR are billed to TMHP.
Benefits under the STAR and STAR+PLUS programs usually begin on the first day of the next month following selection of a plan and primary care provider.
STAR/STAR+PLUS Chart Example 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 panel until the second month after their enrollment effective date.
STAR/STAR+PLUS Chart Example 2
When a client in a PCCM area is determined Medicaid-eligible and is a mandatory enrollee, the client is automatically enrolled in PCCM. Enrollment in PCCM is prospective.
Benefits under the PCCM program usually begin on the first day of the next month following Medicaid eligibility.
PCCM Chart Example
Exception: Newborn enrollments are retroactive to the date of birth (DOB).
Expedited enrollments of pregnant women (program type 40) into the STAR Program may be retroactive.
Benefits under STAR Health begin when the client is placed in conservatorship.
STAR Health Chart Example
NorthSTAR has retroactive enrollment and does not require a primary care provider.
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