TMPPM 2011 > Volume 1, General Information > Section 8: Managed Care > Medicaid Managed Care > Overview

8.1.1 Overview

The Texas Medicaid managed care program was originally called the State of Texas Access Reform (STAR) Program and was established to explore different methods of building a framework of managed care around segments of Texas Medicaid. In 1995, the Texas Legislature adopted Senate Bill 10 and related legislation that authorized HHSC to undertake a comprehensive restructuring of Texas Medicaid 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). The STAR, STAR+PLUS, and STAR Health programs use HMOs to deliver services, but PCCM does not use HMOs. STAR and STAR+PLUS provide services in a select grouping of counties known as service areas (SAs). STAR is available in 9 SAs comprised of 52 metropolitan counties and STAR+PLUS is available in 5 SAs comprised of 29 metropolitan counties. PCCM provides services in the remaining rural 202 counties that consists of 11 regions. Medicaid managed care also uses a behavioral health organization (BHO) in the NorthSTAR program. NorthSTAR provides behavioral health services in the Dallas Service Area. STAR Health is available statewide for some children in foster care.

The principle 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 SAs (see subsection 8.2, "STAR Program" in this section).

•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, Harris, Harris Expansion, Nueces, and Travis SAs (see subsection 8.3, "STAR+PLUS Program" in this section).

•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 subsection 8.4, "NorthSTAR Program" in this section).

•The PCCM Program. Administered by Texas Medicaid & Healthcare Partnership (TMHP), operates under a state plan amendment and provides acute care services for clients who reside in the 202 rural Texas counties (see subsection 8.6, "PCCM" in this section).

•STAR Health. Administered by Superior HealthPlan Network, operates under a 1915(a) waiver, and is a Medicaid managed care program that manages the health care for some children who are enrolled in foster care. Some foster care clients are enrolled in the Permanency Care Assistance (PCA) program and are not considered eligible for enrollment in Medicaid managed care. STAR Health provides services statewide (see subsection 8.5, "STAR Health Program" in this section).

The goals of Medicaid managed care are to:

•Improve 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 Texas Medicaid fee-for-service clients occurs when clients obtain care through ERs or access duplicate 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 (PCP), then actively participating with their PCP to access preventive primary care services. This collaborative approach to health-care delivery usually achieves cost savings for Texas Medicaid by reducing duplicate 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.