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

7.1.3.1 Managed Care Eligibility and Effective Date

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 Program 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 the Texas Medicaid Program 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).

Exception: Newborn enrollments are retroactive to the date of birth.

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).

Clients may receive services under the traditional Medicaid program 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 non-capitated services to TMHP.

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