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

7.1.7 Primary Care Provider Requirements and Information

Under Medicaid Managed Care HMOs, eligible Medicaid clients must select a health plan and a primary care provider. Under Medicaid Managed Care PCCM, eligible Medicaid clients do not select a health plan. PCCM eligible Medicaid clients select a PCCM primary care provider. The primary care provider furnishes primary care-related services, arranges for and coordinates referrals for all medically necessary specialty services, and is available for urgent or emergency care, directly or through on-call arrangements, 24 hours a day, 7 days a week (see "Continuous Access" ). Primary care includes ongoing responsibility for preventive health care, health maintenance, treatment of illness and injuries, and the coordination of access to needed specialist providers or other services.

Primary care providers can choose to contract with PCCM and HMO health plans simultaneously.

Providers should remember that choosing an HMO does not require that providers terminate their contracts with PCCM.

PCCM providers in the STAR metropolitan areas are encouraged to continue to provide ongoing health-care services to PCCM clients who live in contiguous areas. There may be instances where PCCM clients may choose a PCCM primary care provider in a metropolitan (STAR) SA.

Provider types who are eligible to serve as a primary care provider include:

•Pediatricians.

•Family/general practitioners.

•Internists.

•Obstetrician/gynecologists.

•Nurse practitioners or clinical nurse specialists (family practice, women's health, or pediatrics).

•Certified nurse-midwives.

•Physician assistants (PAs).

•Rural health clinics (RHCs).

•Federally qualified health centers (FQHCs).

•Specialists willing to provide medical homes to clients who have special needs.

PAs may be eligible to enroll with Medicaid Managed Care as primary care providers. Contact the individual Medicaid Managed Care health plan for enrollment information.

The primary care provider either furnishes or arranges for all the client's health-care needs, including well check-ups, office visits, referrals, outpatient surgeries, hospitalizations, and health-related services.

Although primary care providers are encouraged to assist clients in accessing these services, Medicaid Managed Care enrollees may self-refer for the following services:

•Emergency services.

•Family planning.

•THSteps services and immunizations.

•Case Management for Early Childhood Intervention (ECI).

•Case Management for Children and Pregnant Women (CPW).

•Obstetric or gynecological services.

•School Health and Related Services (SHARS).

•Department of Assistive and Rehabilitative Services (DARS) case management.

•DSHS case management.

•Department of Aging and Disability Services (DADS) case management.

•Behavioral health services (contact client's health plan for specific requirements).

•Vision care (including ophthalmologic or therapeutic optometry).

Texas Health Steps (THSteps) providers must be enrolled with Medicaid to be reimbursed for services provided to clients. THSteps services are self-referred. Medicaid HMOs determine how their clients will access THSteps services. The HMO may require the client to go to an in-network THSteps provider or may allow the client to go to any Medicaid THSteps provider, whether or not they are in the HMO's network. Clients in PCCM are encouraged to access their primary care provider for THSteps services, but may self-refer to any Medicaid THSteps provider. Providers who perform THSteps must work in collaboration with the client's primary care provider to ensure continuity of care.

Female clients may access obstetrical and gynecological providers directly.

Behavioral health providers must enroll with each HMO to be reimbursed for services provided to managed care clients. Although managed care clients may self-refer for behavioral health services, HMO health plan providers should contact the client's health plan for specific in-network requirements. If a behavioral health provider practices in the Dallas SA, he must be enrolled as a network provider in the NorthSTAR BHO.

Refer to: "NorthSTAR Program" .

PCCM operates an open-specialty network. Therefore, behavioral health providers do not have to enroll with PCCM. PCCM clients may access behavioral health services from any Medicaid-enrolled behavioral health provider.

Providers cannot enroll Medicaid clients; however, educating clients is encouraged. Medicaid clients must enroll through the official state enrollment form or by calling the STAR Help Line at 1-800-964-2777.

Providers should follow these rules when educating patients:

•Providers may not influence patients to choose one HMO health plan over another or one PCCM provider over another.

•HMO providers must inform patients of all Medicaid Managed Care health plans in which the providers participate.

•HMO providers participating in a Medicaid Managed Care HMO may display state-approved, health-related marketing materials in their offices, provided it is done equally for all HMOs in which they participate. HMO providers cannot give out or display plan-specific marketing items or giveaways to patients.

•Providers and subcontractors may only directly contact potential clients with whom they have an established relationship.

•HMO providers may inform patients of special services offered by all Medicaid Managed Care health plans in which the providers participate.

•HMO providers may inform patients of particular hospital services, specialists, or specialty care available in all plans in which the providers participate.

•HMO providers may assist a patient by contacting a plan (or plans) to determine if a particular specialist or service is available, if the patient requests this information.

•HMO providers may not influence patients based on reimbursement rates or methodology used by a particular plan.

•HMO providers can provide the necessary information for the patient to contact a particular plan but cannot promote any plan over another.

•In no instances can HMO providers stock, reproduce, assist in filling out, or otherwise handle the enrollment form. Information can be provided as outlined above, and patients can be reminded that they can easily enroll over the telephone with the enrollment broker. However, the call must be made by the patient, not by the HMO provider or the provider's agent.

•HMO providers may assist clients with completing the Medicaid application.

•PCCM providers may stock primary care provider selection forms and/or provide a blank primary care provider selection form to the client. They may assist the client in filling out the selection forms. However, they may not in any way influence or coerce the client in making a primary care provider selection. Each client must personally complete, sign, and mail their individual form. Providers are prohibited from supplying provider- identified stationary and/or envelopes to the client for this purpose.

•HMO providers may display stickers indicating they participate in a particular Medicaid Managed Care health plan as long as they do not indicate anything more than "(health plan) is accepted or welcomed here."