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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2 Overview of Medicaid Managed Care

Texas Medicaid, which is administered by the Texas Health and Human Services Commission (HHSC), operates Medicaid managed care under the authority of federal waivers and state plan amendments that were approved by the Centers for Medicare & Medicaid Services (CMS).
Medicaid managed care is administered by MCOs, dental maintenance organizations (dental plans), and BHOs that are contracted by HHSC to provide services for Medicaid managed care clients. The Medicaid managed care MCOs and dental plans cover the same services that Texas Medicaid covers for the Medicaid fee-for-service clients. Some plans may also elect to cover value-added services.
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.
Higher use of medical services occurs when clients obtain nonurgent or emergent acute care through emergency rooms or access duplicate services for the same medical condition. In Medicaid managed care, clients assume more responsibility for their personal health care by choosing a health plan and primary care provider (PCP) and by making use of preventive primary care services. Eligible clients may also choose a dental plan and a main dentist. This collaborative approach to health-care delivery helps to reduce costs by eliminating duplicate services and unnecessary emergency and inpatient care.
Clients who are enrolled in Medicaid managed care may reside in metropolitan or rural areas. Medicaid managed care consists of the following programs:
The STAR program uses MCOs to cover acute care services in select groupings of counties known as service areas (SAs). STAR is available statewide. The STAR program operates under a federal 1115 waiver.
The STAR+PLUS program uses MCOs to cover integrated acute and long term services and supports in specific SAs. The STAR+PLUS program operates under a federal 1115 waiver.
The STAR Health program uses an MCO to deliver health-care services to children who are in foster care throughout the state. STAR Health is administered by Superior HealthPlan Network and operates under a federal 1915(a) waiver. The STAR Health program only manages the health care of some of the 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.
The NorthSTAR program is administered by the Department of State Health Services (DSHS). It uses a contracted BHO to provide behavioral health services in the Dallas service area. NorthSTAR operates under a federal 1915(b) waiver.
Children’s Medicaid dental services are administered by dental plans that process dental authorization requests and claims for most Medicaid fee-for-service and Medicaid managed care clients who are 20 years of age and younger regardless of their medical benefit plan.
Refer to:
Section 8, “Children’s Medicaid Dental Services” in this handbook for exceptions and additional information.

Texas Medicaid & Healthcare Partnership
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