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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2 Overview of Medicaid Managed Care : 2.3 General Information About Client Enrollment in Managed Care

Most of the clients who have been determined to be eligible for Texas Medicaid are first enrolled in fee-for-service. Specific client groups within the Texas Medicaid population are eligible for managed care based on certain established criteria. If the client is eligible for Medicaid managed care, the client will choose an MCO and PCP or a dental plan and main dentist or both. The managed care enrollment date is separate from the Medicaid eligibility date. In most cases, Medicaid managed care enrollment is not retroactive.
Refer to:
Claim and authorization transactions for services rendered during the client’s fee-for-service eligibility must be submitted to TMHP, and claim and authorization transactions for services rendered during the client’s Medicaid managed care enrollment must be submitted to the appropriate entity (i.e., TMHP for carve-out services and the MCO or dental plan for managed care services).
If a client loses Medicaid eligibility and then regains eligibility, the client is automatically reassigned to the same health plan and PCP or dental plan that the client had before the client lost Medicaid eligibility.
Refer to:
Section 4: Client Eligibility (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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