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 Medicaid Managed Care

Texas Medicaid is administered through a fee-for-service (FFS) model and a managed care service model:

  • The FFS model is administered by TMHP under the oversight of Texas Health and Human Services (HHS).

  • The managed care model is administered through managed care organizations (MCOs) and dental maintenance organizations (DMOs) that are licensed by the Texas Department of Insurance (TDI) and contracted by HHS.

Each MCO and DMO under contract with HHS administers Texas Medicaid managed care benefits for their members. Providers must enroll with Texas Medicaid and contract with each applicable MCO or DMO to be reimbursed for services rendered to Texas Medicaid managed care members.

HHS pays each MCO and DMO a monthly amount, called a capitation fee, to coordinate health and dental services for Medicaid clients who are enrolled in the health or dental plan. Health and dental plans contract directly with doctors and other health-care professionals to create provider networks that deliver covered services for their members.

Providers can refer to the HHS Medical and Dental Plans website for additional information about the Texas Medicaid managed care program and specific health plans.




MCO List by County

HHS contracts with different MCOs in each of the state’s 13 managed care service areas. A map of MCO coverage by county is available on the HHS website. HHS contracts with two DMOs to provide dental services statewide. Clients are considered for coverage through the applicable managed care program based on their permanent address and the type of health care they require.

Click here for a map of service areas, and medical and dental plans serving those areas (PDF).



Provider Enrollment and Credentialing

In accordance with federal requirements under 42 Code of Federal Regulations (CFR) §455.410, “Enrollment and screening of providers,” all providers must enroll with Texas Medicaid before contracting with MCOs or DMOs. Refer to the HHS Medicaid Provider Enrollment website for more information about provider enrollment in Texas Medicaid.

Providers who would like to enroll as a Texas Medicaid service provider may click the Enroll Today link in the blue bar at the top of this page.

Texas Medicaid providers who wish to contract with an individual MCO or DMO must contact the applicable MCO or DMO for more information. Refer to the HHSC Medical and Dental Plans website for contact information.



Contact information

For questions about FFS or carve out services prior authorized and processed by TMHP, contact the TMHP Call Center at 1-800-925-9126. For a list of carve out services, refer to the Texas Medicaid Provider Procedures Manual Medicaid Managed Care Handbook.

For questions about prior authorizations and claims processed by an MCO or DMO, contact the MCO or DMO. Contact information can be found on the individual MCO’s or DMO’s website. Refer to the HHS Medical and Dental Plans web page for the MCO contact information.
 
For questions about Medicaid managed care medical or dental policy requirements, contact HHSC at Managed_Care_Initiatives@hhsc.state.tx.us or refer to the following resources:

For managed care pharmacy questions, refer to the following resources on the HHS Texas Vendor Drug Program (VDP) website:


Grievances and Complaints

Medicaid managed care providers must exhaust the complaints or grievance process with their managed care medical or dental plan before filing a complaint with HHS. If, after completing this process, the provider believes they did not receive full due process from the managed care medical or dental plan, they may file a:


Helpful Links

Medicaid Managed Care Organizations (MCOs) Participating in the STAR+PLUS Medicare-Medicaid Plan (MMP)
STAR Kids MCO Training Manual TMHP Web Security and Permissions
STAR Kids Screening and Assessment Instrument (SAI) Manual
STAR Kids Screening and Assessment Instrument (SAI) - Complete Copy
Click on the Texas Medicaid Provider Procedures Manual for more information about Medicaid Managed Care


Frequently Asked Questions (FAQs)

Click here for a list of FAQs and answers.


Related News Items

News items related to Texas Medicaid FFS and managed care notifications are posted to the following TMHP web pages:

 
   

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