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
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.
for a map of service areas, and medical and dental plans serving those
Provider Enrollment and Credentialing
In accordance with federal requirements under
42 Code of Federal Regulations (CFR) §455.410, “Enrollment and screening of
,” 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
the Enroll Today
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.
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
refer to the following resources: