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Provider and MCO Guidance for CPW Services

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Note: The Health and Human Services Commission (HHSC) has requested that TMHP publish the following information:

This message is to update potential and current case management for children and pregnant women (CPW) providers on:

Third Party Insurance Requirements

MCOs must first pay and later seek recovery from liable third parties for CPW services.

Professional Liability Insurance Requirements

To maintain professional liability insurance, a CPW provider must attest to the status of their professional liability insurance in the MCO contracting/credentialing application. A CPW provider can attest to any amount, even if the amount is $0. If a CPW provider attests to $0, this means the provider does not hold professional liability insurance. This still fulfills HHSC and MCO requirements and is allowable by the National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC). NCQA and URAC are entities that provide accreditation to MCOs.

However, HHSC requires Medicaid MCOs to maintain information on the professional liability insurance status of its providers. For new CPW provider types that choose to maintain professional liability insurance, an MCO must allow a six-month grace period after a CPW provider completes contracting and credentialing with the MCO before the CPW provider must report their professional liability insurance status.

If a CPW provider chooses not to obtain professional liability insurance (i.e., attests to $0) even after the six-month grace period ends and the MCO documents the CPW provider’s professional liability insurance status, an MCO may not terminate their contract with the CPW provider. This is in compliance with NCQA and URAC requirements:

  • NCQA: CR 3 Element C, Factor 5 (Effective July 1, 2024)
  • URAC: CR 1-1 b. iii, 2-1 b., and 3-1 a. iv. (Version 1.1, effective June 2022)

Note: While malpractice insurance is a type of professional liability insurance, a CPW provider is not required to obtain malpractice insurance.

Federally Qualified Health Centers (FQHCs) as CPW Providers

An FQHC whose case managers have completed HHSC’s standardized case management training can deliver and be reimbursed for CPW services. Case managers working under an FQHC do not need to apply for their own individual National Provider Identifier (NPI) to deliver CPW services. Services are billed under the FQHC NPI.

The FQHC prospective payment system (PPS) wrap payment methodology applies to CPW services and MCOs will be paid the PPS wrap payment by HHSC for CPW services. FQHCs will bill for CPW services using only the CPW procedure code (G9012). FQHCs that deliver CPW services will use their FQHC provider type, specialty code, and taxonomy code. An MCO must not require FQHCs to apply as a CPW provider or use a CPW taxonomy code to deliver CPW services.

Referrals to CPW Providers

HHSC expanded the list of example situations in which an MCO might refer a client to a CPW provider:

  • Supporting admission, review, and dismissal school meetings, 504 or special education services.
  • Locating childcare or subsidies to assist with childcare costs.
  • Locating long-term shelter or domestic violence assistance and shelter.
  • Referring clients to legal services or state programs to establish paternity and orders for support.
  • Ensuring access to immediate services for clients who need urgent assistance.

Continuity of Care

As long as an MCO determines there is no duplication of services, a member can receive CPW services from a CPW provider when the member has a previously established relationship with or prefers to receive services from a CPW provider. A member can also contact a CPW provider directly. The CPW provider may also receive a referral from a third party.

For members transferring from fee-for-service to a new MCO, the new MCO must allow the member to continue to receive CPW services from the CPW provider even if the CPW provider is out-of-network. The CPW services can continue until the member’s case management needs are met or the service plan developed by the CPW provider has been completed. The new MCO is obligated to reimburse the member’s existing out-of-network CPW provider for CPW services provided.

Information Sharing

In addition to non-medical needs screening results, HHSC recommends that MCOs share in the initial referral to the CPW provider:

  • Member’s name, date of birth, and Medicaid ID number
  • Urgency of referral
  • Description of reasons for referral
  • Initial health needs screening results
  • Any other relevant screening or evaluation results
  • Any relevant historical data for the member

Training

In addition to the updates outlined here, there are new training requirements for existing CPW providers due to House Bill 1575, 88th Legislature, Regular Session, 2023 and new policy requirements.

Two new trainings must be completed by all existing CPW providers as a one-time requirement. Starting June 1, 2025, confirmation of completion of the two new trainings will be required as part of an existing CPW provider’s reenrollment or revalidation process. More information on these new requirements was issued in a separate notice: Training Requirements for Existing CPW Program Providers to Be Changed.

Contact

Please email mailto:AskCM@hhs.texas.gov with any questions you may have about becoming a CPW provider or about providing CPW services.

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