The goal of Texas Medicaid is to provide health care to over 4.2 million Texas residents who might otherwise go without medical care for themselves and their children. To achieve this, Texas Medicaid and a variety of health-care programs rely on a network of dedicated professionals to meet the growing health-care needs of our clients.
Enrolling in Texas Medicaid is a prerequisite for enrolling in other state health-care programs. By becoming a provider for Texas Medicaid and other state health-care programs, each provider has the opportunity to improve the health and well-being of Texans in their community by:
Promoting Continuity of Care
When families are faced with unemployment or loss of employer-based health coverage, they turn to Texas Medicaid or another health-care program to provide the health care they and their loved ones need. Providers who enroll as Texas Medicaid and other state health-care programs providers can continue to see existing patients during those times of change.
Providers may also render service to families with mixed coverage (e.g., children enrolled with Texas Medicaid while their parents are covered by their employer's insurance plan).
Providing a Medical Home for Clients
Providers are the crucial players in any quality health-care program. Providers enrolled with Texas Medicaid and other health-care programs render essential medical and preventive health-care services to clients while focusing on providing the best medical care possible. Texas Medicaid providers help ensure that each patient can receive high quality, comprehensive health-care services within their community.
Learn More About Texas State Health-Care Programs
Medicaid serves primarily low-income families, non-disabled children, related caretakers of dependent children, pregnant women, the elderly, and people who have disabilities. Initially, the program was only available to people receiving cash assistance (Temporary Assistance for Needy Families [TANF] or Supplemental Security Income [SSI]). During the late 1980s and early 1990s, Congress expanded Medicaid to include a broader range of people (elderly, disabled, children, and pregnant women). Medicaid is an entitlement program, which means that the federal government does not, and a state cannot, limit the number of eligible people who can enroll.
The Children with Special Health Care Needs (CSHCN) Services Program is administered by the Texas Health and Human Services Commission. The CSHCN Services Program offers medical treatment and equipment, and case management for eligible children with special needs from 20 years of age or younger, and for people of any age with cystic fibrosis. Additionally, the CSHCN Services Program offers Family Support Services, such as respite care, home and vehicle modifications, and some equipment that is not covered under the regular health benefits package.
While similar to Medicaid, the CSHCN Services Program is not a Medicaid program. To enroll in the CSHCN Services Program, providers must be enrolled in Medicaid. For more information, call 800-568-2413, Option 2.
Texas Health Steps, also known as Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, is specifically a children's program under Texas Medicaid which provides medical and dental preventive care and treatment to Medicaid clients who are birth through 20 years of age.
Texas Health Steps Medical provides medical checkups and preventive services which are based on the Texas Health Steps Periodicity Schedule. The Periodicity Schedule lists specific medical screening components for infants, children and youth and the various ages when they are required. Texas Health Steps medical checkups include regularly scheduled examinations and screenings of the general physical and mental health, growth, development, and nutritional status of infants, children and youth.
Texas Health Steps dental services provide early detection and treatment of dental health problems and preventive dental care for Texas Medicaid clients who are birth through 20 years of age. Texas Health Steps dental service standards were designed to meet federal regulations and to incorporate the recommendations of representatives of national and state dental professional groups.
Through outreach and education, Texas Health Steps encourages parents and caregivers of eligible clients to use Texas Health Steps dental services checkups and preventive care when clients first become eligible for Medicaid and each time clients are due for their next dental checkup. All Texas Health Steps clients can also be seen by a dentist at any time if they need emergency dental services for trauma, early childhood caries (ECCs), or any other appropriate dental or therapeutic procedure.
The TVFC program provides vaccines at no cost to the provider. The vaccines are recommended according to the Recommended Childhood and Adolescent Immunization Schedule (Advisory Committee on Immunization Practices [ACIP], AAP, and the American Academy of Family Physician [AAFP]). Medicaid does not reimburse for vaccines/toxoids that are available from TVFC. THSteps providers are strongly encouraged to enroll in TVFC at DSHS and must do so in order to obtain free vaccines for clients who are birth through 18 years of age.
Information on enrolling into the Texas Vaccines for Children program can be found on the DSHS website at dshs.state.tx.us/immunize/tvfc/default.shtm
The Non-Emergency Medical Transportation Program (MTP) is a statewide program that is responsible for ensuring that eligible clients of Medicaid, Children with Special Health Care Needs (CSHCN) Services Program, and Transportation for Indigent Cancer Patients (TICP) can be transported to their medical and dental appointments.
MTP arranges free non-emergency transportation to eligible clients who do not have any other means of transportation to access health-care services. MTP also provides medical transportation services to individuals who are diagnosed with cancer or cancer-related illness in South Texas.
Medical Transportation Program providers enroll, reenroll, and revalidate with HHSC through the Provider Enrollment and Management System (PEMS).
CHIP is available to children whose families have low to moderate income, who earn too much money to qualify for Texas Medicaid, and who do not have private insurance. Mothers-to-be also can apply for CHIP perinatal coverage. CHIP enrollment fees and co-payments are based on the number of people in the family and the family's income and assets. Enrollment fees are no more than $50 a year for all the children in the family. Some families pay no enrollment fee. Co-pays for doctor visits and prescriptions range from $5 to $35, depending on family income.
Long term care provides help with the basic tasks of living – bathing, dressing, personal care, housekeeping or preparing meals. Long-term care services can be provided in a client's home, a daytime program, or a residential setting such as a nursing home or assisted living facility.
The Texas Health and Human Services Commission (HHSC) administers programs providing Long Term Care (LTC) services and institutional care to eligible clients. The Texas Medicaid & Healthcare Partnership (TMHP) LTC team supports the LTC provider community in submitting claims through the Claims Management System. TMHP also supports providers as they submit forms via the LTC Online Portal.
Contract applicants and contractors will use PEMS to enroll in, or revalidate as, a Texas Medicaid provider to obtain or retain a contract with HHSC. You will still need to go through the HHSC process to contract with a specific service.
Kidney Health Care (KHC) is a statewide program that helps Texans with end-stage renal disease (ESRD) pay for dialysis treatments, access surgery, drugs, travel to transplant or dialysis services, and Medicare premiums. The program helps clients who meet the income requirement, but are not eligible for Medicaid medical, drug, or travel benefits.
How to Become a KHC Provider
Providers can enroll, re-enroll, and revalidate with HHSC through the Provider Enrollment and Management System (PEMS). Below are links to assist you in the enrollment process.
- Creating an Account for Enrollment Reasons Only
- PEMS Step-by-Step Guide
- Learning Management System
- LMS Registration and Navigation Job Aid for Providers
For support with PEMS, call the TMHP Contact Center at 800-925-9126.
An MCO LTSS provider is any provider who provides LTSS services under a specific NPI and taxonomy combination and submits claims through Medicaid Managed Care. An MCO LTSS provider will have to enroll with the LTSS Program through PEMS when the NPI and taxonomy combination they bill LTSS services with does not have an active enrollment record in PEMS.
To provide services to a STAR+PLUS client, LTSS providers must complete the contracting and credentialing process through the client’s STAR+PLUS managed care organization (MCO).