Medicaid & CHIP

 Billing For Dual Eligibles: 

  • CMS has conveyed their concern that some physicians are billing Qualified Medicare Beneficiary (QMB) also known as (Dual Eligible) beneficiaries. The QMB program is a Medicaid program that helps very low-income dual eligible beneficiaries — e.g., individuals who are enrolled in both Medicare and Medicaid - with Medicare cost-sharing. Beneficiaries in the QMB program have annual incomes of less than $12,000. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers - even those who do not accept Medicaid - from billing QMB individuals for Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost-sharing reimbursements for QMBs in certain circumstances). Physicians may be subject to sanctions for failing to follow these billing requirements, and CMS has indicated that they may start conducting more frequent audits to address this practice. For additional information, see  MLN Matters, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program.              


NEW INFO - Medicaid Managed Care Contracting and Credentialing - Consolidated Verification Organization (CVO) Initiative:

Physicians wishing to newly contract with Medicaid Managed Care Organizations (MCOs) now have a more streamlined process to do so. A statewide initiative has been implemented that will allow physicians to credential through Aperture, a Credentialing Verification Organization (CVO), for all Medicaid MCOs in Texas. This process will eliminate the need to go through separate credentialing for each MCO with which you wish to contract. Once Aperture has your credentialing file, it can be used to contract with all MCOs. The anticipated CVO start date is April 2018, however some MCOs began using the CVO process in January as part of a Phase I project. 


      The Process:
  • Enroll with TMHP if you have not already done so. Physicians must complete the enrollment process through TMHP/HHSC prior to credentialing with MCOs.
  • Contact the MCO(s) you wish to contract with (you do not need to submit a credentialing application at this point).
  • The MCO(s) will notify Aperture that you wish to contract and Aperture will contact you to begin the credentialing process.
  • Aperture will provide you with an e-credentialing application and instructions to submit to Aperture. CAQH ProView information will be accepted.  A paper application can also be accepted that will be provided to you.
  • Aperture will collect your application and other required documentation (license, DEA, etc.) from you and verify the information provided. However, there may be some information that you will need to provide directly to the MCO(s).
  • This credentialing process is separate from the contracting process. Physicians will still need to engage with the MCO for contracting.


A soon-to-be released single facility application process will also be offered and a recredentialing process is in the works. Additional communications on these initiatives will be forthcoming from Aperture. More information can be found on the TAHP notice.


Non-Participating Providers and Limited Enrollment:  

  • Beginning January 15, 2018, Medicaid will not pay for referrals, prescriptions, supplies, and services for Medicaid patients (whether Medicaid is a primary or secondary payer) from ordering physicians who are not participating with Medicaid. However, providers who do not want to be Medicaid providers can fill out a limited enrollment form which allows them to refer, order, and prescribe for Medicaid patients. You will not become a participating Medicaid provider with this limited enrollment, and will not be listed in any Medicaid provider directories. This limited enrollment will ensure that patients who have Medicaid as a secondary payer (dual eligibles, etc.) receive Medicaid covered services.  If you have not enrolled as a referring/prescribing provider and see a patient with Medicaid coverage, you may receive a letter from TMHP instructing you to fill out a limited enrollment form. For answers to the most common questions, please refer to this FAQ's bulletin or the TMHP website.


Resources and Tools:

HCMS Resources/tools:


 Children's Health Insurance Program (CHIP)

  • Determine Who is Eligible-Both programs provide a wide range of benefits, including regular check-ups and dental care to keep kids healthy. Information concerning who is eligible, what is covered, how to apply, and how to renew can be found on the CHIP/Children's Medicaid



If you are interested in learning more about the Medicaid or CHIP programs, have questions about whether you are eligible, or would like to apply for assistance, please contact the Texas Health & Human Services Commission at (800) 925-9126 or you may wish to call 2-1-1.