Medicaid and CHIP
Medicaid and CHIP are programs that provide medical coverage to eligible needy people in Texas. Medicaid is a State (TMHP) and Federal cooperative venture for those who might otherwise go without medical care for themselves and their children. Most Medicaid in Texas is administered through Medicaid Managed Care Plans (MMP) under contract with the state. Currently, there are four such programs in Texas: STAR, STAR+PLUS, STAR Health, and STAR Kids that, for the most part, offer services through MMPs. These plans often offer additional services not covered by traditional Medicaid (dental, vision, etc.).
The Children's Health Insurance Program (CHIP) offers low-cost health coverage for children from birth through age 18. CHIP is designed for families who earn too much money to qualify for Medicaid but cannot afford to buy private health coverage. These services are all administered by private managed care plans with their own network of providers.
More information on these programs can be found in this reference guide.
Medicaid Managed Care Contracting and Credentialing - Consolidated Verification Organization 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 Enrollment 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.
Expedited credentialing allows providers to serve Medicaid recipients on a provisional basis while their credentialing application is pending. For Medicaid reimbursement purposes only, once the applicant provider submits the required information, the managed care organization (MCO) treats the provider as if they were in the MCO’s network when they provide services to the recipient. If the provider qualifies for expedited credentialing, MCOs will process claims from providers within 30 calendar days after receipt of a complete application, even if the MCO has not yet finished its review of the provider’s credentialing application.
Most providers must revalidate their enrollment with HHSC every three to five years, depending on provider type. Providers who are actively enrolled with TMHP and are eligible to revalidate can complete a revalidation application using the Provider Enrollment on the Portal (PEP) tool. TMHP will notify providers of their revalidation deadline 90 days before the deadline. This 90-day window is the only time revalidation can be completed for each revalidation cycle. Since it usually takes about 60 days for an application to process from beginning to end (depending on how complete and accurate the application is upon submittal), it is highly recommended that providers begin the revalidation process immediately and check status on the application often to avoid disenrollment and claim denials. If deficiencies or omissions are found after the application is submitted, the process could take longer exceeding the 90 day window resulting in disenrollment. Once the provider submits their abbreviated revalidation application, TMHP reviews it for completeness. If any omissions or deficiencies are found, TMHP will notify the provider. Providers who have been disenrolled are not eligible for revalidation and must complete a reenrollment application instead. For instructions, view the Provider Revalidation Job Aid.
"Dual eligible” is a term used to encompass all Medicare beneficiaries who also receive Medicaid assistance, ranging from beneficiaries who receive the full range of Medicaid benefits to beneficiaries who receive assistance only with Medicare premiums or cost sharing. Dual eligible
coverage is dependent on beneficiaries’ income and asset thresholds determined by the state. The dual eligible categories are outlined in this CMS resource.
The Qualified Medicare Beneficiary (QMB) program is a Medicaid program that helps very low-income dual eligible beneficiaries (individuals who are enrolled in both Medicare and Medicaid) with Medicare cost-sharing. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers, including those who do not accept Medicaid, from billing QMB individuals for Medicare deductibles, coinsurance, or co-payments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. For additional information, see the MLN Matters notice and MLN Booklet below.
Dual eligibles may obtain benefits through Medicare and Medicaid, or they may choose to select a Medicare Advantage plan that is designed for dual eligibles known as a Medicare-Medicaid plan (MMP)
for people who have both Medicare and Medicaid coverage. These new MMPs blend a person's Medicare and Medicaid benefits into one plan and physicians need only bill this one plan to receive full payment for both the Medicare and Medicaid benefits. These plans often offer additional benefits not available with Medicare such as case management and wellness programs. In these MMPs, Medicare and Medicaid benefits work together to better meet the member’s health-care needs and the MMPs must provide the full array of Medicaid and Medicare services. This Demonstration Project
includes 3 plan sponsors in Harris county through Amerigroup
, and UnitedHealthcare
. More information can be found in these resources:
Prior Authorization for Drugs
Managed Medicaid Plans Quicklinks
Community Health Choice
Texas Children’s Health Plan
UnitedHealthcare Community Plan