1. Module 1 Medical and Dental Information Series
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Texas Medicaid
Medical and Dental Information Series
The goal of this 8-part series is to provide training for health care providers about Medicaid and to help ensure an adequate supply of health care providers who are engaged in the Texas Medicaid system and willing to provide services to Medicaid patients. This particular teaching series is directed at dental students, dental residents and primary care medical residents.
These Presentations may contain animations. To view the full effect for these slides, please view them in PowerPoint slideshow mode.
Version 1.2 (6/22/2010)
Module 1
2/22/2013
Texas Medicaid Curriculum

2. Medicaid Curriculum Overview
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Medicaid Curriculum Overview
Module 1: General Structure of the Texas Medicaid System
Module 2: Understanding Medicaid Clients and Health Literacy
Module 3: Texas Health Steps
Module 4: Navigating Insurance and Managed Care
Module 5: Interfacing with Medicaid as a Provider
Module 6: Special Medicaid Programs
Module 7: Special Medical Issues
Module 8: Special Dental Issues
The Presenter’s Notes that are included here are designed to augment and expand upon the content of each slide and are written to address the medical/ dental resident or dental student audience. For those slides that include primarily text, these Notes may include additional content but do not supplant the slide text. For those slides that include primarily charts, graphs or other visuals, these Notes will assist the presenter in addressing key points and highlights that are depicted in the visual content.
Additionally, these Notes may include notations that refer to content sources or additional resources.
Key to Abbreviations:
PB= Texas Medicaid and CHIP in Perspective, Ninth Edition - January 2013, commonly known as the "Pink Book”; the Pink Book is divided into 9 chapters, a Glossary and Appendices A-G; a reference to PB 3-10, for example, refers to Chapter 3, page 10. The full source is available here:
Texas Medicaid Curriculum

3. Module 1 General Structure of the Texas Medicaid Program
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Module 1
General Structure of the Texas Medicaid Program
You are viewing Module 1: General Structure of the Texas Medicaid Program.
Please note that the terms clients, patients, recipients and enrollees are all used to refer to the persons who are covered by Medicaid, with an effort to use the most appropriate term for the context in which the term is used.
Texas Medicaid Curriculum

4. Module 1
Module 1: Objectives After completing this module, you should be able to:
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Describe the purpose and background of Medicaid
Identify who benefits from services supported by Texas Medicaid
Contrast Medicaid with other major health programs
Describe the organization of Medicaid in Texas
List features of Medicaid Managed Care
Identify examples of Texas Medicaid programs
Outline advantages to serving as a Medicaid provider
Find Medicaid resources
After you complete this module, you should know what Texas Medicaid is, who it serves, who the key personnel are in its organization and administration, and examples of its programs.
You should understand the benefits of Texas Medicaid within the state, and have a sense of why participating makes good personal and professional sense.
Texas Medicaid Curriculum

5. True or False? Test Your Knowledge about Texas Medicaid:
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True or False? Test Your Knowledge about Texas Medicaid:
Medicaid is funded solely by the federal government.
Medicaid is an entitlement program based solely on age.
Medicaid benefits include many optional services that a state can choose to provide.
Non-disabled children account for more than half of Texas Medicaid spending.
Physician visits, inpatient services, and pharmacy costs are all examples of acute health care costs that Medicaid covers.
Answers and explanations to these questions appear on Slides #51-52
Answers are:
1: False
2: False
3: True
4: False
5: True
Texas Medicaid Curriculum

6. Module 1
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What is Medicaid?
Medicaid is a federal health care program that is jointly funded by federal and state money. Medicaid is jointly funded by the state and federal governments:
About one-third funded by the State of Texas
About two-thirds funded by the Federal Government
In December 2011, about 1 in 7 Texans relied on Medicaid for health insurance or long-term services (3.7 million of the 25.9 million).
Medicaid was created through Title XIX of the 1965 Social Security Act, and established in Texas in 1967.
In Texas, Medicaid is administered by the Texas Health and Human Services Commission (HHSC).
Medicaid is an entitlement program, which means:
The number of eligible people who can enroll cannot be limited.
Any services covered under the program must be paid.
PB 1-1
Medicaid is jointly funded by the federal and state governments, with the actual percentages varying by state and across years. In 2011, the federal government funded about 66% of Medicaid, while the state of Texas funded about 34%. More than 14% of Texans received Medicaid services in 2011.
Texas Medicaid Curriculum

7. What Does Medicaid Cover?
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What Does Medicaid Cover?
Acute and preventive health care for all ages
Physician visits
Inpatient and outpatient services
Pharmacy, lab, and radiology costs
Long-term services for elderly and disabled clients
Mental health and substance abuse treatment
PB 1-1
In general, Medicaid covers acute health care for all ages. It also covers some long-term care for the elderly and disabled. Dental services are restricted to patients under age 21.
Dental Services (for patients under the age of 21)
Preventive
Therapeutic
Texas Medicaid Curriculum

8. Basic Principles of Medicaid Social Security Act
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Basic Principles of Medicaid Social Security Act
Amount, Duration and Scope
States must cover each service in an amount, duration, and scope that is “reasonably sufficient” and may impose limits on services for adult clients. A state may not arbitrarily limit services for any specific illness or condition.
Freedom of Choice
With certain exceptions, including for managed care, the States must allow Medicaid recipients freedom of choice among participating providers of health care services.
Comparability
The same level of services must be available to all clients or patients (e.g., those with similar disabilities).
Statewideness
All services must be available statewide.
PB 2-7
These four principles are set forth by Title XIX of the Social Security Act. They apply to Medicaid in all states.
Slide number 14 addresses the exceptions regarding provider choice.
Texas Medicaid Curriculum

9. Required Benefits Optional Benefits
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Medicaid Benefits
The Social Security Act specifies…
Required Benefits
Optional Benefits
States may define their own amount, duration, and scope
of (or limitations on) Medicaid benefits
Example: Limitations on prescription drugs
PB 2-8
It’s important to note that about 2/3 of spending for Medicaid in is to cover optional benefits and services that the state chooses to provide to improve the health and health care of Texas residents.
Limits on coverage, for both required and optional services, may not be imposed for children under 21 if there is a medical necessity.
Texas Medicaid Curriculum

10. Mandated Services Covered by Texas Medicaid, 2013
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Mandated Services Covered by Texas Medicaid, 2013
EPSDT (Texas Health Steps) medical and dental check-ups and treatments for persons under 21
Physician services
Dental services
Family planning services
Inpatient & outpatient hospital
Lab and radiology
Nursing facility care
Home health care
Services by:
Federally Qualified Health Centers
Rural Health Clinics
Certified Nurse Midwives
Clinical nurse specialists and nurse practitioners
PB 6-2
As noted previously, the Social Security Act specifies a set of required benefits that state Medicaid programs must provide and a set of optional benefits that states may choose to provide; this slide focuses on the Mandated services.
Federal law allows states to define what constitutes reasonably sufficient amount, duration, and scope of Medicaid benefits, but all of the services listed above are mandated, or required by law in every state, including Texas.
In addition, certain types of facilities and care providers that focus on care for low-income patients are also included in the mandated list.
Texas Medicaid Curriculum

11. Examples of Optional Services Covered by Texas Medicaid, 2013
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Examples of Optional Services Covered by Texas Medicaid, 2013
All services are required for children under 21 years of age if medically necessary; restrictions apply for many services to adults.
Hospice services
Maternity service clinics
Prescription drugs
Podiatry
Optometry, including glasses
Hearing instruments
Renal dialysis
Rehabilitation services
Medical or remedial care provided by:
Physician extenders
Mental health providers
Chiropractors
Physical therapists
Occupational therapists
Speech therapists
PB 6-2/3
The state may choose to provide some, all, or no optional services specified under federal law; this slide focuses on the Optional services.
Some optional services that Texas chooses to provide are available only to clients under age 21, and one optional service (Institutions for Mental Disease, or IMD) is available to clients who are under 21 or 65 and over.
If the person is under age 21, all federally allowable and medically necessary services must be provided as required under federal law.
Rehabilitative services for mental illness
In-home respiratory care
Attendant services
Program for All-Inclusive Care for the Elderly (PACE)
Texas Medicaid Curriculum

12. Who is Eligible for Medicaid Benefits?
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Who is Eligible for Medicaid Benefits?
Medicaid primarily serves:
Low-income families
Foster children
Pregnant women
The elderly
People with disabilities
Babies born to mothers receiving benefits at time of delivery
(Services available for one year)
PB 1-3/ 3-1
The general public perhaps most closely associates Medicaid with health care benefits for children. Indeed, children comprise the largest portion of Medicaid beneficiaries (in Texas and elsewhere)– but because most of their benefits support relatively low-cost prevention and screening services, their associated costs are smaller.
During the late 1980s and early 1990s, Congress expanded Medicaid eligibility to include a greater number of people with disabilities, children, pregnant women, and the elderly. These changes helped fuel the growth of the Medicaid program, and the Texas Medicaid population tripled in just a decade, adding more than one million people between 1990 and 1995 alone.
In the mid to late 1990s, caseload declined in part due to the de-linking of Medicaid from cash assistance programs (e.g. welfare) and stricter eligibility requirements for Temporary Assistance for Needy Families (TANF).
Texas Medicaid Curriculum

13. Who is Eligible to Deliver Medicaid Funded Services?
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Who is Eligible to Deliver Medicaid Funded Services?
Individual Health Care Providers
Doctors, dentists, advanced practice registered nurses, physician assistants, physical therapists, optometrists, and psychologists
Outpatient Facilities
Rural health clinics, federally qualified health centers, school clinics, family planning agencies, and mental health centers
Inpatient Facilities
Hospitals and skilled nursing facilities
Providers of Goods & Services
Durable medical equipment, ambulance, pharmacies, radiology, and labs
TMHP Provider Procedures Manual
As will be described later, TMHP is a contractual partnership that administers Medicaid claims and performs other services. The Texas Medicaid Providers Procedures Manual outlines policies and procedures relevant to participating providers. This manual can be found on the TMHP website by going to clinking on the “Providers” link, and then on the “Reference Material” link. You can also access the current manual from the web address provided below.
The term “provider” is used extensively in Texas Medicaid, and includes a full range of individuals (doctors, dentists, advanced practice nurses), as well as facilities and groups. Provider enrollment is available online, through the TMHP website.
Texas Medicaid Curriculum

14. Choosing a Provider: Patient Options
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Choosing a Provider: Patient Options
Although the Social Security Act requires freedom of choice in selecting Medicaid providers, it also allows states to set specific guidelines, especially for managed care organizations
Medicaid fee-for-service patients may choose any Medicaid provider
Patients enrolled in Health Maintenance Organizations (HMOs) have a primary care provider (or PCP) in a medical home
Patients in an HMO may choose any Medicaid primary care provider or specialist within the HMO network
In most cases, a referral for specialty care from the PCP is required for HMO patients
As noted earlier in Slide 9, the Social Security Act requires freedom of choice in selecting Medicaid providers. However, federal rules also allow states to set specific guidelines for managed care.
This slide outlines Texas policy for provider choice among the three most common enrollment models, fee-for-service and HMOs.
Texas Medicaid Curriculum

15. Medicaid vs. Medicare What is the difference?
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Medicaid vs. Medicare What is the difference?
Texas Medicaid
Medicare
Authorized by Social Security Act of 1965
Established in Texas – 1967
Jointly Funded by State and Federal Government, administered by State & regulated by CMS
Funded by Federal Government & administered by CMS
Entitlement program
based on income
Entitlement program
based on age or disability
difference-between-medicare-and-medicaid%3F
It’s important to note the difference between Medicaid and Medicare. Both were authorized by the Social Security Act of 1965, but with different purposes. Research indicates that many health care trainees (including medical students) confuse the two programs.
Medicare focuses exclusively on the elderly (age 65 and older) and is wholly funded by the federal government.
Also important to note is the term “dual eligible's,” those elderly or SSI- disabled who are eligible to receive benefits from both programs.
Medicaid also pays some deductibles, premiums, and coinsurance for dual eligible patients, and covers some categories of medications that Medicare doesn’t cover.
Medicaid also covers long-term care for some patients through waiver programs, which Medicare does not (other than following a hospitalization). Medicaid also covers long-term institutional services and supports and thus covers the cost of nursing home care for dually eligible clients not paid for by Medicare.
Low income families, children, pregnant women, disabled, elderly
People 65 years or older, or people with disabilities
Eligibility and enrollment in both programs concurrently is possible
CMS: Centers for Medicare and Medicaid, US federal agency that administers Medicare, Medicaid, and the Children's Health Insurance Program.
Texas Medicaid Curriculum

16. Medicaid vs. CHIP What is the difference?
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Medicaid vs. CHIP What is the difference?
Texas Medicaid
Children’s Health Insurance Program (CHIP)
Authorized by Social Security Act
of 1965
Authorized by Balance Budget Act
of 1997
Jointly Funded by State and Federal Government
Entitlement program based on income, assets and/or disability
Enrollment based on income
(not an entitlement program)
As with the difference between Medicaid & Medicare, it’s important to distinguish between Medicaid and the Children’s Health Insurance Program (CHIP), both of which are administered in Texas by the Health & Human Services Commission.
The primary distinction between the two programs is that CHIP supports those families with too much income or too many assets to qualify for Medicaid– in other words, the “donut” population who might otherwise go without insurance or health care.
Another distinction is the CHIP supports only prenatal care and children ages 0 to 18 years, whereas Medicaid clients can include adults and other services.
Additionally, CHIP has a maximum annual cost share amount, which consists of a sliding enrollment fee and sliding co-pays.  These costs are paid by the family, and are based on the countable net income of the household. There is no cost sharing in Medicaid.   
Finally, children in the same family may qualify for different programs. For example, households may have their younger children enrolled in Medicaid and their older children enrolled in CHIP.
Low income families, children, pregnant women, disabled, elderly
Children in families with too much income or too many assets to qualify for Medicaid and who meet the CHIP income requirements
Texas Medicaid Curriculum

17. Who can receive Full Medicaid Benefits? Categories of Eligibility
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Who can receive Full Medicaid Benefits? Categories of Eligibility
Low income families, pregnant women, and children
Based on income level, age, caring for a related Medicaid eligible dependent child or pregnancy
Cash assistance recipients
Based on receipt of Supplemental Security Income (SSI)
People age 65 and older and those with disabilities
Based on income level, age, and physical or mental disability
PB 5-1
Medicaid clients listed above include individuals who are eligible for full coverage of acute care services, prescription drugs, and long-term services and supports, depending on need. The majority of children in foster are categorically eligible for Medicaid until age 18 (and may continue to receive Medicaid coverage until age 21 if they have no other coverage and meet income eligibility). Useful definitions include TANF and SSI:
Temporary Assistance to Needy Families (TANF) is the federal-state program of cash assistance for impoverished families formerly known as Aid to Families with Dependent Children (AFDC). States set their own income eligibility guidelines for TANF. Texas’ income cap for a mother with two children is $188 per month, with an asset limit of $1,000. People who are enrolled in or eligible for TANF are automatically eligible for Medicaid. Medicaid was originally linked to TANF.
SSI: Supplemental Security Income (SSI) is the federal cash assistance program for low-income individuals who have disabilities. The federal Social Security Administration sets income eligibility caps, asset limits, and benefit rates, and determines eligibility. The 2011 monthly income limit for SSI is $674 per month with an asset limit of $2,000. In Texas, all people eligible for SSI are also eligible for Medicaid.
Medicaid Qualified Medicare Beneficiaries (MQMB’s). For these individuals, Medicaid pays the deductible and co-insurance for Medicare services and covers all other Medicaid services not covered by Medicare.
Texas Medicaid Curriculum

18. Who can receive Limited Medicaid Benefits? Categories of Eligibility
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Who can receive Limited Medicaid Benefits? Categories of Eligibility
Medicare Beneficiaries
Based on income level and age
Non-Citizens
Legal permanent residents and undocumented persons who are not eligible for Medicaid based on citizenship status may receive emergency services.
PB 5-1
The special groups listed on this slide may be eligible for Medicaid benefits in special programs. However, their benefits may be time-limited or limited to specific services, as noted above.
Texas Medicaid Curriculum

19. How Many People Does Texas Medicaid Serve?
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How Many People Does Texas Medicaid Serve?
At any one time, how many individuals are enrolled in Medicaid? About 3.54 million
PB 5-8
The number of Texas Medicaid recipients can be expressed in two ways: Average Monthly Medicaid Enrollment (this slide) and Annual Unduplicated Medicaid Enrollment (next slide). The monthly average count is the average number of patients on Medicaid per month. This number best answers the question of “At any one time, how many patients are enrolled in Medicaid?”
People may gain and lose Medicaid eligibility at various points during a year. For example, eligibility status can change due to parent or caretaker income changes, a child reaching adulthood, or after childbirth.
Since all clients may not remain eligible for all months of a year, the monthly average count is lower than the unduplicated count.
The monthly average was 2,832,214 people in state fiscal year (SFY) 2007 when only full benefit clients are counted, and 3,025,316 for all Medicaid clients (including non-full benefit clients).
Texas Medicaid Curriculum

20. How Many People Does Texas Medicaid Serve?
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How Many People Does Texas Medicaid Serve?
How many individual Texans received Medicaid-funded services at some point in the year? About 4.57 million
PB 5-3
The “unduplicated count” is the number of Texans who received Medicaid-funded services at some point during the year. This number best answers the question of “How many individual Texans received Medicaid-funded services at some point in the year?”
For SFY 2011, the unduplicated count was 4,567,077 patients, and includes all full benefit clients
As a reminder the abbreviation SFY= State Fiscal Year, which is September 1 - August 31 (as opposed to FFY, Federal Fiscal Year).
Texas Medicaid Curriculum

21. Distribution of Medicaid Enrollees
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Distribution of Medicaid Enrollees
State Total = 3,098,169
As of: August 2010
PB App A-1
The distribution of Medicaid patients across the state of Texas is similar to the distribution of population across Texas, with higher concentrations in urban areas.
In general, Texas Medicaid is administered by Public Health Regions (PHR) in Texas, as shown in this map.
Texas Medicaid Curriculum

22. Texas Medicaid Recipients State Fiscal Year 2011
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Texas Medicaid Recipients State Fiscal Year 2011
Unduplicated Clients
SFY 2011 = 4,567,077
Hispanic
Caucasian
African- American
Other
0-5
6-14
15-20
21-64
65+
PB 5-13 and 5-14
This graph shows the breakdown of Medicaid patients in Texas, across 3 different demographic characteristics: ethnicity, age and gender.
Female
Male
Texas Medicaid Curriculum

23. How does Texas enroll Medicaid participants?
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How does Texas enroll Medicaid participants?
Fee for Service
Traditional arrangement in which a provider is paid for each individual service that a patient receives
Managed Care
Structured clinical, financial, and organizational activities designed to improve continuity and access to health care services, promote appropriate use of services, and contain costs.
PB 7
Texas began implementing Medicaid Managed Care in 1993 in a limited coverage area. Since that time it has expanded to cover all of the state. Two definitions are useful here:
Managed Care Organization: MCO’s are a health organizations that finance and deliver health care through a specific provider network and defined services and products
Health Maintenance Organizations (HMO): The HMO uses a capitated model, meaning that it receives a monthly payment from the state for each person enrolled, based on an average projection of medical expenses for the typical patient. The arrangement allows a fixed price and budget certainty for the state, while the HMO assumes the risk of providing services that are medically necessary. HMOs accept risk for all pre-approved services provided to their enrollees. Examples include FirstCare and United Health Care of Texas.
MCO: Managed Care Organization, a health organization that finances and delivers health care through a specific provider network and defined services and products
Texas Medicaid Curriculum

24. The Medical Home Key Feature of Medicaid Managed Care
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The Medical Home Key Feature of Medicaid Managed Care
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Serves as a source for continuity of care from a primary care provider (PCPs)
Provides comprehensive preventive and primary acute care
Provides specialty referrals and other services offered by a managed care organization and coordinates all levels of patient care
Texas Medicaid PCPs:
Family physicians
Pediatricians
General internists
Obstetricians/gynecologists
Physicians’ assistants
Advanced practice registered nurses
Community clinics including federally qualified health centers (FQHCs) and rural health centers
PB 7-1
A key goal of Texas Medicaid is to encourage a “medical home”– a source of health care where patients have a usual primary care provider who is responsible for maintaining the continuity of patient care.
Texas Medicaid Curriculum

25. Medicaid Managed Care in Texas Overview of Plans
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Medicaid Managed Care in Texas Overview of Plans
STAR (Originally an acronym for State of Texas Access Reform)
A statewide managed care program in which HHSC contracts with MCOs to provide, arrange for, and coordinate preventative, primary, and acute care covered services
STAR+PLUS
Provides integrated acute and long-term services and supports to people with disabilities and the elderly
NorthSTAR
A capitated program in Dallas and surrounding counties that provides behavioral health (mental health and substance abuse) services to Medicaid and medically indigent patients
STAR Health
A statewide program to provide coordinated care to children and youth in foster and kinship care
7-10 – 7-14
This slide includes acronyms and programs that will be described further in some subsequent slides. You should become most familiar with those programs that are in place in your region of Texas. More detail about Medicaid Managed Care will be included in Module #4.
Definition: Capitation- “a fixed per capita payment made periodically to a medical service provider (such as a physician) by a managed care group (such as an HMO) in return for medical care provided to enrolled individuals”
Module 4 includes additional detail on Texas Medicaid Managed Care.
Texas Medicaid Curriculum

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Percentage of Medicaid Clients by Delivery Type, State Fiscal Year 2011
PB 7-17
The number of clients enrolled in Medicaid Managed Care has expanded dramatically since 2003 (when only 40% of Medicaid clients were enrolled in managed care programs). In 2011, on the other hand, managed care programs covered 75% of clients. In 2011, the great majority (84%) of those enrolled in Medicaid Managed Care programs were under 20 years old.
Texas Medicaid Curriculum

27. What are Examples of Texas Medicaid Programs?
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What are Examples of Texas Medicaid Programs?
Texas Health Steps
Provides medical prevention and dental preventive/treatment services to eligible children
Programs for Women and Children
Programs for family planning and pregnant women, Medicaid Buy-In for Children, and women’s cancers
Prescription Drugs
Prescription medications through local pharmacies
Behavioral Health Services
Mental, emotional, and chemical dependency treatment for eligible patients
Future modules in this curriculum will provide additional details about Texas Medicaid programs, a few of which are listed here.
Long-Term Services and Supports
Programs for those with physical, intellectual and developmental disabilities
Texas Medicaid Curriculum

28. Module 3 will focus specifically on Texas Health Steps.
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Texas Health Steps
Perhaps the best known of Texas Medicaid programs is THSteps, which provides medial and dental preventive care and screening to eligible children.
THSteps is the name for the federally-required Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services in Texas.
PB 6-3
Perhaps the best known of Texas Medicaid programs is the support it provides to children for preventive care and screening. The EPSDT is part of the mandated coverage for children under 21, and therefore is included in the Medicaid coverage in all states. Module #3 will focus specifically on Texas Health Steps.
Module 3 will focus specifically on Texas Health Steps.
Texas Medicaid Curriculum

29. Components of THSteps Medical Checkups
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Components of THSteps Medical Checkups
Medical history
A complete physical examination
Screening of nutritional, developmental, and mental-health needs
Age appropriate laboratory tests (including lead screening)
Routine immunizations
Health education
Vision and hearing screening
Oral health screening and referral to a dental home
Referrals to other health care providers as needed
PB 6-4
Medical and dental check-ups are provided periodically through THSteps. The interval between scheduled medical checkups depends on the child’s age. More medical checkups are scheduled for the birth through 2 years of age population and annual checkups are indicated for children ages 3 through 20. This slide lists the general components for medical check-ups.
Texas Medicaid Curriculum

30. Components of THSteps Dental Checkups and Services
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Components of THSteps Dental Checkups and Services
Preventive services
Dental examinations, cleanings, oral health education, topical fluoride applications, application of sealants, maintenance of space
Treatment services
Restorations (fillings and crowns), endodontic treatment, periodontic treatment, prosthodontics, oral surgery, implant services and maxillofacial prosthetics
Emergency treatment
Procedures to control and treat bleeding, pain, acute infection, immediate tooth loss, and injury to teeth or supporting structures
Health Related Orthodontic Services (prior authorization needed)
Correction of cleft palate, crossbite therapy, treatment of severe malocclusion, and treatment of facial accidents involving severe traumatic deviation
PB 6-5
THSteps provides comprehensive dental prevention and treatment services. This slide lists components for dental check-ups.
Texas Medicaid Curriculum

31. The Medicaid Team Providers: Medical, Dental and Other Services
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The Medicaid Team
HHSC: Single State Agency charged with the administration & supervision of the Medicaid plan
Providers: Medical, Dental and Other Services
MCOs: Managed Care Organizations
TMHP: Claims Administrator
DSHS
DARS
MAXIMUS: Medicaid and
CHIP Enrollment Broker
DADS
Covering more than 3 million Texans requires a complex infrastructure. The slides that follow outline the structure of Medicaid in Texas and introduce you to the organizations, offices, and entities within that infrastructure that function together as the Texas Medicaid team.
ICHP: Quality Monitor
Texas Medicaid Curriculum

32. Texas Medicaid Operating Departments
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Texas Medicaid Operating Departments
Governor of Texas
Health & Human Services (HHSC) Executive Commissioner
Single State Agency (HHSC)
Department of State Health Services (DSHS)
Department of Assistive & Rehabilitative Services (DARS)
Department of Aging & Disability Services (DADS)
PB 2-12
The Social Security Act requires that each state plan must designate a single state agency to be responsible for administration and supervision of the Medicaid plan. This slide shows HHSC agencies that also have key Medicaid responsibilities, as shown on the following slides.
Texas Medicaid Curriculum

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Medicaid Functions
Operates as the single state agency responsible for Medicaid
Serves as primary contact point for the federal government
Administers the state Medicaid plan
Contracts with other state agencies to carryout certain Medicaid functions
Determines Medicaid eligibility
Operates the state’s acute care, prescription drug, and most managed care programs
Develops Medicaid policies, rules, and reimbursement rates
Organizes and coordinates initiatives to maximize federal funding
Manages the Medical Care Advisory Committee (MCAC)
PB 2-12
This slide lists Medicaid functions of the HHSC in Texas.
Texas Medicaid Curriculum

34. Medicaid Functions Texas Health Steps
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Medicaid Functions
Texas Health Steps
Case Management for pregnant women and children
Newborn metabolic screening, newborn hearing screening
Family planning
Targeted case management and rehabilitation
Services for people diagnosed with a mental health condition
NorthSTAR Administrator
YES Waiver program for children with severe emotional disturbance
PB 2-12
This slide lists the Medicaid functions of the Texas Department of State Health Services, an agency of HHSC. The Texas DSHS was created in 2003 through the merging of four state agencies: the Texas Department of Health, Texas Department of Mental Health and Mental Retardation, Texas Health Care Information Council, and Texas Commission on Alcohol and Drug Abuse.
Texas Medicaid Curriculum

35. Medicaid Functions Early childhood intervention
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Medicaid Functions
Early childhood intervention
Targeted case management for Blind Children’s Vocational Discover and Developmental Program (BCVDDP)
PB 2-12
The Texas Department of Assistive and Rehabilitative Services (DARS) is an agency of the HHSC. It works with Texans with disabilities and developmental delays to improve the quality of their lives and to enable their full participation in society. This slide lists the Medicaid functions for which DARS is responsible.
Texas Medicaid Curriculum

36. Medicaid Functions Nursing facility programs and services
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Medicaid Functions
Nursing facility programs and services
Long-term care licensing and certification
Program of All-Inclusive Care for the Elderly (PACE)
Hospice
Nursing home Preadmission Screening and Resident Review (PASRR)
Intermediate Care Facilities and Mental Retardation Facilities, including State Supported Living Centers.
Targeted case management for people with intellectual disabilities
Home and community-based services for people with developmental disabilities and those who would otherwise require nursing facility level of care
PB 2-12
Texas Department of Aging and Disability Services (DADS) is a state agency that supports the state's elderly and disabled population. This slides lists the Medicaid functions for which DADS is responsible.
Texas Medicaid Curriculum

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TMHP acts as the state's Medicaid fiscal agent and is responsible for paying acute care claims, while the state of Texas is responsible for covering the cost of claims.
Affiliated Computer Services, Inc. (ACS) meets consolidated contractual Medicaid responsibilities with a team of subcontractors under the name of TMHP (Texas Medicaid & Healthcare Partnership).
Responsibilities
Administers fee-for-service Medicaid claims
Manages policy development
Collects HMO encounter data
Enrolls providers
Supplies provider relations representatives to enrolled providers
PB G-35
On a day-to-day basis, most providers who care for fee-for-service (FFS) patients will deal primarily with TMHP, the Texas Medicaid and Healthcare Partnership that was formed from the contractual relationship between ACS and HHSC.
TMHP serves as the claims administrator, network administrator, and enrolls providers for Texas Medicaid FFS programs.
Texas Medicaid Curriculum

38. What Does Medicaid Cost?
Module 1
4/16/2017
Module 1
What Does Medicaid Cost?
In 1967, Texas Medicaid served fewer than 1 million people at a cost of less than $200 million
In 2011, Texas Medicaid served more than 3 million people at a cost of $29.4 billion, representing about 26% of the total state budget
Federal funds are based on the Federal Medicaid Assistance Percentage (FMAP) the matching rate that changes annually.
For federal fiscal year (FFY) 2011, the Texas FMAP was 66.46%.
PB 1-2
Kaiser Commission on Medicaid Facts:
The following slides take a look at Medicaid spending.
The FMAP is derived from each state’s average per capita income, and is updated annually by the Centers for Medicare & Medicaid (CMS). Consequently, the percentage of total Medicaid spending that is paid with federal funds also changes annually.
Because of the size of the Medicaid program, even small changes in the FMAP can result in federal funding fluctuations worth millions of dollars.
Texas Medicaid Curriculum

39. Federal Medical Assistance Percentages (FMAP), Fiscal Year 2011
Module 1
Federal Medical Assistance Percentages (FMAP), Fiscal Year 2011
Source: Federal Register
Medicaid is jointly operated and financed by the federal government and the states with the federal government setting broad criteria for how the program operates and each of the states implementing the program and setting specific eligibility and benefit levels. The share of total costs that the federal government pays (the match rate) is based on the per capita income of the state. At a minimum, the federal government pays 50 percent of the costs of the program, but the poorest states receive a higher match rate. On average, the federal government pays about 57 percent of the costs of the program.
Texas
66.46%
*Note: Percentages do not reflect temporary increases in FMAP provided by the American Recovery and Reinvestment Act of 2009.

40. Texas Medicaid Spending The Big Picture
Module 1
Texas Medicaid Spending The Big Picture
4/16/2017
Module 1
By Services Type, State Fiscal Year 2010
PB 8-15
This is a very full & “busy” slide– the details are less important than the fact that the overall “pie” for Texas Medicaid has many different pieces and covers many types of programs and services.
Note: ICF-IID= Intermediate Care Facilities for Individuals with Intellectual Disabilities
Texas Medicaid Curriculum

41. Texas Medicaid Spending The Major Categories
Module 1
Texas Medicaid Spending The Major Categories
4/16/2017
Module 1
By Services Type, State Fiscal Year 2011
House Appropriations Committee Presentation
Source: Medicaid Management Information System (MMIS)
Prepared by Strategic Decision Support, THHSC, April 2012
Note, due to rounding, totals may not add up exactly
This slide shows the general categories of Medicaid Spending for FY 2011
Texas Medicaid Curriculum

42. Module 1
4/16/2017
Module 1
Average Monthly Medicaid Spending by Type of Eligibility, State Fiscal Year 2011
PB 8-18
As shown on Slide #12, non-disabled children account for 66% of the Medicaid caseload in Texas. However, the care for those children represents only about 33% of the spending.
Texas Medicaid Curriculum

43. Federal Health Care Reform and Texas Medicaid
Module 1
4/16/2017
Module 1
Federal Health Care Reform and Texas Medicaid
The federal health care reform Affordable Care Act (ACA) will impact Texas Medicaid, the Texas HHSC and other agencies. Examples of ACA changes include:
Benefit changes:
Concurrent hospice care and treatment services for children enrolled in Medicaid and CHIP
Birthing centers as a Medicaid provider
Expanded Medicaid formulary
New provisions to address fraud and abuse
Increased use of the National Provider Identifier (NPI) on claims and applications
Requiring face-to-face encounters with patients for the certification of home health services and durable medical equipment
PB 3-5/6
The full implications of the ACA for Texas Medicaid are still in development. The majority of ACA provisions become effective in 2014.
Texas Medicaid Curriculum

44. ACA Medicaid Eligibility Expansion
Module 1
4/16/2017
Module 1
ACA Medicaid Eligibility Expansion
Effective January 1, 2014, ACA expands Medicaid to the following groups:
Former foster care youth through age 25
Children ages 6-18 whose families have an income 100%-133% of the FPL; this is the population of children currently eligible for CHIP
The “individual mandate” for health insurance could lead to the enrollment of about 130,000 people who are currently eligible for Medicaid or CHIP, but are not currently enrolled
If a Medicaid expansion is pursued by the state, income eligibility could be expanded to adults ages 19 to 64 who are not currently eligible for Medicaid, and have incomes ≤133% of the FPL.
PB 3-7
New Medicaid populations in Texas could include:
• Parents and caretakers above 12 and up to and including 133 percent of the FPL, and
• Childless adults up to and including 133 percent of the FPL.
With this option Texas could expect to experience a caseload growth in 2014 of approximately 340,976.
Texas Medicaid Curriculum

45. Module 1
4/16/2017
Module 1
Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver
In December 2011, Texas was granted a waiver of certain federal Medicaid requirements under Section 1115 of the Social Security Act; the waiver:
Expands Medicaid managed care to the entire state, including managed care for dental and prescription drug services
Creates 2 new funding pools, one to reimburse
hospitals for Uncompensated Care (UC) for
Medicaid and uninsured patients and one for
Delivery System Reform Incentive Payment
(DSRIP) to provide financial incentives to
encourage hospitals and other providers to
achieve quality health outcomes
What is being “waived”?
Certain aspects of the Statewideness,
Comparability of Services and Freedom of
Choice requirements of the Social Security Act
Regional Healthcare
Partnership Regions
PB 4; See also Slide #8, which explains the Social Security Act
The 1115 Transformation Waiver is a five-year demonstration waiver running through September 2016.
Texas Medicaid Curriculum

46. The Face of Medicaid: The Patient’s Perspective
Module 1
4/16/2017
Module 1
The Face of Medicaid: The Patient’s Perspective
Amy and her husband Josh have
a 4-year old son, Ian, and another
child due in 6 months.
Josh’s work hours at a local
lumberyard have recently been
reduced. Amy is a full-time
cosmetology student and
does not currently work.
The family income is currently about $1,900 per month, which is less than 120% of the current federal poverty level for a family of 3.
What services and support can Amy’s family expect from Texas Medicaid this year?
Let’s take a look at some ways that Texas Medicaid has a real-life impact on families. This slide and the next focus on the patient’s perspective, in this case a young woman named Amy and her growing family. Data above are based on FPL
Texas Medicaid Curriculum

47. How Can Texas Medicaid Help Amy’s Family?
Module 1
4/16/2017
Module 1
How Can Texas Medicaid Help Amy’s Family?
Medicaid for Ian and the new baby (when it is born)
Medicaid: Treatment and prescriptions for any of the children's acute illnesses or chronic conditions that are medically necessary
THSteps
Medical check-ups, including routine immunizations, physical examinations, and anticipatory guidance/health education
Dental check-ups, including preventive services and treatment
Amy
Medicaid: Pre-natal and pregnancy services for Amy, including the delivery of her baby, and post- partum care
Women’s Health Program: Family planning after the baby is born
Medicaid can assist Amy during her pregnancy and beyond, her son, and her baby.
Texas Medicaid Curriculum

48. The Face of Medicaid: The Provider’s Perspective
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4/16/2017
Module 1
The Face of Medicaid: The Provider’s Perspective
Lauren will graduate from dental school in
Texas this year, and she plans to establish
a general practice in her hometown in the
Texas Panhandle, in a county considered
to be “dental lagging.”
She’s looking forward to building
a practice and taking care of a wide range
of patients, including those with Medicaid.
What services and support can Lauren expect from Texas Medicaid when she enrolls as a Texas Health Steps Provider?
Let’s take a look at some ways that Texas Medicaid has a real-life impact on providers, including doctors and dentists. This slide and the one that follows focus on Lauren, a young dentist.
Lagging counties are those that are below the state averages for timeliness of medical and/or dental checkup services for Texas Health Steps eligible persons.
Texas Medicaid Curriculum

49. How Can Texas Medicaid Help Lauren Build Her Practice?
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Module 1
How Can Texas Medicaid Help Lauren Build Her Practice?
Payment to establish a dental home for her patients as young as 6 months of age. The first dental home visit can include (but is not limited to) an oral exam, oral hygiene instruction, dental prophylaxis, topical fluoride application, and caries risk assessment.
Payment for dental services for her child patients, 6 months to 21 years, to cover dental visits every 6 months for diagnostic, preventive, and routine therapeutic care.
Note that support for loan repayment is dependent on funding, and is highly competitive. During the program’s first year, HHSC received 527 qualified applications and funded 300 (111 to dentists, 150 to primary care physicians, and 39 to subspecialists).
Here is the website regarding this initiative:
Texas Medicaid Curriculum

50. How Does Texas Medicaid Remain Dynamic & Progressive?
Module 1
How Does Texas Medicaid Remain Dynamic & Progressive?
4/16/2017
Module 1
Medicaid adjusts and grows to meet Texas’ changing health care needs of its recipients and providers:
Legislation has led to expanded services and populations covered
Professional organizations provide feedback, medical recommendations, and suggestions about practice guidelines
Provider feedback is actively sought
The Interactive Medicaid Provider Voice System allows providers to submit concerns & suggestions to share with the HHSC Medicaid Staff
Medicaid is not a static system. On the contrary, its goal is constant improvement to meet changing health care needs in Texas. One example is the IMPROVE system, which invites online provider feedback.
Texas Medicaid Curriculum

51. Medicaid is a rigid, one-size-fits- all program.
Module 1
4/16/2017
Module 1
Common Medicaid Myths
Myth
Medicaid is a rigid, one-size-fits- all program.
Medicaid is designed with minimum federal standards, which require states to cover certain populations and provide certain benefits to key populations.
In many ways it is a system that operates as 50 separate state coverage programs, with states having the choice to cover populations and services beyond minimum standards.
Fact
States have taken advantage of Medicaid’s flexibility to customize their programs—about 2/3 of Medicaid spending is for “optional” services or populations.
Because Medicaid has such a diverse set of obligations and is run jointly by federal and state governments, it is the subject of a number of myths and misunderstandings. Each of these Medicaid modules will attempt to expose the facts behind typical Medicaid myths.
Additional information about Medicaid Myths & Facts is available from the Kaiser Commission on Medicaid and the Uninsured.
Texas Medicaid Curriculum

52. Common Medicaid Myths Myth Fact
Module 1
4/16/2017
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Common Medicaid Myths
Myth
Medicaid is a poor-quality program that has little impact on access to care or health and Medicaid patients dislike the program.
Research supports Medicaid’s role in improving access to care for the people it serves.
Medicaid beneficiaries value their coverage, are grateful for the assistance it provides, and often report satisfaction with their coverage at the same levels as those with commercial insurance coverage.
Fact
Medicaid offers access to primary and preventive health care for its patients that is comparable to that of commercial coverage and greatly exceeds that of the uninsured.
The Health Care Education Affordability Reconciliation Act (H.R. 4872), signed into law on March 30, 2010, will raise Medicaid payments to family medicine physicians, general internists and pediatricians for evaluation and management services and immunizations to at least Medicare rates in 2013 and The legislation also provides 100 percent federal funding for the incremental costs to states of meeting this requirement. Thus, it is likely that Medicaid will be even more appealing in the future for both patients and providers.
Texas Medicaid Curriculum

53. Test Your Knowledge about Texas Medicaid: True or False?
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4/16/2017
Module 1
Test Your Knowledge about Texas Medicaid: True or False?
Medicaid is funded by the federal government.
FALSE: Medicaid is jointly funded by the federal and state governments. In 2011, the state funded more than 33% of Medicaid costs.
Medicaid is an entitlement program based on age.
FALSE: Medicaid is an entitlement program, but one based on income, assets, and disability/age.
Medicaid benefits include many optional services that a state can choose to provide.
TRUE: About 2/3 of the services provided under Texas Medicaid are considered optional for adults, rather than mandatory. Optional benefits in Texas include durable medical equipment, optometry, and prescription drugs. All federally allowable and medically necessary services are provided to children under 21 years of age.
Reference slides for each question:
Q1: Slide 6
Q2: Slide 15
Q3: Slide 11
Texas Medicaid Curriculum

54. Test Your Knowledge about Texas Medicaid: True or False?
Module 1
4/16/2017
Module 1
Test Your Knowledge about Texas Medicaid: True or False?
Non-disabled children account for more than half of Texas Medicaid spending.
FALSE: Although non-disabled children account for about 66% of the Medicaid caseload, they account for only about 33% of the costs
Physician visits, inpatient services, and pharmacy costs are all examples of acute health care costs that Medicaid covers.
TRUE: Medicaid covers all such acute care costs.
Reference slides for each question:
Q4: Slides 12 & 42
Q5: Slide 7
Texas Medicaid Curriculum

55. Providers > Reference Manual
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TMHP Provider Manual
The Texas Medicaid Procedures Manual is available online:
Manual updates become available in May and are designed to be user-friendly. The manual includes sections for provider type and other improvements as suggested by Texas Health Steps during provider focus groups and from provider questionnaires.
Providers > Reference Manual
Texas Medicaid Curriculum

56. Module 1
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Medicaid Resources
Texas Health & Human Services Commission Texas Medicaid & Healthcare Partnership Texas Health Steps CHIP/Children’s Medicaid
These web-based resources are available for more information on various aspects of Texas Medicaid.
Texas Medicaid Curriculum

57. This Texas Medicaid curriculum was prepared by
Module 1
4/16/2017
This Texas Medicaid curriculum was prepared by
Betsy Goebel Jones, EdD Project Director
Tim Hayes, MAM Project Designer
Authors: Module 1 Betsy Goebel Jones, EdD
David Trotter, MA
Department of Family & Community Medicine
Module 1
Texas Medicaid Curriculum