In my recent visit to Texas, I decided to research how Medicaid works there.
How Medicaid Works in Texas
MANAGED CARE-Health Maintenance Organizations (HMO)
In Managed Care, each client has to choose a Primary Care Provider (PCP) who is then responsible for administering the preventive and primary care of the client, including medical screens and immunizations. The client may only choose a PCP from the network of providers that the Managed Care plan has contracted with. When the client needs specialized or acute care, the PCP refers the client to other health care specialists who are part of the network for those services. The HMO receives a monthly capitation payment for each member enrolled based on a projection of what it may typically cost to treat that patient.
MANAGED CARE-Primary Care Case Management (PCCM)
In Managed Care, PCCM is a fee-for-service alternative to capitated HMOs. In it, each client has to choose a Primary Care Provider (PCP) who is then responsible for administering the preventive and primary care of the client, including medical screens and immunizations. When the client needs specialized or acute care, the PCP refers the client to other health care specialists for those services. The client may only choose a PCP from the network of physicians that the State has contracted with.
FEE-FOR-SERVICES (FFS)-Traditional Medicaid
In a Fee-For-Services system, each client may choose any physician or health care specialist who is a Medicaid provider as and when needed. The State directly contracts with physicians and health care specialists who receive payment for services rendered.
In the Bexar County area, Medicaid Managed Care is delivered through the following models:
Health Maintenance Organization (HMO) model, and
Primary Care Case Management (PCCM) model.
In the Bexar County area, the State contracted with the following HMOs:
The State contracted with Birch and Davis (Texas Health Network) to administer the PCCM model.
At the local level, the project works closely with organizations and individual providers serving CSHCN. These include the Bexar County Case Management Coalition, local agencies and organizations serving CSHCN, and families of CSHCN through out Project Advisory Committee. The project is a member of the Regional Medicaid Managed Care Advisory Committee, and functions as Chair of the Sub-committee on CSHCN.
The project has formal memoranda of understanding with the two largest providers of services to CSHCN, Any Baby Can of San Antonio and The ARC of San Antonio, who support project research and survey activities.