Managed Care
Overview
Beginning March 1, 2012, people with Medicaid managed care or CHIP will obtain their pharmacy benefits through a managed care plan.
Managed Care Resources
- HHSC Medicaid Managed Care Initiatives
- Pharmacy notification letter
- Service Areas
- Billing Assistance chart (how to bill claims, who to call for assistance)
- Enrollment chart (how to enroll with plans)
Questions about changes should be sent by e-mail to ManagedCare_Exp2012@hhsc.state.tx.us.
About
HHSC is implementing changes to the delivery of Medicaid and the Children’s Health Insurance Program (CHIP) services. Prescription drug benefits, currently administered through the Vendor Drug Program will be delivered through the Medicaid and CHIP managed care organizations (MCOs). Each MCO will contract with a pharmacy benefits manager (PBM) that will process prescription claims and contract and work with pharmacies that serve CHIP and Medicaid managed care clients.
Beginning March 1, the Vendor Drug Program will:
- Still enroll pharmacy providers that want to provide Medicaid and CHIP services.
- Continue to manage Vendor Drug Medicaid and CHIP formularies.
- Continue to process claims for clients enrolled in fee-for-service Medicaid, the DSHS Children with Special Health Care Needs (CSHCN) Services Program, and the DSHS Kidney Health Care (KHC) Program.
- Deny claims for clients enrolled in Medicaid managed care or CHIP with NCPDP error code “AF” (“Patient Enrolled Under Managed Care”). The name of the responsible Medicaid or CHIP health plan will be returned in “Additional Message Information" (Field 526-FQ) to assist pharmacies.
MCOs should be offering pharmacy provider training sessions leading up to the March 1 transition. Pharmacy staff is encouraged to attend and learn the procedures for submitting claims, where to call for claim overrides or prior authorization assistance, and any other unique claim policies/procedures for Medicaid and CHIP clients.