HHSC contracts with managed care organizations (MCO) and pays each MCO a monthly amount to coordinate health services for people enrolled in Medicaid or Children’s Health Insurance Program (CHIP) MCOs. A majority of Medicaid and all CHIP prescription drug benefits are delivered through the managed care model. Each MCO contracts directly with pharmacy benefit managers (PBM) to create pharmacy provider networks people can use to fill prescriptions.
There are five Medicaid managed care programs in Texas, including traditional Medicaid: STAR, STAR+PLUS, STAR Health, STAR Kids, and the Medicare-Medicaid plans. The type of Medicaid coverage a person gets depends on where the person lives and what kind of health issues the person has.
- Medicaid for children, newborns, pregnant women and some families and children. People in STAR get their services through an MCO.
- Medicaid program for people who have disabilities or are age 65 or older. People in STAR+PLUS get Medicaid basic medical services and long-term services through an MCO.
- STAR Health
- Medicaid program for children who receive coverage through the Texas Department of Family and Protective Services. STAR Health also is for young adults who were previously in foster care.
- STAR Kids
- Statewide Medicaid program providing Medicaid benefits to children and adults 20 and younger who have disabilities.
- STAR+PLUS Medicare-Medicaid Plans
- HHSC and the federal Centers for Medicare and Medicaid Services (CMS) have set up combined Medicare-Medicaid plans for people in those counties who have both Medicare and Medicaid coverage, known as dual eligibles. By having one plan, Medicare and Medicaid benefits work together to better meet the member’s healthcare needs by offering basic health care and long-term services and supports.