6. Eligibility

6.1. Identification Numbers

6.1.1. Medicaid

6.1.1.1. Fee-for-Service 

Fee-for-service, or traditional, Medicaid is for people who cannot be in managed care. Pharmacy claims must be submitted with the values identified in the table below. Refer to the VDP website "Pharmacy Payer Sheets" page to review specific transaction, segment, and field requirements on the Claim Billing Transaction (B1) payer sheet.

Field Name Field Number Submitted Value

BIN Number

101-A1

61ØØ84

Processor Control Number

1Ø4-A4

DRTXPROD

Group ID 301-C1 MEDICAID

Pharmacy claims for newborns who have not had a Medicaid ID number assigned should not be submitted with the Mother’s ID number. These claims may be submitted on the Pharmacy Claims Billing Request. Refer to the "Pharmacy Claims Billing Request" section in the System Requirements section.

6.1.1.2. Managed Care

The type of Medicaid coverage a person receives depends on where the person lives and what kind of health issues the person has.

  • STAR is Medicaid for children, newborns, pregnant women and some families and children. People in STAR get their services through health plans, also called managed care plans.
  • STAR+PLUS is a 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 a health plan, also called a managed care plan.
  • STAR Health is a statewide, comprehensive healthcare system that was designed to better coordinate and improve access to health care for:
    • Children in Department of Family and Protective Services (DFPS) conservatorship (under age 18).
    • Young adults in CPS extended foster care (ages 18 through 20)
    • Young adults who were previously under DFPS conservatorship and have returned to foster care through voluntary foster care agreements (ages 18 through 20.)
    • Young adults eligible for Medicaid for Former Foster Care Children (FFCC) will continue coverage through the STAR Medicaid Managed Care plan of their choice from age 21 through the month of their 26th birthday.

Pharmacy providers should refer to the managed care organization's provider manual and policy materials. Refer to the Managed Care section for more information on contacting MCOs in your area.

6.1.1.3. Medicaid Copayment Information

There are no prescription drug co-payments for Medicaid-eligible clients.

6.1.1.4. Temporary Medicaid Eligibility Verification

Medicaid-eligible people may present the Medicaid Eligibility Verification (HHSC Form 1027-A) as evidence of Medicaid eligibility.  While the form does not have a Medicaid ID number, it is an official state eligibility document that can be relied upon as proof of Medicaid eligibility until the person and/or family receives the Your Texas Benefits Card.  Medicaid numbers should be assigned within one month of the original presentation.  Pharmacy staff are encouraged to verify the drug is on the formulary, fill the prescription, and then submit the claim to Medicaid once the cardholder ID number is assigned.

6.1.1.5. Medicaid Presumptive Eligibility

Medicaid Presumptive Eligibility (PE) is a process that allows qualified hospitals (QH) and other qualified entities (QE) to determine if a Medicaid-eligible person can get short-term Medicaid. The Affordable Care Act (ACA) requires states to allow QH/QE groups that have gone through the qualification process to make PE determinations consistent with HHSC policies and procedures.

QH/QE staff will provide the person with the Short-term Medicaid Notice (HHSC Form H1266) if the person is determined to be presumptively eligible.  Pharmacy staff may be presented with Form H1266.  This form is not a substitute for the Medicaid Eligibility Verification (Form 1027-A) or the Your Texas Benefits Medicaid card.  In order for a person to receive pharmacy benefits after receiving a Form H1266, the person should:

  • Request a Medicaid Eligibility Verification (Form 1027-A) at an HHSC benefits office, or
  • Print a Medicaid card at YourTexasBenefits.com.

To learn more about presumptive eligibility please visit TexasPresumptiveEligibility.com.

6.1.2. Children’s Health Insurance Program Eligibility

Pharmacy claims for CHIP-eligible client are processed through the person’s MCO. In addition, there is a copayment amount required for the majority of CHIP-eligible clients. Pharmacy providers should refer to the managed care organization's provider manual and policy materials. Refer to the Managed Care section for more information on contacting MCOs in your area.

B1 transactions for CHIP submitted to VDP will reject but include a message that includes the name of the person’s MCO. E1 transactions for CHIP submitted to VDP will return only the name of the MCO. Refer to the System Requirements section for more information about the eligibility verification transaction.

6.1.3. Children with Special Health Care Needs Services Program Eligibility

6.1.3.2. CSHCN Identification Form

Each person is assigned a unique six-digit program ID.  These program ID numbers are generated sequentially by the program eligibility system, and appear on the eligibility forms that eligible people should take to the pharmacy.  Pharmacy staff should convert the six-digit number to a nine-digit number to submit the claim online.

To convert for claim submission, add the number “9” to the beginning of the core six-digit program ID number, followed by “ØØ” after the core program ID number, as shown in the below table. Failure to correct the cardholder ID prior to transmission will result in NCPDPD error code 52 (“Non-matched Cardholder ID”). 

Assigned Program ID Submitted Cardholder ID
123456 9123456ØØ

6.1.3.3. CSHCN Pharmacy Claims Submission

Pharmacy claims must be submitted with the values identified in the table below.  Refer to the “NCPDP B1 Transaction Billing Request” payer sheet for specific transaction, segment, and field requirements.  Refer to the VDP website "Pharmacy Payer Sheets" page for more information.

Field Name Field Number Submitted Value

BIN Number

101-A1

61ØØ84

Processor Control Number

1Ø4-A4

DRTXPROD

Group ID 301-C1 MEDICAID

6.1.3.4. CSHCN Copayment Information

There are no prescription drug copayments for CSHCN-eligible clients.

6.1.4. Kidney Health Care Program Eligibility

6.1.4.1. KHC Identification Card

KHC does not issue eligibility cards. People enrolled in KHC will receive an explanation of benefits (EOB) that indicates if they are eligible for the drug benefit, but updated EOBs are not issued on a regular basis or when drug benefits change. Pharmacy staff may contact the KHC program or the VDP Pharmacy Benefits Access Help Desk to verify eligibility. Refer to the Contact Information section for contact information, or below to learn about real-time eligibility verification methods.

6.1.4.2. KHC Pharmacy Claims Submission

Pharmacy claims must be submitted with the values identified in the table below.  Refer to the “NCPDP B1 Transaction Billing Request” payer sheet for specific transaction, segment, and field requirements.  Refer to the VDP website "Pharmacy Payer Sheets" page for more information.

Field Name Field Number Submitted Value

BIN Number

101-A1

61ØØ84

Processor Control Number

1Ø4-A4

DRTXPRODKH

Group ID 301-C1 MEDICAID

6.1.4.3. KHC Copayment Information

Pharmacy staff should contact the KHC Program for copayment information. The copay amount due is returned in the "Patient Pay Amount" field (505-F5) of the pharmacy paid claim response. Refer to the Pharmacy Provider Payer Sheets for information about values and field returned on the paid and rejected response transactions.

Pharmacy staff can perform an Eligibility Verification (E1) transaction to find the person’s copayment amount. Refer to the System Requirements section for information about claim transactions. Refer to the "Field Responses for an Accepted Eligibility Verification" in the NCPDP E1 Transaction Accepted Response payer sheet for further explanation about the response.

6.1.5. STAR Health Eligibility

STAR Health is a statewide, comprehensive healthcare system designed to better coordinate and improve access to health care for:

  • Children in Department of Family and Protective Services (DFPS) conservatorship (under age 18).
  • Young adults in CPS extended foster care (ages 18 through 20)
  • Young adults who were previously under DFPS conservatorship and have returned to foster care through voluntary foster care agreements (ages 18 through 20.)
  • Young adults eligible for Medicaid for Former Foster Care Children (FFCC) will continue coverage through the STAR Medicaid Managed Care plan of their choice from age 21 through the month of their 26th birthday.

STAR Health provides a full-range of Medicaid covered medical and behavioral health services for children in DFPS conservatorship and young adults in DFPS paid placements.  Children taken into state conservatorship will be issued one or more of the following forms:

  • Medicaid Eligibility Verification (HHSC Form 1027-A)
  • Designation of Medical Consenter for non-DFPS Employee (DFPS Form 2085-B)

These forms will include either a Medicaid ID number or the 16-digit DFPS number. Pharmacy staff are allowed to submit prescription claims with the DFPS number immediately, without having to wait for a Medicaid ID to be assigned. After the person receives a Medicaid number, pharmacy staff must submit subsequent claims using the Medicaid ID and not the DFPS number.

6.1.5.1. STAR Health Pharmacy Claims Submission

Pharmacy claims using the DFPS number must be submitted with the values identified in the table below.  Refer to the “NCPDP B1 Transaction Billing Request” payer sheet for specific transaction, segment, and field requirements.  Refer to the VDP website "Pharmacy Payer Sheets" page for more information.

Field Name Field Number Submitted Value

BIN Number

101-A1

61ØØ84

Processor Control Number

1Ø4-A4

DRTXPROD

Group ID

301-C1

MEDICAID

Cardholder ID

302-C2

16-digit DFPS number

Prior Authorization Type Code

461-EU

8

Prior Authorization Number Submitted

462-EV

1Ø27

6.1.6. Healthy Texas Women Program Eligibility

1.6.1 HTW Pharmacy Claims Submission

The pharmacy must submit claims with the values identified in the table below.  Refer to the "NCPDP B1 Transaction Billing Request" payer sheet for the specific transaction, segment, and field requirements. Refer to the VDP website "Pharmacy Payer Sheets" page for more information.

Field Name Field Number Submitted Value

BIN Number

101-A1

61ØØ84

Processor Control Number

1Ø4-A4

DRTXPROD

Group ID      301-C1 MEDICAID

6.2. Pharmacy Verification of Eligibility

Pharmacy staff have various sources and methods that may be utilized to verify a person’s enrollment status, pharmacy benefits, participation in managed care, and Medicare coverage. Pharmacy staff should verify eligibility with the same processor that will be used to eventually process the claim.

6.2.1 Real-time Verification

Pharmacy staff using the following real-time eligibility tools will query the VDP Pharmacy Claims System using the person’s Medicaid, CHIP, KHC, or CSHCN cardholder ID number.  The expanded messaging that is returned will include the most current or last effective eligibility period, prescription limitations, MCO name, and  Medicare Part B and D coverage.

6.2.1.1 Eligibility Verification (E1) Transaction

The National Council for Prescription Drug Programs (NCPDP) Eligibility Verification transaction is submitted from the pharmacy’s point-of-sale claim system. Pharmacy providers should contact their software company to discuss E1 submission issues and to ensure the “Additional Message Information” field (526-FQ) is returned for all responses.

Refer to the System Requirements section to learn more about the NCPDP standards for pharmacy claim transactions. Refer to the VDP website "Pharmacy Payer Sheets" page to review the list of the expanded messages on the Eligibility Verification Transaction (E1) payer sheet.

6.2.1.2 VDP Eligibility Verification Portal

The Pharmacy Eligibility Verification Portal (EVP) (https://txpcra.pharmacy.services.conduent.com/PBMPortal/login.jsp) is a browser-based application used to obtain a person’s enrollment status, pharmacy benefits, and managed care participation. All Medicaid-enrolled pharmacy providers are eligible to create a free account. The EVP is accessible only through the Microsoft® Internet Explorer® browser.

Refer to the Forms section for the form and submission instructions.

Refer to the Contact Information section for EVP Correspondence.

6.2.2 Your Texas Benefits Medicaid Card

People eligible for Medicaid should present the Your Texas Benefits Medicaid ID card to obtain Medicaid services when visiting a doctor or dentist office, a clinic, or pharmacy. The card is plastic, like a credit card. New cards are not sent to Medicaid-eligible people each month, and people should keep using the card even if he or she changes MCO.

While prescribing providers may verify eligibility and view available health information at the provider portal, pharmacy staff should use one of the VDP real-time eligibility verification tools to obtain outpatient pharmacy eligibility and prescription benefit information.

Pharmacy staff may call the Your Texas Benefits Provider Help Desk to find enrollment status and the name of the person’s MCO. Refer to the “Your Texas Benefits” section of the Contact Information section for about the YourTexasBenefitsCard.com provider portal and help desk.