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

Fee-for-service, or traditional, Medicaid is for people who are not enrolled in managed care. Pharmacies must submit claims with the values identified below. Refer to the Claims Billing (B1) Transaction for instructions and payer sheets.

Pharmacies should not submit claims for newborns without an assigned Medicaid ID number with their Mother’s ID number. Pharmacies must submit these claims on the Pharmacy Claims Billing Request.

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 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 18).
  • Young adults in CPS extended foster care (18 through 20)
  • Young adults who were previously under DFPS conservatorship and have returned to foster care through voluntary foster care agreements (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.

Pharmacies providers should contact the client's specific MCO for its provider manual and policy materials.

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.

The QH or QE will provide the person with the Short-term Medicaid Notice (HHS Form H1266) if the person is determined to be presumptively eligible. The person may present the pharmacy with this form. 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.

Medicaid clients 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 HHSC eligibility document pharmacies can rely on as proof of Medicaid eligibility until the person or family receives its Your Texas Benefits Card. HHSC should assign Medicaid numbers within one month of the original presentation. Pharmacies are encouraged to verify drug coverage, fill the prescription, and then submit the claim to Medicaid once the cardholder ID number is assigned.

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

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 providers 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 “00” after the core program ID number, as shown below. Failure to correct the cardholder ID prior to transmission will result in NCPDPD error code 52 (“Non-matched Cardholder ID”).

The pharmacy must submit claims with the values identified below. Refer to the Claims Billing (B1) Transaction payer sheets for specific transaction, segment, and field requirements.

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 Claims Billing (B1) Transaction payer sheets for specific transaction, segment, and field requirements.

Pharmacy providers can perform an eligibility verification transaction to find the client's copayment amount. Refer to the Eligibility Verification (E1) Transaction for specific transaction, segment, field requirements, and response messages.

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.

Contact the KHC program for questions about program eligibility. Refer to the Real-time Verification section to determine eligibility online.

Pharmacy claims must be submitted with the values identified below. Refer to the Claims Billing (B1) Transaction payer sheets for specific transaction, segment, and field requirements.

Pharmacy claims using the DFPS number must be submitted with the values identified below. Refer to the Claims Billing (B1) Transaction for instructions and payer sheets.

Pharmacies submit the National Council for Prescription Drug Programs (NCPDP) Eligibility Verification (E1) Transaction from its 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 E1 Transaction: Accepted Response to review the list of the expanded messages returned on the eligibility verification transaction.

The Pharmacy Eligibility Verification Portal (EVP) (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 Pharmacy Operations Forms section for the form and submission instructions.

Refer to the Contact Information section for EVP Correspondence.