Medicaid Fee-for-Service Eligibility

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.

Field Name Field Number Submitted Value

BIN Number

101-A1

610084

Processor Control Number

104-A4

DRTXPROD
Group ID 301-C1 MEDICAID

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.

Medicaid Managed Care Eligibility

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

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.

Temporary Medicaid Eligibility Verification

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.