What is Medicaid?
Medicaid is jointly funded by Federal and State governments to assist states in providing medical and long-term care assistance to people who meet certain eligibility criteria. Within broad national guidelines established by Federal statutes and Center for Medicare & Medicaid Services (CMS) regulations and policies, each State (1) establishes its own eligibility standards; (2) determines the type, amount, duration, and scope of services; (3) sets the rate of payment for services; and (4) administers its own program. Therefore, Medicaid policies for eligibility, services, and payment vary considerably from state to state.
The Texas Medicaid Program
The Texas Medicaid Program began in 1967 and the Health & Human Services Commission (HHSC) is the state agency responsible for administering and operating the program. As the costs of the Medicaid program increased, Medicaid services shifted to being provided through a managed care model. For more information on the current status of the Texas Medicaid managed care roll out, refer to HHSC’s Medicaid Managed Care webpage. For an in depth understanding of Texas Medicaid managed care, including the history and development of Medicaid managed care in Texas, refer to Chapter 7 in Texas Medicaid in Perspective, also known as the Pink Book.
What Providers Need to Know Before Enrolling
HHSC contracts with the (TMHP) to provide the Medicaid provider relations and claims payment functions. Therefore, APRNs become providers in the Texas Medicaid Program through TMHP.
Most providers must be enrolled in Medicare before they can enroll as a Medicaid provider. Exceptions include Certified Nurse-Midwives (CNMs), and APRNs whose focus is caring for pediatric or neonatal populations (e.g., Pediatric Nurse Practitioners [PNPs], Neonatal Nurse Practitioners [NNPs], and Pediatric Clinical Nurse Specialists [PCNSs]). Those only enrolled to provide Texas Health Steps screening exams also do not need to have a Medicare provider number. In addition, TMHP may waive the Medicare enrollment prerequisite for other physicians or APRNs whose type of practice and service may never be billed to Medicare.
All providers must obtain a National Provider Identifier (NPI) before enrolling as a Texas Medicaid provider. APRNs who do not have an NPI need to read “The NPI: What You Need to Know”
To enroll as a provider in the Texas Medicaid Program, activate an account and complete the online application available through TMHP’s Provider Enrollment webpage. Enrolling online is preferred and the most efficient method. However, APRNs may download the Medicaid Provider Enrollment Application and Instructions from the Provider Enrollment webpage, and mail the application to:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin , TX 78720-0795
The Provider Enrollment webpage also includes an enrollment form for ordering and referring providers. These are providers who need to refer or order services for Medicaid clients, but do not bill the Texas Medicaid Program. The webpage also includes contact information for enrollment assistance.
TMHP also enrolls providers’ and administers’ claims for several other programs for the State of Texas. Qualified health care providers enrolling in Medicaid, are automatically enrolled as Texas Health Steps and Children with Special Health Care Needs Program providers unless they elect to opt out of those programs. To find more information about any of these state programs, click the following links:
Children with Special Health Care Needs (CSHCN)
Texas Health Steps (THSteps)
Texas Women’s Health Program (TWHP)
Texas Vendor Drug Program (VDP)
The VDP administers the outpatient drug and home health supply services for five health coverage programs. It enrolls pharmacy providers and determines the drugs on the formulary/Preferred Drug List (PDL) for Medicaid, CHIP, CSHCN, TWHP, and the Kidney Health Program (KHP). Prescribers should check the VDP website for drugs that require prior authorization.
Starting November 1, 2016, children with disabilities will receive all their services, including drugs and medical supplies, through managed care organizations. Those providing health care for these children will find the following documents helpful.
- Effective 11/01/2016 Texas Vendor Drug Program (VDP) Service Delivery Area Assistance Chart
- Effective 11/01/2016 VDP Prescriber Assistance Chart
- National Drug Code (NDC)-to-HCPCS Crosswalk for clinician-administered drugs