Texas Managed Care Program Features (2018)

Overview

In 2018, the Texas Health and Human Services Commission (HHSC) continued to refine its Managed Care Program (MCP) to improve health outcomes for Medicaid beneficiaries while maintaining fiscal responsibility. The program focuses on providing comprehensive, coordinated care through a network of Managed Care Organizations (MCOs) that contract with the state.

Key Program Features

1. Managed Care Delivery System

• Managed Care Organizations (MCOs): Stateapproved MCOs administer primary, specialty, and behavioral health services for enrolled members.
• RiskBased Contracts: MCOs receive a permember permonth (PMPM) capitation payment adjusted for enrollee health status and demographic factors.
• Network Adequacy: Minimum provider-tomember ratios are set to ensure timely access to primary care, specialty, and emergency services.

2. Eligibility and Enrollment

• All individuals qualifying for Texas Medicaid are automatically enrolled unless they opt out.
• Children, pregnant women, adults with disabilities, and seniors are primary target groups.
• Annual reenrollment cycles allow members to confirm or change their MCO selection.

3. Covered Services

The MCP provides a comprehensive benefit package that includes:

• Primary and preventive care
• Hospital inpatient and outpatient services
• Emergency department care
• Specialty care (e.g., cardiology, orthopedics)
• Behavioral health services, including substanceuse treatment
• Pharmacy benefits
• Dental services for children and adults with special needs
• Rehabilitative and longterm services

4. Quality Measurement and Improvement

• Texas Medicaid and Childrens Health Plan (CHP) Quality Measures: MCOs are evaluated on preventive screenings, chronic disease management, immunizations, and patientexperience indicators.
• PerformanceBased Incentives: MCOs receive bonus payments for meeting or exceeding quality targets; penalties apply for subperformance.
• Data Transparency: Monthly reporting to HHSC includes utilization, cost, and quality metrics accessible to the public through the Texas Health and Human Services website.

• Capitation rates are set annually based on actuarial analyses, with adjustments for inflation, regional cost variations, and the health status of the enrollee pool.
• Risk corridors protect both the state and MCOs from extreme cost fluctuations.
• Member costsharing is minimal; most services are provided at no charge to the beneficiary.

6. Provider Engagement

• Provider directories are maintained online and updated quarterly.
• Clinical integration initiatives encourage coordination between primary care, specialists, and behavioral health providers.
• Continuing education and performance feedback are offered to improve provider adherence to evidencebased guidelines.

7. Consumer Protections

• Members have the right to appeal coverage decisions and to request a change of MCO.
• A 24hour hotline provides assistance with enrollment, provider lookup, and grievance filing.
• Language access services, including interpreter and translated materials, are required for limitedEnglishproficient beneficiaries.

Program Outcomes (2018)

Preliminary data from the 2018 fiscal year show measurable progress:

• Improved Preventive Care: Immunization rates for children rose from 71% to 78%.
• Reduced Hospital Admissions: Allcause inpatient admissions decreased by 4% compared with 2017.
• Cost Containment: Average permember permonth expenditures fell 2.3% while maintaining service levels.
• Member Satisfaction: 86% of surveyed enrollees reported being satisfied or very satisfied with their MCO.

Challenges and Future Directions

While the 2018 MCP demonstrated positive trends, several challenges remain:

• Provider Shortages: Rural areas continue to face limited access to specialists.
• Behavioral Health Integration: Coordinating mental health with primary care needs stronger data sharing mechanisms.
• Data Analytics: Enhancing realtime analytics will improve risk adjustment and early identification of highcost members.

Future initiatives planned by HHSC include:

• Expanding telehealth services, especially for behavioral health.
• Incentivizing valuebased contracts that reward longterm health outcomes.
• Strengthening partnerships with communitybased organizations to address social determinants of health.

How to Learn More

Detailed program guidelines, performance reports, and enrollment resources are available on the Texas Health and Human Services website. Stakeholders can also request technical assistance by contacting the Managed Care Division at managedcare@hhsc.texas.gov.