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Frew v. Janek Consent Decree

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Submit Suggestions for Medicaid Clinical Quality Improvement Initiatives

ACA PCP Rate Increase Frequently Asked Questions

  1. Which Medicaid providers qualify for the increased primary care payment?

    To be eligible for supplemental payments, providers must complete and submit an attestation form (PDF) to TMHP. The form is available on the TMHP website.  Only physicians who meet the specialty and board certification or Medicaid billing volume requirements described on the attestation form are eligible for supplemental payments.

  2. Will health plans need to collect attestation forms or verify providers are qualified?

    No. TMHP will collect the attestation forms and verify provider qualifications. Health plans will be responsible for passing payments through to providers that are on the file HHSC provides to each plan.

  3. What is the cutoff date when providers must attest by to receive retro-active payments back to January 1, 2013?

    Physicians who complete the form before April 1, 2014, will qualify for rate increase payments for services provided since January 1, 2013. Providers who complete the form after April 1 will get the rate increase payments only for services provided from the date they completed the form. Note: The state will use the original date a form is submitted even if the provider is asked to provide additional information.

  4. How often will the eligible provider list be updated?

    TMHP has generated a list of all attestation forms (PDF) received up to October 16, 2013.   An additional list will be generated and posted on www.tmhp.com by the end of February 2014.  All completed attestations received before April 1, 2014, will be retroactive to January 1, 2013.

  5. What will qualified providers be paid?

    Qualified providers will be paid the difference between the paid amount reflected on the submitted encounter and the minimum payment required under federal law.

  6. When will providers' supplemental payments be paid?

    Texas will issue quarterly supplemental payments to providers to cover the difference between the regular Medicaid rate for the service and the temporary increase. The supplemental payments began in January 2014 for managed care services and will begin in April 2014 for fee-for-service payments.

  7. How will capitated managed care PCPs payments be calculated?

    The state will use the fee-for-service Medicaid rate as the "paid amount" in the payment calculation. For qualifying encounter events with the "capitated provider" Financial Arrangement Code (where the paid amount is $0), providers will receive a supplemental payment for the difference between the fee-for-service Medicaid rate and the corresponding Medicare rate for the service.

  8. How will vaccines administration payments be calculated?

    Supplemental payments for vaccine administration services are determined based on the difference between the calculated 2013 or 2014 Medicare rate as defined in the ACA/federal statue and the amount a provider was reimbursed for each vaccine administration service to a client.

  9. Do providers practicing in federally qualified health centers (FQHCs) and rural health clinics (RHCs) qualify for higher payment?

    No.

  10. Can non-physician practitioners such as nurse practitioners receive the higher payment?

    Per federal law, only a physician can self-attest to meeting the qualifications for the rate increase. Non-physician practitioners can receive the higher payment only if they bill under the supervision of a qualified attested physician’s national provider identifier (NPI). Only encounters submitted with an attested provider’s NPI in the rendering/performing provider field are eligible for supplemental payments.

  11. Who do I call for questions about the policy or my payment?

    Providers can call the TMHP contact center at 1-800-925-9126 for questions related to the ACA PCP rate increase.

  12. What if the provider did not attest all Texas Provider Identifier (TPI) numbers. Are they still eligible for the retro payment back to January 1, 2013?

    Providers must complete the self-attestation process and include all the appropriate information on the form including all associated TPI’s and group TPI’s to be eligible for the ACA PCP rate increase. TMHP will be reaching out to providers whose form is incorrect or incomplete. If a provider has additional questions about the completion of the form, they can call the TMHP contact center at 1-800-925-9126.

  13. Why did the payments not include the full list of providers identified on TMHPs website?

    Interim payments are limited to providers for which TMHP has confirmed there are no inaccuracies on the original attestation form and that qualify for the payment. Providers that submitted attestation forms with outstanding questions will be contacted by TMHP and held-harmless to the original submission date.

ACA PCP Rate Increase Payment

The Affordable Care Act (ACA) provides a rate increase for certain primary care Medicaid services in 2013 and 2014.  Texas will issue quarterly supplemental payments to providers to cover the difference between the regular Medicaid rate for the service and the temporary increase. The supplemental payments will begin in January for managed care services and in April for fee-for-service payments.

To get the rate increase payments, physicians must meet one of these standards:

  • Be board certified in family medicine, general internal medicine, pediatric medicine or a subspecialists within those designations as recognized by the American Board of Medical Specialties, the American Osteopathic Association, or the American Board of Physician Specialties.

Or

  • Have 60 percent of their Medicaid billings for the prior year from the Evaluation and Management (E&M) codes specified in federal regulation.  Services eligible for the rate increase are E&M codes 99201 through 99499, and services related to the Administration of Vaccines (90465, 90466, 90467, 90468, 90471, 90472, 90473 and 90474).

To get the rate increase payments, providers must complete this form:

Texas Medicaid Attestation for ACA Primary Care Services Rate Increase Form (PDF)

Physicians who complete the form by April 1 will qualify to get rate increase payments for services provided since January 1, 2013. Those who complete the form after April 1 will get the rate increase payments only for services provided from the date they complete the form.

For a list of providers whose forms have been received through October 16, 2013, please review this list:

Providers With Attestation Forms on File (PDF)

Physicians who submitted an attestation form, but whose name is not on the list or information is incorrect, should contact TMHP by email at ACARateForm@tmhp.com

Responses Posted for Managed Transportation Organizations

HHSC's Medical Transportation Program has posted responses to questions collected during recent public forums regarding proposed opportunities for managed transportation organizations.

The Your Texas Benefits Medicaid Card: Information for Providers and Community Service Organizations

Your Texas Benefits card Providers can use the Your Texas Benefits Medicaid Card to verify a patient’s Medicaid eligibility. A person’s unique Medicaid ID number appears on the front of their card. That same number is embedded in a magnetic strip on the back of the card, accessible with a basic swipe-style card reader.
With the card, providers have a choice of ways to verify the person’s Medicaid eligibility:

  • Swipe the card or enter the Medicaid ID number at the YourTexasBenefitsCard.com, a secure website where providers can verify eligibility, view patient Medicaid health history, and more.
  • Use TexMedConnect on the Texas Medicaid & Healthcare Partnership (TMHP) provider home page.
  • Call the TMHP Contact Center at 1-800-925-9126.

YourTexasBenefitsCard.com Frequently Asked Questions

Community Service Organizations
Organizations that serve Medicaid clients (i.e., Head Start, Salvation Army, Women, Infants and Children [WIC], etc.) can still use the Medicaid ID number to determine a person’s active Medicaid status:

  • Call the Provider Help Desk at 1-855-827-3747.
  • Choose Option 3 at the voice prompt.
  • Enter the person’s Medicaid ID number from the front of the card.
  • Enter the person’s birth date.

For more information about the new Your Texas Benefits Medicaid card or the new Medicaid eligibility verification website, call 1-855-827-3747.

Texas Medicaid Wellness Program

The goal of the Texas Medicaid Wellness Program is to help clients with long-lasting or serious health conditions improve their health. People who get traditional fee-for-service Medicaid can join the wellness program. The program includes nurses, pharmacists, social workers, behavioral health specialists, dieticians, certified diabetes educators and community health workers. For more information on the Wellness Program, visit the Texas Medicaid Wellness Program web page.

IMPROVE Gives New Voice to Medicaid Providers

Attention Medicaid Providers: HHSC wants to hear from you. Do you have an idea, issue, recurring, or suggestion about Texas Medicaid?  If so, check out the IMPROVE system.


Additional Resources

  • How to get Help

  • Texas Medicaid and CHIP in Perspective
    "The Pink Book" provides basic information on the structure and operations of the Texas Medicaid/CHIP programs.

  • Employee Education about False Claims Recoveries
    Effective Jan. 1, 2007, all providers and other entities that receive or make annual Medicaid payments of $5 million or more must educate employees, contractors and agents about federal and state fraud and false claims laws, and the whistleblower protections available under those laws.

  • Alberto N. v. Suehs
    HHSC has settled a lawsuit that affects Texas Health Steps, Comprehensive Care Program-eligible children under 21 years of age. The terms of the settlement apply to Medicaid-funded nursing services, personal care services and durable medical equipment and supplies.  

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