How does the new system work?

Expedited Eligibility
(Applies to Medicaid-eligible women throughout the state):

• Within 15 days of receipt, DHS will process Medicaid applications for pregnant women
• To simplify the applications, the verification requirements have been streamlined. Citizenship, residence, pregnancy (including Form 3037) and income verification can be postponed until after certification, however, proof of identity is still required
• If the patient prefers, she can call the local DHS office to request an application. After submitting the application, she can request a interview by phone
• Once the an applicant is certified as a Medicaid eligible, a Medicaid ID card (Form 3087) will be issued to verify eligibility and to facilitate provider reimbursement

Expedited Medicaid Managed Care Enrollment
(Applies to STAR Program service areas):

• If a Medicaid-eligible pregnant women lives in a managed care service area, she will be contacted by the enrolment broker, MAXIMUS, to begin the enrollment process. The patient may also contact MAXIMUS directly at 1-800-964-2777 (STAR Help line). Patients may may select a Medicaid HMO or, where available, the PCCM model
• The Patient has 16 days from the date of the Medicaid application to select a Medicaid managed care plan. Patients who do not voluntarily select a plan or PCP will be assigned to a plan
• To protect continuity of care and patient choice, MAXIMUS will work with each pregnant women to select a health plan  that includes her current prenatal care provider or to choose an obstetrical care provider that meets her needs

Expedited Medicaid Managed Care Enrollment
(Applies to STAR Program services areas) continued:

• The effective coverage date in a Medicaid managed care plan will depend upon when the client is certified for Medicaid:

  •  Women certified 1-10th of the month are enrolled retroactively in managed care effective the first of the month of certification.  Women certified from the 11th-EOM are enrolled prospectively in managed care effective the first of the month following the month of certification.

  • Exceptions to above:  Women who are certified at any time in their estimated month of delivery will be prospectively enrolled in managed care the first of the following month.  Women who are certified at any time in their actual month of delivery (if known by TDHS prior to certification) will be prospectively enrolled in managed care the first of the following month.

  Until coverage begins in a Medicaid managed care health plan, clients will be covered under traditional Medicaid fee-for-service.  Clients may initially receive a Medicaid ID card (Form 3087) that shows them to be a member of a STAR health plan but that does not list the plan name.  To ensure proper billing, providers should call MAXIMUS at 800-964-2777 (STAR Helpline) to obtain the name of the patient’s plan.  The plan name should appear on the Medicaid ID card the following month.  However, patient eligibility should always be verified.
  

• within 14 days of enrolling in a health plan, a plan representative will contact the new member to help arrange her first prenatal appointment
• Physicians should also expect contact from the health plans to facilitate prenatal appointments for new health plan members
• Physicians and other prenatal care providers are encouraged to make prenatal appointments within 2 weeks or as soon as possible