Texas

In Texas:
 
  • As of July 1, 2011, there were 3,943,189 beneficiaries enrolled in Texas’s Medicaid program. Of these, 2,786,985 were enrolled in managed care. Texas has multiple comprehensive Medicaid managed care programs. Its STAR program is mandatory for Medicaid-enrolled children in managed care service areas and covers physical, behavioral, and oral health services. A primary care case management program provides these services to children in areas not covered by the STAR program. A managed care program for foster children, STAR Health, provides comprehensive and coordinated services.
  • In a small number of counties, a Behavioral Health Organization operates the Texas NorthSTAR program to provide comprehensive mental and substance abuse benefits to enrollees, including children in those counties.
  • Home and Community-Based Services are provided through waivers, including:
    • Medically Dependent Children Program, provides services to support families caring for children and young adults who are medically dependent and to encourage de-institutionalization of children in nursing facilities;
    • Youth Empowerment Services, which provides HCBS services for Medicaid-eligible children with serious emotional disturbance and their family; and
 
As of 2012, 3,589,690 individuals were eligible for Texas’s Health Steps (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to CMS data from 2012, Texas achieved an EPSDT screening ratio of 74% and a participation ratio of 62%. 2,120,116 children received dental services of any kind, with 1,686,946 receiving preventive dental services.
 
Last updated February 2014.
 
Medical Necessity
Under the Texas Administrative Code, medically necessary means:
 
“For Medicaid members birth through age 20, the following Texas Health Steps services:
  • screening, vision, dental, and hearing services; and
  • other health care services or dental services that are necessary to correct or ameliorate a defect or physical or mental illness or condition. A determination of whether a service is necessary to correct or ameliorate a defect or physical or mental illness or condition:
    • must comply with the requirements of a final court order that applies to the Texas Medicaid program or the Texas Medicaid managed care program as a whole;”
The definition also specifies that medical necessity for children may take into account other factors relevant in the state’s adult medical necessity definition, including the following.

For non-behavioral health services, that services are:
     

  • provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s health conditions;
  • consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies;
  • consistent with the member’s diagnoses;
  • no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
  • not experimental or investigative; and
  • not primarily for the convenience of the member or provider.
For behavioral health services, that services:
  • are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;
  • are furnished in the most appropriate and least restrictive setting in which services can be safely provided;
  • are the most appropriate level or supply of service that can safely be provided;
  • could not be omitted without adversely affecting the member’s mental and/or physical health or the quality of care rendered;
  • are not experimental or investigative; and are not primarily for the convenience of the member or provider.
Initiatives to Improve Access
 
Reporting & Data Collection
The Texas Health and Human Services Commission requires managed care organizations to report on the number of check-ups provided to children under Texas Health Steps.
Behavioral Health
Behavioral health screenings are required at each Texas Health Steps checkup. Texas Health Steps offers primary care providers several developmental and behavioral health screening forms:
  • The Ages and Stages Questionnaire
  • The Modified Checklist for Autism in Toddlers (M-CHAT)
  • Parents’ Evaluation of Developmental Status (PEDS)
Texas Health Steps requires one of those standardized instruments to be used for a checkup to be considered complete.
Support to Providers and Families
Support to Families
The state has a Texas Health Steps webpage to help families understand how a child can get a checkup, as well as additional available services like transportation. A dedicated webpage for teens is aimed at informing adolescents about the benefit and helping to connect them to services.
 
Support to Providers
Texas Health Steps offers free online provider education on a number of topics, including:
  • Adolescent Health,
  • Pediatric Referral Guidelines,
  • Developmental and Mental Health Screening,
  • Prevention and Wellness, and
  • Oral Health.
In addition, the website provides introductions to Texas Medicaid Programs for Children and Texas Health Steps in particular.
 
Texas Health Steps also offers providers Child Health Clinical Record Forms to assist providers in documenting all the required components of a well-child visit. The use of these forms is not mandatory. 
Care Coordination
Texas Health Steps offers an online training module for primary care providers on creating and maintaining medical homes for children and adolescents.
 
Primary care provider that provide a medical home for Medicaid enrollees under age 20 who have special health care needs can receive payment for Clinician-Directed Care Coordination Services. Primary care providers offering these services to children and adolescents must provide:
  • A written care plan shared among providers, agencies, and organizations involved with the child,
  • Coordination of care among multiple providers,
  • A central record of all pertinent medical information about the child,
  • Assistance to the family in communicating clinical issues when the child is referred for additional care.
 
These may be both face-to-face and non face-to-face.
 
Standardized referral forms for children provided by the state help primary care providers to link children with needed services.
 
A managed care plan for foster children, STAR Health, provides a coordinated, comprehensive health system for enrolled children. Children receive a medical home and coordination of physical and behavioral health services, as well as other clinical service management benefits.
Oral Health
Pediatric and general dentists participating in Texas Health Steps are being trained to provide children aged 6-35 months with a First Dental Home. Dentists can bill an all inclusive bundled code for a First Dental Home visit, which has the following components:
  • Caries risk assessment.
  • Dental prophylaxis.
  • Oral hygiene instructions with primary caregiver.
  • Application of topical fluoride varnish.
  • Dental anticipatory guidance.
  • Establishment of recall schedule.