Haris Ashley
Medicaid is a program that provides free or low-cost medical benefits to eligible individuals, especially those with low incomes. In Texas, Medicaid programs are managed by the Health and Human Services Commission (HHSC). It is possible for Medicaid beneficiaries to have one or more additional sources of coverage for healthcare services, and in such cases, Medicaid is the last payer on a claim. This article explores whether Medicaid can be a secondary insurance in Texas and the processes involved in billing and reimbursement.
| Characteristics | Values |
|---|---|
| Can Medicaid be a secondary insurance in Texas? | Yes, it is possible for Medicaid beneficiaries to have one or more additional sources of coverage for health care services. |
| Who is eligible for Medicaid in Texas? | To be eligible for Medicaid in Texas, you must be a U.S. citizen or have acceptable immigration status, live in Texas, and meet certain income rules. |
| What is the process for enrolling in Medicaid in Texas? | To enroll in Medicaid in Texas, individuals can apply online through the Health Insurance Marketplace or visit their local Health and Human Services Commission (HHSC) office. |
| What information is required for enrollment? | The information required for enrollment may vary but can include proof of income, Social Security numbers, and details about current health insurance. |
| How does billing work when Medicaid is secondary insurance? | When Medicaid is secondary insurance, it is the payer of last resort, meaning that other insurance providers are billed first, and Medicaid pays the remaining balance, if any. |
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What You'll Learn
Medicaid as a secondary insurance in Texas: Blue Cross and Blue Shield
In Texas, Medicaid is always the payer of last resort if a commercial payer exists. Blue Cross and Blue Shield of Texas (BCBSTX) coordinates benefits with other carriers and programs that a member may have for coverage, including Medicare. This means that when applicable, Blue Cross and Blue Shield of Texas can be used as a secondary insurance.
BCBSTX offers individual health plans, Medicare and Medicaid plans, and other health plan options to best fit the needs of its customers. When submitting a claim to BCBSTX as a secondary insurance, it is important to specify the other coverage and include the following:
- Loop 2320 – Claim Level Adjustments (if the primary claim was paid by the primary payer and claim level adjustments were made at the claim level)
- Loop 2430 – Line Adjudication Information (if the primary claim was paid by the primary payer and service level adjustments were made at the service line level)
Secondary claims may be submitted to BCBSTX by paper (using the CMS-1500 and UB-04 claim forms), or electronically via Availity® or your preferred web vendor. BCBSTX must receive Coordination of Benefits (COB) claims within 95 days from the date on the other carrier’s or program’s Remittance Advice (RA) or letter of denial of coverage.
If you have questions about how to file electronic secondary claims with BCBSTX, you may contact BCBSTX’s Provider eBusiness Consultants at [email protected].
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Texas Medicaid for children with disabilities
Texas residents can apply for Medicaid for their children with disabilities. To be eligible, the child must be 20 years old or younger, and the family must meet certain income requirements. Texas Medicaid can provide free or low-cost health care, as well as long-term services and support to children with disabilities.
There are two types of Medicaid: Traditional Medicaid and Medicaid Managed Care Programs. Traditional Medicaid allows your child to see any doctor who accepts Medicaid. Medicaid pays these doctors directly for their services. However, most children with disabilities are required to enroll in a managed care program and will not be able to get traditional Medicaid. Managed Care Programs allow your child to see doctors and healthcare professionals within a specific network. These networks are run by managed care organizations that contract with the state of Texas.
There are also specific Medicaid programs, also known as waivers, to help children with disabilities or special healthcare needs live and thrive in community settings. These include the STAR Kids program, which is for children age 20 and younger who receive SSI or Medicaid waiver services. STAR Kids covers basic medical services and long-term services and supports. There is also the STAR+PLUS program, which serves Texans over the age of 21 with disabilities or special healthcare needs. Most children with disabilities who receive Medicaid transition to STAR+PLUS when they turn 21.
Additionally, the Medicaid Buy-In and Medicaid Buy-In for Children programs allow families who do not meet the income requirements for Medicaid to purchase coverage. The rates are set on a sliding scale based on the family's income.
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Texas Medicaid: Coordination of Benefits
Texas residents can apply for Medicaid for their children through the Health and Human Services Commission (HHSC). The Children's Health Insurance Program (CHIP) is also available for children in families who earn too much to qualify for regular Medicaid. Medicaid is not considered an insurance plan, but many people refer to it as such. It is a program that helps people get many different types of medical and health-related services, depending on their needs and what they are approved for.
Coordination of Benefits (COB) refers to the activities involved in determining Medicaid benefits when an enrollee has coverage through an individual, entity, insurance, or program that is liable to pay for healthcare services. This means that individuals eligible for Medicaid assign their rights to third-party payments to the State Medicaid Agency. Third Party Liability (TPL) refers to the legal obligation of third parties (insurers, programs, etc.) to pay part or all of the expenditures for medical assistance furnished under a Medicaid state plan. By law, all other available third-party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid.
When submitting COB claims, it is important to specify the other coverage. This can be done by paper, using the CMS-1500 and UB-04 claim forms, or electronically via Availity or your preferred web vendor. When submitting electronic BCBSTX Medicaid claims as secondary, it is important to include Loop 2320 – Claim Level Adjustments and Loop 2430 – Line Adjudication Information.
In Texas, when a member has other primary insurance, and that primary insurance requires prior authorization, you won’t have to submit a prior authorization request to UnitedHealthcare Community Plan. If the member has primary insurance through another UnitedHealthcare plan, you should submit your prior authorization request through the UnitedHealthcare Provider Portal.
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Texas Medicaid: UnitedHealthcare Community Plan
Texas Medicaid is a federal and state program that provides health coverage for low-income children, families, seniors, and people with disabilities. UnitedHealthcare Community Plan is one of the health plans offered under Texas Medicaid. It offers a range of benefits, including:
- The STAR+PLUS plan: This plan covers adults with disabilities, people aged 65 and older, and women with breast or cervical cancer. It includes all Texas Medicaid benefits, as well as extra services like allowances for vision and dental services.
- The STAR plan: This plan covers children, pregnant women, and some families. It also includes all Texas Medicaid benefits, plus additional services such as sports and school physicals for children.
- The STAR Kids program: This program is designed for children and adults 20 and younger with disabilities. It covers all Texas Medicaid benefits and provides health and wellness services, as well as online resources for families.
- Dual Special Needs Plans (D-SNPs): These plans are for individuals who have both Medicaid and Medicare. D-SNPs cover most doctor visits, hospital stays, and prescription drugs, and they offer benefits beyond those provided by Original Medicare or Medicaid.
- Texas CHIP: This program is for children and unborn children in families who earn too much to qualify for Medicaid but cannot afford private insurance.
UnitedHealthcare Community Plan members in Texas may also have other health insurance, such as commercial or Medicare, as their primary coverage. In these cases, Medicaid serves as the last payer on a claim. When billing, members should first bill their primary insurance, and prior authorization should be requested only from the primary insurance provider.
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Applying for Texas Medicaid
In Texas, Medicaid is the last payer on a claim when a member has other primary insurance. However, it is possible to have Medicaid as secondary insurance.
You can visit the Your Texas Benefits website and choose "Apply for new benefits". Alternatively, you can call 2-1-1 (TTY 711) toll-free, Monday to Friday, from 8 am to 6 pm Central Time. You can also print or request a paper form and submit it by mail, or visit a Texas Health and Human Services (HHS) benefits office near you. You can find one by calling 2-1-1 or visiting the Find an Office page. You may also visit a community partner near you.
You can also create an account with the Health Insurance Marketplace and fill out an application. If it looks like anyone in your household qualifies for Medicaid or CHIP, your information will be sent to your state agency, and they will contact you about enrollment.
When you apply for Medicaid, you may need to provide certain information or documentation. This depends on your state, and your state Medicaid agency will be able to tell you what is required. This may include information about any insurance plan offered to you by your employer or any insurance plan you currently have.
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Frequently asked questions
Yes, Medicaid can be a secondary insurance in Texas. Medicaid is a program that helps people get different types of medical and health-related services depending on their needs and what they are approved for. It is not considered an insurance plan, but many refer to it as one.
To apply for Medicaid in Texas, you can visit your local Health and Human Services Commission (HHSC) office. You can find the nearest office by calling 2-1-1 or visiting their website. You can also apply for Medicaid online on the Your Texas Benefits website.
When applying for Medicaid, you may need to provide certain information or documentation, which varies depending on the state. Generally, you will need to provide proof of income, social security numbers, and details about current health insurance.
Yes, your child can receive Medicaid. There are specific programs designed to ensure children with disabilities or special health care needs have health care coverage, such as the STAR Health program.
