Beginning September 1, 2025, the Texas Health and Human Services Commission (HHSC) will transition Medicaid-only services for dually eligible clients (clients who are eligible for both Medicare and Medicaid) enrolled in Medicaid managed care from a fee-for-service (FFS) to a managed care service delivery system. Community First Health Plans will be responsible for the adjudication of these claims.
Provider Responsibilities:
Providers must submit claims for Medicaid-only services for dual eligible Community First Members enrolled in Medicaid managed care directly to Community First. If a Provider submits a claim to TMHP in error:
- TMHP will forward the claim to the appropriate MCO; and
- TMHP’s claim response will reflect that the claim was forwarded, but TMHP will not issue an Electronic Remittance and Status (ER&S) Report.
TMHP will forward these claims based on dates of service on or after September 1, 2025. TMHP will no longer adjudicate these claims.
Providers should contact Community First directly for claim status updates and questions related to adjudication.
For a list of Medicaid-only services impacted by this change, see the Rider 32 Procedure Code List, attached.
Rider 32 does NOT impact the following:
- How providers bill for Medicare services provided to Dual Eligible Community First Members.
- Which services are covered by Medicare for Community First Dual Eligible Members; or
- Which services are covered by Community First for Non-Dual Eligible Members.
There are no changes to Member Medicare or Medicaid coverage or costs. Members will continue to receive long-term care benefits through Community First.
Action:
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.
Resources: