Medicaid and CHIP Quality and Efficiency Improvement

Most Texas Medicaid and CHIP members receive their services through a managed care organization (MCO). The four main Medicaid programs are: STAR, STAR Health, STAR Kids and STAR+PLUS.

  • STAR is a statewide managed care program primarily for pregnant women, low-income children and their caretakers. Most people in Texas Medicaid get their coverage through STAR.
  • STAR Health is a statewide managed care program that provides coordinated health services to children and youth in foster care and kinship care. STAR Health benefits 191 Glossary include medical, dental and behavioral health services—as well as service coordination and a web-based electronic medical record, known as the Health Passport.
  • STAR Kids is a statewide managed care program for children and youth age 20 and younger with disabilities, including children and youth receiving benefits under the Medically Dependent Children Program (MDCP) waiver.
  • STAR+PLUS is a statewide managed care program for adults with disabilities and those age 65 and older.

In addition to services offered through Medicaid, Texas children may be covered through the Children’s Health Insurance Program (CHIP) and CHIP Perinatal:

  • CHIP provides acute care, behavioral health care, dental services and pharmacy services for children in families with too much income to qualify for Medicaid but cannot afford to buy private health insurance. Children covered through CHIP generally receive similar services as children covered through Medicaid.
  • CHIP Perinatal services are for the unborn children of pregnant women who are uninsured and do not qualify for Medicaid. Services include prenatal visits, prescription prenatal vitamins, labor and delivery, and postpartum care.

Currently, seventeen MCOs provide services to Texas Medicaid and CHIP beneficiaries, along with three dental maintenance organizations DMOs. Texas has 13 managed care service areas, 10 of which are built around major metropolitan population centers and three that cover large rural sections of its regions. There also is a CHIP rural service area that combines the three Medicaid rural service areas and Hidalgo. A map of Texas MCO service areas (PDF) shows their distribution and which MCOs cover them.

Texas Medicaid and CHIP are focused on improving the quality and efficiency of healthcare services and promoting value-based care (VBC). Central to VBC is the concept of value-based payment (VBP), which means a payment system that rewards MCOs, DMOs, hospitals, doctors and all the other healthcare providers for delivering high quality and efficient medical care. HHSC's efforts around quality and efficiency improvement involve different projects. Senate Bill 200, 84th Legislature, Regular Session, 2015 directs HHS to develop a comprehensive plan to improve the coordination and transparency of state healthcare quality initiatives, formally called the Healthcare Quality Plan. In addition, the 2021 Value-Based Purchasing Roadmap (PDF) provides a detailed description of the quality improvement initiatives that HHSC is taking in relation to value-based payment.

Key Projects:

Quality Resources:

For questions, comments and suggestions email HHSC Quality.