Information for Providers on Health Plan Changes

Health and dental plan changes in service areas are usually the result of a formal business review we do every few years. Sometimes a health plan might decide to leave the program.

If a plan is leaving a service area you serve, you will be notified by the health plan. You can find updates about service area changes below.

Contracting with a new plan

All providers must be enrolled with the Texas Medicaid program before contracting with any health plan.

If you want to contract with a new health plan, find the contact on the Managed Care Organization (MCO) and Dental Maintenance Organization (DMO) Provider Services Contact Information page and contact them to complete their contract and credentialing application. You will need to negotiate rates with the plan.

As a reminder, you must not solicit members to receive services from you or a certain health plan. View the marketing guidelines.

Providing a smooth transition

If a plan you are contracted with leaves one of your service areas or a member switches to a new plan you are not contracted with, you must continue to provide services to the member as they transition to their new plan.

Prior authorizations

If a member has a prior authorization, the new MCO or DMO must continue to provide services for a certain amount of time:

  • Up to six months for long-term services and supports
  • Up to three months for acute and dental services

If you are an OB/GYN, you can continue to see pregnant members who are past the 24th week of pregnancy through their postpartum checkup, even if you’re out-of-network for their new plan.

Submitting claims

You must submit all claims within 95 days of the date of service. If the claim is not received by the MCO or DMO within 95 days, they can deny the claim. If your claim is denied, you can appeal the decision.

Need more information?

If you have questions about health plan changes, reach out to your plan’s provider services contact.