COD E R E D

Table 5. Texas Medicaid Recipient Months and Costs per Month by StrategyStrategy Description2003Experienced2004Estimates2005BudgetedAged and Disabled Risk GroupsAverage aged and Medicare recipient months per month 316,143 320,882 325,375Average disabled and blind recipient months per month 208,957 221,711 235,235Average aged and Medicare related cost per recipient months $105.07 $136.17 $160.20Average disabled and blind cost per recipient months $573.33 $573.13 $542.07TANF Adults and Children Risk GroupsAverage TANF adult recipient months per month 116,710 89,927 83,632Average TANF child recipient months per month 374,821 341,435 326,070Average TANF adult cost per recipient months $204.50 $215.57 $218.07Average TANF child cost per recipient months $101.60 $99.99 $95.41Pregnant Women Risk GroupAverage pregnant woman recipient months per month 102,736 112,234 128,350Average pregnant woman cost per recipient months $526.81 $548.09 $564.43Children and Medically Needy Risk GroupsAverage child recipient months per month 1,300,952 1,531,141 1,774,322Average medically needy recipient months per month 45,657 43,731 52,464Average child cost per recipient months $139.73 $129.23 $127.61Average medically needy cost per recipient months $626.43 $406.77 $390.24Health Steps (EPSDT) MedicalAverage THSteps (EPSDT) medical recipient months permonth605,072 655,417 723,183Number of newborns receiving hearing screens 381,705 391,298 401,504Average cost per THSteps (EPSDT) medical recipient months $117.45 $116.76 $122.75per monthSource: Texas Health and Human Services Commission, HHSC Legislative Appropriations Request (LAR) FY2006-2007, available at http://www.hhsc.state.tx.us/about_hhsc/finance/FY06-07_LAR/LAR_TOC.html,accessed January 13, 2005.Note: Table does not include the following Medicaid strategies: STAR+PLUS, Medicare payments, cost reimbursedservices, Medicaid vendor drug program, medical transportation, Medicaid family planning; health steps dentaland health steps comprehensive care program, and State Medicaid Office.Medicaid beneficiaries in Texas are enrolled in either traditional fee-for-service (FFS) Medicaidor a Medicaid managed care program, depending on their location and other factors. Managedcare is an arrangement where specific health care providers agree to provide coordination andhealth services to a defined group of people for a specified payment per person. It has fourmain features that differ from FFS. 1) Managed care has primary care providers (PCPs) thatprovide a medical home and coordinate care for patients, 2) managed care uses a definednetwork of providers that the company has contracted with, so patients’ choice of providers islimited, 3) managed care uses utilization review and utilization management to monitor andcontrol services and costs, and 4) capitation is used under managed care to buy health careservices at a fixed per person price, therefore the managed care organization is assuming risk iftreatment costs rise above the fixed payments. 108Texas uses two different models for managed care delivery, health maintenance organizations(HMO) and primary care case management (PCCM). HMOs are licensed by the TexasDepartment of Insurance and receive a monthly capitation payment for each enrollee based onan estimate of average medical expenses. PCCM is a non-capitated model where eachB-23