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enrollee is assigned a primary care provider (PCP), who must authorize most other services forthe person before they will be paid by Medicaid. The state sets up the provider networks andcontracts directly with them, and reimbursement is fee-for service, plus a small monthly casemanagement fee for PCPs. Over one-third of Texas Medicaid clients are enrolled in managedcare, and nationally, over half of enrollees are in managed care—only three states do not havemanaged care programs. 109House Bill 7 was passed by the Texas Legislature in 1991 to authorize Medicaid managed carepilot programs to try to control rising health care costs. The first two managed care pilots wereimplemented in 1993 in Travis County and in the tri-county area of Jefferson, Chambers, andGalveston Counties (three more counties were added to the tri-county pilot in 1995). In 1995,Senate Bill 10 and related legislation was passed to restructure Medicaid statewide andincorporate managed care, and the state accomplished the managed care expansion through1915(b) waivers. The managed care program, or STAR (State of Texas Access Reform) wasexpanded again in 1996 to add additional counties and populations. 110In 1997, the STAR program was expanded in Harris County to include acute care and long-termcare services for SSI clients, and this pilot is called STAR+PLUS. In 1999, Senate Bill 2896 puta moratorium on further expansion of managed care, after the Dallas and El Pasoimplementations were finished, and directed HHSC to evaluate Medicaid managed care inTexas (the moratorium was lifted after the evaluation was finished in 2001 and expansion wasallowed where cost-effective). Part of the Dallas area project includes a unique behavioralhealth managed care pilot called NorthSTAR, which provides behavioral health and substanceabuse services to Medicaid enrollees and certain other people below 200 percent FPL. 111Texas SCHIP Program InformationAs of November 1, 2004, there were 340,101 children enrolled in SCHIP in Texas. 112 Parentscan mail in an application for SCHIP for their children or apply over the phone, and mostchildren must wait 90 days before their benefits can begin. 113 If approved, parents must choosea health plan (if there is more than one to choose from in their location) and a primary caredoctor for their enrolled children. SCHIP benefits last for six months, at which time parentsneed to send in a renewal form for their children if they remain eligible. Renewal can be donethrough the mail—parents either sign a form saying there have been no changes to their incomeor expenses in the last six months, or note any changes and send in proof with the renewalform. 114If approved, families pay from $15-$25 a month total in premiums for all their children whoqualify, depending on income levels, and some people may qualify to pay no premiums.Beneficiaries pay from $3-$10 per office visit and $3-$20 per prescription, though some may beeligible to pay no copayments. 115 As of November 1, 2004, monthly premiums for SCHIP aretemporarily suspended. A Governor’s Directive was issued on August 11, 2004, to HHSC torequest that it delay the implementation of a plan to disenroll families who had missed three ormore premium payments, and to study effective alternatives for cost-sharing. Since it would notbe fair for some families to not pay their premiums and still be eligible for services, while otherswith the same income levels continued to pay, HHSC suspended premium payments (notcopayments for services) for all enrollees. 116 See the following table for the number of childrenin SCHIP each year since the current program started and their total costs.B-24