Denise has run her Houston agency for eight years. She knows TMHP and STAR+PLUS. She's still losing approximately $12,300/month to authorization drain, unworked denials, and compliance gaps she doesn't have the staff to fix.
Texas Medicaid has specific billing requirements, MCO contracting rules, waiver programs, and EVV mandates that differ from other states. This page covers what Texas home care agency operators need to understand to bill correctly, manage authorizations, and avoid the revenue gaps that come from getting any of it wrong.
Denise has run her Houston agency for eight years. She knows TMHP and STAR+PLUS. She's still losing approximately $12,300/month to authorization drain, unworked denials, and compliance gaps she doesn't have the staff to fix.
These aren't general Medicaid billing principles — they're Texas-specific rules that catch agencies by surprise. Operators moving from another state, or operators building their agency for the first time, make the same mistakes here repeatedly.
Most Texas Medicaid PAS patients are in STAR+PLUS managed care, not fee-for-service. This means most of your billing activity is through MCO portals, not TMHP directly. TMHP enrollment is still required as a prerequisite, but day-to-day billing is MCO portal work.
Texas fee-for-service Medicaid has a 95-day timely filing window — shorter than the 12 months in Georgia or the 12 months in many other states. This catches agencies that manage their denials slowly. A denied claim that sits for three months before rework may be past the TMHP timely filing window.
Texas STAR+PLUS MCOs operate in specific Service Delivery Areas (SDAs). Not all four MCOs are available in every Texas SDA. Check HHSC's SDA maps before applying to MCOs — you need to know which MCOs serve your specific service area.
Texas has two primary license types relevant to home care: PAS (Personal Assistance Services) for non-medical personal care, and HCSSA (Home and Community Support Services Agency) for agencies providing skilled services. Your license type determines which services you can provide and bill for. Most Medicaid personal care agencies hold a PAS license.
In the Houston area (Denise's market), all four STAR+PLUS MCOs — Amerigroup, Molina, Superior HealthPlan, and UnitedHealthcare — have meaningful enrollment. The MCO market share in Houston means not contracting with all four significantly limits your potential patient population. Apply simultaneously, not sequentially.
STAR+PLUS prior authorizations are managed by MCO case managers. Each MCO has its own authorization request process, renewal timeline, and utilization review criteria. Authorization hours that aren't fully utilized before the authorization period ends cannot be retroactively billed. At 90 patients with 40 caregivers — Denise's scale — the authorization utilization gap compounds significantly without systematic tracking.
Denise has run her Houston agency for eight years. She knows TMHP and STAR+PLUS. She's still losing approximately $12,300/month to authorization drain, unworked denials, and compliance gaps she doesn't have the staff to fix.
100+ agencies. The authorization and billing gaps that produce CareDrain losses look the same in every state — approved hours expiring before they're scheduled, claims denied and left unworked, compliance gaps interrupting billing. The state-specific version of that story in Texas runs through its MCO landscape and waiver program rules.
HHSC conducts licensing surveys for Texas PAS and HCSSA agencies. Survey frequency increases after deficiency findings. Texas HHSC surveyors look at caregiver credential files, supervisory visit documentation, and care plan compliance. Credential lapses and supervisory visit gaps are common citation areas.
Credential lapses found during a survey are both a compliance deficiency and a billing problem — visits delivered during the lapsed period may not be billable, and survey citations create corrective action requirements. CareBravo's credentialing function tracks every Texas caregiver credential with expiration alerts and schedule gating before lapses become survey or billing issues.
STAR+PLUS is Texas Medicaid's managed care program for adults who are aged, blind, or disabled and who need long-term services and supports (LTSS), including personal care assistance. Most Texas Medicaid patients who qualify for home care are enrolled in STAR+PLUS rather than fee-for-service Medicaid. To serve STAR+PLUS patients, home care agencies must contract with the STAR+PLUS MCOs operating in their Service Delivery Area. STAR+PLUS managed care means the MCO — not the state Medicaid agency — authorizes care, manages utilization, and processes your claims.
TMHP — the Texas Medicaid & Healthcare Partnership — is the state's contracted Medicaid administrator that processes fee-for-service claims and manages provider enrollment. Texas fee-for-service Medicaid claims are submitted through TMHP. However, most Texas Medicaid PAS patients are in STAR+PLUS managed care, so most of a typical Texas agency's daily billing activity is through MCO portals rather than TMHP. TMHP enrollment is still required as a prerequisite for STAR+PLUS participation.
STAR+PLUS prior authorizations are issued and managed by each MCO's care management team. MCO case managers conduct assessments to determine the authorized hours and service type for each member. When the MCO authorizes a member for home care services, it specifies the weekly hours and service period. The agency cannot bill for hours delivered beyond the authorized amount, and hours not delivered before the authorization period ends are permanently lost. Denise's authorization utilization gap — hours authorized but not scheduled — is the largest single revenue drain for most Texas STAR+PLUS agencies.
Texas allows agencies to choose among EVV vendors that comply with state specifications, rather than mandating a single vendor the way Georgia mandates HHAeXchange. Texas EVV data must be transmitted to the state's EVV aggregator for Medicaid reporting. Individual STAR+PLUS MCOs may specify EVV requirements beyond the state baseline in their provider contracts — verify specific EVV requirements with each MCO during contracting.
Texas fee-for-service Medicaid (through TMHP) has a 95-day timely filing window from the date of service. This is shorter than the 12-month window in Georgia and many other states, which catches agencies that manage their denial backlogs slowly. A claim denied and left unworked for 60 days may already be approaching the TMHP timely filing limit. STAR+PLUS MCO timely filing windows vary by contract — some are 90 days, some 180 days. Always confirm with each contracted MCO.
The billing facts above explain how Texas Medicaid works. The diagnostic shows what the gaps are costing your specific agency — authorization hours expiring in your waiver program, claims denied and unworked in your MCO mix, compliance issues in your caregiver roster — on your real records.