Children and pregnant women (CPW) Case Management Update

Date: June 6, 2025

Attention: CPW providers

Call to action: The purpose of this message is to update potential and current case management for children and pregnant women (CPW) providers on:

Guidance about coordinating CPW services between managed care organization (MCO)/Texas Children’s Health Plan (TCHP) staff, HHSC, and CPW providers.
Changes made to the Texas Medicaid Provider Procedures Manual. Refer to Section 3 of the Behavioral Health and Case Management Services Handbook for more details.

How this impacts providers: Professional Liability Insurance Requirements
To maintain professional liability insurance, a CPW provider must attest to the status of their professional liability insurance in the TCHP/MCO contracting/credentialing application. A CPW provider can attest to any amount, even if the amount is $0. If a CPW provider attests to $0, this means the provider does not hold professional liability insurance. This still fulfills HHSC and TCHP/MCO requirements and is allowable by the National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC). NCQA and URAC are entities that provide accreditation to TCHP/MCOs.

However, HHSC requires TCHP/Medicaid MCOs to maintain information on the professional liability insurance status of its providers. For new CPW provider types that choose to maintain professional liability insurance, TCHP/an MCO must allow a six-month grace period after a CPW provider completes contracting and credentialing with the MCO before the CPW provider must report their professional liability insurance status.

If a CPW provider chooses not to obtain professional liability insurance (i.e., attests to $0) even after the six-month grace period ends and the MCO documents the CPW provider’s professional liability insurance status, TCHP/an MCO may not terminate their contract with the CPW provider. This is in compliance with NCQA and URAC requirements:

NCQA: CR 3 Element C, Factor 5 (Effective July 1, 2024)
URAC: CR 1-1 b. iii, 2-1 b., and 3-1 a. iv. (Version 1.1, effective June 2022)

Note: While malpractice insurance is a type of professional liability insurance, a CPW provider is not required to obtain malpractice insurance.

Federally Qualified Health Centers (FQHCs) as CPW Providers
An FQHC whose case managers have completed HHSC’s standardized case management training can deliver and be reimbursed for CPW services. Case managers working under an FQHC do not need to apply for their own individual National Provider Identifier (NPI) to deliver CPW services. Services are billed under the FQHC NPI.

The FQHC prospective payment system (PPS) wrap payment methodology applies to CPW services and MCOs will be paid the PPS wrap payment by HHSC for CPW services. FQHCs will bill for CPW services using only the CPW procedure code (G9012). FQHCs that deliver CPW services will use their FQHC provider type, specialty code, and taxonomy code. An MCO must not require FQHCs to apply as a CPW provider or use a CPW taxonomy code to deliver CPW services.

Referrals to CPW Providers

HHSC expanded the list of example situations in which an MCO might refer a client to a CPW provider:

Supporting admission, review, and dismissal school meetings, 504 or special education services.
Locating childcare or subsidies to assist with childcare costs.
Locating long-term shelter or domestic violence assistance and shelter.
Referring clients to legal services or state programs to establish paternity and orders for support.
Ensuring access to immediate services for clients who need urgent assistance.

Continuity of Care
As long as an MCO determines there is no duplication of services, a member can receive CPW services from a CPW provider when the member has a previously established relationship with or prefers to receive services from a CPW provider. A member can also contact a CPW provider directly. The CPW provider may also receive a referral from a third party.

For members transferring from fee-for-service to a new MCO, the new MCO must allow the member to continue to receive CPW services from the CPW provider even if the CPW provider is out-of-network. The CPW services can continue until the member’s case management needs are met or the service plan developed by the CPW provider has been completed. The new MCO is obligated to reimburse the member’s existing out-of-network CPW provider for CPW services provided.

Information Sharing
In addition to non-medical needs screening results, HHSC recommends that MCOs share in the initial referral to the CPW provider:

Member’s name, date of birth, and Medicaid ID number
Urgency of referral
Description of reasons for referral
Initial health needs screening results
Any other relevant screening or evaluation results
Any relevant historical data for the member

Training
In addition to the updates outlined here, there are new training requirements for existing CPW providers due to House Bill 1575, 88th Legislature, Regular Session, 2023 and new policy requirements.

Two new trainings must be completed by all existing CPW providers as a one-time requirement. Starting June 1, 2025, confirmation of completion of the two new trainings will be required as part of an existing CPW provider’s reenrollment or revalidation process. More information on these new requirements was issued in a separate notice: Training Requirements for Existing CPW Program Providers to Be Changed.

Resources

Next step for Providers: CPW Providers are strongly advised to follow the guidance outlined above regarding credentialing requirements related to professional liability insurance and training requirements.

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

For access to all provider alerts: www.texaschildrenshealthplan.org/provideralerts.