SKH, Section 1000, Overview and Eligibility
Revision 1718-1; Effective June March 1, 20178
Senate Bill 7 from the 83rd Legislature, Regular Session, 2013 required the Texas Health and Human Services Commission (HHSC) to create the State of Texas Access Reform (STAR) Kids program. STAR Kids is a Medicaid managed care program for children with disabilities in Texas, which integrates acute care and long term services and supports (LTSS) delivered by a managed care organization (MCO).
STAR Kids does not change or impact an individual's Medicaid eligibility, nor does STAR Kids impact access to Medicaid services and supports. STAR Kids does change the way in which services are delivered. Children and young adults, ages birth through 20, enrolled in a STAR Kids managed care organization (MCO) are called members of the MCO. All STAR Kids members have access to service coordination, provided by an MCO employee or through a member's primary care provider, authorized by the MCO.
Service coordination is specialized care management performed by a service coordinator and includes but is not limited to:
- identification of needs, including physical health, behavioral health services, and LTSS development of an individual service plan (ISP) to address those identified needs;
- assistance to ensure timely and a coordinated access to an array of providers and services;
- attention to addressing unique needs of members; and
- coordination of Medicaid benefits with non-Medicaid services and supports, as necessary and appropriate.
All STAR Kids members receive a comprehensive assessment of their physical and functional needs by a service coordinator using the STAR Kids Screening and Assessment Instrument (SK-SAI), annually. If a member has a change in their physical or behavioral health, or a change in functional ability or caregiver supports, the MCO must reassess the member and update their individual service plan (ISP), as applicable, and authorize necessary services. U upon request from the member, their legally authorized representative (LAR), authorized representative (AR), or health home, the MCO must update their individual service plan (ISP), as applicable, and authorize necessary services.
In addition to traditional Medicaid services, STAR Kids MCOs are responsible for delivering additional services to children enrolled in the Medically Dependent Children Program (MDCP). MDCP provides respite, flexible family support services, adaptive aids, minor home modifications, employment services, and transition assistance to children and young adults who meet the level of care provided in a nursing facility (NF) so they can safely live in the community. The state of Texas appropriates the program a limited number of slots, so HHSC maintains an interest list for MDCP. A child, young adult, or their legally authorized representative (LAR) or AR may ask their MCO about how to be placed on the MDCP interest list at any time.
1100 Legal Basis and Values
Revision 1718-1; Effective June March 1, 20172018
STAR Kids Medicaid Managed Care Program is required by Texas Government Code, §533.00253. Texas Administrative Code, Title 1, Part 15, Chapter 353, Subchapter M, Home and Community Based Services in Managed Care, and Subchapter N, STAR Kids, outline the delivery of Medically Dependent Children Program services (MDCP), as well as the STAR Kids program. Requirements pertaining to managed care organizations (MCOs) are outlined in the STAR Kids Managed Care Contract and in this handbook.
The STAR Kids Handbook includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies, and the contractors and providers in the delivery of STAR Kids Program services to eligible members.
1110 Mission Statement
Revision 17-1; Effective June 1, 2017
The Texas Health and Human Services Commission (HHSC) mission is to provide individually appropriate Medicaid managed care services to children and young adults with disabilities to enable them to live and thrive in a setting that maximizes their health, safety and overall well-being. To achieve HHSC’s mission, the STAR Kids program is established to:
- coordinate care across service arrays;
- improve quality, continuity and customization of care;
- improve access to care and provide person-centered health homes;
- improve ease of program participation for members, managed care organizations and providers;
- improve provider collaboration and integration of different services;
- improve member outcomes to the greatest extent achievable;
- prepare young adults for the transition to adulthood;
- foster program innovation; and
- achieve cost efficiency and cost containment.
1200 STAR Kids Services and Service Delivery Options
Revision 1718-1; Effective June March 1, 20172018
STAR Kids members are entitled to all medically and functionally necessary services available in the same amount, duration and scope as in traditional fee-for-service Medicaid, described in the Texas Medicaid state plan and the Texas Medicaid Provider Procedure Manual (TMPPM) through the member’s selected managed care organization (MCO).
1210 Acute Care Services
Revision 17-1; Effective June 1, 2017
STAR Kids members may receive any medically necessary services through their managed care organization (MCO), and as required under the Early and Periodic Screening, Diagnostics and Treatment (EPSDT), (42 CFR Part 441). This includes, but is not limited to:
- ambulance services;
- audiology services, including hearing aids;
- behavioral health services, including:
- in-patient mental health services;
- out-patient mental health services;
- out-patient chemical dependency services for children;
- detoxification services; and
- psychiatry services;
- birthing services provided by a certified nurse midwife in a birthing center;
- chiropractic services;
- dialysis;
- durable medical equipment and supplies;
- emergency services;
- family planning services;
- home health care services;
- hospital services, inpatient;
- hospital services, out-patient;
- laboratory;
- medical checkups and Comprehensive Care Program (CCP) services for children and young adults through the Texas Health Steps Program;
- oral evaluation and fluoride varnish in conjunction with Texas Health Steps medical checkup for children six months through 35 months of age;
- optometry, glasses and contact lenses, if medically necessary;
- podiatry;
- prenatal care;
- primary care services;
- radiology, imaging and X-rays;
- specialty physician services;
- therapies, including physical, occupational and speech;
- transplantation of organs and tissues; and
- vision.
STAR Kids members who have other insurance, like Medicare or private insurance, will receive most of their acute care services through their primary insurance. Members receive dental care through their primary insurer, through their selected Medicaid dental maintenance organization (DMO), or through a Medicaid fee-for-service model.
1220 Long Term Services and Supports
Revision 1718-1; Effective June March 1, 20172018
STAR Kids members who have an assessed need for long term services and supports (LTSS), identified by the STAR Kids Screening and Assessment Instrument (SK-SAI), may receive the following services through their STAR Kids managed care organization (MCO):
- Day Activity activity Health health Services services (DAHS) for members age 18 through 20. DAHS includes nursing and personal care services, therapy extension services, nutrition services, transportation services and other supportive services.
- Personal care services (PCS), which provide assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks.
- Prescribed pediatric extended care center (PPECC), which is a facility that provides nonresidential basic services, including medical, nursing, psychosocial, therapeutic, and developmental services to medically dependent or technologically dependent individuals members under the age of 21 up to 12 hours/ per day.
- Private duty nursing (PDN) is nursing services for members who meet medical necessity (MN) criteria outlined in the STAR Kids Screening and Assessment Instrument (SK-SAI) and who require individualized, continuous skilled care beyond the level of skilled nursing visits provided under Texas Medicaid home health services.
STAR Kids members who have an assessed need for LTSS, identified by the SK-SAI and who meet an institutional level of care (LOC), may receive the following service through their STAR Kids MCO.
Community First Choice (CFC), which is available to all STAR Kids members who meet an institutional level of careLOC for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), or an institution for mental disease. Members enrolled in a waiver program for individuals with an intellectual disability or related condition (IID) receive CFC through their waiver provider. CFC services include:
- Personal Aassistance Sservices (PAS), also called CFC-PAS or CFC-personal care services, which provide assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks.
Note: CFC-PAS is the same service as PCS. The key difference is that CFC-PAS is part of the CFC benefit and must be reported differently. Members may choose to receive CFC -PAS only if they do not need or want CFC habilitation.
- Habilitation, also called CFC habilitation or CFC-HAB, which provides acquisition, maintenance and enhancement of skills necessary for the individual member to accomplish ADLs, IADLs and health-related tasks.
- Emergency Rresponse Sservices (ERS), which is back-up systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports.
- Support Mmanagement, which is training provided to members, and/or the members' legally authorized representatives (LARs) or authorized representatives (ARs) on how to manage and dismiss their attendants.
STAR Kids members enrolled in the Medically Dependent Children Program (MDCP) are eligible for additional services through their MCO as a cost-effective alternative to living in a nursing facility (NF). Receipt of MDCP services does not impact a member's eligibility for other LTSS available in STAR Kids. Additional services available to STAR Kids members in MDCP are:
- Adaptive aids, which are needed to treat, rehabilitate, prevent or compensate for a condition that results in a disability or a loss of function and helps a member perform the activities of daily livingADLs or control the environment in which they live. Adaptive aids must only be authorized after exhausting all Medicaid state plan services and other third-party resources.
- Employment assistance, which is assistance provided to a member to help the member locate paid, competitive employment in the community.
- Financial management services (FMS) for members who choose the Consumer Directed Services (CDS) option. FMS provides assistance to members with managing funds associated with the services elected for self-direction. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers.
- Flexible family support services are direct care services needed because of a member's disability that help a member participate in child care, post-secondary education, employment, independent living, or support a member's move to an independent living situation.
- Minor home modifications are physical changes to a member's residence that are needed to prevent institutionalization or to support the most integrated setting for a member to remain in the community.
- Respite services are direct care services needed because of a member's disability that provides a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.
- Supported employment provides assistance to sustain paid, competitive employment to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which members without disabilities are employed.
- Transition assistance services are a one-time service provided to a Medicaid-eligible resident of a nursing facility NF located in Texas to assist the resident in moving from the nursing facilityNF into the community to receive MDCP services.
1230 Service Delivery Options for Certain Long Term Services and Supports
Revision 1718-1; Effective June March 1, 20172018
STAR Kids provides members with an array of services, as identified on the individual service plan (ISP). Services are delivered by providers contracted with managed care organizations (MCOs) to provide those services. The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services.
STAR Kids members may choose from three service delivery options for the delivery of certain long term services and supports (LTSS). The options are agency, service responsibility, and consumer directed. State plan LTSS which can be delivered through these service delivery options are:
- Community First Choice habilitation (CFC -HAB);
- Community First Choice personal assistance services (CFC -PAS); and
- Personal care services (PCS).
STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose from these service delivery options for the following services:
- Employment assistance;
- Flexible family support services;
- Respite; and
- Supported employment.
STAR Kids members,or their legally authorized representatives (LARs) or authorized representatives(ARs) may choose to participate in the agency option, consumer directed services (CDS) or service responsibility option (SRO) delivery models. Members who choose the agency model select an MCO-contracted agency to coordinate service delivery for the services on their ISP. Members who choose CDS are given the authority to self-direct certain services. If the member chooses to self-direct certain services, the MCO coordinates delivery of non-member directed services.
In the SRO model, an agency is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to agency policies and standards before sending them to the member’s home. The member,or his LAR or AR is responsible for most of the day-to-day management of the attendant's activities, beginning with interviewing and selecting the person who will be the attendant.
In the CDS model, the member,or LAR, or AR with assistance from a financial management service agency (FMSA), ensures all supplies necessary to provide all authorized services. These personnel may be employed directly by or through personal service agreements or subcontracts with the providers.
More information about these service delivery options is available in Section 5000, Service Delivery Options.
1300 Service Coordination
Revision 1718-1; Effective June March 1, 20172018
All STAR Kids members have access to service coordination from their managed care organization (MCO). The MCO may employ service coordinators, but may also enter into an arrangement with an integrated health home that offers service coordinators to provide some service coordination functions through the member's health home. To integrate the member’s care while remaining informed of the member’s needs and condition, the service coordinator must actively involve the member’s primary and specialty care providers, including behavioral health service providers, and providers of non-capitated services and non-covered services. When members,or their legally authorized representatives (LARs) or authorized representatives (ARs) request information regarding a referral to a nursing or other long-term care facility, the service coordinator must inform the member, or LAR or AR about options available through home and community based services (HCBS) programs, in addition to facility-based options.
MCO service coordinators are responsible for assessing a member's needs using the STAR Kids Screening and Assessment Instrument (SK-SAI), developing an individual service plan (ISP) for every member, and authorizing services identified on the ISP. During the annual face-to-face visit, the service coordinator must:
- Review the member’s current short-term and long-term goals and objectives, as documented in the ISP;
- Acknowledge and document goals and objectives the member has achieved or with which the member has made progress;
- Acknowledge and document goals and objectives that may need to be adjusted;
- Develop new goals and objectives with input from the member, member’s family and member’s providers;
- Update the member’s ISP;
- Assist with development and management of the ISP and budget for members receiving Medically Dependent Children Program (MDCP) services;
- Inform members receiving long term services and supports (LTSS) about the consumer directed services (CDS) and service responsibility options (SROs);
- Educate the member,and member’s LAR or AR about their his or her rights regarding acts that constitute Abuse or Neglect (Child Protective Services) and Abuse, Neglect or Exploitation (Adult Protective Services); and
- Review member rights and MCO processes for service authorization, appeals and complaints.
1310 Service Coordination Requirements