What is STAR Kids?

STAR Kids is a new Texas Medicaid managed care program that will provide Medicaid benefits, beginning November 1, 2016, to children and adults 20 and younger who have disabilities.
STAR Kids is designed to meet the unique needs of youth and children with disabilities. The program will provide benefits such as prescription drugs, hospital care, primary and specialty care, preventive care, personal care services, private duty nursing, and durable medical equipment and supplies. 1

What is the impact of the STAR Kids program on the Texas Children’s System?

Texas Children’s System is uniquely qualified to care for this fragile population, and in fact, many Texas families already seek care at multiple points in our system.  Under this new program, this population will see a significant increase in care coordination to better manage the right care, at the right place, and the right time.  Primary and outpatient subspecialty care and diagnostics will play a vital role to coordinated care by providing timely and innovative access to help these families avoid unneeded emergency room visits and unplanned hospital stays.

Who is considered a part of this population?

The STAR Kids population is considered to be children with medical complexities reflecting broad differences in diagnoses, conditions, treatments, development, environment, age, family dynamics, and geography. Medicaid populations who can participate in STAR Kids include children and young adults aged 20 and younger with diagnosis such as (Trach/Vent, Developmental Delay/IDD, Cerebral Palsy, Autism, Gtube, Seizure, and Down syndrome).

What are the other payors that have STAR Kids patients?

Texas Children’s Health Plan is one of the payors for STAR Kids in Harris and Jefferson counties; other payors serving these counties include United STAR Kids and AmeriGroup.

Has open enrollment closed?

Open enrollment closed on October 12, 2016. Families that did not select a health plan will be assigned to one for rollout on November 1, 2016.

Can families change health plans?

Yes, families can choose a different plan at any time. Changes in plans do not become effective until the first of the next month and can take the Health and Human Services Commission up to 30-45 days to process. 2

How many times can a family change their primary care provider?

There is no limit on how many times a family can change their child’s primary care provider. They can change primary care providers by calling TCHP toll-free at 1-800-659-5764 or writing to:

Texas Children’s Health Plan
Member Services Department
PO Box 301011
Houston, TX 77230

When will the new primary care provider change become effective?

When a client changes their primary care provider, the change will take effect the next day. A new member ID card will be mailed to the client. 3

What are the Managed Care Service Areas?

Figure 1 Texas Managed Care Service Areas

For more information regarding service areas, please see the Health & Human Services Commission’s website.

Questions regarding Scheduling, Referrals, and Coordination

Will there be changes to Medicaid dental services?

There will be no changes to dental services. Families will continue to get dental services as they do today. 4

Does STAR Kids only impact the Complex Care Clinic?

No, all locations will be impacted.  Children in STAR Kids will be primarily managed through a primary care medical home – within the Texas Children’s system that could be the Complex Care Clinic (Formerly named the Special Needs Clinic), The Centers for Women and Children, or Texas Children’s Pediatrics.  Because of the complexity of these children there will still be subspecialty, diagnostic, and therapeutic services needed.  Centralized Care Coordinators will play a vital role in scheduling appropriate care, with a goal of always helping these families avoid unneeded emergency room visits and unplanned hospital stays.

Will patients be able to continue receiving service through their current providers?

Continuity of Care for Texas Children’s Health Plan:

  1. Existing authorizations for acute care services (like physical, occupational, or speech therapy) will be honored for six months, until the authorization expires, or until the health plan conducts a new assessment.
  2. Existing authorizations for long-term services and supports (like private duty nursing and personal care services) will be honored for six months or until the health plan conducts a new assessment.
  3. Texas Children’s Health Plan will, for the first twelve (12) months following implementation (Nov 1, 2016 – Oct 31, 2017) allow members to see out-of-network physicians (including hospital-affiliated physicians), including physicians outside the service delivery area, for Medicaid covered services. Such out-of-network physicians would need to be valid, attested Medicaid providers if they wish to receive payment for their services from TCHP as the primary payer. Authorizations and referrals to see such out-of-network physicians will not be required. Authorizations for services and treatments may still be required.
Texas Children’s Health Plan – Out-of-Network Providers

Texas Children’s Health Plan ensure that the healthcare of newly enrolled Members is not disrupted, compromised, or interrupted. The Health Plan will take special care to provide continuity in the care of enrolled Members who are Fragile and those whose physical or behavioral health could be placed in jeopardy if Medically Necessary Covered Services are disrupted, compromised, or interrupted.

Upon notification from a Member or Provider of the existence of a Prior Authorization, Texas Children’s Health Plan will ensure Members receiving services through a Prior Authorization from either another Health Plan or FFS receive continued authorization of those services for the same amount, duration, and scope for the shortest period of one of the following: (1) 90 calendar days after the transition to Texas Children’s Health Plan, (2) until the end of the current authorization period, or (3) until the Health Plan has appropriately evaluated and administered the STAR Kids Screening and Assessment Process and issued or denied a new authorization. 5

What is the policies regarding referrals for Texas Children’s Health Plan?

Texas Children’s Health Plan does not require approval, referral, or authorization to in-network physician specialists, including behavioral health care, women’s health care, or urgent care. From November 1, 2016 through October 31, 2017, Texas Children’s Health Plan will not require approval, referral, or authorization to an out-of-network physician specialist either in or out of the service area. The out-of-network physician must be a valid Medicaid provider to receive payment for services from Texas Children’s Health Plan. 6

What if a parent has question about which plan they should choose?

If parents have a question about what plan to choose, they have several options for researching which plan fits their needs best.

Options for parents:

  1. Visit the website and/or call each of the health plans for their area to see what they offer.
  2. Visit the Health & Human Services Commission website to review plan profiles information specific to each plan.
  3. Visit the Health & Human Services Commission website for most up-to-date information, including, FAQs.
  4. Contact Maximus, the enrollment broker, to discuss plan options: 1-877-782-6440. 7
  5. Email the Health and Human Services Commission with questions.

Glossary of Terms

Complex Need – A condition or situation resulting in a need for coordination or access to services beyond what a Primary Care Provider (PCP) would normally provide, triggering the MCOs determination that Care Coordination is required.

Continuity of Care (CoC) – Continuity of care is concerned with quality of care over time and is a process aimed at ensuring no gaps in coverage through the transition phase. 8
STAR Kids health plans must honor existing authorizations for:
Long-term services and supports, like Personal Care Services, Community First Choice, or Private Duty Nursing, for six months, or until the health plan does a new assessment.
Acute services, like doctor visits, hospital visits, and labs, are honored for six months, until the end of the current authorization, or until the health plan does a new assessment. 9

Medically Fragile – Refers to a person with a serious, ongoing illness or a chronic condition that:

  1. Has lasted or is anticipated to last 12 or more months;
  2. Has required at least one month of hospitalization and which requires daily, ongoing medical treatments and monitoring by appropriately trained personnel which may include parents or other family members; or
    Requires the routine use of a medical device or the use of assistive technology to compensate for the loss of usefulness of a body function needed to participate in activities of daily living; or lives with an ongoing threat to his/her continued well-being.

The following are some examples of conditions that could be regarded as meeting the definition of “medically fragile.” This is not an exhaustive list. Ventilator dependence, tracheotomy dependence/breathing through tracheostomy tube, nutritional difficulties causing gastrostomy tube dependence, bronchial or tracheal malacia, congestive heart problems, life threatening respiratory infections, apnea monitoring, kidney dialysis, conditions requiring suctioning of lung and throat, or state of health is tenuous to the point of being life threatening. 10

1. Health and Human Services Commission STAR Kids
2. Health and Human Services Commission STAR Kids
3. Texas Children’s Health Plan Member Handbook
4. Health and Human Services Commission STAR Kids
5. Texas Children’s Health Plan Provider Manual
6. Texas Children’s Health Plan Provider Profiles
7. What is the STAR Kids Program?
8. Texas Children’s Health Plan Provider Manual
9. Health and Human Services Commission STAR Kids Family FAQs
10. Education Service Center Region 11 Instructional Support: Medically Fragile

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