What You Need To Know About the STAR Kids Rollout

In just two months, on Nov. 1, 2016, a new Medicaid managed program, STAR Kids, will begin covering roughly 180,000 children and young adults who are currently enrolled in the Texas Medicaid program.

With many questions circulating about this new program, including who will be eligible, what will be covered, and more, TAHP is seeking to share important facts and updates with legislators and the public to ensure Texans have the most accurate and current information.

What is STAR Kids?

STAR Kids is a new Medicaid managed care program that will provide health care to children and adults 20 years and younger who have disabilities. These individuals were previously covered through the fee-for-service Medicaid model.

Who is Eligible?

Medicaid clients who meet at least one of the following will be enrolled in STAR Kids:

  • Receive Supplemental Security Income (SSI)
  • Receive Medicare benefits
  • Receive services through the Medically Dependent Children Program (MDCP) waiver
  • Receive services through the Youth Empowerment Services (YES) waiver
  • Live in a community-based intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) or nursing facility
  • Receive services through a Medicaid Buy-In program
  • Receive services through any of the following Department of Aging and Disability Services (DADS) intellectual and developmental disability (IDD) waiver programs: Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD); Home and Community-based Services (HCS); Texas Home Living (TxHmL)

How Will It Work?

Under STAR Kids, Medicaid clients will access their Medicaid benefits, including prescription drugs, hospital care, primary care, preventive care, private duty nursing, durable medical equipment and long term services and supports through the health plan, also called a managed care organization (MCO), they have chosen. Individuals must choose a health plan in their service area or have one assigned to them. Access to services will be through the network of providers who have contracted with the health plan. The health plan is responsible for ensuring access to needed services for its members.

STAR Kids is designed to meet the unique needs of youth and children with disabilities. A key component of STAR Kids is service coordination. Through STAR Kids, families will receive help from a service coordinator in identifying and coordinating needed medical and social services, whereas in the former fee-for-service model the care was fragmented and families had to navigate for themselves.

Another component of the STAR Kids program is transition planning. Beginning at the age of 15, a Transition Specialist will work with clients and their families to prepare for a successful transition out of STAR Kids and into adulthood.

STAR Kids MCOs will assess each member’s service needs, which will be used to help the member’s family and the MCO create an individual service plan. In addition to basic Medicaid benefits, each MCO offers a set of extra “value-added” services to help clients to stay healthy and live as independently as possible at home.

Provider Network Requirements and Safeguards

The Texas Health and Human Services Commission (HHSC) and the Texas Department of Insurance (TDI) set rigorous standards for provider network access and adequacy. Health plans undergo readiness testing prior to implementation, and HHSC requires numerous reports and audits to continue to monitor these, as well as various other contract requirements.

Strengthening, building and evaluating the adequacy of their provider networks is an ongoing priority for health plans and does not end on the day of implementation. Health plans continue to reach out to providers who currently see many of the children that will be transitioning into STAR Kids to ensure a smooth transition and to invite them to join their networks. There are ongoing efforts with professional organizations, advocacy groups and the Medicaid clients to educate and encourage qualified providers to join the health plan’s network.

Additionally, health plans can pay providers outside their service area in certain situations, such as emergency services and to maintain ongoing care with an existing provider. The STAR Kids’ health plans will have a process to help clients if they must see providers outside their service area.

STAR KIDS TEXAS MANAGED CARE SERVICE AREAS

For questions about the new STAR Kids program, please contact Laurie Vanhoose with the Texas Association of Health Plans, lvanhoose@tahp.org. Questions can also be directed to HHSC at: Managed_Care_Initiatives@hhsc.state.tx.us.