Health plans must have an adequate network of providers and provide services members need inside their service delivery area as a general rule. Health plans do have flexibility to provide contracts for services outside their service area in certain situations, such as maintaining an existing provider relationship.
STAR Kids Frequently Asked Questions
If you have Medicare and Medicaid (also known as a "dual eligible"), you will keep getting regular health care services through your Medicare doctors. STAR Kids will not change the way you get Medicare services.
Medicare will pay first, then Medicaid will pay for those services that are covered by Medicaid but are not covered by Medicare. You will not pick a main doctor, as your main doctor will be provided through Medicare.
Everyone will get:
- Their own care plan. This will help your doctors and other providers know what kind of care you need. A service coordinator who works for the STAR Kids health plan will work with you to create this plan. The service coordinator will also help you to find doctors, make appointments, and deal with any problems you might have.
- A main doctor, nurse, or clinic (a primary care provider). You will get most of your preventive healthcare through this provider. The main doctor can also refer you to specialists, if needed.
- If you get Medicare, you will not choose a main doctor.
- Medicaid services like you get now, such as doctor’s visits, hospital visits, therapies, specialist visit, medical equipment, and medical supplies.
- Long term services and supports, like nursing and personal care services in the home.
- If you get services through a DADS IDD waiver, the YES waiver, or live in an ICF-IID, you will get your long-term services and supports through your waiver or facility, the same way you do today.
- If you get services through MDCP, you will also get your MDCP services through the health plan you choose.
- Help finding doctors who will take Medicaid. A STAR Kids service coordinator will work with your doctors to make sure you get the care you need.
- Extra services (also called value added services) offered by the STAR Kids health plan you choose.
STAR Kids plans provide all the Medicaid services as well as unlimited prescriptions, and other services. Each plan also offers extra services (value-added services). These extra services are provided by the health plans on top of the traditional Medicaid services.
A health plan service delivery area means the part of the state where your health plan does most of its business. You can see what service delivery area you are part of here: https://www.hhsc.state.tx.us/medicaid/managed-care/mmc/Managed-Care-Service-Areas-Map.pdf
There will be no change to dental services. You or your child will continue to get dental services through your Medicaid dental plan.
The law requires that orders, referrals, and prescriptions for Medicaid services come from a Medicaid enrolled provider. If your main doctor will be ordering, referring, or prescribing Medicaid services, your doctor will need to be enrolled in Medicaid.
HHSC is working with private providers around the state to try to get them to enroll in Medicaid, but it is important for you to talk to your providers and tell them about how important it is to enroll with Medicaid, too. There are no fees to complete the process, and enrollment can be completed electronically or on paper. If your private provider is ordering, referring, or prescribing Medicaid services, they should visit the following links:
- Information for Ordering and Referring-Only providers
- Enroll Online: https://secure.tmhp.com/ProviderEnrollment
- Paper Application
After you have picked a health plan, your STAR Kids service coordinator should help coordinate between private providers and Medicaid (and Medicare) providers, if applicable.
No, you will need to choose a STAR Kids health plan in the service area in which you live.
The state will continue to manage waiver interest lists. Your health plan will help you with next steps when you come to the top of the MDCP interest list. When you come to the top of the list for other IDD waiver programs (HCS, CLASS, TxHmL, DBMD), DADS will help you with the next steps. When you come to the top of the YES waiver interest list, DSHS will help you with the next steps.
A medical home means a medical relationship between a main doctor and a patient, in which the main doctor provides broad basic care to the patient, and helps build relationships between the doctor, the patient, other care providers, and the family. Also see Texas Government Code § 533.0029(a).
If you have Medicare and Medicaid (also known as a "dual eligible"), you will keep getting regular health care services through your Medicare doctors. STAR Kids will not change the way you get Medicare services.
Medicare will pay first, then Medicaid will pay for those services that are covered by Medicaid but are not covered by Medicare. You will not pick a main doctor, as your main doctor will be provided through Medicare.
When you join STAR Kids, you will pick a main doctor. This is a doctor, nurse, or clinic where you will get basic medical care and get referrals for other care. Main doctors provide a medical home to members by getting to know you and your health history. Your main doctor can be one of the following:
- Family practice doctor
- Pediatrician (children’s doctor)
- Internal medicine doctor
- Clinic (Federally Qualified Health Center or Rural Health Clinic)
- Specialist physicians willing to provide a health home to selected members with special needs or conditions
STAR Kids is a Texas Medicaid managed care program for children and adults 20 and younger with disabilities. A network of doctors and health care providers deliver Medicaid services. Managed care means you get Medicaid services through a health plan you choose. You also pick a main doctor. If you have both Medicaid and Medicare, you will not need to pick a main doctor.
Along with regular Medicaid services, STAR Kids offers long-term services and supports (LTSS) if you need them. Long-term services and supports include things like help in your home with basic daily activities and help making changes to your home so you can safely move around.
You can file a complaint or an appeal by contacting your health plan. Information on the complaint and appeal process will be included in your STAR Kids member handbook, which your health plan will send you.
You can also request a fair hearing from the State by following the instructions in the member handbook and on the health plan denial letter for State Fair Hearings.
State Fair Hearing Contact information:
Call 1-800-659-5764 or TDD 1-800-735-2989
STAR Kids will begin statewide November 1, 2016.
If you do not pick a main doctor, one will be assigned for you. You can always change main doctors by calling your health plan.
Managed care is health care provided through a group of doctors, hospitals, and other health care providers through a health plan you select.
Families will start getting information about STAR Kids in the mail this summer, including information on how to pick a health plan.
- Families will get an introduction letter in July 2016. This letter will have basic information about STAR Kids.
- Families will get a STAR Kids enrollment packet in August 2016. The enrollment packet will have provider directories for the health plans in your service area, instructions about how to pick a health plan, and other helpful information. It also will include a phone number for getting help or asking questions about picking a health plan.
- Families who don't pick a health plan will get a reminder letter in September 2016.
- If you haven't picked a health plan by early October 2016, you will be assigned to a health plan.
- To enroll you can call: 1-877-782-6440 or TDD 1-800-735-2989
CDS will continue to operate the same as it does today. The only difference is that the CDS agency will be paid by the STAR Kids health plan instead of by the Department of Aging and Disability Services (DADS).
Once you get your enrollment packet, check the enclosed provider directory for the providers you see today. If one of your doctors is not listed, you can call the Health Plan to see if they are contracted with them. You can also talk to your doctor about reaching out to the Health Plan to try to contract.
Once you get your enrollment packet, check the enclosed provider directory for the providers you see today. If one of your doctors is not listed, you can look up the health plan or call the health plan to see if they are contracted with them. You can also talk to your doctor about reaching out to the health plans to try to contract. STAR Kids health plans must try to contract with all Medicaid providers that people going into STAR Kids see today, but providers may choose not to contract with a health plan if they don't want to. Health plans can choose to do a single case agreement in some situations if a provider only wants to see you, but not everyone else in STAR Kids.
Yes. Call your health plan to change your main doctor.
No. When you are in STAR Kids, you will have a Health Plan service coordinator. This service coordinator will do the things that your DADS case manager does today, like service planning and assessments.
You must join STAR Kids if you are 20 and younger, covered by Medicaid, and meet at least one of the following:
- Get Supplemental Security Income (SSI), or
- Get Supplemental Security Income and Medicare, or
- Get services through the Medically Dependent Children Program (MDCP) waiver, or
- Get services through the Youth Empowerment Services (YES) waiver, or
- Live in a community-based intermediate care facility for individuals with an intellectual disability or related condition (ICF-IID) or nursing facility, or
- Get services through a Medicaid Buy-In program, or
- Get 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)
All MDCP services offered today will be offered to people in MDCP in STAR Kids. Things like respite, van lifts, and Camp, will continue to be offered.
The goals of managed are to focus on preventive care, improve access to care, improve health outcomes, make sure services are used correctly, and to provide a medical home and a main doctor.
Contact MAXIMUS, the State's enrollment broker by:
- Phone -- 1-877-782-6440
- Phone (TDD) -- 1-800-735-2989
- Fax -- 1-855-671-6038 (Toll-free)
Hours of Operation: Monday through Friday 8:00 a.m. to 6:00 p.m. (CST)
In person at presentation sites and enrollment events -- http://www.texmedicaidevents.com/
Yes, as long as your specialist is willing to act as your main doctor. If this is something you want to do, you should talk to your specialist and your health plan.
If you have private health insurance, your private insurance will pay first, then Medicaid will pay for those services covered by Medicaid.
If you receive SSI, you should update your address with the Social Security Administration. You can do this online at: https://www.ssa.gov/myaccount/ or call 1-800-772-1213. Everyone should also confirm Medicaid has the correct address for you at Your Texas Benefits. You can check online at: www.yourtexasbenefits.com, or you can call 2-1-1.
Yes. Your MCO service coordinator will help you make a service plan for MDCP services within your approved budget.
MDCP in STAR Kids will work a lot like it does today. There will still be a MDCP interest list and a set number of MDCP slots. HHSC and your health plan will help you through the process when you come to the top of the interest list. If you or your child is already enrolled in MDCP, you will continue to receive the same array of MDCP services that you get today.
Most children today who get PCS will be in STAR Kids. If you get PCS and:
- Have SSI
- Have SSI-related Medicaid
- Get services through
- MDCP
- YES
- CLASS, DBMD, HCS, or TxHmL
- Or meet the criteria listed above, then you must enroll in STAR Kids
There are some children in STAR who do not have SSI and get PCS. If you do not have SSI and get PCS, you will continue to get PCS through DSHS, with services authorized by DSHS through your DSHS case manager.
Your main doctor, nurse, or clinic will help you with basic medical care. If you need other medical services, your doctor will give you a referral. For example, if you need to see a specialist or go to the hospital, then your main doctor will set that up for you. You do not need a referral from your main doctor for some services like:
- Mental health and drug and alcohol abuse treatment
- Texas Health Steps checkups
- Emergency room services
Senate Bill (SB) 7, 83rd Legislature, Regular Session, 2013, directs HHSC to create the STAR Kids managed care program for children and young adults with disabilities. SB 7 also requires the Medically Dependent Children Program (MDCP) be provided through STAR Kids, and that HHSC work closely with the STAR Kids Managed Care Advisory Committee and the Children's Policy Council on the implementation of this program.
Yes. You can change health plans at any time by contacting MAXIMUS, the State's enrollment broker. It can take 30 to 45 days for the change to go into effect.
- Phone -- 1-877-782-6440
- Phone (TDD) -- 1-800-735-2989.
- Fax -- 1-855-671-6038 (toll-free)
In person at presentation sites and enrollment events -- http://www.txmedicaidevents.com/
Texas Children’s Health Plan will host quarterly Member Advisory Group meetings to gain valuable feedback from our current members on the initiatives, services, and programs offered by the health plan. The information and member feedback gathered during these meeting will be used to guide future programs.
These meetings will last no longer than one hour. These quarterly meetings are being mandated by the state. Texas Children’s Health Plan must maintain a record of member advisory group meetings, including agendas, and minutes.
The law requires that orders, referrals, and prescriptions for Medicaid services come from a Medicaid enrolled provider. If your main doctor will be ordering, referring, or prescribing Medicaid services, your doctor will need to be enrolled in Medicaid.
HHSC is working with private providers around the state to try to get them to enroll in Medicaid, but it is important for you to talk to your providers and tell them about how important it is to enroll with Medicaid, too. There are no fees to complete the process, and enrollment can be completed electronically or on paper. If your private provider is ordering, referring, or prescribing Medicaid services, they should visit the following links:
- Information for Ordering and Referring-Only providers
- Enroll Online: https://secure.tmhp.com/ProviderEnrollment
- Paper Application
After you have picked a health plan, your STAR Kids service coordinator should help coordinate between private providers and Medicaid (and Medicare) providers, if applicable.
You cannot be in STAR Kids if you:
- Are in foster care and get Medicaid services through traditional Medicaid or STAR Health
- Are 21 or older
- Live in the Truman W. Smith Children’s Care Center
- Live in a state veteran's home
- Live in a State Supported Living Center (SSLC)
You can get eye exams without a referral from your main doctor. To use these services, call Envolve Vision at 1-844-212-7269.
The state will continue to manage waiver interest lists. Your health plan will help you with next steps when you come to the top of the MDCP interest list. When you come to the top of the list for other IDD waiver programs (HCS, CLASS, TxHmL, DBMD), DADS will help you with the next steps. When you come to the top of the YES waiver interest list, DSHS will help you with the next steps.
Contact Member Services at 832-828-1003 or toll-free at 1-800-659-5764.