Managed care means you get Medicaid services through a select group of doctors, hospitals, and other health care providers — called a provider network — through a health plan you pick.
A health plan is an insurer that is licensed or approved by the Texas Department of Insurance and has a contract with the Texas Health and Human Services Commission (HHSC) to deliver Medicaid-covered services to its members.
All the providers who agree to deliver services to a health plan's members.
Someone getting Medicaid-covered services who has picked and enrolled with a health plan.
You will get an enrollment packet in the mail that includes information about the health plans in your area and the providers in the health plans' provider networks.
The service area includes the counties where the Medicaid health plan operates. There are 13 Medicaid managed care areas in the state. You can see which service area you are in here.
Everyone in managed care has at least two health plans in their service area. The service area you are in is based on the most current address on record with Medicaid or the Social Security Administration. Please make sure your addresses are up to date.
For Medicaid, make changes to your address and phone number by going to the Your Texas Benefits website. You can also make changes by phone.
Phone: Call one of these toll-free numbers
Web: Go to www.YourTexasBenefits.com and follow these steps:
After you do this, you will be shown a "Getting started" page that will walk you through the rest of the process.
If you get Supplemental Security Income (SSI), don't have a U.S. mailing address, or can't change your address online, call us at 1-800-772-1213 (TTY 1-800-325-0778), 7 a.m. to 7 p.m., Monday through Friday or contact your local Social Security office.
Managed care is designed to improve healthcare by improving access to care and coordination of care. This will help make sure you are getting the right services, have a primary care provider and a medical home.
Lawmakers directed HHSC to create STAR Kids in 2013. The program serves children and young adults 20 and younger with disabilities. Senate Bill 7 requires STAR Kids health plans to provide Medically Dependent Children Program (MDCP) waiver services. HHSC is working closely with the STAR Kids Managed Care Advisory Committee and the Children's Policy Council to start this program.
A medical home is where you get your basic care. It includes your primary care provider. It helps build the relationships between the patient and family with the doctor and other care providers.
When you join STAR Kids, you will pick a primary care provider. This is a doctor, nurse, or clinic where you will get basic medical care and get referrals for other care. Primary care providers are a medical home to members. They get to know you and your health history. Your primary care provider can be one of the following:
If you have Medicare, you won't need to pick a primary care provider.
Yes, members enrolled in STAR Kids are required to have a primary care provider within their health plan network. If you see a non-Medicaid primary care provider through your private insurance, you can keep seeing this provider.
If you don't pick a primary care provider, one will be assigned for you and will be listed on your health plan ID card. You can always change this provider by calling your health plan. If you see a non-Medicaid primary care provider through your private insurance, this provider may not be listed on your health plan ID card.
Yes. Call your health plan member services hotline to change your primary care provider.
Yes, as long as your specialist is willing to act as your primary care provider. If this is something you want, talk to your specialist and your health plan. They must work with your caregivers and other providers to make sure your Medicaid medical and behavioral health care needs are met.
Your primary care provider will help you with basic medical care. If you need other medical services, they will give you a referral. For example, if you need to see a specialist or go to the hospital, they will set that up for you. The health plans can choose what services need referrals. Check with the health plans in your area to find out about their referral process.
You don't need a referral from your primary care provider for some services, like:
Some plans may not require referrals for certain services.
STAR Kids is a new Texas Medicaid managed care program for children and adults 20 or younger who have disabilities. Under STAR Kids, you will get basic medical and long-term services and supports through the health plan's provider network. Long-term services and supports include things like help in your home with basic daily activities, and help participating in community activities, if you are eligible. You also will get Medically Dependent Children's Program (MDCP) waiver services through the health plan's provider network, if you are eligible.
STAR Kids will begin statewide November 1, 2016.
You must join STAR Kids if you are 20 or younger, covered by Medicaid, and meet one or more of the following conditions:
You can't be in STAR Kids if you:
Young adults who are turning 21 in November 2016, December 2016, and January 2017, will not go into STAR Kids. They will remain in their current program until they turn 21.
The health plans you can pick depend on where you live in the state. Health plans cover different parts of the state that are called "service areas." The health plans that serve each service are listed below. You always have a choice between at least two health plans.
Everyone will get:
Yes. To ensure ongoing care, STAR Kids health plans must honor existing authorizations for:
If you enroll on November 1, you can keep seeing your current providers, even if they do not join your health plan's network, for six months after you change to STAR Kids. This will help your health plan try to get your providers in their network, if they are not already. Starting May 1, 2017, if your providers have not joined the health plan's network, your health plan service coordinator will work with you to make sure you keep getting the care you need.
If your current provider is not enrolled in Medicaid, but just provides referrals or prescriptions, you can also keep seeing them after November 1.
There will be no change to dental services. You will continue to get dental services as you do today.
If you get services through these services, or live in an intermediate care facility, you will get your long-term services and supports through your waiver or facility, the way you do today. You will also keep working with your current waiver service coordinator or case manager. Your health plan service coordinator will work with your waiver providers to make sure you are getting everything you need.
Starting November 1, 2016, or when you start receiving services through your STAR Kids health plan, the health plan you pick will contact you within 15 days from the time you enroll to complete a telephonic screening and determine the best time to schedule an in-home assessment. Your health plan will schedule your in-home assessment depending on the type of services you have in place and the month your current authorizations end, or if you have an urgent or unmet need for services. The health plan is required to complete all in home assessments within six months from your enrollment date. Your services may change based upon outcome of the assessment.
Families will start getting information about STAR Kids in the mail this summer, including information on how to pick a health plan.
You can contact MAXIMUS, the State's enrollment broker, for help picking a STAR Kids health plan. You can also directly contact the STAR Kids health plans in your area. Your STAR Kids enrollment packet, which will be mailed in August, will have contact information for MAXIMUS, and the health plans in your area.
Starting August 1, 2016, you can call MAXIMUS, the State's enrollment broker, to ask questions. Once MAXIMUS and the health plans are ready to take calls, their information will be listed below. MAXIMUS and STAR Kids health plan contact information also will be included in the enrollment packet you get in August.
Value-added services, approved by HHSC, are extra health services offered by the health plans in addition to regular Medicaid services.
When you get your enrollment packet in August, check the enclosed provider directories for the providers you see today. All STAR Kids health plans will also have up to date online resources available to identify current provider directories and provider searches available in your area as these are updated frequently. If one of your doctors isn't listed, you can call the health plan to see if they are contracted with them. You can also ask your doctor to join your health plan's network.
You can make a list of all the providers your child sees, and contact them to encourage them to enroll with the STAR Kids health plans in your service area. You can also share your provider list with the STAR Kids health plans in your service area and ask them to contract with your providers if they haven't done so already. You can do this today.
When you get your enrollment packet in August, check the enclosed provider directory for the providers you see today. If one of your doctors isn't listed, you can look up the health plan's providers on their website or call the health plan to see if they are contracted with them. You can also talk to your doctor about signing up for the health plan. STAR Kids health plans must try to contract with all Medicaid providers who see children going into STAR Kids today. Providers don't have to contract with a health plan if they don't want to. Health plans and providers can do single-case agreements in some situations if a provider only wants to see you, but not everyone else in STAR Kids.
Yes, you can change health plans any time by contacting MAXIMUS, the State's enrollment broker. It can take 30 to 45 days for the change to go into effect. Once MAXIMUS and the health plans are ready to accept calls, their information will be listed below. MAXIMUS and STAR Kids health plan contact information also will be in the enrollment packet you get in August.
If you have private health insurance through your employer, the health insurance marketplace, or another entity, your private insurance will pay first. Then, your STAR Kids health plan will pay the rest of any service covered by Medicaid.
No. If you see a primary care provider through your private insurance, you do not have to pick this provider through your STAR Kids health plan and your health plan will not assign one. Please tell your health plan service coordinator that you are seeing a primary care provider through your private insurance. This provider will not be listed on your health plan ID card.
At this time, services, prescriptions, and medical equipment that is ordered, referred, or prescribed by a non-Medicaid enrolled provider will be paid by the MCO.
You can keep seeing your private primary care provider and other private providers, even if they are not a Medicaid provider. However, the federal Affordable Care Act requires that orders, referrals, and prescriptions for Medicaid services come from a Medicaid enrolled provider. The ACA requires that all providers who order, refer for, or prescribe Medicaid services are enrolled in Medicaid. If your private primary care provider will be ordering, referring, or prescribing Medicaid services, your doctor must complete a shortened application to continue ordering, referring, or prescribing services or medicines that will be paid for by your STAR Kids health plan. Becoming this type of Medicaid provider does not require your primary care provider to see all Medicaid members.
HHSC is working with private providers around the state to enroll them in Medicaid. However, it is important for you to talk to your providers, too. Tell them how important it is to enroll with Medicaid so they can continue your care. There are no fees to complete the shortened ordering, referring, and prescribing process, and they can sign up electronically or on paper. If your private provider is ordering, referring, or prescribing Medicaid services, they should visit the following links:
After you have picked a health plan, your STAR Kids service coordinator can help coordinate between private providers and Medicaid providers.
If you have Medicare and Medicaid, you are known as a "dual eligible," and will keep getting most of your basic health-care services through your Medicare doctors. STAR Kids will not change the way you get Medicare services.
Medicare will pay for most of your basic healthcare services, and traditional Medicaid will pay for services that are covered by Medicaid but aren't covered by Medicare. If you have Medicare, you won't pick a STAR Kids primary care provider.
After you have picked a health plan, your STAR Kids service coordinator will help coordinate between Medicare providers and Medicaid providers.
No, you must choose a STAR Kids health plan in the service area where you live.
Health plans must have an adequate network of providers and provide services members need inside their service area. 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. Sometimes you might need to go outside your service area to get the care you need. The STAR Kids health plan you select will have a process to help you if you must see providers outside your service area. Please call your service coordinator if you need to see a provider in a different service area.
STAR Kids health plans are able to include providers outside their home service areas in their networks. Your health plan service coordinator will work with you to find the providers and care you need, when you need them.
STAR Kids won't change how you become eligible for MDCP. There will still be a MDCP interest list and a set number of MDCP slots. To become eligible for MDCP services, you must come to the top of the MDCP interest list and meet medical necessity and other program requirements. HHSC and your STAR Kids health plan will help you through the process when you come to the top of the interest list.
If your child is already enrolled in MDCP, you will continue to get the same MDCP services you get today through the STAR Kids health plan you pick. Under STAR Kids, the health plan will do the assessment, develop the service plan, and authorize MDCP services.
Yes. Your health plan service coordinator will help you make a service plan for MDCP services within your approved budget.
No. When you are in STAR Kids, you will have a STAR Kids health plan service coordinator. This service coordinator will do the things your DADS case manager does today, like service planning and assessments.
Consumer Directed Services will still be available once STAR Kids begins. If you get services from one of the waivers below and use the services, they will continue to be available through DADS.
CDS for the Medically Dependent Children's Program will be available through the STAR Kids health plan you pick instead of DADS.
If you use CDS for Personal Care Services or Community First Choice, and aren't getting services through the programs listed above, they will be available through the STAR Kids health plan you pick.