Managed Care

Managed Care Organizations

In accordance with legislation passed in the 83rd Texas legislature, the Health and Human Services Commission has started the process of transitioning certain programs and services to Managed Care Organizations. What is a Managed Care Organization (MCO) and what does this mean? An MCO is an insurance company contracted to perform the management and administration of programs or services for the state. In a managed care delivery system, people get most or all of their Medicaid services from an organization under contract with the state. This means that instead of dealing directly with Medicaid, you would be dealing with an insurance company.

What is this called?

There are many delivery methods for Medicaid delivered through the managed care model; CHIP, Star, Star Health, Star+Plus, and Star Kids. Each serves a different but similar service, and depending on age and need, you may be placed in one of these delivery models.

Star+Plus:
Who qualifies?

STAR+PLUS is a Texas Medicaid managed care program for people who have disabilities over the age of 21 or are age 65 or older. To get services through STAR+PLUS you must: (1) be approved for Medicaid, , and (2) be one or more of the following: Age 21 or older, getting Supplemental Security Income (SSI) benefits, and able to get Medicaid due to low income; Not getting SSI and able to get STAR+PLUS Home and Community-Based Waiver Services due to medical need; Age 21 or older, getting Medicaid through what are called “Social Security Exclusion programs” and meet program rules for income and asset levels;

What services are provided?

Star+Plus provides long term services and supports to eligible recipients. Long-term services and supports can include; Day Activity and Health Services and Primary Home Care. Other services under the waiver include; PAS, Adaptive aids, adult foster care home services, assisted living, emergency response services, home delivered meals, medical supplies, minor home modifications, nursing services, respite care, therapy, transitional assistance services, and support consultation.

More info and how to access this program…

Another feature of STAR+PLUS is service coordination. A STAR+PLUS staff member from the individuals MCO, works with the member, the member’s family and the member’s doctors and other providers to help the member get the medical and long-term services and support they need. To obtain Star+Plus services you can call 211 and request Star+Plus services.

Star Health:
Who Qualifies?

Star Health is a Texas Medicaid managed care program for children and young adults in foster care or under conservatorship of DFPS.

What services are provided?

Physical and behavioral healthcare, Dental, Vision, Service coordination, Nursing, Respite, PAS, Therapy, Emergency Care, Transportation to health care appointments, and Prescriptions. Currently all Star Health services are provided by Superior Health Plan.

More info and how to access this program…

For a child enrolled in the STAR Health program, DFPS staff, caregivers and medical consenters can get information and help with finding a provider, scheduling an appointment, or getting services by:

Calling STAR Health Member Services at 1-866-912-6283.
Using the STAR Health website at www.fostercaretx.comExternal Link.

STAR Kids:
Who Qualifies?

Star Kids is a new Texas Medicaid managed care program that provides Medicaid benefits, effective November 1, 2016, to children and adults 20 and younger who have disabilities. This program is required for those who are 20 or young, covered by Medicaid, and meet at least one of the following terms: get Supplemental Security Income, get SSI and Medicare, get services through the MDCP waiver, get services through the YES waiver, live in a community-based intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) or nursing facility, get services through a Medicaid Buy-in program, get services through any of the following DADS intellectual and IDD waiver programs: CLASS, DBMD, HCS, TxHmL.

What services are provided?

Prescription drugs, hospital care, primary and specialty care, preventative care, personal care services, private duty nursing, and durable medical equipment and supplies. Children and youth who get additional services through MDCP will receive their MDCP services through STAR Kids.

More info and how to access this program…

Managed care means that you will pick a health plan that will provide the health services you need through a network of doctors, specialists, and other providers. Those enrolling in the STAR Kids program will choose a health plan, as well as a primary care physician or clinic who will provide basic medical services, like check-ups, and provide referrals to a specialist when needed.

Through STAR Kids, families will also receive help with coordinating care. Each health plan will provide service coordination, which will help identify needs and connect members to services and qualified providers. STAR Kids MCOs will assess each member’s service needs, which will be used to help the family and the MCO create an individual service plan.

For more information, visit https://hhs.texas.gov/services/health/medicaid-and-chip/programs/star-kids

STAR

STAR is the program through which most people in Texas get their Medicaid coverage. People in STAR Medicaid get their services through medical plans, also known as managed care plans, which they choose. You pick a medical plan that provides your Medicaid services and a main doctor that is your point of contact for Medicaid services. In addition to your main doctor, each plan has a large group of specialists, therapists, clinics, and hospitals that can provide you with Medicaid services.

Star Services

The STAR program gives you all of the benefits Medicaid has to offer. You also get:

  • No limit on the number of days you can stay in a hospital for needed care.
  • No limit on the number of medicines.
  • Health education classes.
  • Medical plans that offer extra services not covered by Medicaid.  These are called value-added services.

Who Qualifies

You must enroll in the STAR program if you are approved for Medicaid and any of the following applies to you:

  • You get cash assistance (Temporary Assistance for Needy Families – TANF).
  • You are pregnant.
  • You or your children have limited income.
  • You are a newborn baby.
  • You are an adult age 21 or older who gets Supplemental Security Income (SSI) but not  Medicare, and you live in the Medicaid Rural Service Area (RSA) (PDF).

CHIP

CHIP is a Medicaid option for children through the Managed Care model that provides a range of benefits including:

  • Doctor, hospital, X-ray and lab services
  • Well-baby and well-child visits
  • Prescription drugs
  • Vision services
  • Dental care