STAR
The Medicaid State of Texas Access Reform (STAR) program provides primary, acute care, and pharmacy services for pregnant women, newborns, and children with limited income. Acute care services include doctor’s visits, pharmacy, home health, medical equipment, lab, x-ray, and hospital services. The program operates statewide under the authority of the Texas Health Care Transformation and Quality Improvement Program 1115 Waiver. Services are delivered through managed care organizations (MCOs) under contract with the Health and Human Services Commission (HHSC).
Other individuals may be required to enroll in STAR or have the option. Former foster care children ages 18-20 are mandated to enroll into managed care, but may choose to be in either STAR or STAR Health. Former foster care children ages 21-25 are
mandated to enroll into STAR as STAR Health is not an option for this population.
Individuals under the age of 19 who receive services through the Youth Empowerment Services (YES) program can voluntarily enroll into STAR. Other than those populations described above, individuals who reside in institutions or nursing facilities; receive SSI or Medicare; are in a DADS 1915(c) waiver program; or are medically needy or are in state conservatorship are generally excluded from STAR enrollment. SSI Children may voluntarily enroll in STAR.
STAR program members have access to a PCP that knows their health care needs and can coordinate their care through a medical home. PCPs provide preventive checkups, treat the majority of conditions that STAR members experience, and refer enrollees to specialty care when necessary. STAR also offers additional services not available in traditional FFS. Under the FFS program, adult clients are limited to three prescriptions per month while STAR members can receive unlimited medically necessary
prescriptions. Additionally, STAR members are not subject to the 30-day spell of illness limitation for adults that exists in the FFS program.
STAR+PLUS
The Medicaid STAR+PLUS program provides acute care services plus long-term services and supports (LTSS) by integrating primary care, pharmacy services, and LTSS for individuals who are age 65 or older or have a disability. LTSS includes services such as attendant care and adult day health care. The program operates statewide under the authority of the Texas Health Care Transformation and Quality Improvement Program 1115 Waiver. Services are delivered through managed care organizations (MCOs).
The STAR+PLUS MCOs are responsible for coordinating acute care and LTSS for STAR+PLUS members with complex medical conditions. The STAR+PLUS program serves SSI, SSI-related individuals, and adults who qualify for Medicaid because they meet medical necessity criteria and, as a result, receive Home and Community Based Services (HCBS) STAR+PLUS waiver services. If eligible for STAR+PLUS, adults are required to participate in the program while children may choose to participate or
receive Medicaid benefits through fee-for-service. STAR+PLUS members with complex medical conditions are assigned a service coordinator who is responsible for
coordinating acute care and long-term services and supports. The service coordinator develops an individual plan of care with the member, the individual’s family members, and providers and can authorize certain services. The program also ensures that each member has a primary care doctor.
The HCBS STAR+PLUS waiver is also part of the STAR+PLUS program. The
STAR+PLUS HCBS waiver provides additional LTSS to clients who are elderly or who have disabilities as a cost-effective alternative to living in a nursing facility. These services are non-traditional long-term services and supports such as nursing, personal assistance services, adaptive aids, medical supplies, and minor home modifications to make member’s homes more accessible. These clients must be age 21 or older, be a Medicaid recipient, or be otherwise financially eligible for waiver services. To be eligible for HCBS STAR+PLUS waiver services, a member must meet income and resource
requirements for Medicaid nursing facility care, and receive a determination from HHSC that they meet the medical necessity criteria to be in a nursing facility.
STAR+PLUS enrollees who are eligible for both Medicaid and Medicare receive LTSS through STAR+PLUS and most acute care services through Medicare. If enrollees meet the medical necessity criteria to be in a nursing facility, they may receive the additional LTSS through the HCBS STAR+PLUS waiver.
The STAR+PLUS program provides only acute care services to non-dual eligible members receiving services from an intermediate care facility for individuals with intellectual disabilities or related conditions (ICF/IID) or a 1915(c) waiver program for individuals with intellectual and developmental disabilities (IDD) operated by DADS.
Adults in an IDD waiver or residing in an ICF/IID are required to participate in
STAR+PLUS for acute care services only while children may choose to participate. All dual eligible individuals who are currently living in an ICF-IID or receiving IDD waiver services or individuals residing in a state supported living center are excluded from participation in the STAR+PLUS program.
Children and young adults under the age of 21 who receive services through the YES program can voluntarily enroll into STAR+PLUS. Children and young adults under the age of 21 who receive services through MDCP cannot voluntarily enroll into
STAR+PLUS unless they disenroll from MDCP.
NorthSTAR
NorthSTAR is an integrated behavioral health delivery system in the Dallas service area, serving people who are eligible for Medicaid or who meet other eligibility criteria. It is an initiative of the Department of State Health Services (DSHS). Services are
provided via a fully capitated contract with a licensed behavioral health organization.
STAR clients in Dallas and six contiguous counties (Collin, Ellis, Hunt, Kaufman, Navarro, and Rockwall) around Dallas receive behavioral health services through NorthSTAR.
NorthSTAR was created in 1999 to integrate the publicly funded systems of mental health and substance use disorder services. Using Medicaid, state general revenue, federal block grant funds, and some local funds, NorthSTAR is designed to create a better coordinated and more efficient and flexible system of public behavioral health care.
Most Medicaid eligible recipients who reside in the service area are automatically enrolled in the program based on their Medicaid status. Non-Medicaid eligible
individuals who reside in the service area and meet clinical and income criteria are eligible to receive services through NorthSTAR via an application process.
NorthSTAR is administered through a DSHS contract with a behavioral health
organization (BHO). The BHO contract includes outcome and performance measures specifically designed for behavioral health. The BHO is required to subcontract with a specialty provider network for the provision of a set of specialty treatment services and service coordination for enrollees with serious mental illness and serious emotional disturbance. The BHO is also contractually required to maintain an adequate network for other provider specialties for behavioral health. These include psychiatrists,
psychologists, licensed therapists, substance use treatment facilities, and hospitals.
The North Texas Behavioral Health Authority, which was specifically formed for the NorthSTAR project, ensures that there is local oversight and that local communities are given a voice in the delivery of publicly funded managed behavioral health care. The North Texas Behavioral Health Authority represents both mental health and substance use disorder interests and concerns
In 2008, DSHS collaborated with the University of Illinois at Chicago to develop a Self-Directed Care (SDC) pilot program within NorthSTAR. SDC is a new way of providing mental health services in which adults with serious mental illnesses directly manage funds to assist in their recovery. With assistance from an SDC advisor, the Texas SDC participants create a person-centered recovery plan and a budget for the purchase of traditional mental health services and non-traditional goods and services in the
community that are tied to their recovery. The project study with the University of Illinois ended in December of 2012. In a randomized controlled trial, the SDC model achieved superior client outcomes for no greater service delivery expenditures than those
resulting from the traditional service delivery system. The North Texas Behavioral Health Authority was able to continue the program through January of 2013.
STAR Health
STAR Health is a statewide program designed to provide medical, dental, vision, and behavioral health benefits, including unlimited prescriptions, for children and youth in conservatorship of the Department of Family and Protective Services (DFPS), including those in foster care and kinship care. Services are delivered through a single managed care organizations (MCO) under contract with the Health and Human Services
Commission (HHSC).
HHSC, in collaboration with DFPS, implemented STAR Health on April 1, 2008. The STAR Health program serves children in state conservatorship; young adults up to the month of their 22nd birthday who have voluntary foster care placement agreements;
young adults up to the month of their 21st birthday who were formerly in foster care and are receiving Medicaid services under the titles Former Foster Care Children (FFCC) and Medicaid for Transitioning Foster Care Youth (MTFCY), and young adults up to the month of their 23rd birthday not eligible under the aforementioned categories, but who enroll in higher education. Clients can begin receiving services as soon as they enter state conservatorship.
STAR Health members receive services through a medical home. Additional benefits include service management, service coordination, value-added services, and the