6410 Program Overview
Revision 18-1; Effective June 15, 2018
The 74th Texas Legislature implemented the State of Texas Access Reform Plus (STAR+PLUS) program to create a cost-neutral managed care system that would combine acute care as well as Long-term Services and Supports. The STAR+PLUS program does not change Medicaid eligibility or services. It changes the way Medicaid services are delivered.
The STAR+PLUS program combines acute care and Long-term Services and Supports, such as assisting in an individual's home with daily activities, home modifications, respite (short-term supervision) and personal assistance. These services are delivered through providers contracted with managed care organizations (MCOs). STAR+PLUS provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid individuals.
Service coordination, available to all members, is the main feature of STAR+PLUS. It is a specialized case management service for program members who need or request it. Service coordination means that plan members, family members and providers can work together to help members get acute care, Long-term Services and Supports, Medicare services for dual eligible individuals and other community support services.
Elements of the STAR+PLUS system that are different from traditional service delivery include:
- 1115 Waiver – Authority granted to the state of Texas to allow delivery of Medicaid State Plan acute, Long-term Services and Supports (Primary Home Care and Day Activity and Health Services) and delivery of Long-term Services and Supports that assists individuals to live in the community in lieu of a nursing facility through a managed care delivery system.
- Enrollment broker – A contracted entity that assists individuals in selecting and enrolling with an MCO. If requested by the individual, the enrollment broker also may assist in choosing a primary care provider (PCP). Members of STAR+PLUS may request an MCO change at any time by contacting the enrollment broker. The change will be effective the first day of the subsequent month if the request is made before the state cutoff date or the first of the following month if the request is made after cutoff.
- Texas Health and Human Services Commission (HHSC) – The state agency responsible for Medicaid. HHSC staff receiving a request for STAR+PLUS Home and Community Based Services (HCBS) will notify the HHSC Program Support Unit of the request.
- MCO – An insurer licensed by the Texas Department of Insurance as a managed care organization in accordance with Chapter 843 of the Texas Insurance Code. MCOs provide Medicaid benefits for individuals who are required to enroll in STAR+PLUS.
- Member – An individual who is enrolled in and receiving services through a STAR+PLUS MCO.
- Plan of care (POC) – A care plan the MCO develops for its members that includes acute care and Long-term Services and Supports. The plan of care is not the same as the individual service plan (ISP) for STAR+PLUS HCBS program services.
- Program Support Unit (PSU) – HHSC staff who support certain aspects of STAR+PLUS case management.
- Texas Medicaid & Healthcare Partnership (TMHP) – The Texas contractor administering Medicaid claims processing and the Medicaid primary care case management services program.
- TexMedCentral – A secure internet bulletin board that the state and the MCOs use to share information.
- Upgrade – An existing STAR+PLUS individual enrolled in the 1915(b) waiver who requests and is granted STAR+PLUS HCBS (1115 waiver) program services.
6411 Services Available Under the STAR+PLUS Option
Revision 18-1; Effective June 15, 2018
Managed care organizations (MCOs) are required to contact all members upon enrollment. If there is a need identified or a request from the member, the MCO will assess the member to determine needs and to develop an appropriate individual plan of care (POC). Because MCOs are at risk for paying for a range of acute care and long term services and supports, there is an incentive to provide innovative, cost-effective care from the outset in order to prevent or delay the need for more costly institutionalization.
STAR+PLUS Medicaid-only individuals are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These individuals receive all services (both acute care and long term service and supports) from the MCO.
Individuals who receive both Medicaid and Medicare (dual eligible) choose an MCO, but not PCP. This is because they receive acute care from their Medicare providers. STAR+PLUS does not impact Medicare services or service delivery in any way. The STAR+PLUS MCO only provides Medicaid Long-term Services and Supports (LTSS) to dual eligible individuals.
STAR+PLUS serves as an insurance policy that will be available if members have a need for LTSS at a future time.
Medicaid-only individuals (those who do not receive Medicare) receive traditional Medicaid acute care services, plus an annual check-up. For these individuals, the cost of acute care services is included in the payment to the MCO. For dual eligible individuals, the MCO payment does not include the cost of acute care.
Long-term Services and Supports
Additional services are available under the STAR+PLUS HCBS program.
6420 STAR+PLUS Members Requesting Non-Medicaid Services
Revision 18-1; Effective June 15, 2018
Requirements of the 1115 Waiver dictate that STAR+PLUS HCBS program recipients receive all services excluding hospice through the waiver. The CCSE case worker must not authorize any Title XX services for individuals enrolled in the STAR+PLUS HCBS program.
For non-waiver recipients on the STAR+PLUS program, participation in a Medicaid managed care program is not sufficient cause for denial of the right to access non-Medicaid services. Non-Medicaid services should be viewed as any other community resource available to a managed care organization (MCO) member.
STAR+PLUS members are entitled to Title XX services if all eligibility criteria are met. However, the case worker must first ensure that approval of the request would not result in a duplication of services.
See Appendix XX, Mutually Exclusive Services, to determine which Title XX services are available to members in the STAR+PLUS program.
Individuals on the STAR+PLUS program requesting Title XX services will continue to be added to any applicable interest list at the time of the request in order to protect the date and time of the request. The case worker must first determine whether or not there is a slot available for the requested service. If not, the individual’s name is added to the appropriate interest list by entering the information in the Community Services Interest List (CSIL) system. Individuals are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted as slots for services become available.
When the member’s name is released from the interest list, the case worker must verify the Managed Care Organization’s (MCO) service array does not include a service equivalent of the Title XX service requested by viewing the STAR+PLUS Program Health Plan Comparison Charts and value-added services on the Health and Human Services (HHSC) website at:
Value-added services offered by an MCO are extra services approved by HHSC. Value-added services will vary by MCO.
STAR+PLUS Health Plan profiles are located on the Health and Human Services (HHS) website at:
The case worker is no longer required to wait for appeal decisions from MCOs to process requests for Title XX services if the service requested is not a value-added service on the member’s plan. Once released from the Title XX interest list, the case worker verifies the applicant’s MCO does not offer an equivalent service as a value-added service and proceeds with the eligibility determination for the requested Title XX service.
In some situations, a STAR+PLUS member or his MCO may request and be granted disenrollment of the member from managed care. Whether the disenrollment is voluntary or involuntary, disenrolled individuals can receive available HHSC services (both Medicaid and Title XX) if determined eligible.
6421 Disenrollment from STAR+PLUS
Revision 17-1; Effective March 15, 2017
In some situations, a STAR+PLUS member or his managed care organization (MCO) may request and be granted disenrollment of the member from managed care. Whether the disenrollment is voluntary or involuntary, disenrolled individuals can receive available HHSC services (both Medicaid and Title XX) if determined eligible.
6421.1 Disenrollment Due to Health and Safety Issues
Revision 17-1; Effective March 15, 2017
When a managed care organization (MCO) requests disenrollment for a STAR+PLUS member due to non-compliance, including behavioral issues, the MCO submits a disenrollment request to the Texas Health and Human Services Commission (HHSC) Health Plan Management (HPM). The HPM team reviews the request to determine if there is sufficient information to send to the HHSC Disenrollment Committee. The Disenrollment Committee reviews the information and determines if disenrollment is appropriate. If so, the STAR+PLUS member is disenrolled from STAR+PLUS.
When an individual on STAR+PLUS personal attendant services or STAR+PLUS Waiver services is disenrolled from STAR+PLUS due to threatening behaviors, the individual may immediately apply with HHSC for services.
HPM will send an email to the HHSC Regional Support and Program Improvement (RSPI) worker advising when a STAR+PLUS member has been disenrolled from STAR+PLUS due to threats to health and safety and will provide information on the nature of the behavioral issues. This is to protect the health and safety of service providers and HHSC staff who will assess the individual for HHSC services. The RSPI worker will send the information to the regional director of the region where the individual lives advising that the individual has been disenrolled from STAR+PLUS and may be calling HHSC to apply for services. The regional director will establish procedures for disseminating this information to staff who perform intakes.
If the individual calls HHSC requesting services, the intake is assigned to a case worker. The intake staff must note in the Comments section on Form 2110, Community Care Intake, this individual has been disenrolled from STAR+PLUS due to threats to health and safety and include all information provided from the regional director.
The case worker conducts the initial interview and assessment according to standard procedures, but during the initial interview the case worker advises the individual:
- he must comply with program guidelines; and
- any threatening behavior may result in immediate termination of services.
Unless the individual displays threatening behavior during the initial interview, the case worker proceeds with the application process and authorizes services if the individual meets eligibility requirements. The case worker must issue a written notice to the individual at the initial authorization advising the individual he must comply with service delivery provisions or his services may be terminated immediately on the first report of any behavior that threatens health or safety.
If the HHSC case worker encounters threatening or non-compliant behavior or receives a report from the Home and Community Support Services Agency (HCSSA) or other providers of threatening behavior or non-compliance with services delivery provisions, services are immediately suspended.
The case worker must consult with the supervisor regarding the alleged behaviors. If the supervisor determines the alleged behavior does not warrant termination, the case worker follows the policy in Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions.
If the supervisor agrees the individual is a threat to health or safety, then services are terminated. The case worker sends Form 2065-A, Notification of Community Care Services, to the individual terminating services on the date of the suspension. The case worker cites 40 Texas Administrative Code (TAC) §48.3903 (b) and enters a statement in comments that services are terminated due to threats to health and safety.
The individual has the right to appeal, but services do not continue during the appeal process. The case worker must document the consultation and all other actions in the case record.
6430 Transition Between HHSC and STAR+PLUS
Revision 22-3; Effective Sept. 1, 2022
Mandatory STAR+PLUS members may continue to receive their current non-Medicaid services from HHSC until the managed care organization (MCO) can authorize Medicaid services.
Example: A member can continue to receive Family Care until the MCO authorizes Primary Home Care (PHC).
These members may also be placed on an interest list for a non-Medicaid service.
Applicants who are already enrolled with an MCO and request PHC or Day Activity and Health Services (DAHS) from HHSC must be advised to contact their MCO.
Use the following procedures for recipients who become eligible for Supplemental Security Income (SSI) or any Medicaid eligibility program that requires mandatory enrollment for STAR+PLUS while on Family Care (FC), Community Attendant Services (CAS) or Title XX DAHS:
- If the recipient is already enrolled when CCSE staff are notified of the Medicaid eligibility, check with the provider to see if they have received a service authorization from the MCO.
- If yes, terminate the case the day before the STAR+PLUS service authorization’s begin date.
- If no, terminate the case and refer the recipient to the MCO. Send Form 2065-A, Notification of Community Care Services, with the contact information for the enrollment broker, deny services and allow 30 calendar days adverse action for the recipient to contact the enrollment broker and request services from the MCO.
- If the recipient is not enrolled when CCSE staff are notified of the Medicaid eligibility, CAS or Title XX DAHS will be transferred to PHC or Title XIX DAHS. CCSE staff will notify the recipient of the transfer and refer them to the enrollment broker to choose an MCO that serves their area.
- Once notified that the recipient has been enrolled with an MCO, CCSE staff will terminate the PHC or Title XIX DAHS effective the day before the enrollment begin date.
Since Medicaid may be authorized retroactively, billing issues may occur during the MCO enrollment process. CCSE staff should address any billing issues that occur with the Regional Claims Management Services coordinator.
To help identify any STAR+PLUS issues, regional staff currently receive a report identifying recipients who are potentially eligible for STAR+PLUS. Regional staff also receive a report to help identify recipients receiving PHC or DAHS but are also enrolled in STAR+PLUS and receiving PAS or DAHS through their health maintenance organization (HMO).
Upon receipt of these reports, staff must review and take appropriate action. Either deny or notify the recipient that they need to contact the enrollment broker for enrollment with an MCO using the same procedures as above.
Interest List Procedures, 2230