An official State of Texas website.
Revision 22-3; Effective Dec. 1, 2022
STAR Kids members are entitled to all medically and functionally necessary services available in the same amount, duration and scope as in traditional fee-for-service Medicaid. This is described in the Texas Medicaid State Plan and the Texas Medicaid Provider Procedure Manual (TMPPM) through the member’s selected managed care organization (MCO).
1210 Acute Care Services
Revision 22-3; Effective Dec. 1, 2022
STAR Kids members must receive any medically necessary services through their managed care organization (MCO) per the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) of Individuals Under Age 21, (42 CFR Part 441). This includes, but is not limited to:
- ambulance services;
- audiology services, including hearing aids;
- behavioral health services, including:
- in-patient mental health services;
- out-patient mental health services;
- out-patient chemical dependency services for children;
- detoxification services; and
- psychiatry services;
- birthing services provided by a certified nurse midwife in a birthing center;
- chiropractic services;
- dialysis;
- durable medical equipment and supplies;
- emergency services;
- family planning services;
- home health care services;
- hospital services, inpatient;
- hospital services, out-patient;
- laboratory;
- medical checkups and Comprehensive Care Program (CCP) services for children and young adults through the Texas Health Steps (THSteps) Program;
- oral evaluation and fluoride varnish in conjunction with THSteps medical checkup for children six months through 35 months of age;
- optometry, glasses and contact lenses, if medically necessary;
- podiatry;
- prenatal care;
- primary care services;
- radiology;
- specialty physician services;
- therapies, including physical, occupational and speech;
- transplantation of organs and tissues; and
- vision services.
STAR Kids members who have other insurance, like Medicare or private insurance, will receive most of their acute care services through their primary insurance. Members receive dental care through their primary insurer, through their selected Medicaid dental maintenance organization (DMO), or through a Medicaid fee-for-service model.
1220 Long Term Services and Supports
Revision 23-4; Effective Dec. 1, 2023
STAR Kids members who have an assessed need for long term services and supports (LTSS), identified by the STAR Kids Screening and Assessment Instrument (SK-SAI), may receive the following services through their STAR Kids managed care organization (MCO):
- Attendant care is hands-on medical and non-medical care specific to meet the needs of a person. It includes skilled medical care, to the extent permitted by state law, and housekeeping activities which are incidental to the performance of the client-based care. Attendant care services include:
- Day activity and health services (DAHS) which includes nursing and personal care services, therapy extension services, nutrition services, transportation services and other supportive services. DAHS is for members 18 through 20 years and is provided at an adult day center.
- Personal care services (PCS) are a Texas Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) benefit for STAR Kids members.
- PCS includes help with activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks. Members who meet an institutional level of care receive personal care services through Community First Choice Personal Assistance Services (CFC-PAS). See below for more information.
- Prescribed pediatric extended care center (PPECC) is a facility that provides nonresidential basic services. These services include medical, nursing, psychosocial, therapeutic and developmental services to medically dependent or technologically-dependent members under 21 for up to 12 hours per day. Members who qualify for private duty nursing also qualify for PPECC services.
- Private duty nursing (PDN) services are a Texas Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) benefit for STAR Kids members. PDN services are nursing services, as described by the Texas Nursing Practice Act and its implementing regulations, for clients who meet the medical necessity criteria and who require individualized, continuous, skilled care beyond the level of skilled nursing (SN) visits normally authorized under Texas Medicaid Home Health SN and Home Health Aide (HHA) services.
Community First Choice (CFC)
CFC services are available to all STAR Kids members who have an assessed need for LTSS, identified by the SK-SAI, and who meet an institutional level of care (LOC) for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), or an institution for mental disease.
Members enrolled in a Section 1915(c) Medicaid waiver program for individuals with an intellectual disability or related condition (ID/RC) receive CFC through their waiver provider. CFC services include:
- Personal Assistance Services, also called CFC-PAS assists with ADLs, IADLs, and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks. Members who meet a CFC LOC must have PAS billed through CFC. Members may not be authorized for PCS and CFC-PAS at the same time.
- Habilitation, also called CFC habilitation or CFC-HAB, provides acquisition, maintenance and enhancement of skills necessary for the member to accomplish ADLs, IADLs and health-related tasks.
- Emergency response services (ERS), which are back-up systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports.
- Support management, which is training provided to members or legally authorized representatives (LARs) on how to manage and dismiss their attendants.
Medically Dependent Children Program (MDCP) – Additional Services
STAR Kids members enrolled in the Medically Dependent Children Program (MDCP) are eligible for additional services through their MCO as a cost-effective alternative to living in a nursing facility (NF). Receipt of MDCP services does not impact a member's eligibility for other LTSS available in STAR Kids. Additional services available to STAR Kids members in MDCP include:
- Adaptive aids needed to treat, rehabilitate, prevent or compensate for a condition that results in a disability or a loss of function and helps a member perform the ADLs or control the environment where they live. Adaptive aids must only be authorized after exhausting all Medicaid state plan services and other third-party resources.
- Employment assistance is provided to a member to help the member locate paid, competitive employment in the community.
- Financial management services (FMS) for members who choose the Consumer Directed Services (CDS) option. FMS helps members manage funds related to the services delivered through the CDS option. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers.
- Flexible family support services, which are direct care services needed because of a member's disability that help a member participate in child care, post-secondary education, employment, independent living, or support a member's move to an independent living situation.
- Minor home modifications are physical changes to a member's residence that are needed to prevent institutionalization or to support the most integrated setting for a member to stay in the community.
- Respite services are short-term direct care services needed because of a member's disability. They provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.
- Supported employment helps to sustain paid, competitive employment to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting where members without disabilities are employed.
- Transition assistance services are a one-time service provided to a Medicaid-eligible resident of an NF located in Texas to help the resident move from the NF into the community to receive MDCP services.
1230 Service Delivery Options for Certain Long-Term Services and Supports
Revision 22-3; Effective Dec. 1, 2022
STAR Kids provides members with an array of services identified on the individual service plan (ISP). Services are delivered by providers contracted with managed care organizations (MCOs) to provide those services. The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services.
STAR Kids members may choose from the following three service delivery options for the delivery of certain long-term services and supports (LTSS):
- Agency option
- Service Responsibility Option (SRO)
- Consumer Directed Services (CDS)
Members who choose the agency option select an MCO-contracted agency to deliver the services on their ISP.
Members who choose CDS are given the authority to self-direct certain services. If the member chooses to self-direct one or more approved CDS services, the MCO coordinates delivery of non-member directed services. In the CDS option, the member or their LAR, with assistance from a financial management service agency (FMSA), ensures the necessary supplies are obtained to provide all authorized services. FMSA personnel may be employed directly by, or through personal service agreements or contracts with, the providers.
In the delivery of state plan LTSS, the SRO may only be used for attendant care. A provider agency chosen by the member or their LAR is the employer of record for the attendant and handles business details (for example, paying taxes and conducting payroll). The agency also orients attendants to agency policies and standards before sending them to the member’s home. The member or their LAR is responsible for most of the day-to-day management of the attendant's activities, beginning with interviewing and selecting the person who will be the attendant.
State plan LTSS available through the CDS and SRO service delivery options are:
- Community First Choice habilitation (CFC-HAB);
- Community First Choice personal assistance services (CFC-PAS), referred to as CFC-PCS for children; and
- Personal care services (PCS) (non-CFC).
STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose the CDS option for the following services:
- employment assistance;
- flexible family support services;
- respite;
- supported employment;
- minor home modifications; and
- adaptive aids.
STAR Kids members receiving MDCP services may choose the SRO option for the following services:
- Employment assistance
- Flexible family support services
- Respite
- Supported employment
Find more information about these service delivery options in 5000, Service Delivery Options.