1300, STAR+PLUS Services and Service Delivery Options

Revision 19-13; Effective November 5, 2019

Individuals enrolled in the STAR+PLUS program may select a service delivery model for personal assistance services (PAS) or Community First Choice (CFC) services identified on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H6516, Community First Choice Assessment, and Form H2060-A, Addendum to Form H2060. Individuals receiving STAR+PLUS Home and Community Based Services (HCBS) program services may reside alone, with family members or others at locations of their choice in the community, including adult foster care (AFC) homes or licensed assisted living facilities (ALFs).

The STAR+PLUS HCBS program provides individuals with an array of services necessary to allow the individual to remain in, or return to, a community setting. Providers contracted with managed care organizations (MCOs) provide STAR+PLUS HCBS program services identified on the individual service plan (ISP). The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services. Program Support Unit (PSU) staff coordinate with Medicaid for the Elderly and People with Disabilities (MEPD) specialists to determine financial eligibility for individuals not eligible for Supplemental Security Income (SSI). SSI eligible individuals are Medicaid eligible and can obtain STAR+PLUS HCBS program services without additional financial screening. Refer to Section 3110, Medicaid, Medicare and Dual-Eligibles, for additional information.

STAR+PLUS members choose to participate in the agency option (AO), consumer directed services (CDS) option or service responsibility option (SRO) delivery models.

  • Members who choose the AO model work with the MCO to coordinate service delivery for each service in the ISP.
  • Members who choose the CDS model are given the authority to self-direct designated services. The MCO coordinates delivery of non-member-directed designated services if the member chooses to self-direct designated services. In the CDS model, providers employed by the member or authorized representative (AR) must be qualified personnel to provide authorized services when services are necessary. These personnel may be employed directly by, or through, personal service agreements or subcontracts with the providers. A member's services and service providers must be based on an MCO assessment of the member’s individual needs. Refer to the STAR+PLUS Handbook (SPH), Appendix XXVIII, CDS Training for Service Coordinators and CDS Training Manual, for additional information.
  • In the SRO model, the provider is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The provider also orients attendants to provider policies and standards before sending them to members' homes. The member or designated representative (DR) 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.

Refer to SPH Section 8000, Service Delivery Options, for additional information.

 

1310 Program Services

Revision 19-13; Effective November 5, 2019

 

1311 Services Available Under STAR+PLUS

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) will assess the member and develop an appropriate individual service plan (ISP) when the service coordinator identifies a need or the member requests additional services. Since MCOs are at risk for paying for a range of acute care and long-term services and supports (LTSS), there is an incentive to provide innovative, cost effective care from the onset in order to prevent or delay the need for more costly institutionalization.

STAR+PLUS members who do not have Medicare are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These individuals can choose a specialist to be their PCP and they receive all services, both acute care and LTSS, from the MCO.

Members who receive both Medicaid and Medicare (dual-eligible) choose an MCO, but not a PCP, because dual-eligible members receive acute care from their Medicare providers. The STAR+PLUS program does not impact Medicare services or service delivery in any way. The STAR+PLUS MCO only provides Medicaid LTSS to dual-eligible members.

The STAR+PLUS program serves as an insurance policy if members have a need for LTSS at a future time. Refer to Section 3110, Medicaid, Medicare and Dual-Eligible, for additional information on dual-eligible coverage.

Medicaid-only members (those who do not receive Medicare) receive traditional Medicaid acute care services plus an annual check-up. For these members, the cost of acute care services is included in the capitation payment to the MCO. For dual-eligible members, the MCO’s capitation payment does not include the cost of acute care.

 

1312 Long Term Services and Supports

Revision 19-13; Effective November 5, 2019

Day Activity and Health Services (DAHS) and personal attendant services (PAS) are available to STAR+PLUS members who meet functional eligibility requirements. Community First Choice (CFC) services are available to STAR+PLUS members who meet an institutional level of care (LOC), meet functional eligibility requirements, and who receive Supplemental Security Income (SSI) or receive SSI-related Medicaid. Additional services are available under the STAR+PLUS Home and Community Based Services (HCBS) program. For a complete list of services provided under the STAR+PLUS program, refer to the managed care contracts governing the STAR+PLUS program at https://hhs.texas.gov/services/health/provider-information/managed-care-contracts-manuals.

 

1320 Services Available to STAR+PLUS Members

Revision 19-13; Effective November 5, 2019

STAR+PLUS program members have access to medically and functionally necessary services available in the Medicaid state plan. Some members are eligible for additional services available in the STAR+PLUS Home and Community Based Services (HCBS) program, in addition to their traditional Medicaid state plan STAR+PLUS services.

The Texas Health and Human Services Commission (HHSC) contracts with Medicaid managed care organizations (MCOs) for the provision of STAR+PLUS services. These Medicaid MCOs are responsible for providing a benefit package to members that include all medically-necessary services covered under the traditional, fee-for-service (FFS) Medicaid programs, except for non-capitated services provided to Medicaid members outside of the MCO capitation and listed in each managed care contract. (For example, Attachment B-1, Section 8.2.2.8, of the Uniform Managed Care Contract (UMCC).

STAR+PLUS members also receive enhanced benefits compared to the traditional FFS Medicaid coverage:

  • waiver of the three-prescription per month limit for members not covered by Medicare; and
  • waiver of spell illness limitation for members admitted to a facility as a result of the serious and persistent mental illness (SPMI).

Medicaid MCO contractors are responsible for providing a benefit package to members that includes an annual adult well check for members and prescription drugs. STAR+PLUS MCO contractors should refer to the current Texas Medicaid Provider Procedures Manual (TMPPM) and the Texas Medicaid Bulletin postings for a more inclusive listing of limitations and exclusions that apply to each Medicaid benefit category. (These documents can be accessed online at: www.tmhp.com.)

The services listed in the managed care contracts (for example, UMCC) are subject to modification based on federal and state laws and regulations and program policy updates.

 

1330 Acute Care Services Included Under the MCO Capitation Payment

Revision 19-13; Effective November 5, 2019

Services included under the managed care organization (MCO) capitation payment include:

  • ambulance services;
  • audiology services, including hearing aids;
  • behavioral health services, including:
    • inpatient mental health services;
    • outpatient mental health services;
    • outpatient chemical dependency services;
    • mental health rehabilitation for non-duals;
    • mental health targeted case management for non-duals;
    • detoxification services;
    • psychiatry services; and
    • counseling services;
  • birthing services provided by a certified nurse midwife in a birthing center;
  • chiropractic services;
  • dialysis;
  • durable medical equipment (DME) and supplies;
  • Emergency Response Services (ERS);
  • family planning services;
  • home health care services for acute conditions;
  • hospital services;
  • laboratory;
  • long-term services and supports (LTSS) (Refer to Section 1340, Long Term Services and Support Listing, below);
  • medical checkups and Comprehensive Care Program (CCP) services for Medicaid for Breast and Cervical Cancer (MBCC) members under age 21;
  • oncology services;
  • optometry, glasses and contact lenses, if medically necessary;
  • podiatry;
  • prenatal care;
  • prescription drugs;
  • primary care services (PCS);
  • preventive services including an annual adult well check;
  • radiology, imaging and X-rays;
  • specialty physician services;
  • therapies, including physical, occupational and speech for acute conditions;
  • transplantation of organs and tissues; and
  • vision services.

 

1340 Long Term Services and Support Listing

Revision 19-13; Effective November 5, 2019

The following is a non-exhaustive, high-level listing of community-based long-term services and supports (LTSS) included under the STAR+PLUS program:

  • Community First Choice (CFC) - Available to all Medicaid-eligible members (except for members who are considered medical assistance only (MAO) 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 psychiatric hospital (also called an institution for mental disease). CFC services are provided in a community-based setting. Community-based settings do not include:
    • hospitals;
    • NFs;
    • institutions for mental disease (IMD);
    • ICF/IID; and
    • any setting with the characteristics of an institution.
  • CFC services include:
    • Emergency Response Services (ERS), which are backup systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports;
    • habilitation services, which provide acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks;
    • personal assistance services (PAS), which help with ADLs, IADLs and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks; and
    • support management, which is training provided to members or authorized representatives (ARs) on how to manage and dismiss their attendants.
  • Day Activity and Health Services (DAHS) — All members of a STAR+PLUS managed care organization (MCO) may receive medically and functionally necessary DAHS. DAHS includes nursing and PAS, therapy extension services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed by the state.
  • Nursing facilities (NFs) — Institutional care to a member whose physician has certified that the member has a medical condition that requires 24-hour nursing care that meets medical necessity (MN) requirements. The need for custodial care solely does not constitute MN for an NF placement. Institutional care includes coverage for the medical, social and psychological needs of each resident, including room and board (R&B) charges, social services, medications not covered by Medicare Part B or D, medical supplies and equipment, rehabilitative services and personal needs items.
  • PAS, formerly known as Primary Home Care (PHC) PAS — All members may receive medically and functionally necessary PAS. PAS includes assisting the member with the performance of ADLs and household chores necessary to maintain the home in a clean, sanitary and safe environment. The level of assistance provided is determined by the member's need and the plan of care (POC). To be eligible for Medicaid state plan PAS, the MCO must assess applicants in a face-to-face visit. Members are assessed using Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment. To be eligible for PAS through programs other than CFC or the STAR+PLUS Home and Community Based Services (HCBS) program, members must score at least 24 on Form H2060. PAS includes three service delivery options:
    • Agency Option (AO);
    • Consumer Directed Services Option (CDS); and
    • Service Responsibility Option (SRO).
  • STAR+PLUS HCBS program — This is for those members who qualify for such services. The state also provides an enriched array of services to members who would otherwise qualify for NF care through the STAR+PLUS HCBS program. The MCO must also provide medically necessary services that are available to members who meet the functional and financial eligibility for the STAR+PLUS HCBS program.

 

1350 Services Available to STAR+PLUS HCBS Program Members

Revision 19-13; Effective November 5, 2019

Services necessary for the member to remain in or return to the community are identified from the array of services available through the STAR+PLUS Home and Community Based Services (HCBS) program. STAR+PLUS HCBS program services include:

  • Adaptive aids and medical supplies;
  • Adult foster care (AFC);
  • Assisted living (AL) services;
  • Cognitive rehabilitation therapy (CRT);
  • Dental services;
  • Emergency Response Services (ERS);
  • Employment Assistance (EA) services;
  • Financial Management Services (FMS);
  • Home-delivered meals (HDM);
  • Minor home modifications (MHMs);
  • Nursing services;
  • Occupational therapy (OT) services;
  • Personal assistance services (PAS);
  • Physical therapy (PT) services;
  • Respite care services;
  • Speech therapy (ST) services;
  • Supported Employment (SE) services; and
  • Transition Assistance Services (TAS).