Participation in the STAR Kids program is required for those who are 20 or younger, covered by Medicaid, and meet at least one of the following criteria:
- Receive Supplemental Security Income (SSI)
- Receive SSI and Medicare
- Receive services through the Medically Dependent Children Program (MDCP) waiver
- Receive services through the Youth Empowerment Services waiver
- Live in a community-based intermediate care facility for individuals with an intellectual disability or related condition or nursing facility
- Receive services through a Medicaid buy-in program
- Receive services through any of the following programs:
- Department of Aging and Disability Services
- Intellectual and Developmental Disability Waiver
- Community Living Assistance and Support Services
- Deaf Blind with Multiple Disabilities
- Home and Community-based Services
- Texas Home Living
Patient- Centered Care Planning
The STAR Kids program facilitates patient- and family- centered care planning through the use of an Individual Service Plan (ISP). The ISP helps coordinate communication between key health care providers, the patient, family/caregiver, and the managed care organization (MCO). The ISP includes the following information:
- Short and long-term patient and family goals
- Health care service needs and preferences
- Clinical assessment findings
The ISP is a customizable document informed by input from the patient, family/caregiver, clinician, and service coordinator. The ISP is also informed by results from the STAR Kids Screening and Assessment Instrument (SK-SAI), which is comprised of multiple assessment modules. All STAR Kids members complete the core SK-SAI module, which assesses the following information:
- Patient and family preferences
- Follow-up assessment needs
- Appropriate level of care coordination services necessary for each patient
- Medical necessity and Resource Utilization Group levels for members in MDCP
- Medical necessity for Medicaid state plan service Community First Choice
Information obtained through the core SK-SAI module may result in the completion of additional SK-SAI modules, depending on patient, family, and caregiver needs. Additional SK-SAI modules focus on topics such as personal care and nursing care needs.
Service coordinators are responsible for adhering to, monitoring, and appropriately updating ISPs for each patient and family. To ensure the ISP remains relevant and current, the document must be updated annually and with any of the following events:
- Following a significant change in a health condition
- Upon request from the patient, family/caregiver, and/or clinician
- Following a change in life circumstance
- Following the first administration of the SK-SAI, or a reassessment process
The ISP may also be used to measure health outcomes over time by the MCO and the Texas Health and Human Services Commission.
As part of the Texas STAR Kids program, each health plan supports service coordination services, which help identify patient and family needs and subsequently connect patients and families to appropriate supports and services. As part of the service coordination structure, MCOs must establish relationships with state, local, and community programs, such as Title V, in order to make appropriate referrals for patients and families.
All STAR Kids members are eligible to receive service coordination virtually (via telephone) and in-person through a designated STAR Kids service coordinator. Members are individually matched to service coordinators with appropriate experience to help identify, select, obtain, coordinate, and utilize appropriate supports and services.
Service coordinators are required to implement the following activities:
- Conduct a holistic evaluation of the member's individual needs and preferences
- Provide health-related information, such as results from the SK-SAI and the ISP, to the patient, caregiver, and professionals who provide care to each member and family
- Identify physical, behavioral, functional, and psychological needs and ensure services are received in a timely and appropriate manner
- Engage the member, family, and/or caregiver in the creation of the ISP
- Coordinate and connect the patient, family, and/or caregiver to necessary supports and services
- Intervene on behalf of the patient in approved circumstances
Additionally, patients that are determined to benefit from a multidisciplinary approach to service coordination, or require specialized service coordination expertise, will receive access to an individualized service coordination team. Service coordination may also be provided through a practice that functions as a medical home and meets STAR Kids program requirements (see below).
Access to a Medical Home Approach to Care
The STAR Kids program facilitates a medical home approach to care for members and families based on individual needs, which are determined through a combination of SK-SAI results and ISP development, as well as conversations and goals of the families and members.
Clinicians are contracted with a managed care organization to provide Medicaid managed care services. All participating primary care providers must serve as a medical home for STAR Kids members. Under Texas Government Code § 533.00253(a)(2), a medical home must incorporate the following characteristics:
- A team-based approach to care
- Comprehensive care coordination services
- Family-centered care
- A system of data management to improve outcome-based quality of care and increase member, family, and clinician satisfaction
Minimum required medical home services include the following:
- Self-management education for members and families/caregiver
- Education to assist clinicians with implementing components of the medical home model
- Member- and family-centered care
- Evidence-based models and minimum standards of care
- Support to members, families, and caregivers (including any person or entity acting on behalf of the member with written consent)
In addition to provision of care within a medical home, the STAR Kids program includes provisions to enable families to seek out-of-service area and out-of-network providers who are critical to their care, thereby enhancing access to specialty care services, particularly for children with medical complexity.