Most Medicaid recipients are enrolled in STAR Medicaid. They include individuals who receive cash assistance, are pregnant, or have limited income. Most children who receive Medicaid benefits are enrolled in STAR Medicaid.
STAR MCOs are responsible for providing service management to clients identified as “members with special health care needs” (MSHCN). Service management is an administrative benefit performed by the MCO to help develop a service plan and coordination of services among a member’s primary care provider, specialty health-care providers, and non-medical providers. The service plan and service coordination ensure that each member with special health-care needs has access to—and appropriately uses—medically necessary covered services, non-capitated services, and other services and supports.
Service management may include assistance with setting up appointments, locating specialty providers, and member health assessments. Service management is available to MSHCN and other populations such as women with high-risk pregnancies, individuals with mental illness and co-occurring substance abuse, children of migrant farmworkers, and children formerly in foster care.
These services are usually provided by telephone and may differ from the Case Management for Children and Pregnant Women services that a client may require. In those cases, a client may receive service management from his or her MCO as well as services from Case Management for Children and Pregnant Women.
Twenty-year-old Twila is pregnant, homeless, and depressed. She receives prenatal health care through STAR Medicaid. Her Case Management for Children and Pregnant Women case manager helps Twila locate temporary housing and refers her to a mental health counselor.
Six-year-old Miley is having behavioral problems in school. She is aggressive toward other students and throws herself to the ground when she is upset. Her case manager assists Miley’s mother by providing referrals to a child psychiatrist and play therapy. The case manager also helps Miley’s mother arrange an evaluation at school and attends school meetings to advocate for a behavioral plan and other school services that could help Miley.
STAR Health Medicaid
All Texas children and youth in foster care are enrolled in STAR Health.
The MCO is responsible for all service coordination needs. For case management needs beyond the capacity of STAR Health, the MCO contacts HHSC for a referral to the Texas Department of State Health Services (DSHS) regional case management program.
STAR Kids Medicaid
STAR Kids provides Medicaid benefits to Texas children and young adults 20 years and younger who have disabilities. Medicaid recipients must meet at least one of the following requirements:
- Receive SSI
- Receive SSI and Medicare
- Receive services through the Medically Dependent Children Program (MDCP) waiver
- Receive services through the Youth Empowerment Services (YES) waiver
- Live in a community-based intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) or nursing facility
- Receive services through a Medicaid Buy-In program
- Receive services through any of the programs for intellectual and developmental disability waivers:
- Community Living Assistance and Support Services (CLASS)
- Deaf Blind with Multiple Disabilities (DBMD)
- Home and Community-based Services (HCS)
- Texas Home Living (TxHmL)
STAR Kids MCOs provide service coordination for their members. Each client has an individual MCO service coordinator or service coordination team. The number of required service coordination visits or telephone calls and level of service coordination varies by need and the personal preference of clients or their legally authorized representatives. Because the MCO is responsible for service coordination to address all medical needs, including mental health, the role of the Case Management for Children and Pregnant Women case manager is different for individuals covered by STAR Kids.
A Case Management for Children and Pregnant Women case manager can help when there is a need for assisting with, advocating for, and coordinating education or school services for a client.
Eight-year-old Trent has autism spectrum disorder (ASD). His STAR Kids service coordinator performed an assessment recently, which allowed Trent to begin receiving personal care services at home. However, Trent’s mother is concerned because he does not receive assistance with toileting and eating at school. For example, Trent can easily choke if his food is not cut into small pieces. His STAR Kids service coordinator makes a referral to Case Management for Children and Pregnant Women to assist with Trent’s school needs. The case manager helps Trent’s mother set up a school meeting and then attends the meeting to provide advocacy for Trent.
Traditional Fee-For-Service Medicaid
Traditional FFS Medicaid covers new recipients for 30 to 45 days after they are approved for benefits. After that, recipients begin receiving benefits from an MCO in their area.
Vincent and his family recently moved to Texas from out of state. Vincent is diagnosed with bipolar disorder and takes medications. The Case Management for Children and Pregnant Women case manager helps Vincent’s father find a pediatric primary care provider, a child psychiatrist, and a mental health counselor. Vincent receives SSI benefits so he will transition to STAR Kids Medicaid next month. The case manager also will attend a school meeting at the father’s request to help advocate for accommodations for Vincent at his new school.
Quick Guide to Eligibility for Services from Case Management for Children and Pregnant Women
|Type of Medicaid
|Service Coordination/Case Management provided by health plan?
|May be eligible for Case Management for Children and Pregnant Women?
|Service management to MSHCN
|Yes; only for school-related needs
|No health plan