Managed care means you get Medicaid services through a select group of doctors, hospitals, and other health care providers --called a provider network -- through a health plan you pick.
A medical home is where you get your basic care. It includes your primary care provider. It helps build the relationships between the patient and family with the doctor and other care providers.
When you join STAR Kids, you will pick a primary care provider. This is a doctor, nurse, or clinic where you will get basic medical care and get referrals for other care. Primary care providers are a medical home to members. They get to know you and your health history. Your primary care provider can be one of the following:
If you have Medicare, you won't need to pick a primary care provider.
You may change your PCP by making a request through our secure member portal or by calling Member Services toll-free at 1-855-607-7827.
Your primary care provider will help you with basic medical care. If you need other medical services, your primary care provider will give you a referral. For example, if you need to see a specialist or go to the hospital, your primary care provider will set that up for you.
You don't need a referral from your primary care provider for some services, like:
STAR Kids is a new Texas Medicaid managed care program for children and adults 20 or younger who have disabilities. Under STAR Kids, you get basic medical and long-term services and supports through Community First’s provider network. Long-term services and supports include things like help in your home with basic daily activities, and help participating in community activities, if you are eligible. You also will get Medically Dependent Children Program (MDCP) waiver services through Community First’s provider network, if you are eligible. STAR Kids will begin November 1, 2016.
Everyone will get:
If you get services through a Department of Aging and Disability Services (DADS) intellectual and developmental disability (IDD) waiver, the Youth Empowerment Services (YES) waiver, or live in an Intermediate Care Facility (ICF-IID), you will get your long-term services and supports through your waiver or facility, the way you do today.
If you get services through Medically Dependent Children Program (MDCP) waiver, you will get those services through Community First Health Plans.
Community First Health Plans nurses and other professionals will be your service coordinators. Their services include things like:
These are the extra services offered by Community First Health Plans. They include:
When you get your enrollment packet in August, check the enclosed provider directories for the providers you see today. If one of your doctors isn't listed, call Community First at 1-855-607-7827 to see if they are contracted with them. You can also talk to your doctor about joining Community First Health Plans.
You can make a list of all the providers your child sees, and contact them to encourage them to enroll with Community First Health Plans. You can also share your provider list with Community First and ask them to contract with your providers if they haven't done so already. You can do this today.
STAR Kids health plans must try to contract with all Medicaid providers who see children going into STAR Kids today. Providers don't have to contract with a health plan if they don't want to. Health plans and providers can do single-case agreements in some situations if a provider only wants to see you, but not everyone else in STAR Kids.
If you have private health insurance, your private insurance will pay first, then Community First will pay the rest of any service covered by Medicaid.
The law requires that orders, referrals, and prescriptions for Medicaid services come from a Medicaid enrolled provider. If your private primary care provider will be ordering, referring, or prescribing Medicaid services, your doctor must complete a shortened application to continue ordering, referring, or prescribing services or medicines that will be reimbursed by Medicaid.
HHSC is working with private providers around the state to try to get them to enroll in Medicaid, but it is important for you to talk to your providers, too. Tell them how important it is to enroll with Medicaid so they can continue your care. There are no fees to complete the shortened ordering, referring, and prescribing process, and they can sign up electronically or on paper. If your private provider is ordering, referring, or prescribing Medicaid services, they should visit the following links:
After you have joined Community First, your STAR Kids service coordinator can help coordinate between private providers and Medicaid providers.
If you have Medicare and Medicaid, you are known as a "dual eligible," and will keep getting most of your basic health-care services through your Medicare doctors. STAR Kids will not change the way you get Medicare services.
Medicare will pay for most of your basic healthcare services, and traditional Medicaid will pay for services that are covered by Medicaid but aren't covered by Medicare. If you have Medicare, you won't pick a STAR Kids primary care provider.
After you have picked Community First as your health plan, your Community First STAR Kids service coordinator will help coordinate between Medicare providers and Medicaid providers.
If your private primary care provider isn't contracted with Community First Health Plans, you will have to pick a STAR Kids primary care provider. This means you will have two primary care providers: a private primary care provider and a STAR Kids primary care provider. After you have picked Community First as your health plan and primary care provider, your Community First service coordinator will help coordinate between private providers, Medicaid providers, and Medicare providers.
For more information about the STAR Kids program, visit the Texas Health and Human Services Commission website.