Texas Health and Human Services Commission
Effective: June 2, 2014
State of Texas Access Reform Plus (STAR+PLUS) Managed Care
1100 Program Overview
The 74th Texas Legislature implemented the State of Texas Access Reform Plus (STAR+PLUS) program to create a cost-neutral managed care system to combine acute care with long-term services and supports (LTSS). The STAR+PLUS program does not change Medicaid eligibility or services. It does change the way Medicaid services are delivered.
The STAR+PLUS program combines acute care and LTSS, such as assisting in a member's home with activities of daily living, home modifications, respite (short-term supervision) and personal assistance. These services are delivered through providers contracted with managed care organizations (MCOs).
STAR+PLUS provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid members.
Service coordination, available to all members, is the main feature of STAR+PLUS. It is a specialized case management service for program members who need or request it. Service coordination means that plan members, family members, and providers can work together to help members get acute care, LTSS, Medicare services for dually-eligible members and other community support services.
The HCBS STAR+PLUS Waiver (SPW) is a waiver approved for the managed care delivery system, designed to allow individuals who qualify for nursing facility care to receive LTSS in order to be able to live in the community.
Elements of the STAR+PLUS system are different from traditional service delivery. See the Glossary for the definition of terms specific to STAR+PLUS. For a dictionary of acronyms used in the STAR+PLUS Program, refer to Appendix VII, Acronyms Common to STAR+PLUS.
1110 Legal Basis
Statutory basis for the STAR+PLUS program:
- STAR+PLUS services
- HCBS STAR+PLUS Waiver (SPW)
- Texas Administrative Code §§353.601-607
The principles and practices that form the foundation for the HCBS STAR+PLUS Waiver (SPW) are based on the following values:
- Members receive waiver services based on their choices and ongoing assessment of their medical and functional needs.
- The service delivery system is accessible to the member, responsive to his/her needs and preferences, and flexible in honoring choices regarding living arrangement, services and mode of service delivery.
- Members use available family, community and third-party services and resources, as well as those provided through the waiver to meet their needs and identified goals.
- Services provided to the member must provide safe and cost-effective alternatives to nursing facility placement that allow the member the opportunity to use and maintain family and community contacts and services.
- The service plan reflects the member's active participation in the assessment and planning process and his/her responsibility to provide as much self-care as possible.
- Services must support the member's efforts to retain or regain as much independence as possible in the activities of daily living, living arrangement, other areas of personal choice and in meeting any goals.
- Managed care organizations are given the training, support and respect necessary to provide the quantity and quality of services required to support the member's efforts to remain in or return to the community.
- Within the constraints imposed by the cost limit on a member's individual service plan (ISP), the program promotes the member's active involvement and choices regarding the services provided.
1130 Service Model
1131 Service Delivery Model
Individuals receiving HCBS STAR+PLUS Waiver (SPW) services may reside alone, with family members or others at locations of their choice in the community, in Adult Foster Care homes, or in Assisted Living facilities licensed as personal care facilities.
The SPW provides individuals with an array of services, as identified on the individual service plan (ISP), necessary to allow the individual to remain in or return to a community setting. Services are delivered by providers contracted with managed care organizations (MCOs) to provide waiver services. The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services. The Program Support Unit coordinates with Medicaid for the Elderly and People with Disabilities staff to determine financial eligibility for those individuals not already eligible for Supplemental Security Income (SSI) and uses financial determinations by the Social Security Administration for those individuals already eligible for SSI. (See Section 3110, Medicaid, Medicare and Dual-Eligibles.)
SPW members may choose to participate in the agency option, consumer-directed services (CDS) or service responsibility option (SRO) delivery models. Members who choose the agency model select an MCO to coordinate service delivery for each service in the ISP. Members who choose CDS are given the authority to self-direct designated services. If the member chooses to self-direct designated services, the MCO coordinates delivery of non-member-directed designated services.
In the CDS model, providers must make available qualified personnel and equipment necessary to provide all authorized services when services are necessary. These personnel may be employed directly by or through personal service agreements or subcontracts with the providers. Linkages between members and service providers must be based on an MCO assessment of the memberís individual needs.
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.
1140 Program Services
1141 Services Available Under STAR+PLUS
Managed care organizations (MCOs) are required to contact all members upon enrollment and at least annually thereafter. If there is a need identified or a request from the member, the MCO assesses the member to determine needs and to develop an appropriate service plan (SP). 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 Medicaid-only members are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These individuals 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. STAR+PLUS does not impact Medicare services or service delivery in any way. The STAR+PLUS MCO only provides Medicaid LTSS to dual-eligible members.
STAR+PLUS serves as an insurance policy if members have a need for LTSS at a future time. See Section 3110, Medicaid, Medicare and Dual-Eligibles, 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 MCOís capitation payment does not include the cost of acute care.
1142 Long-term Services and Supports
Day Activity and Health Services and Primary Home Care are available to STAR+PLUS members who meet functional eligibility requirements. Additional services are available under the HCBS STAR+PLUS Waiver (SPW) which provides services and supports similar to those available under the Community Based Alternatives (CBA) Waiver. While eligibility criteria are similar, policies and procedures for the SPW differ from CBA policies and procedures. For a complete list of services provided under STAR+PLUS, refer to the STAR+PLUS website at: www.hhsc.state.tx.us/medicaid/manged-care/UniformManagedCareContract.pdf.
1143 STAR+PLUS Services
Services available to STAR+PLUS Program members depend on whether they receive HCBS STAR+PLUS Waiver services in addition to their regular STAR+PLUS services. See:
- Section 1143.1, Services Available to STAR+PLUS Members; and
- Section 1143.2, Services Available to HCBS STAR+PLUS Waiver Members.
1143.1 Services Available to STAR+PLUS Members
Medicaid managed care organization (MCO) contractors are responsible for providing a benefit package to members that includes all medically-necessary services covered under the traditional, fee-for-service Medicaid programs, with the exception of non-capitated services provided to Medicaid members outside of the MCO capitation and listed in Attachment B-1, Section 22.214.171.124, of the Uniform Managed Care Contract (UMCC).
STAR+PLUS members also receive two enhanced benefits compared to the traditional, fee-for-service Medicaid coverage:
- waiver of the three-prescription per month limit for members not covered by Medicare; and
- waiver of the $200,000 individual annual limit on inpatient services.
Medicaid MCO contractors are responsible for providing a benefit package to members that includes an annual adult well check for patients 21 years of age and over. Prescription drug benefits to MCO members are provided outside of the MCO capitation.
STAR+PLUS MCO contractors should refer to the current Texas Medicaid Provider Procedures Manual and the bi-monthly Texas Medicaid Bulletin 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 UMCC are subject to modification based on federal and state laws and regulations and program policy updates.
1143.1.1 Services Included Under the MCO Capitation Payment
Services included under managed care organization (MCO) capitation payment include:
- ambulance services;
- audiology services, including hearing aids, for adults (audiology services and hearing aids for children are a non-capitated service);
- behavioral health services, including:
- in-patient mental health services for adults and children;
- out-patient mental health services for adults and children;
- out-patient chemical dependency services for children (under age 21);
- detoxification services;
- psychiatry services; and
- counseling services for adults (21 years of age and over);
- birthing services provided by a certified nurse midwife in a birthing center;
- chiropractic services;
- durable medical equipment and supplies;
- emergency services;
- family planning services;
- home health care services;
- hospital services, out-patient;
- medical checkups and Comprehensive Care Program (CCP) services for children (under age 21) through the Texas Health Steps Program;
- oral evaluation and fluoride varnish in conjunction with Texas Health Steps medical checkup for children 6 months through 35 months of age;
- optometry, glasses and contact lenses, if medically necessary;
- prenatal care;
- primary care services;
- preventive services including an annual adult well check for patients 21 years of age and over;
- radiology, imaging and X-rays;
- specialty physician services;
- therapies, including physical, occupational and speech;
- transplantation of organs and tissues; and
1143.1.2 Long-term Services and Support Listing
The following is a non-exhaustive, high-level listing of community-based long-term services and supports included under the STAR+PLUS Program:
- Primary Home Care (PHC) — All members may receive medically and functionally necessary PHC. PHC includes assisting the member with the performance of activities of daily living 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 needs and the plan of care. Services may also include the provision of nursing tasks delegated by a registered nurse in accordance with state rules promulgated by the Texas Board of Nursing, and protective supervision provided solely to ensure the health and welfare of a member with cognitive/memory impairment and/or physical weakness.
PHC includes three service delivery options: Agency Option; Consumer Directed Services Option; and Service Responsibility Option.
- 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 personal care services, physical rehabilitative services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed certified by the Texas Department of Aging and Disability Services (DADS).
- HCBS STAR+PLUS Waiver (SPW) for those members who qualify for such services — The state also provides an enriched array of services to members who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The MCO must also provide medically necessary services that are available to members through the CBA waiver in traditional Medicaid to those members who meet the functional and financial eligibility for SPW:
- in-home or out-of-home respite services;
- nursing services (in the home);
- Emergency Response Services (emergency call button);
- Home-Delivered Meals;
- minor home modifications;
- adaptive aids and medical equipment; and
- medical supplies not available under the Texas Medicaid State Plan/STAR+PLUS.
1143.2 Services Available to HCBS STAR+PLUS Waiver Members
Services necessary for the individual to remain in or return to the community are identified from the array of services available through the HCBS STAR+PLUS Waiver (SPW) program. SPW services include:
- Adaptive Aids and Medical Supplies — Medical equipment and supplies that include devices, controls or appliances specified in the plan of care that enable individuals to increase their abilities to perform activities of daily living or to perceive, control or communicate with the environment in which they live.
- Adult Foster Care — A 24-hour living arrangement in a contracted Department of Aging and Disability Services (DADS) foster home for persons who, because of physical or mental limitations, are unable to continue residing in their own homes. Services may include meal preparation, housekeeping, personal care, help with activities of daily living, supervision and the provision of or arrangement of transportation.
- Assisted Living (AL) Services — A 24-hour living arrangement in licensed personal care facilities in which personal care, home management, escort, social and recreational activities, 24-hour supervision, provision or arrangement of transportation, and supervision of, assistance with and direct administration of medications are provided. Under the SPW program, personal care facilities may contract to provide services in two distinct types of living arrangements:
- AL apartments; or
- AL non-apartment settings.
- Cognitive Rehabilitation Therapy — A service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions. Cognitive rehabilitation therapy is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. The assessment is not included under this service provision. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.
- Dental Services — The services provided by a dentist to preserve teeth and meet the medical need of the member. Allowable services include emergency dental treatment necessary to control bleeding, relieve pain and eliminate acute infection; preventative procedures required to prevent the imminent loss of teeth; the treatment of injuries to teeth or supporting structures; dentures and the cost of preparation and fitting; and routine procedures necessary to maintain good oral health.
- Emergency Response Services — An electronic monitoring system for use by functionally impaired individuals who live alone or are isolated in the community or at high risk of institutionalization. In an emergency, the member can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-days-a-week capability, helps insure that the appropriate persons or service provider respond to an alarm call from the member.
- Financial Management Services — Assistance to members with managing funds associated with services elected for self-direction and is provided by the consumer directed services agency. This service includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.
- Home-Delivered Meals — Services that provide nutritionally sound meals delivered to the memberís home.
- Minor Home Modifications — Services that assess the need for, arrange for and provide modifications and/or improvements to an individual's residence to enable the individual to reside in the community and to ensure safety, security and accessibility.
- Nursing Services — Includes, but is not limited to, assessing and evaluating health problems and the direct delivery of nursing tasks, providing treatments and health care procedures ordered by a physician and/or required by standards of professional practice or state law, delegating nursing tasks to unlicensed persons according to state rules promulgated by the Texas Board of Nursing, developing the health care plan and teaching individuals about proper health maintenance.
- Occupational Therapy Services — Interventions and procedures to promote or enhance safety and performance in instrumental activities of daily living, education, work, play, leisure and social participation. Services include the full range of activities provided by an occupational therapist or a licensed occupational therapy assistant under the direction of a licensed occupational therapist, within the scope of the therapistís state licensure.
- Primary Home Care (PHC) — Includes assisting the member with the performance of activities of daily living and household chores necessary to maintain the home in a clean, sanitary and safe environment. The level of assistance provided is determined by the memberís needs and the plan of care. Services may also include the provision of nursing tasks delegated by a registered nurse in accordance with state rules promulgated by the Texas Board of Nursing and protective supervision provided solely to ensure the health and welfare of a member with cognitive/memory impairment and/or physical weakness.
- Physical Therapy Services — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. Services include the full range of activities provided by a physical therapist or a licensed physical therapy assistant under the direction of a licensed physical therapist, within the scope of the therapistís state licensure.
- Prescribed Drugs — Prescriptions beyond the three-per-month limit available under the Texas Medicaid State Plan unless the member is dually eligible for both Medicare and Medicaid. A member who is dually eligible must obtain prescription drugs through the Medicare Prescription Drug Plan or (for certain drugs excluded from Medicare) the Texas Medicaid State Plan.
- Respite Care Services — Temporary relief to persons caring for functionally impaired adults in community settings other than Adult Foster Care homes or Assisted Living facilities. Respite services are provided on an in-home basis and out-of-home basis and are limited to 30 days per individual service plan year. Room and board is included in the waiver payment for out-of-home settings.
- Speech and/or Language Pathology Services — The evaluation and treatment of impairments, disorders or deficiencies related to a memberís speech and language. Services include the full range of activities provided by speech and language pathologists under the scope of their state licensure.
- Transition Assistance Services — Assists members with non-recurring, set-up expenses for transitioning from nursing homes to the community. Services may include assistance with security deposits for leases on apartments or homes, essential household furnishings, set-up fees for utilities, moving expenses, pest eradication or one-time cleaning.
1144 Service Coordination Through the MCO
All applicants or recipients of long-term services and supports (LTSS) receive service coordination from the managed care organization (MCO). Service coordination is intended to bring together acute care and LTSS. Service coordination includes development of an individual service plan with the individual, family members and provider, as well as authorization of LTSS for the member.