STAR Kids is a managed care program that gives Medicaid benefits to children and adults with disabilities and special health care needs age 20 and younger. There are rules about who is eligible for the program that you can read about on the STAR Kids page on the Texas Health and Human Services website.
Children and young adults who are on STAR Kids are enrolled in a managed care organization (MCO), also called a "health plan," based on where they live. This map of Managed Care Service Areas shows which health plan is in your service area. All of the health plans have information about STAR Kids on their websites. This STAR Kids FAQ document explains the program and answers questions you may have.
Each STAR Kids health plan provides service coordination to families. One parent we spoke to said:
“I feel that the service coordinator is the key to understanding the system. If I did not have her to help me navigate through, I would be lost. Who would I even call for that? I would sit there for hours. The coordinator is working on it for me.”
A service coordinator is a nurse, social worker, or other child specialist who works for the health plan. Their job is to help you and your child by coordinating care for your child. They usually live in your area so they are familiar with the services and programs in your community.
Everyone in STAR Kids gets a screening and assessment at least once a year. The assessment helps to inform the services your child will have for the annual service planning period. It is the service coordinator or nurse assessor who does the assessment with you and your child. The STAR Kids Screening and Assessment Instrument (SAI) is used to create an Individual Service Plan (ISP) for your child and determines medical necessity and an annual cost limit for those members enrolled in the Medically Dependent Children Program (MDCP). The approved services are then listed on the ISP. You can learn more about what happens at this annual assessment meeting by reading the STAR Kids handbook. Parents we spoke to wanted you to know that you should plan on having plenty of time for this assessment. Some suggested at least 2-4 hours.
Service coordinators help you learn about and connect to any service that will help your child. This can include social services, waivers, doctors, therapies, or durable medical equipment, to name a few. They can help you create a medical home and keep all of your child’s doctors informed about what is going on with your child. They can also connect you with non-Medicaid services. However, the service coordinator cannot determine eligibility for any programs or services outside those the MCO is responsible for providing.
The amount and kind of service coordination each child gets depends on the child’s needs. This means some children and/or parents receive many face-to-face meetings and phone calls from their service coordinators, and others do not receive as many.
STAR Kids group children into 3 levels of need. Level 1 is for children with the highest need, and Level 3 is for those with fewer needs. You can call the 1-800 number on the back of your health plan ID card or talk to your service coordinator directly and ask them what level your child is. You can also search for the “Service Coordination Requirements” section in the STAR Kids handbook to learn more. Some health plans may not offer a specific and named service coordination to all children. Instead you work with anyone in the service coordination department. But if you tell your health plan that you want one person to be your service coordinator, they must provide one for you.
Each MCO has a member portal where you can easily get important information about your health plan services. The member portal is on the health plan’s website. Many of the health plans list the service coordinator’s name and their contact information on the member portal. You can log into the member portal to get the name and contact information for your service coordinator.
You should have access to a service coordinator whenever you need one.
Here are some important things to know about getting the most out of your relationship with your service coordinator.
We talked to parents about their experiences with a service coordinator. Here are some quotes that stood out.
“I can just make a quick phone call, and she [the service coordinator] will get back to me. It saves time, which in my life is critical. I feel that having someone from the other side know my child and [that] he is not just a name on a piece of paper. She has met him [and] seen him, and I think that helps the process. It helps her want to fight for us. It helps her want to find the answers if she does not know them. It really gives it a personal spin on it that we have not had before.”
“Our service coordinator has been someone young and early in their career but seemed well versed in the plan's services and resources available. They are very compassionate, friendly people who want to help as much as they can.”
“The service coordinator is someone who knows about benefits you may not know about and someone to help with some of the never-ending phone calls in managing and coordinating services.”
“We had tried to get a wheelchair. My son is not wheelchair-bound but he is hypotonic so he gets tired. We got denied. When I got with her [the service coordinator] I asked her to see if we could get it. She got us approved, and now we are waiting to get one. Normally, I would have been denied and said, ‘OK he did not qualify and I don’t have any more time on this.’ But I asked her, and she checked, and the next thing I knew is that she followed up and got us one.”
“They [the service coordinator] reached out proactively to schedule the annual assessments and about the half-year time to see if we needed any assistance as well. They also proactively called when we were stuck waiting on speech and occupational therapy services to start after switching providers. The provider said they were still waiting on insurance approval, and I hadn't had time to follow up myself. She found out that the insurance did give the approval authorization through their online system. The provider was expecting a fax.”
Sometimes the services may be not approved or might be reduced that you think your child needs or that your child has been receiving already. If a service is reduced or completely denied, you have options. If this happens, you have the right to appeal (ask for a second opinion on) their decision. There are certain rules about appealing.
Here are some of the rules and tips from a parent who appealed her child’s health care decision: