STAR Kids – Service Coordination

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.”

What Is a Service Coordinator and What Can They Do for You?

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.

• If you have a general question for your service coordinator and you can’t reach them, leave a message and they should get back to you within a couple of business days.
• If you need to speak to a service coordinator at night, call the service coordinator number on the back of your health plan ID card. They should be able to answer your question or begin to research the answer for you.
• If you have an urgent situation and you can’t reach your service coordinator, call either the service coordinator department number or the customer service department number on the back of your health plan ID card. If customer service can’t help you, they can connect you to a service coordinator. You can do this for urgent situations. For example, if you are at a doctor’s office and they aren’t sure whether a service is covered, you can call to find the answer.

How to Get the Most Out of Service Coordination

Here are some important things to know about getting the most out of your relationship with your service coordinator.

1. Ask for help. Sharing your concerns, needs, and wants can help your service coordinator know what your child needs help with and what your family is struggling with. Knowing this information helps them help you. You can say and ask things like:
   • I need help with finding a new speech therapist.
   • We want our son to have a car seat. Can you help us get one?
   • What other services are available for my child?
   • Where are we in the process of getting approval for a new therapy?
   • Please resend the documents to the primary doctor or specialty doctor for approval.
   • I need help understanding the legal options for my child when they are age 18 and beyond.
2. Keep your service coordinator well informed. It is important for your service coordinator to know what is going on with your child and your family so that they can make sure your child is getting the services they need. For example, a child could receive limited attendant care services because the child’s mother and grandmother are helping at home. If there is a change, and the grandmother moves out of the house or the mother is working more hours, the service coordinator should be told. This could change the number of attendant care hours the child gets.
3. Be open and honest with your service coordinator. Sometimes it is embarrassing to talk about behavioral or mental health issues. If you share your concerns with the service coordinator, they may be able to help you find services you did not know about. Most service coordinators live in the communities they serve, so they are well educated about programs and services in your area.
4. You can communicate with your service coordinator in the way you want and need. You can ask to talk with them in a way that works for you and your family. For example, if you do not have time or do not like to talk on the phone, you can ask to use email or text instead.

What Are Parents Saying About Service Coordinators?

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.”

What If I Have a Problem with My Service Coordinator or My Child Is Denied Services?

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:

• The appeal process must be explained in the health plan’s member handbook. If you do not understand the process, you can call customer service and ask to speak to the member advocate. Each health plan is required to have a member advocate in your service area. The member advocate is responsible for keeping you informed about this process.
• If you want to appeal a decision, you should call your health plan the day you get the denial letter to make an appeal. Denial letters are mailed to the address that the MCO has on file for you. Then you should follow up your appeal request in writing. You have 10 days from when you get the denial letter to make an appeal. See your member handbook or ask the member advocate to learn more about the important time frames for appeals. Timing is very important so be sure to ask specific questions like, “When do you need to have this?” or, “Do you need to have this in writing? If so, by when?”
• The health plan must respond to the appeal within 5 business days to let you know they received the appeal.
• The appeal should usually be completed in 30 days.
• Your child might be able to receive the service in question during the appeal process. Be sure to ask your health plan about this.
• If you think your child’s health could be hurt by waiting the standard time for an appeal process, you can ask to review your case quickly. This is called an expedited appeal. Call your health plan to ask for this. You can ask the member advocate or someone in the appeals department.
• Always write down who you spoke to and the date and time you spoke to them.
• Each appeal case is given a reference number. Be sure to get this number for your records.
• If your appeal is denied, do not give up. Ask what the next step in the appeal process is. The next step might be a fair hearing.
• If your service coordinator is not meeting your needs for any reason, you can ask your health plan for a different service coordinator.