Navigating healthcare options can be complex, especially when it comes to programs like Medicaid. If you’re in Texas and seeking long-term services and support through Medicaid, you might have come across the STAR+PLUS Medicaid Managed Care Program. This program is designed to help certain adults get the healthcare and long-term services they need in a managed care setting. Let’s break down who can benefit from STAR+PLUS, how it works, and how to enroll.
Who is Eligible for STAR+PLUS?
Eligibility for STAR+PLUS is based on specific criteria related to age, income, and health needs. To access services through STAR+PLUS, you must first be approved for Texas Medicaid. Beyond Medicaid approval, you need to fit into at least one of the following categories:
- Supplemental Security Income (SSI) Recipients: Individuals aged 21 or older who receive SSI benefits due to low income and are eligible for Medicaid.
- Need for Home and Community-Based Services: Adults aged 21 and over who don’t receive SSI but require the level of care provided through STAR+PLUS Home and Community-Based Services to live safely outside of a nursing home.
- Social Security Exclusion Programs: Individuals 21 or older receiving Medicaid through “Social Security Exclusion programs” and meeting specific income and asset rules for those programs.
- Nursing Home Residents: Adults aged 21 or older residing in a nursing home and receiving Medicaid to cover their care within the facility.
- Medicaid for Breast and Cervical Cancer Program Participants: Individuals enrolled in the Medicaid for Breast and Cervical Cancer program.
However, certain individuals are not eligible for the STAR+PLUS program. These exclusions include:
- 1915(c) Waiver Services or IDD Community Home Residents with Medicare: People over 21 receiving Medicaid 1915(c) waiver services or living in community homes for individuals with Intellectual and Developmental Disabilities (IDD) who also have Medicare.
- Limited Medicaid Benefit Recipients: Individuals who do not qualify for full Medicaid benefits, such as Frail Elderly program members, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, Qualified Disabled Working Individuals, and undocumented immigrants.
- Non-Medicaid Eligible Individuals: Those who do not meet the basic requirements for Medicaid eligibility in Texas.
- Children in State Foster Care: Children under the care of the state foster system.
- Young Adults Under 21 (Except Specific Program): Individuals aged 20 or younger, unless they are enrolled in the Medicaid for Breast and Cervical Cancer program.
Important Considerations for Medicare Beneficiaries:
It’s crucial to understand the interaction between STAR+PLUS and Medicare. You can participate in STAR+PLUS even if you are enrolled in Medicare, unless you are receiving Medicaid 1915(c) waiver services or reside in an IDD facility.
If you have both Medicare and Medicaid (“dual eligible”) and enroll in STAR+PLUS, your Medicare benefits will remain unchanged. You will continue to receive your regular healthcare services through your Medicare providers. STAR+PLUS focuses on providing and coordinating your Medicaid long-term services and supports, without altering your Medicare coverage.
How STAR+PLUS Works for Dual Eligible Individuals
For adults who are “dual eligible,” meaning they qualify for both Medicare and Medicaid, STAR+PLUS acts as a supplement to their existing Medicare coverage. It does not replace Medicare. Individuals in STAR+PLUS continue to access their regular medical care through their Medicare doctors, providers, or Medicare managed care plans.
Upon enrolling in STAR+PLUS, you will choose a STAR+PLUS health plan. This plan will then be responsible for coordinating and providing your Medicaid long-term services and supports. Think of STAR+PLUS as enhancing your support system by adding specialized services tailored to long-term care needs, while your Medicare handles your standard healthcare.
Enrolling in STAR+PLUS: A Step-by-Step Guide
STAR+PLUS is a Texas Medicaid program, so the first step to enrollment is Medicaid eligibility. If you are not already a Medicaid recipient, you must apply and be approved for Texas Medicaid to participate in STAR+PLUS.
To apply for Medicaid in Texas:
- Visit Your Texas Benefits: Go to the Your Texas Benefits website to apply online.
- Call 2-1-1: Dial 2-1-1 to speak with a representative who can guide you through the application process.
Once your Medicaid application is approved and you are deemed eligible for STAR+PLUS, you will receive an enrollment packet in the mail. This packet contains essential information about the program and instructions on how to select a STAR+PLUS health plan. If you do not have Medicare, you will also need to choose a primary care physician (PCP) within the STAR+PLUS network.
You have 15 days from receiving the enrollment packet to make your health plan selection. If you do not choose a plan within this timeframe, the Texas Health and Human Services Commission (HHSC) will automatically assign a plan to you.
You can submit your health plan choices through several methods:
- Phone: Call the number provided in your enrollment packet.
- Mail: Return the completed enrollment form by mail.
- Enrollment Events: Attend a STAR+PLUS enrollment event or presentation and complete a form on-site. You can find a calendar of events at Texas Medicaid Events.
Accessing Services After Enrollment:
After you’ve enrolled in a STAR+PLUS health plan, your chosen plan will assist you in setting up your services. A crucial aspect of STAR+PLUS is the service coordinator. Within 30 days of your enrollment, a service coordinator from your health plan will contact you. They will work with you to understand your goals, interests, and healthcare needs. This collaborative process leads to the development of your individualized service plan.
Your service plan is a roadmap for your care, created in partnership with you, your family (if you choose), your doctor, other healthcare providers, and your health plan. It outlines the regular healthcare services and long-term services and supports you will receive through STAR+PLUS. Your primary care doctor will manage your routine medical needs and provide referrals to specialists when necessary.
Flexibility within STAR+PLUS: Changing Plans or Doctors
STAR+PLUS offers flexibility to ensure you receive the best possible care. You have the option to change your STAR+PLUS health plan or primary care doctor once a month. To initiate a change, you need to request the change through the appropriate channels (contact your current plan or HHSC). However, it’s important to note that you must wait for official confirmation that the change has been processed before seeking care from your new doctor or through your new health plan.
Overview of STAR+PLUS Services
STAR+PLUS provides a comprehensive range of services, focusing on both healthcare and long-term support. Your service coordinator plays a vital role in connecting you with the services you need, based on your personalized service plan.
Long-term services and supports available through STAR+PLUS can include:
- Day Activity and Health Services (DAHS): Structured programs providing daytime care, activities, and health-related services in a group setting.
- Personal Assistance Services (PAS): Assistance with daily living activities such as bathing, dressing, and meal preparation.
- Habilitation Services: Support and training to develop or maintain skills needed for daily living and independence.
- Emergency Response Services (ERS): Electronic systems that allow you to call for help in case of an emergency.
The STAR+PLUS Home and Community-Based Services (HCBS) program, sometimes referred to as the STAR+PLUS Waiver, offers an expanded set of services designed to help individuals remain in their homes and communities instead of requiring nursing facility care. These HCBS services can include:
- Personal Assistance Services
- Adaptive Aids: Assistive devices and equipment to enhance independence.
- Adult Foster Care Home Services: Care provided in a licensed private home setting.
- Assisted Living: Supportive services in a licensed assisted living facility.
- Emergency Response Services
- Home Delivered Meals: Meal delivery services to your home.
- Medical Supplies: Necessary medical supplies delivered to your home.
- Minor Home Modifications: Modifications to your home to improve accessibility and safety.
- Nursing Services: Skilled nursing care provided in your home.
- Respite Care: Temporary care to relieve family caregivers.
- Therapies: Occupational, physical, and speech-language therapies.
- Transition Assistance Services: Support for individuals moving out of a nursing facility back to their home.
Value-Added Services: Extra Benefits from STAR+PLUS Plans
In addition to the standard Medicaid services and long-term supports, each STAR+PLUS health plan offers value-added services. These are extra benefits and services not typically covered by traditional Medicaid. Value-added services vary by plan and can include things like:
- Vision or dental care
- Transportation assistance
- Wellness programs
- Caregiver support services
When you receive your STAR+PLUS enrollment packet, it will include comparison charts detailing the specific value-added services offered by each health plan in your service area. Reviewing these charts is essential to choosing a plan that best meets your individual needs and preferences. You can also access general comparison charts online at STAR+PLUS Value-Added Comparison Charts.
Understanding Home and Community Based Services (HCBS) in STAR+PLUS
The STAR+PLUS Home and Community Based Services (HCBS) program is a critical component for many STAR+PLUS participants. It is designed to provide services to individuals who require a level of care typically provided in a nursing facility, but who wish to live at home or in a community setting.
When you apply for Medicaid in Texas, HHSC will assess your need for HCBS. This assessment determines if you meet the criteria for requiring nursing facility level care and if HCBS is appropriate for your situation. The goal of HCBS is to empower individuals to live as independently as possible in their preferred setting while receiving the necessary support and services.
For further information about the STAR+PLUS program or HCBS, you can contact Managed Care Initiatives.
By understanding the intricacies of the STAR+PLUS Medicaid Managed Care Program, eligible individuals in Texas can confidently access the healthcare and long-term services and supports they need to live healthier, more independent lives.
