Texas STAR Kids Program: Eligibility, Coverage, and MDCP Waiver

The Texas STAR Kids program is a no-cost Medicaid managed care plan for children and young adults age 20 or younger who have disabilities or complex medical needs.1Texas Health and Human Services. STAR Kids It bundles medical care, behavioral health, prescriptions, long-term services and supports, and a dedicated service coordinator into one health plan. Enrollment is mandatory for children who qualify, and the gateway is full Texas Medicaid: without it, nothing else on the eligibility list matters.

Who Qualifies

A child or young adult must already have full Texas Medicaid and meet at least one of the following criteria:1Texas Health and Human Services. STAR Kids

  • Receives Supplemental Security Income (SSI).
  • Receives both Medicaid and Medicare.
  • Lives in a community-based intermediate care facility for individuals with intellectual disabilities or related conditions, or in a nursing facility.
  • Gets services through the Medically Dependent Children Program (MDCP) waiver, which serves children who would otherwise need nursing-facility-level care but can be safely cared for at home.
  • Gets services through the Youth Empowerment Services (YES) waiver, for children with serious emotional disturbances.
  • Gets services through an intellectual and developmental disability waiver: Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS), or Texas Home Living (TxHmL).

The disqualifier families miss most often is the Medicaid piece itself. A child with partial or limited Medicaid cannot enroll, no matter how clearly they meet a disability criterion.1Texas Health and Human Services. STAR Kids A missed renewal, an income change, or a documentation gap that drops full Medicaid will also drop STAR Kids.

How to Apply and Enroll

You do not apply for STAR Kids directly. You apply for Medicaid, and once the state confirms your child meets a qualifying category, it places them into STAR Kids and sends information about health plan choices.

Applying for Medicaid

Apply online at YourTexasBenefits.com, by calling 2-1-1, or by mailing a paper application.2Your Texas Benefits. Your Texas Benefits Gather these before you start:

  • Social Security numbers for the applicant and all household members.
  • Proof of income such as recent pay stubs, benefit statements, or tax returns.
  • Proof of disability status such as an SSI award letter, medical records, or a physician’s statement.
  • Proof of identity and citizenship such as a birth certificate or passport.3Your Texas Benefits. Documents To Send With Your Application

Federal rules give the state 45 days to process most Medicaid applications and 90 days for disability-related applications because they need extra medical verification. Texas has sometimes exceeded these timelines, so check your status online as the deadline approaches.

Choosing a Health Plan

Texas is divided into 13 managed care service areas, and each area offers two or three managed care organizations (MCOs) for STAR Kids.4Texas Health and Human Services. Texas Managed Care Service Areas Map A few examples of what’s available locally:

  • Harris County: Texas Children’s, United, Wellpoint.
  • Dallas: Aetna, Wellpoint.
  • Bexar: Superior, Community First.
  • Tarrant: Aetna, Cook Children’s.
  • Travis: Blue Cross and Blue Shield of Texas, Superior.

An enrollment broker provides free, unbiased counseling to help you compare plans. The single most important question when choosing: are your child’s current doctors and specialists in that MCO’s network? You will also pick a primary care provider who oversees care and gives referrals. If you do not choose within the window, the state assigns an MCO for you, and the default may not include your current providers.

What STAR Kids Covers

STAR Kids pulls a wide range of medical and support services under one plan.1Texas Health and Human Services. STAR Kids Covered services include:

  • Primary care and specialist visits, including chronic disease management and referrals.
  • Behavioral health, including mental health counseling and substance use treatment when clinically needed.
  • Prescriptions and vaccines through the MCO’s pharmacy network.
  • Lab tests and X-rays ordered by the treating physician.
  • Hospital care, including inpatient stays, emergency room visits, and surgeries.
  • Long-term services and supports such as personal care assistance and private duty nursing that let children live at home instead of in an institution.
  • Medical supplies and equipment, including enteral feeding equipment, mobility aids, and other durable medical equipment.

Every service has to be deemed medically necessary, a determination made by the treating physician in coordination with the MCO.

Vision and Dental

Vision is included in STAR Kids and covers eye exams along with Medicaid-covered glasses or contact lenses. Dental is handled differently. It runs through a separate statewide managed care dental plan rather than through your STAR Kids MCO, and families pick a dental plan separately from one of three options: DentaQuest, UnitedHealthcare Dental, or MCNA Dental.

Extra Services Under the MDCP Waiver

Children enrolled in the Medically Dependent Children Program waiver get supports beyond standard STAR Kids benefits. To qualify for MDCP, a child must have a medical necessity determination based on the STAR Kids screening tool, need nursing-facility-level care, and have an individual service plan whose MDCP costs do not exceed 50 percent of what the state would pay for nursing facility care.5Texas Health and Human Services. STAR Kids Handbook – 1500, MDCP Eligibility MDCP members must use at least one waiver service per service-plan year to keep their enrollment, and children under 18 on MDCP must live with a family member such as a parent, guardian, or grandparent.

Your Service Coordinator and the Yearly Assessment

Every STAR Kids member is assigned a named service coordinator who helps the family find providers, build a care plan, and work through problems. The MCO must complete the STAR Kids Screening and Assessment Instrument, called the SK-SAI, at least once a year or sooner if the child’s condition changes.6Texas Health and Human Services. STAR Kids Handbook – 3100, STAR Kids Screening and Assessment The results drive two things: how intensive your service coordination will be and what goes into the Individual Service Plan.

Treat the SK-SAI as the moment to be specific about daily challenges and unmet needs. The more accurately it captures your child’s real life, the more appropriate the service plan will be. If things get worse between annual visits, you can ask for a reassessment at any time. Coordination is organized into three tiers based on complexity, from quarterly in-person visits for the highest needs down to a single annual visit for less complex cases.7Texas Health and Human Services. STAR Kids Handbook – 1300, Service Coordination If the assigned level doesn’t fit your child, raise it with the coordinator; the MCO can move a child up based on SK-SAI results and its own clinical findings.

The Individual Service Plan

After the SK-SAI, the service coordinator works with the family to build an Individual Service Plan (ISP). The ISP lays out your child’s specific care goals, the services they’ll receive, how and when those services will be delivered, and what natural supports exist at home.8Texas Health and Human Services. Form 2603, STAR Kids Individual Service Plan (ISP) Narrative

The process is required to be person-centered, which means your input as a family member is central, not optional. The coordinator should ask about strengths, preferences, and goals, not only diagnoses. If your child is old enough to participate, their voice counts too; when a child can’t participate because of age or disability, the coordinator gathers information from the parent or legal representative. The ISP is updated at least annually after the SK-SAI reassessment and can be changed during the year if needs shift. The MCO must give you a printed or electronic copy after any significant update.

If a Service Is Denied

When an MCO denies, reduces, or terminates a service your child was getting or asked for, you can challenge the decision. There are two layers: an internal MCO appeal first, then a State Fair Hearing if the internal appeal fails.

Start by contacting the MCO as directed on the denial notice. If that doesn’t resolve the issue, you can request a State Fair Hearing, and the MCO must submit your hearing request to the state within five business days.9Texas Health and Human Services. STAR Kids Handbook – 7300, State Fair Hearing Requests – Appealing MCO Actions Before the hearing, both sides prepare evidence. The MCO must send its evidence to you at least 10 business days ahead so you can review what they plan to present.

Federal rules require the state to take final action on the combined appeal process within 90 days from the date you first filed the MCO appeal, not counting any time between the MCO decision and when you filed for the State Fair Hearing.10eCFR. Fair Hearings for Applicants and Beneficiaries If the hearing officer rules in your favor, the decision specifies the corrective action the MCO must take and sets a 10-day deadline. A denial letter is not the final word. If you believe a service is medically necessary, use the appeal rights.

What Happens at Age 21

STAR Kids eligibility ends on the last day of the month in which the member turns 21. The first day of the following month, the young adult moves to STAR+PLUS, Texas’s Medicaid managed care program for adults.11Texas Health and Human Services. STAR Kids Handbook – 3500, Member Transition to Adult Programs Several pediatric services end at that point, including MDCP waiver services, Texas Health Steps comprehensive care, and prescribed pediatric extended care center services.12Texas Health and Human Services. STAR+PLUS Program Support Unit Operational Procedures Handbook – 3400 Transferring Into STAR+PLUS

Young adults who were receiving MDCP, private duty nursing, Community First Choice, or personal care services can apply for STAR+PLUS Home and Community Based Services to keep community-based care in place and avoid institutionalization.11Texas Health and Human Services. STAR Kids Handbook – 3500, Member Transition to Adult Programs Start that process well before the 21st birthday. Waiting until the last month creates gaps in care that advance planning avoids. Your STAR Kids service coordinator should help set the transition in motion, but don’t assume it’s happening on its own. Ask about it at least six months out.