Sec. 533.00253. STAR KIDS MEDICAID MANAGED CARE PROGRAM. (a) In this section:
(1) "Advisory committee" means the STAR Kids Managed Care Advisory Committee established under Section 533.00254.
(2) "Health home" means a primary care provider practice, or, if appropriate, a specialty care provider practice, incorporating several features, including comprehensive care coordination, family-centered care, and data management, that are focused on improving outcome-based quality of care and increasing patient and provider satisfaction under Medicaid.
(3) "Potentially preventable event" has the meaning assigned by Section 536.001.
(b) Subject to Section 533.0025, the commission shall, in consultation with the Children's Policy Council established under Section 22.035, Human Resources Code, establish a mandatory STAR Kids capitated managed care program tailored to provide Medicaid benefits to children with disabilities. The managed care program developed under this section must:
(1) provide Medicaid benefits that are customized to meet the health care needs of recipients under the program through a defined system of care;
(2) better coordinate care of recipients under the program;
(3) improve the health outcomes of recipients;
(4) improve recipients' access to health care services;
(5) achieve cost containment and cost efficiency;
(6) reduce the administrative complexity of delivering Medicaid benefits;
(7) reduce the incidence of unnecessary institutionalizations and potentially preventable events by ensuring the availability of appropriate services and care management;
(8) require a health home; and
(9) coordinate and collaborate with long-term care service providers and long-term care management providers, if recipients are receiving long-term services and supports outside of the managed care organization.
(c) The commission may require that care management services made available as provided by Subsection (b)(7):
(1) incorporate best practices, as determined by the commission;
(2) integrate with a nurse advice line to ensure appropriate redirection rates;
(3) use an identification and stratification methodology that identifies recipients who have the greatest need for services;
(4) provide a care needs assessment for a recipient that is comprehensive, holistic, consumer-directed, evidence-based, and takes into consideration social and medical issues, for purposes of prioritizing the recipient's needs that threaten independent living;
(5) are delivered through multidisciplinary care teams located in different geographic areas of this state that use in-person contact with recipients and their caregivers;
(6) identify immediate interventions for transition of care;
(7) include monitoring and reporting outcomes that, at a minimum, include:
(A) recipient quality of life;
(B) recipient satisfaction; and
(C) other financial and clinical metrics determined appropriate by the commission; and
(8) use innovations in the provision of services.
(d) The commission shall provide Medicaid benefits through the STAR Kids managed care program established under this section to children who are receiving benefits under the medically dependent children (MDCP) waiver program. The commission shall ensure that the STAR Kids managed care program provides all of the benefits provided under the medically dependent children (MDCP) waiver program to the extent necessary to implement this subsection.
(e) The commission shall ensure that there is a plan for transitioning the provision of Medicaid benefits to recipients 21 years of age or older from under the STAR Kids program to under the STAR + PLUS Medicaid managed care program that protects continuity of care. The plan must ensure that coordination between the programs begins when a recipient reaches 18 years of age.
(f) The commission shall seek ongoing input from the Children's Policy Council regarding the establishment and implementation of the STAR Kids managed care program. This subsection expires on the date the Children's Policy Council is abolished under Section 22.035(n), Human Resources Code.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 2.02, eff. September 1, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.216, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.217, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.14, eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.14, eff. January 1, 2016.
For expiration of this section, see Subsection (f).
Last modified: September 28, 2016