Navigating the landscape of healthcare programs can be complex, especially when seeking support for long-term care needs. You might be exploring options like a “house plus care program” for yourself or a loved one. While “house plus care program” might not be the official name, it effectively describes programs designed to provide comprehensive care services within a home or community setting. In Texas, a prominent program embodying this concept is STAR+PLUS, a Medicaid program focused on providing healthcare and long-term services and supports. This article will delve into the details of STAR+PLUS, helping you understand what it offers and whether it might be the right fit for your needs.
Who is Eligible for STAR+PLUS?
STAR+PLUS is designed for adults in Texas who need both healthcare and long-term services and supports. To be eligible for STAR+PLUS, individuals must first qualify for Texas Medicaid. Beyond Medicaid eligibility, specific criteria determine who can enroll in STAR+PLUS. You may be eligible if you meet one or more of the following conditions:
- Age 21 or older and receiving Supplemental Security Income (SSI) benefits: If you are 21 or older, receive SSI, and qualify for Medicaid due to limited income, you may be eligible.
- Age 21 or older, not receiving SSI but needing Home and Community-Based Services: Individuals aged 21 and over who do not receive SSI but require the level of care provided through STAR+PLUS Home and Community-Based Services (HCBS) may qualify. This is a key aspect for those seeking a “house plus care” type of program, as HCBS focuses on providing care in your own home or community rather than in an institution.
- Age 21 or older and receiving Medicaid through Social Security Exclusion programs: Certain Social Security Exclusion programs allow individuals over 21 to receive Medicaid while meeting specific income and asset requirements. Participants in these programs may also be eligible for STAR+PLUS.
- Age 21 or over residing in a nursing home and receiving Medicaid: Individuals of 21 years or older who live in a nursing facility and are covered by Medicaid are included in the STAR+PLUS program.
- Participants in the Medicaid for Breast and Cervical Cancer program: This specific Medicaid program also provides a pathway to STAR+PLUS eligibility.
However, it’s important to note certain exclusions. The following groups are not eligible for STAR+PLUS:
- Individuals receiving 1915(c) waiver services or living in community homes for individuals with Intellectual and Developmental Disabilities (IDD) and receiving Medicare: If you are over 21 and receive these specific waiver services or reside in IDD community homes while also having Medicare, you are not eligible for STAR+PLUS.
- Individuals not eligible for full Medicaid benefits: This includes participants in programs like the Frail Elderly program, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, Qualified Disabled Working Individuals, and undocumented immigrants who do not have full Medicaid benefits.
- Individuals who cannot get Medicaid: Basic Medicaid eligibility is a prerequisite for STAR+PLUS.
- Children in state foster care: STAR+PLUS is designed for adults.
- Individuals aged 20 or younger and not in the Medicaid for Breast and Cervical Cancer program: Unless participating in the Medicaid for Breast and Cervical Cancer program, individuals under 21 are generally not eligible.
Alt text: Texas STAR+PLUS Health Plan Service Areas by County: A map displaying the regions and counties in Texas covered by different STAR+PLUS health plans.
Important Considerations for Medicare Beneficiaries:
It’s crucial to understand how STAR+PLUS interacts with Medicare.
- Dual Eligibility: You can be enrolled in STAR+PLUS even if you have Medicare, unless you are receiving 1915(c) waiver services or live in facilities for people with IDD. Many individuals are “dual eligible,” meaning they qualify for both Medicare and Medicaid.
- Medicare Services Remain Separate: STAR+PLUS does not alter your Medicare benefits. You will continue to receive your regular healthcare services through your Medicare providers or Medicare managed care plan. STAR+PLUS focuses on providing Medicaid long-term services and supports.
How STAR+PLUS Works for Dual Eligibles
For adults who are dually eligible for both Medicaid and Medicare, STAR+PLUS acts as a complement to their existing Medicare coverage. It’s essential to reiterate that STAR+PLUS does not change how you access your Medicare services. You maintain your relationship with your Medicare doctors and providers, or your Medicare Advantage plan, for your primary healthcare needs.
When you enroll in STAR+PLUS, you choose a STAR+PLUS health plan. This health plan becomes your point of contact for accessing Medicaid long-term services and supports. Think of it as adding a layer of coordinated care focused on your long-term needs, working alongside your existing Medicare coverage.
Enrollment in STAR+PLUS: Getting Started
STAR+PLUS is a Texas Medicaid program, so the first step is Medicaid enrollment. To apply for Medicaid in Texas:
- Visit Your Texas Benefits website: You can apply online at Your Texas Benefits.
- Call 2-1-1: Alternatively, you can call 2-1-1 to get information and assistance with 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 detailed information about the STAR+PLUS program and instructions on how to choose a health plan. If you do not have Medicare, you will also need to select a primary care physician (PCP).
Choosing a Health Plan and PCP:
After receiving the enrollment packet, you have a 15-day window to select a STAR+PLUS health plan and, if applicable, a PCP. If you do not make a selection within this timeframe, the Texas Health and Human Services Commission (HHSC) will choose a plan and PCP for you.
You can communicate your choices in several ways:
- Phone: Call the number provided in your enrollment packet.
- Mail: Return the enrollment form by mail.
- Enrollment Events: Attend an enrollment event or presentation and complete a form on-site. You can find a calendar of events at Enrollment event calendar.
Alt text: Texas STAR+PLUS Rural Service Areas Map: Illustrates the designated rural service areas within Texas for STAR+PLUS health plan coverage.
Accessing Services:
Once enrolled in a STAR+PLUS health plan, your plan will work with you to arrange the services you need. A crucial element of STAR+PLUS is service coordination. Within 30 days of your enrollment, a service coordinator from your health plan will contact you to:
- Understand your goals, interests, and needs.
- Collaboratively develop a service plan. This plan is created with your input, along with your family, doctor, other healthcare providers, and your health plan. You can also include other individuals important to you in the planning process.
Your PCP will manage your routine medical care and provide referrals to specialists when necessary. Your overall care, encompassing both regular healthcare and long-term services and supports, will be guided by your personalized service plan.
Flexibility in Changing Plans or Doctors
STAR+PLUS offers flexibility. You can change your STAR+PLUS health plan or your PCP once a month. However, it’s important to wait for official confirmation that the change has been processed before seeking care from your new doctor or through your new plan.
Services Offered Through STAR+PLUS: A Closer Look at “House Plus Care”
STAR+PLUS is designed to provide a comprehensive suite of services, aligning with the concept of a “house plus care program” by bringing necessary support directly to individuals within their homes and communities. The program offers both long-term services and supports (LTSS) and other essential services.
Long-Term Services and Supports (LTSS) may include:
- Day Activity and Health Services (DAHS): These centers provide daytime care, activities, and health-related services in a community setting.
- Personal Assistance Services (PAS): PAS offers assistance with daily living activities such as bathing, dressing, and meal preparation, enabling individuals to maintain independence at home. This is a core component of “care” in a “house plus care” model.
- Habilitation Services: These services focus on helping individuals develop or maintain skills needed for daily living and community integration.
- Emergency Response Services (ERS): ERS provide access to immediate help in case of emergencies, enhancing safety and security at home.
Additional Services under STAR+PLUS Home and Community-Based Services (HCBS):
The STAR+PLUS HCBS program further expands the “house plus care” concept by offering a wider range of services to support individuals living at home who might otherwise require nursing facility care. These services include:
- Personal Assistance Services: (As described above)
- Adaptive Aids: Devices and equipment to assist with daily living activities and improve independence.
- Adult Foster Care Home Services: Care provided in a licensed private home setting for adults who cannot live independently.
- Assisted Living: Supportive services in a licensed assisted living facility for individuals needing help with daily living but not requiring skilled nursing care.
- Emergency Response Services: (As described above)
- Home-Delivered Meals: Nutritious meals brought to your home, ensuring proper nutrition.
- Medical Supplies: Necessary medical supplies delivered to your home.
- Minor Home Modifications: Changes to your home environment to improve safety and accessibility, such as ramps or grab bars, directly supporting the “house” aspect of “house plus care.”
- Nursing Services: Skilled nursing care provided in your home.
- Respite Care: Temporary care to give family caregivers a break from their caregiving responsibilities.
- Therapies: Occupational, physical, and speech-language therapies to improve function and independence.
- Transition Assistance Services: Support for individuals moving out of a nursing facility and back into their own home or community setting.
Value-Added Services: Extra Benefits
In addition to the standard Medicaid services and the extensive list above, each STAR+PLUS health plan offers value-added services. These are extra benefits not covered by traditional Medicaid, and they vary from plan to plan.
When you receive your STAR+PLUS enrollment packet, it will include comparison charts outlining the value-added services offered by each health plan in your area. Reviewing these charts is crucial to understand the additional benefits available and choose a plan that best meets your needs. You can also access general comparison charts at STAR+PLUS value-added comparison charts.
Understanding Home and Community Based Services (HCBS)
The STAR+PLUS Home and Community Based Services (HCBS) program, sometimes called the “STAR+PLUS Waiver,” is central to the “house plus care” idea. It’s specifically designed to provide services that enable individuals who would otherwise need nursing home care to live and receive care at home or in their community.
When you apply for Medicaid and indicate a need for long-term services and supports, HHSC will assess your eligibility for the HCBS program. This assessment determines if HCBS is appropriate for your needs, allowing you to access the home and community-based services described above.
For further information about the STAR+PLUS program, you can contact Managed Care Initiatives.
In conclusion, while “house plus care program” may be a general term, STAR+PLUS in Texas effectively embodies this concept by providing a wide range of healthcare and long-term services and supports within a home and community setting. Understanding the eligibility criteria, services offered, and how to enroll can empower you to access the care you or your loved one needs to live as independently as possible.
