Covered Services

The following is a general list of covered services included under the STAR Kids Medicaid managed care program. Texas Children’s Health Plan is responsible for providing a benefit package to STAR Kids Members that includes all medically necessary services covered under the traditional, fee-for-service Medicaid programs, except for Non-capitated Services provided to Medicaid Members outside of the health plan’s capitation.

Capitation is a payment arrangement to pay provider’s a set amount for each member whether or not they receive care.

Non-capitated services are the Texas Medicaid programs and services that are not included with the Texas Children’s Health Plan covered services. However, members may be eligible to receive the services from Texas Medicaid providers on a Fee-for-Service basis.

Covered services and benefits:

• Ambulance services
• Audiology services including hearing aids
• Behavioral Health Services* including:
  1. Inpatient mental health services. 
  2. The MCO may provide these services in a free-standing psychiatric hospital in lieu of an acute care inpatient hospital setting.
  3. Outpatient mental health services
  4. Psychiatry services
  5. Substance use disorder treatment service
• Outpatient services, such as:
  1. Assessment
  2. Detoxification services
  3. Counseling treatment
  4. Medication assisted therapy
• Residential services, which may be provided in a chemical dependency treatment facility in lieu of an acute care inpatient hospital setting, including:
  1. Detoxification services
  2. Substance use disorder treatment (including room and board)
• Prenatal care provided by a physician, certified nurse midwife (CNM), nurse practitioner (NP), clinical nurse specialist (CNS), and physician assistant (PA) in a licensed birthing center
• Birthing services provided by a physician and CNM in a licensed birthing center
• Birthing services provided by a licensed birthing center
• Cancer screening, diagnostic, and treatment service
• Chiropractic services
• Dialysis
• Drugs and biologicals provided in an inpatient setting
• Durable medical equipment and supplies
• Early Childhood Intervention (ECI) services
• Emergency Services
• Family planning services
• Home health care services
• Hospital services, inpatient and outpatient
• Laboratory
• Mastectomy, breast reconstruction, and related follow-up procedures, including:
  1. inpatient services; outpatient services provided at an outpatient hospital and ambulatory health care center as clinically appropriate; and physician and professional services provided in an office, inpatient, or outpatient setting for:
     1. all stages of reconstruction on the breast(s) on which medically necessary mastectomy procedure(s) have been performed.
     2. surgery and reconstruction on the other breast to produce symmetrical appearance.
     3. treatment of physical complications from the mastectomy and treatment of lymphedemas.
     4. prophylactic mastectomy to prevent the development of breast cancer.external breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed.
• Medical checkups and Comprehensive Care Program (CCP) Services through the Texas Health Steps Program (EPSDT).
• Mental health rehabilitation services.
• Mental health targeted case management.
• Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas Health Steps medical checkup for children 6 months through 35 months of age.
• Optometry, glasses, and contact lenses, if medically necessary.
• Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biological.
• Personal Care Services (PCS).
• Podiatry.
• Prescribed pediatric extended care center (PPECC) services.
• Primary care services.
• Private Duty Nursing (PDN) services.
• Radiology, imaging, and X-rays.
• Specialty physician services.
• Telemonitoring.
• Telehealth.
• Therapies – physical, occupational, and speech.
• Transplantation of organs and tissues.
• Vision services.

*These services are not subject to the quantitative treatment limitations that apply under traditional, fee-for-service Medicaid coverage. The services may be subject to the Texas Children’s Health Plan’s non-quantitative treatment limitations, provided such limitations comply with the requirements of the Mental Health Parity and Addiction Equity Act of 2008.

Covered services for MDCP STAR Kids:

The following is a list of covered services for members who qualify for MDCP STAR Kids services. Texas Children’s Health Plan must provide medically and functionally necessary services to members who meet the functional and financial eligibility for MDCP STAR Kids.

• Respite Care.
• Supported Employment.
• Financial Management Services.
• Adaptive Aids.
• Employment Assistance.
• Flexible Family Support Services.
• Minor home modifications.
• Transition Assistance Services.