K. Court Orders for Medical Services
If a healthcare professional has been consulted regarding a healthcare service, procedure, or treatment for a child in DFPS conservatorship, a court must make findings in the record supporting its decision if the court declines to follow the recommendation of the healthcare professional. Tex. Fam. Code § 266.005.
Special Issue: If the child needs a service not covered by Medicaid, the judge may order that a physician assess the need for the service if that has not already been done. Also, the judge may order the service and DFPS will seek that service through a private pay contract. When entering orders for services that are not covered by Medicaid, a judge might consider drafting an order that provides DFPS the maximum flexibility in contracting because a particular provider may not be in the position to fulfill the contract as dictated by the court order. Also, a copy of the signed order should be sent via fax to Superior HealthPlan at 1-866-702-4837 or the court order can be escalated through the DFPS Well-being Specialist who works directly with the STAR Health Liaison.
STAR Health is required to pay for Medicaid covered services ordered by a court pursuant to the statutory citations listed below. STAR Health cannot deny, reduce, or controvert the court's orders for Medicaid inpatient mental health covered services for members from birth through age 20, when such inpatient mental health services are provided pursuant to:
• A court order; or
• As a condition of probation.
STAR Health cannot deny, reduce, or controvert the court orders for Medicaid inpatient mental health covered services for members of any age if the court-ordered services are delivered in an acute care hospital.
STAR Health may not limit substance use disorder treatment or outpatient mental health services for members of any age provided pursuant to:
• A court order; or
• A condition of probation.
STAR Health cannot apply its own utilization management criteria through prior authorizations, concurrent reviews, or retrospective reviews for such services. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination. A member who has been ordered to receive treatment pursuant to a court order can only appeal the court order through the court system. STAR Health is required to have a mechanism to receive court order documents from providers at the time of an authorization request.
STAR Health must provide all Medicaid inpatient psychiatric covered services to members and outpatient covered services to members of any age who have been ordered to receive the services by:
• A court of competent jurisdiction including services ordered pursuant to the Tex. Health & Safety Code Chapters 573, Subchapters B and C, Tex. Health and Safety Code Chapter 574, Subchapters A-G, Tex. Fam. Code 55, Subchapter D; or
• As a condition of probation.
Federal statute prohibits Medicaid funding for services delivered to Medicaid members ages 21-64 while residing in an IMD. For STAR Health members ages 21 or older, STAR Health may provide inpatient services for acute psychiatric conditions in a free-standing psychiatric hospital for up to 15 days per calendar month in lieu of an acute care inpatient hospital setting as allowed by 42 C.F.R. §438.6(e).
STAR Health must provide Medicaid-covered substance use disorder treatment services, including substance use disorder residential treatment services, required as a court order consistent with Tex. Health and Safety Code Chapter 462, Subchapter D, or as a condition of probation.
These requirements are not applicable when the member is considered to be incarcerated.