MY CIGNA-HEALTHSPRING STAR+PLUS MEMBER HANDBOOK

Transcription

1 MY CIGNA-HEALTHSPRING STAR+PLUS MEMBER HANDBOOK Member Services (TTY: 7-1-1) Monday to Friday 8 a.m. to 5 p.m. Central Time September MCDTX_17_

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3 WELCOME TO BETTER HEALTH We are here to help in every way Congratulations on choosing Cigna HealthSpring as your STAR+PLUS plan. We thank you for your membership. Our team looks forward to helping you improve your health, well being and sense of security. At Cigna HealthSpring, our goal is to give you more from life. This includes helping you get quality care that is affordable, easy to understand and tailored to meet your individual needs. This Member Handbook can help you get the most from your STAR+PLUS plan. It is important to read it carefully and keep it in a safe, convenient place. You will learn many important things from your Member Handbook, such as: What is the role of your main doctor or Primary Care Provider (PCP) How to find out what drugs are covered on the preferred drug list When you need a referral or prior authorization from your main doctor Who to call and what to do if you become ill or injured How to take advantage of preventive health services and other benefits At Cigna HealthSpring, we want you to be involved in your own health. This means you need to follow the advice of your main doctor (Primary Care Provider). It also means you should call us when you have a question about your health plan. We are always ready to guide you in the right direction. Our team is your team. We are here to help you. If you have questions about your STAR+PLUS plan, please call Member Services at , Monday to Friday, 8 a.m. to 5 p.m. Central Time. If you have questions about your health, you can call the nurses at our 24 Hour Nurse Line at On behalf of the entire Cigna HealthSpring family in Texas and beyond, I welcome you. We look forward to helping you lead a healthier life. Healthy regards, Introduction to Cigna HealthSpring Jay L. Hurt Texas Division President Cigna HealthSpring Life & Health Insurance Co., Inc. P.S. Please let us know if you would like your Member Handbook in audio, larger print, braille or another language. We are happy to help. a

4 Important phone numbers CALL US WHEN YOU NEED HELP It is important that you know where to turn when you need help. Your team is ready to guide you in the right direction. If you have a health question or concern, you can call the nurses at our 24 Hour Nurse Line at If you need help or information, call Member Services at You can also reach our mental health crisis line 24 hours a day, 7 days a week by calling Important If you have a life threatening emergency or an emergency that poses a threat to the life or property of others, call or go directly to the nearest emergency room. Monitor your progress toward your health care goals. You can call your Cigna HealthSpring Service Coordinator at You can also call your Service Coordinator through Member Services at Behavioral health and substance abuse services For questions about behavioral health and substance abuse, call the behavioral health line at If you have a mental health crisis, you can get help by calling our mental health crisis hotline at , 24 hours a day, and 7 days a week. Qualified mental health professionals will be ready to: Answer your questions. Assess your mental health. Provide and coordinate services as needed. Bilingual or interpreter services Cigna HealthSpring representatives are ready to help in English and Spanish. Other language interpreter services are ready upon request. Cigna HealthSpring can provide interpreter and translation services in over 170 languages. b Cigna HealthSpring Member Services You can get immediate answers to questions about your benefits, the provider network or any other issues related to your plan. Please call Member Services at , Monday to Friday 8 a.m. to 5 p.m. Central Time, excluding state approved holidays. Bilingual or interpreter services Cigna HealthSpring representatives are ready to help in English and Spanish. Cigna HealthSpring can provide interpreter and translation services in over 170 languages. Please call Member Services at for assistance. Hearing impaired If you are hearing impaired, please call TTY: For more services, please call TTY/Texas Relay at (English) or (Spanish). After hours If you call after hours, on a weekend or holiday, you can leave a voice message. We will return your call on the next business day. Service Coordination Cigna HealthSpring provides Service Coordination. You and your Service Coordinator will work together to: Assess your health needs. Create a care plan. Organize all your services. Please remember If you have a life threatening emergency or an emergency that poses a threat to the life or property of others, call or go directly to the nearest emergency room. 24 Hour Nurse Line Cigna HealthSpring gives you access to experienced registered nurses 24 hours a day, 365 days a year. Our nurses offer immediate, reliable information for any health concern. Please call Help is ready in English or Spanish. Eye care Members eligible for Medicaid only can get routine eye care services by calling Superior Vision at If you need eye care for an illness or injury to your eye, call your main doctor for help first. You do not need a referral for specialty eye care from an ophthalmologist. Dental care Members eligible for Medicaid only who are 21 years of age or older can get routine dental care services. STAR+PLUS Waiver Members are also eligible for some dental care. To get covered dental care, call DentaQuest at

5 Ombudsman and STAR+PLUS Ombudsman Managed Care Assistance Team: (TTY: ) STAR+PLUS Program Help Line: Medical Transportation Program (MTP) Member Handbook information 2208 Hwy 121, Suite 210 Bedford, TX Cigna HealthSpring Member Services (TTY: 7-1-1) Monday to Friday, 8 a.m. to 5 p.m. Central Time StarPlus.MyCignaHealthSpring.com Don t forget Your satisfaction is very important to us. If you have any concerns, please let us know. We will be happy to help. Important phone numbers Quick Reference Guide Member Services Eye care Bilingual/interpreter services Dental care Member Services for hearing impaired TTY Ombudsman Managed Care Assistance Team TTY/Texas Relay English TTY/Texas Relay Spanish Ombudsman Managed Care Assistance Team for hearing impaired STAR+PLUS Program Help Line Service Coordination Behavioral health and substance abuse Mental health crisis Medical transportation services Hidalgo or MRSA Northeast service areas Tarrant service area Hour Nurse Line (English/Spanish) Medicaid prescription help line c

6 Table of contents Introduction to Cigna HealthSpring Important phone numbers Cigna HealthSpring Member Services Bilingual or interpreter services Hearing impaired After hours Service Coordination Behavioral health and substance abuse services Bilingual or interpreter services 24-Hour Nurse Line Eye care Dental care Ombudsman and STAR+PLUS Medical Transportation Program Member Handbook information Cigna HealthSpring Member Services Quick Reference Guide a b b b b b b b b b b b c c c c c Welcome to Cigna-HealthSpring 1 What is Cigna HealthSpring? 1 What does Cigna HealthSpring do? 1 How has Cigna HealthSpring changed? 1 What makes Cigna HealthSpring unique? 1 What does Cigna HealthSpring offer? 1 Your Cigna-HealthSpring ID card 2 How to use your ID card 2 How to read your ID card 2 How to replace your ID card 3 Your Texas Benefits (YTB) Medicaid ID Card 4 Your Texas Benefits Medicaid website 4 Temporary verification form (Medicaid form 1027 A) 5 Your main doctor 6 What is a Primary Care Provider (PCP or main doctor)? 6 How do I pick my main doctor? 6 What type of provider can I pick as my main doctor? 6 Can a specialist ever be considered a Primary Care Provider? 6 Can a clinic be my Primary Care Provider? (Rural health clinic/federally qualified health center) 6 How can I change my Primary Care Provider? 6 How can I change my Primary Care Provider if I receive Medicare benefits? 6 How many times can I change my/my child s Primary Care Provider? 6 When will my Primary Care Provider change become effective? 6 Are there any reasons why a request to change a Primary Care Provider may be denied? 7 What do I need to bring with me to my doctor s appointment? 7 Can my Primary Care Provider move me to another Primary Care Provider for non compliance? 7

7 What if I choose to go to another doctor who is not my Primary Care Provider? 7 How do I get medical care after my Primary Care Provider s office is closed? 7 What is the Medicaid Lock In Program? 7 What is the Physician Incentive Plan? 7 Health plan changes 8 What if I want to change health plans? 8 Who do I call? 8 How many times can I change health plans? 8 When will my health plan change become effective? 8 Can Cigna HealthSpring ask that I get dropped from their health plan (for non-compliance, etc.)? 8 Table of contents Health care benefits 8 What are my health care benefits? 8 How do I get these services? 10 Are there any limits to covered services? 10 What are Long-Term Services and Supports (LTSS) benefits? 11 How do I get these services? 11 What number do I call to find out about these services? 11 What is Cognitive Rehabilitation Therapy (CRT)? 11 How do I get the CRT service? 11 What are Consumer Directed Services (CDS) and Financial Management Services (FMS)? 11 Who do I call to learn more about FMS? 11 Will my STAR+PLUS benefits change if I am in a Nursing Facility? 11 What are my Acute Care benefits? 11 How do I get these services? 11 What number do I call to find out about these services? 12 What services are not covered? 12 What is the ICF IDD (Intermediate Care Facility Intellectual and Developmental Disability) program? 12 What does IDD waiver mean? 12 What services am I eligible for as an ICF IDD Program or IDD Waiver member? 12 What services am I eligible for as a Medicaid for Breast and Cervical Cancer (MBCC) Member? 12 What are my prescription drug benefits? 12 What extra benefits do I get as Member of Cigna HealthSpring? 12 What Value Added Services can Cigna HealthSpring STAR+PLUS Dual Members get? 12 What Value Added Services can Cigna HealthSpring STAR+PLUS Medicaid only Members get? 13 How can I get these benefits? 13 What health education classes does Cigna HealthSpring offer? 13 What other services can Cigna HealthSpring help me get (non-capitated services)? 13 Can Cigna HealthSpring help me get non covered community resources? 13 Health care and other services 13 What does medically necessary mean? 13 What is routine medical care? 14 How soon can I expect to be seen? 14 What is urgent medical care? 14 What should I do if my child or I need urgent medical care? 14

8 Table of contents How soon can I expect to be seen? 14 What is emergency medical care? 14 How soon can I expect to be seen? 15 Are emergency dental services covered by the health plan? 15 What do I do if my child needs emergency dental care? 15 What is post stabilization? 15 When should I call to make an appointment? 15 How do I get medical care when my Primary Care Provider s office is closed? 15 What if I get sick when I am out of town or traveling? 15 What if I am out of the state? 15 What if I am out of the country? 15 What if I need to see a special doctor (specialist)? 16 What is a referral? 16 How soon can I expect to be seen by a specialist? 16 What services do not need a referral? 16 How can I ask for a second opinion? 16 What is the My Personal Health Coach program? 16 How can I contact My Personal Health Coach? 16 Behavioral health 16 What are behavioral health services? 16 How do I get help if I have behavioral (mental) health, alcohol, or drug problems? 16 How do I get emergency help for behavioral health or substance abuse issues? 16 Do I need a referral for this? 17 What are mental health rehabilitation services and mental health targeted case management? 17 How do I get these services? 17 What behavioral health services are available? 17 What outpatient substance abuse services are available? 17 What is a behavioral health Service Coordinator? 17 What if I am already in treatment? 17 Can a mental health mental retardation center be my behavioral health care provider? 17 Prescription drug and pharmacy benefits 18 What are my prescription drug benefits? 18 How do I get my medications? 18 How do I find a network drug store? 18 What if I go to a drug store not in the network? 18 What do I need to bring with me to the drug store? 18 What if I need my medications delivered to me? 18 Who do I call if I have problems getting my medications? 18 What if I can t get the medication my doctor ordered approved? 18 What if I lose my medications? 18 What if I also have Medicare? 18 How do I get my medications if I am in a nursing facility? 18 What if I need Durable Medical Equipment (DME) or other products normally found in a pharmacy? 18 What is the Medicaid Lock In program? 19

9 Family planning 19 How do I get family planning services? 19 Where do I find a family planning services provider? 19 Do I need a referral for this? 19 Case Management for Children and Pregnant Women 19 What is Case Management for Children and Pregnant Women (CPW)? 19 Need help finding and getting services? 19 Who can get a case manager? 19 What do case managers do? 19 What kind of help can you get? 19 How can you get a case manager? 19 What is Service Coordination? 20 What will a Service Coordinator do for me? 20 How can I talk with a Service Coordinator? 20 What is Early Childhood Intervention (ECI)? 20 Do I need a referral for this? 20 Where do I find an ECI provider? 20 Table of contents Texas Health Steps 20 What is Texas Health Steps? 20 What services are offered by Texas Health Steps? 20 How and when do I get Texas Health Steps medical and dental checkups for my child? 21 What dental services does Texas Health Steps offer for my child? 21 Does my doctor have to be part of the Cigna HealthSpring network? 21 Do I have to have a referral? 21 What if I need to cancel an appointment? 21 What if I am out of town and my child is due for a Texas Health Steps checkup? 21 What if I am a migrant farmworker? 21 Medical Transportation Program (MTP) 22 What is MTP? 22 What services are offered by MTP? 22 Eye care 22 How do I get eye care services? 22 Child s dental care 23 What dental services does Cigna-HealthSpring cover for children? 23 Interpretation services 23 Can someone interpret for me when I talk with my doctor? 23 Who do I call for an interpreter? 23 How far in advance do I need to call? 23 How can I get a face to face interpreter in the provider s office? 23

10 Table of contents OB/GYN care 23 What if I need OB/GYN care? 23 Do I have the right to choose an OB/GYN? 23 How do I choose an OB/GYN? 23 If I do not choose an OB/GYN, do I have direct access? 24 Will I need a referral? 24 How soon can I be seen after contacting my OB/GYN for an appointment? 24 Can I stay with my OB/GYN if they are not with Cigna HealthSpring? 24 Prenatal and pregnancy care 24 What if I am pregnant? 24 Who do I need to call? 24 What other services/activities/education does Cigna HealthSpring offer pregnant women? 24 Where can I find a list of birthing centers? 24 Can I pick a Primary Care Provider for my baby before the baby is born? 24 How and when can I switch my baby s Primary Care Provider? 24 How do I sign up my newborn baby? 24 How and when do I tell my health plan? 24 How can I receive healthcare after my baby is born (and I am no longer covered by Medicaid)? 24 How and when do I tell my Caseworker? 25 Special needs and advance directives 25 Who do I call if I have special health care needs and need someone to help me? 25 What if I am too sick to make a decision about my medical care? 25 What are advance directives? 26 How do I get an advance directive? 26 What do I do with an advance directive? 26 How do I change or cancel an advance directive? 26 Bills, change of address, and lost or limited coverage 26 What if I get a bill from my doctor? 26 What do I have to do if I move? 26 What do I have to do if I need help with completing my renewal application? 26 What happens if I lose my Medicaid coverage? 26 What is the Medicaid Lock In program? 26 Medicaid-Medicare beneficiaries (Duals) 27 What if I also have Medicare? 27 Can my Medicare provider bill me for services or supplies if I am in both Medicare and Medicaid? 27 What if I have other health insurance in addition to Medicaid? 27 What if I need Durable Medical Equipment (DME) or other products normally found in a pharmacy? 27 Rights and responsibilities 27 What are my rights and responsibilities? 27 Complaints 28 What should I do if I have a complaint? 28 Who do I call? 29

11 Can someone from Cigna HealthSpring help me file a complaint? 29 How long will it take to process my complaint? 29 What are the requirements and timeframes for filing a complaint? 29 Information on how to file a Complaint with HHSC, once I have gone through the Cigna HealthSpring Complaint process: 29 Appeals 29 What can I do if my doctor asks for a service or medicine for me that s covered but Cigna HealthSpring denies or limits it? 29 How will I find out if services are denied? 29 What is the timeframe for an Appeal? 29 When do I have a right to ask for an Appeal? 29 How can I keep getting services while my Appeal is in process? 30 Can I file my Appeal verbally? 30 Can someone from Cigna HealthSpring help me file an Appeal? 30 When can I ask a State Fair Hearing to review my Appeal? 30 Table of contents Expedited Appeals 30 What is an Expedited Appeal? 30 How do I ask for an Expedited Appeal? 30 How do I ask for a prescription drug/pharmacy Expedited Appeal? 30 Does my request have to be in writing? 30 What are the timeframes for an Expedited Appeal? 30 What is the timeframe for an emergency Expedited Appeal? 30 What happens if the MCO denies the request for an Expedited Appeal? 30 Who can help me file an Expedited Appeal? 31 State Fair Hearing 31 Can I ask for a State Fair Hearing? 31 Where do I send my request for a State Fair Hearing? 31 Where do I send my request for a State Fair Hearing related to prescription drugs/pharmacy? 31 Can I keep getting services that are not approved if I filed for a State Fair Hearing? 31 Who can I talk to about a State Fair Hearing? 31 Reporting Abuse, Neglect, and Exploitation 32 What are Abuse, Neglect, and Exploitation? 32 Reporting Abuse, Neglect, and Exploitation 32 Helpful Information for Filing a Report 32 Waste, fraud, and abuse 32 Do you want to report waste, abuse, or fraud? 32 To report waste, abuse, or fraud, choose one of the following: 32 When reporting a provider (a doctor, dentist, counselor, etc.) include: 32 When reporting about someone who gets benefits, include: 32 Annual information 33 Information 33 Notice of Nondiscrimination 33 Multi-language Interpreter Services 34

12 Welcome to Cigna-HealthSpring DISCOVER THE CIGNA-HEALTHSPRING DIFFERENCE What is Cigna HealthSpring? In 2012, Cigna and HealthSpring joined to create a company that offers many different health plans. Together, Cigna HealthSpring offers the strength of a leading health services company with the hands on focus of a local STAR+PLUS managed care company. Today, Cigna HealthSpring serves the needs of millions of people all over the world. We welcome you to the family. What does Cigna HealthSpring do? Cigna HealthSpring works with the state of Texas to help people and families get health coverage in the Texas STAR+PLUS Program. STAR+PLUS is a Texas Medicaid managed care program that provides health care, acute care and Long-Term Services and Supports. Through STAR+PLUS, Cigna HealthSpring provides Members with many quality health care services. We are excited to help you get started. How has Cigna HealthSpring changed? We are the same company you might already know, but now we offer you the extra strength and resources of Cigna. We understand your needs and we are here for you. You can call us at any time. What makes Cigna HealthSpring unique? Cigna HealthSpring offers a unique team approach to your care. Our doctors focus on preventive health and quality care to keep you healthier and living life to its fullest. Our focus on prevention supports healthier Members and lowers medical costs. This is all good news for you. What does Cigna HealthSpring offer? Primary and specialty provider care Medical supplies Behavioral health and substance abuse services Hospital care Routine dental services Eye care Over-The-Counter Health Products monthly allowance Service Coordination Transportation services Helpful hint If you have questions, please call Member Services at You can also call the phone numbers listed in the Quick Reference Guide. Member Services Bilingual or interpreter services 24 Hour Nurse Line Hearing impaired help 1

13 ENJOY THE PEACE OF MIND THAT COMES WITH YOUR MEMBERSHIP How to use your ID card Your Cigna HealthSpring Member ID card tells doctors and hospitals that you are a Member of our plan. Take your ID card every time you go to the following: Doctor s visit Laboratory testing Emergency room Urgent care center Long-term care services Your Cigna-HealthSpring ID card How to read your ID card Below is a sample of the Cigna HealthSpring Medicaid Only eligibility ID card. If you have a Medicaid Only eligibility ID card, it will contain important information such as: STAR+PLUS Member ID Card - Medicaid Only Issuer/Emisor SAMPLE Member ID/N. o de identificación del miembro: <ID Number> Name/Nombre: <Name> PCP Name/Nombre del PCP: <PCP Name> PCP Phone/Teléfono del PCP: <PCP Phone number> PCP Effective Date/Fecha de vigencia del PCP: <Date> In case of emergency, call 911 or go to the closest emergency room. After treatment, call your PCP within 24 hours or as soon as possible. En caso de emergencia, llame al 911 o vaya a la sala de emergencias más cercana. Después de recibir tratamiento, llame al PCP dentro de las 24 horas o tan pronto como sea posible. Front 1. Cigna HealthSpring and STAR+PLUS logos. 2. Medicaid Member ID#, issued by Health and Human services Commission (HHSC). 3. Your name. 4. Name of your main doctor (PCP or main doctor). 5. Phone number of your main doctor. 6. Date you were given your main doctor. 1 Member Services/Departamento de Servicios a los Miembros: < > Hearing Impaired/Personas con problemas auditivos: <7-1-1> Service Coordination/Coordinación de servicios: < > Behavioral Health and Substance Abuse/Servicios de salud mental y abuso de sustancias: < > Available 24 hours a day, 7 days a week Disponible las 24 horas del día, los 7 días de la semana SAMPLE For Prior Authorization/Para autorización previa: < > Cigna-HealthSpring STAR+PLUS Claims: <P.O. Box STAR+PLUS> <El Paso, TX > Back Optum Rx RxBIN: RxPCN: CIHSCAID RxGroup: MEDICAID 7. Member Services phone number, available Monday to Friday, 8 a.m. to 5 p.m. Central Time. Voice mail is available after 5 p.m. and on weekends along with our 24 Hour Nurse Line. 8. TTY number for hearing impaired Members. For additional hearing impaired services, please call TTY/Texas Relay at (English) or (Spanish). 9. Service Coordination department phone number. 10. Behavioral health crisis hotline number. 11. Phone number a provider will call to get prior authorization for hospital visits, doctors visits and long-term care services. 12. Address where providers will send claims

14 Your Cigna-HealthSpring ID card Below is a sample of the Cigna HealthSpring Medicare and Medicaid Dual eligibility ID card. If you have a Medicare and Medicaid Dual Eligible ID card, it shows important information such as: STAR+PLUS Member ID Card - Dual Eligibile 2 3 Issuer/Emisor Member ID/N. o de identificación del miembro: Name/Nombre: SAMPLE You receive primary, acute and behavioral health services through Medicare. You receive only long term care services through Cigna-HealthSpring. In case of emergency, call 911 or go to the closest emergency room. After treatment, call your PCP within 24 hours or as soon as possible. Usted recibe servicios de salud primarios, de cuidados agudos y del comportamiento a través de Medicare. Usted solamente recibe servicios de atención a largo plazo a través de Cigna-HealthSpring. En caso de emergencia, llame al 911 o vaya a la sala de emergencias más cercana. Después de recibir tratamiento, llame al PCP dentro de las 24 horas o tan pronto como sea posible <Member ID> <Member Name> Member Services/Departamento de Servicios a los Miembros: < > Hearing Impaired/Personas con problemas auditivos: <7-1-1> Service Coordination/Coordinación de servicios: < > Behavioral Health and Substance Abuse/Servicios de salud mental y abuso de sustancias: < > Available 24 hours a day, 7 days a week Disponible las 24 horas del día, los 7 días de la semana SAMPLE Long Term Care Service ONLY/Sólo servicios de atención a largo plazo For Prior Authorization/Para autorización previa: < > Cigna-HealthSpring STAR+PLUS Claims: <P.O. Box STAR+PLUS> <El Paso, TX > Optum Rx RxBIN: RxPCN: CIHSCAID RxGroup: MEDICAID Front 1. Cigna HealthSpring and STAR+PLUS logos. 2. Medicaid Member ID#, issued by Health and Human services Commission (HHSC). 3. Your name. Back 4. Member Services phone number, available Monday to Friday, 8 a.m. to 5 p.m. Central Time. 5. TTY number for hearing impaired Members. For additional hearing impaired services, please call TTY/Texas Relay at (English) or (Spanish). 6. Service Coordination department phone number. 7. Behavioral health crisis hotline number. 8. Phone number a provider will call to get prior authorization for hospital visits, doctors visits and long-term care services. 9. Address where providers will send claims. How to replace your ID card If you lose your Member ID Card, please call Member Services at We will send you a replacement card. 3

15 Your Texas Benefits (YTB) Medicaid ID Card When you are approved for Medicaid, you will get a YTB Medicaid ID card. This plastic card will be your everyday Medicaid ID card. You should carry and protect it just like your driver s license or a credit card. The card has a magnetic strip that holds your Medicaid ID number. Your doctor can use the card to find out if you have Medicaid benefits when you go for a visit. You will only be issued one card, and will only receive a new card in the event of the card being lost or stolen. If your Medicaid ID card is lost or stolen, you can get a new one by calling toll free If you are not sure if you are covered by Medicaid, you can find out by calling toll free at You can also call First, pick a language and then pick option 2. Your health history is a list of medical services and drugs that you have gotten through Medicaid. We share it with Medicaid doctors to help them decide what health care you need. If you don t want your doctors to see your health history through the secure online network, call toll-free at Your Cigna-HealthSpring ID card Your Texas Benefits Health and Human Services Commission Need help? Necesita ayuda? Member name: 2 Member ID: 3 Issuer ID: 4 Date card sent: Note to Provider: Ask this member for the card from their Medicaid medical plan. Providers should use that card for billing assistance. No medical plan card? Pharmacists can use the non-managed care billing information on the back of this card. Members: Keep this card with you. This is your medical ID card. Show this card to your doctor when you get services. To learn more, go to or call Miembros: Lleve esta tarjeta con usted. Muestre esta tarjeta a su doctor al recibir servicios. Para más información, vaya a o llame al THIS CARD DOES NOT GUARANTEE ELIGIBILITY OR PAYMENT FOR SERVICES. Providers: To verify eligibility, call Non-pharmacy providers can also verify eligibility at Non-managed care pharmacy claims assistance: Non-managed care Rx billing: RxBIN: / RxPCN: DRTXPROD / RxGRP: MEDICAID TX-CA The Your Texas Benefits Medicaid card has these facts printed on the front: 1. This is where your name appears. 2. This is your Medicaid ID number. 3. This is HHSC s agency ID number. Doctors and other providers need this number. 4. This is the date the card was sent to you. The Your Texas Benefits Medicaid card has these facts printed on the back: 5. This message is for you. 6. This reminds your doctor to make sure you are still in the Medicaid program before giving you services. 7. These messages help doctors and providers get paid for the Medicaid services they give you. The back of the Your Texas Benefits Medicaid card has a website you can visit ( and a phone number you can call toll free ( ) if you have questions about the new card. If you forget your card, your doctor, dentist, or drug store can use the phone or the Internet to make sure you get Medicaid benefits. 4

16 Temporary Verification Form Temporary verification form (Medicaid form 1027 A) The Medicaid form 1027 A is your temporary ID card. You may have received it from the Department of Aging and Disability services. Form 1027 Ais your proof of Medicaid eligibility until you receive Your Texas Benefits Medicaid card. Please remember to present Your Texas Benefits Medicaid card with your Cigna HealthSpring ID card at all of your health care visits, and when receiving any long-term care services. If you have can t get Form 1027-A or Your Texas Benefits Medicaid card, please call the Medicaid Hotline at You can also apply for the temporary form in person at a Health and Human Services Commission (HHSC) benefits office. To find the nearest office, call 211 (pick a language and then pick option 2). Texas Department of Human Services Form 1027-A/ Name of the Doctor Name of the Pharmacy MEDICAID ELIGIBILITY VERIFICATION THIS FORM COVERS ONLY THE DATES SHOWN BELOW. IT IS NOT VALID FOR ANY DAYS BEFORE OR AFTER THESE DATES Each person listed below is eligible for MEDICAID BENEFITS for dates indicated below. The Medicaid identification form is lost or late. The client number must appear on all claims for health services. Verification Method Date Eligibility Verified TIERS STAR/STAR+PLUS HEALTH PLAN INFORMATION Plan Name and Member Services Toll-Free Telephone No. ELIGIBILITY DATES MEDICARE THROUGH CLAIM NO. FROM DATE OF CLIENT NAME BIRTH CLIENT NO. I hereby certify, under penalty of perjury and/or fraud, that the above client(s) have lost, have not received, or have no access to the Medicaid Identification (Form 3087) for the current month. I have requested and received Form 1027-A, Medical Eligibility Verification, to use as proof of eligibility for the dates shown above. I understand that using this form to obtain Medicaid benefits (services or supplies) for people not listed above is fraud and is punishable by fine and/or imprisonment. CAUTION: If you accept Medicaid benefits (services or supplies), you give and assign to the state of Texas your right to receive payments for those services or supplies from other insurance companies and other liable sources, up to the amount needed to cover what Medicaid spent. SAMPLE Signature-Client or Representative Date Name of the Worker Worker Number Worker Signature Date Office Address and Telephone No. Name of the Supervisor* Supervisor Number* Supervisor Signature* Date * or Authorized Lead Worker 5 Sample Form 1027 A

17 CHOOSE THE RIGHT DOCTOR TO MEET YOUR NEEDS What is a Primary Care Provider (PCP or main doctor)? A Primary Care Provider can be called your PCP or main doctor. Your Primary Care Provider is the main doctor, nurse or clinic that gives you most of your health care. Your main doctor can also help coordinate other services you need. How do I pick my main doctor? When you enroll in Cigna HealthSpring, you need to pick your main doctor from the Provider Directory. If you need help choosing a main doctor, please call Member Services at What type of provider can I pick as my main doctor? You can pick the following types of providers as your main doctor: Doctors specializing in family practice. Doctors specializing in general practice. Doctors specializing in internal medicine. Physician Assistant (PA). Advanced Practice Registered Nurse (APRNs) Practitioners specializing in adult and family practice. Federally qualified health center. Rural health clinic. Female Members and Members with gender specific needs can also pick from the following Primary Care Providers: Doctors specializing in Obstetrics/ Gynecology (OB/GYN). Advanced practice registered nurse practitioners specializing in women s health. Members under age 21 can only pick from the following type of Primary Care Providers: Pediatricians. Family practitioners who treat children of the Member s age. Certified registered nurse practitioners specializing in pediatrics. Can a specialist ever be considered a Primary Care Provider? You can pick a specialist to act as your main doctor. The specialist must be in the Cigna HealthSpring provider network and agree to handle all of the duties of a Primary Care Provider. Reminder STAR+PLUS Members covered by Medicare will keep seeing their Medicare Primary Care Provider. You will not need to pick a new main doctor for STAR+PLUS. Can a clinic be my Primary Care Provider? (Rural health clinic/federally qualified health center) Yes, you can pick the following type of clinic to act as your main doctor: Federally qualified health center. Rural health clinic. How can I change my Primary Care Provider? If you would like to change your main doctor, you can call Member Services at Please tell the representative that you want to change your main doctor. They can help you pick a new main doctor if you still need to pick one. How can I change my Primary Care Provider if I receive Medicare benefits? Some Members may also have coverage for their doctor visits through a Medicare Advantage plan. If you get Medicare benefits and STAR+PLUS, you need to call your Medicare plan to change your main doctor. How many times can I change my/my child s Primary Care Provider? There is no limit on how many times you can change your or your child s Primary Care Provider. You can change Primary Care Providers by calling us toll free at or writing to: Cigna HealthSpring Attention: Membership Accounting PO Box Nashville, TN When will my Primary Care Provider change become effective? If you ask to change your main doctor, the change will start on the business day after the request. The change will show up in the Cigna HealthSpring system within three business days. Cigna HealthSpring will mail you a new ID card within five business days of the request. The actual delivery time depends on the U.S. Postal Service. Your main doctor 6

18 Your main doctor Are there any reasons why a request to change a Primary Care Provider may be denied? Your request to change your main doctor can be denied if: The provider is not age or gender appropriate. The provider is not in Cigna HealthSpring s network. The provider is not accepting new patients. If you can t get your choice of main doctor at the time of enrollment, we will assign you to a doctor close to your home. At other times, a Member Services representative can tell you why you did not get the main doctor you chose. You can call Member Services to ask for a different main doctor, or to ask why you did not get your choice. Please note For STAR+PLUS Members who are covered by Medicare, no Primary Care Provider will be assigned. Tip Always keep your ID cards with you in a safe, convenient place. Your ID card is important to ensure a quick, easy and satisfying experience. Remember For most services, you should see the main doctor you picked when you joined Cigna HealthSpring. What do I need to bring with me to my doctor s appointment? When you go to a doctor s visit, have lab tests done, go to the emergency room or urgent care center or receive long-term care services, you must bring the following: Your Cigna HealthSpring ID card and either: Your Texas Benefits Medicaid card, or Your Temporary Medicaid ID form Form 1027 A. Can my Primary Care Provider move me to another Primary Care Provider for non compliance? Yes, your main doctor can ask to switch you to another main doctor for the following reasons: Non compliance to treatment. Failure to call before missing office visits. Failure to follow your main doctor s advice. Failure to get along with your main doctor. Threatening behavior. All requests are individually reviewed by Cigna HealthSpring. You will be told of the decision in writing within 10 days. We will ask you to call Member Services to pick a new main doctor. If you don t pick a new main doctor, Cigna HealthSpring will pick one for you. We will write to tell you of the change. If your main doctor is no longer able or willing to be part of Cigna HealthSpring s provider network, you will be assigned to a new main doctor. You will get a new Cigna HealthSpring ID card. If you get a new main doctor, you will get one that is near your home. The new provider will also be suitable for your age and gender. What if I choose to go to another doctor who is not my Primary Care Provider? If you want to go to a different main doctor in the provider network, the services are covered. How do I get medical care after my Primary Care Provider s office is closed? If you get sick during the evening, weekend or a holiday, you should: Call your main doctor (Primary Care Provider) at the phone number on the back of your Cigna HealthSpring ID card. Call early in the day to help make sure you get the earliest appointment. Leave a message with the answering service or the answering system. Make sure to leave your name and a phone number where your doctor can call you back. Your doctor should call you back within 30 minutes. If your main doctor does not call you back within 30 minutes, you can go to the nearest urgent care center. Look in your Provider Directory for a list of urgent care centers and acute care hospitals. You can also call the nurses at the 24 Hour Nurse Line for advice. Based on your symptoms, the nurse will recommend care. What is the Medicaid Lock In Program? You may be put in the Lock In Program if you do not follow Medicaid rules. It checks how you use Medicaid pharmacy services. Your Medicaid benefits remain the same. Changing to a different MCO will not change the Lock In status. To avoid being put in the Medicaid Lock In Program: Pick one drug store at one location to use all the time. Be sure your main doctor, main dentist, or the specialists they refer you to are the only doctors that give you prescriptions. Do not get the same type of medicine from different doctors. To learn more call Cigna HealthSpring Member Services at What is the Physician Incentive Plan? The MCO cannot make payments under a physician incentive plan if the payments are designed to induce providers to reduce or limit Medically Necessary Covered Services to Members. Right now, Cigna HealthSpring does not have a physician incentive plan. 7

19 GET THE HELP YOU NEED TO MAKE CHANGES What if I want to change health plans? You can change your health plan by calling the Texas STAR or STAR+PLUS Program Helpline at You can change health plans as often as you want. If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that. For example: If you call on or before April 15, your change will take place on May 1. If you call after April 15, your change will take place on June 1. Who do I call? To change your health plan, please call the Texas STAR or STAR+PLUS Program Helpline at How many times can I change health plans? You can change health plans as often as you want. GET MORE BENEFITS AND SERVICES 72 hour supplies of emergency prescriptions When will my health plan change become effective? If you call to ask to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that. For example: If you call on or before April 15, your change will take place on May 1. If you call after April 15, your change will take place on June 1. Can Cigna HealthSpring ask that I get dropped from their health plan (for non compliance, etc.)? Yes, Cigna HealthSpring can ask the Texas Health and Human Services Commission to remove you from their health plan for not following the rules when: Cigna HealthSpring takes reasonable measures to help your behavior through education and/or counseling, and You continue to refuse to meet the program rules and restrictions. If the HHSC Disenrollment Committee agrees to remove you, Cigna HealthSpring will help with the process. If you feel that the HHSC Disenrollment Committee has wrongly dropped you, you can ask for an Appeal from the Disenrollment Committee. What are my health care benefits? The following list shows the health care services and benefits that you receive as a Member of Cigna HealthSpring. You can receive all the covered services you need that are medically necessary. Some services are only for people of a certain age or who have a certain health problem. Birthing services provided by a physician or advanced practice nurse in a licensed birthing center Health plan changes Health care benefits Ambulance services Cancer screening, diagnostic, and treatment services Audiology services (hearing tests) Chiropractic services Birthing services provided by a licensed birthing center Dialysis 8

20 Health care benefits Behavioral health services Including: Inpatient mental health services for adults and children. Outpatient mental health services for adults and children. Outpatient drug treatment services for children (under age 21). Detoxification services. Psychiatry services. Counseling services for adults (age 21 and older). Substance use disorder treatment services, including. Outpatient services, including: Assessment. Detoxification services. Counseling treatment. Medication assisted therapy. Residential services, including: Detoxification services. Substance use disorder treatment (including room and board). Mental health rehabilitative services services that reduce a Member s disability resulting from severe mental illness, serious emotional, behavioral, or mental disorders. Targeted case management services that assist Members with getting access to needed medical, social, educational, and other services and supports. Disease management programs Home health care services, including home telemonitoring Drugs and biologicals provided in an inpatient setting Hospital services, inpatient and outpatient Durable medical equipment and supplies Laboratory services Early childhood intervention services Medical checkups and comprehensive care program services for children (age 0 20) through the Texas Health Steps Program Emergency services OB/GYN Family planning services Optometry, glasses and contact lenses, if medically necessary 9 Health education related to obesity Oral evaluation and fluoride varnish in the medical home in conjunction with Texas Health Steps medical checkup for children age 6 months through 35 months

21 Mastectomy, breast reconstruction, and related follow up procedures Including: 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: All stages of reconstruction on the breast(s) on which medically necessary mastectomy procedure(s) have been performed. Surgery and reconstruction on the other breast to produce symmetrical appearance; Treatment of physical complications from the mastectomy and treatment of lymphedemas. 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. Health care benefits Outpatient drugs and biologicals; including pharmacy dispensed and provider administered outpatient drugs and biologicals Radiology, imaging and x rays Outpatient drug programs Service Coordination Podiatry Specialty physician services Prenatal care Transplantation of organs and tissues Preventive services including a yearly wellness checkup for Members age 21 and older Vision Primary care services In addition, you can get other services through Medicaid including: Transportation to doctor visits. Hearing tests and hearing aids for children. WIC services. Are there any limits to covered services? Generally, you can receive all medically necessary Medicaid covered services that you need to stay healthy. Some services need to be reviewed by Cigna HealthSpring before a doctor or hospital can perform the service. If you have questions about your covered services by Cigna HealthSpring, call Member Services at How do I get these services? Your main doctor can give you most of the care you need or refer you to another physician for specialized care. You can also call your main doctor and let the office know what service you need. If you have questions about your Cigna HealthSpring benefits, call Member Services at Remember If you receive Medicare and Medicaid, Medicare covers your health care benefits. 10

22 Health care benefits 11 What are Long-Term Services and Supports (LTSS) benefits? You may be eligible for the following Long-Term Services and Supports: Adaptive aids and medical equipment such as wheelchairs, walkers and canes. Adult foster care. Assisted living services. Cognitive rehabilitation services. Day activity and health services. Dental services. Emergency response services. Employment assistance and supported employment services. Employment assistance helps people locate paid employment in the community. Supported employment is provided to a person who has paid employment in a setting that includes non disabled workers to help him or her sustain that employment. Home delivered meals. Medical supplies not available under the Texas Medicaid State Plan/HCBS STAR+PLUS Waiver. Minor home modifications. Nursing services (in home) not available under Texas Medicaid State Plan HCBS STAR+PLUS Waiver. Personal assistance services. Respite care services. Therapy services (physical, occupational and speech therapy). Transitional assistance services. How do I get these services? You and your Service Coordinator will complete a health risk assessment that helps to identify services that meet your health care needs. Some of these services may include those services in the list above. If you are eligible for these services and the service is medically necessary, you will work with your Cigna HealthSpring Service Coordinator and main doctor to get services in place. What number do I call to find out about these services? If you have questions about your Long-Term Services and Supports benefits, call your Service Coordinator at or Member Services at What is Cognitive Rehabilitation Therapy (CRT)? An LTSS benefit that assists a Member in learning or relearning cognitive skills that have been lost or altered as a result of an acquired brain injury and allows Member to re gain some of the lost cognitive functions. How do I get the CRT service? The determination to complete the necessary testing will be made by your Service Coordinator. Call your Service Coordinator at or Member Services at What are Consumer Directed Services (CDS) and Financial Management Services (FMS)? Consumer Directed services (CDS), now known as Financial Management Services (FMS), gives you a way that you can have more choice and control over some of the Long-Term Services and Supports you get. As a STAR+PLUS Member, you can pick the CDS option. With CDS, you can: Find, screen hire and fire (if needed) the people who provide your services. Train and direct your staff. You can manage the following FMS services: Attendant care. Respite care. Nursing. Physical therapy. Occupational therapy. Speech therapy. CRT. If you choose to be in FMS, you will contract with a Financial Management Services agency. The Financial Management Services agency will help you get started and give you training and support if you need it. The Financial Management Services agency will do your payroll and file your taxes. Call your Service Coordinator to find out more about FMS. Who do I call to learn more about FMS? To learn more about FMS, call your Service Coordinator at or Member Services at Will my STAR+PLUS benefits change if I am in a Nursing Facility? (STAR+PLUS Only) No, your benefits are determined by your eligibility. Please call Cigna HealthSpring Member Services at for more information. What are my Acute Care benefits? Your Acute Care benefits are the same as your health care benefits listed on page 8. How do I get these services? Your main doctor can give you most of the care you need or refer you to another physician or provider for more specialized care. You can also call your main doctor and let the office know what service you need.