STAR MEMBER HANDBOOK. Member Services: Travis Service Area:

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1 STAR MEMBER HANDBOOK Member Services: Travis Service Area: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis & Williamson Counties SMH-MAR /2014

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3 Page ii Table of Contents Page IMPORTANT INFORMATION!...1 SENDERO HEALTH PLANS AND STAR...2 YOUR STAR ID CARD...4 Reading the Sendero STAR ID card...4 Using the Sendero STAR ID card...4 If you lose your Sendero ID card or move...4 Your Texas Benefits Medicaid card...4 Medicaid Eligibility Verification (Temporary Form 1027-A)...5 ALL ABOUT PCPS...6 What is a Primary Care Provider (PCP)?...6 Can a clinic be my Primary Care Provider (PCP)?...6 What do I need to bring with me to the doctor s appointment?...6 How can I change my/my child s Primary Care Provider (PCP)?...6 When will my Primary Care Provider change become effective?...7 How many times can I change my/my child s Primary Care Provider?...7 Are there any reasons why my request to change Primary Care Provider may be denied?...7 Can my Primary Care Provider move me to another Primary Care Provider for non-compliance?...7 What if I choose to go to another doctor who is not my Primary Care Provider?...8 How do I get medical care after my Primary Care Provider s office is closed?...8 What is the Medicaid Limited program?...8 PHYSICIAN INCENTIVE PLAN INFORMATION...8 CHANGING HEALTH PLANS...9 What if I want to change health plans?...9 Who do I call?...9 How many times can I change health plans?...9 When will my health plan change be effective?...9 Can Sendero ask that I get dropped from their plan (for non-compliance, etc.)?...10 BENEFITS AVAILABLE FROM SENDERO STAR...10 STAR Member Handbook

4 Page iii What are my health care benefits?...10 How do I get these services?...11 Are there any limits to any covered services?...11 What number do I call to find out about these services?...11 What services are not covered?...11 What are my prescription drug benefits?...12 What extra benefits does a member of Sendero get?...12 How can I get these benefits?...12 What health education does Sendero offer?...13 What other services can Sendero help me get?...13 HEALTH CARE AND OTHER SERVICES...14 What does Medically Necessary mean?...14 What is routine medical care?...15 How soon can I expect my child to be seen?...15 What is urgent medical care?...16 How soon can I expect my child to be seen?...16 What is emergency medical care?...16 How soon can I expect to be seen?...17 Are emergency dental services covered?...17 What do I do if my child needs emergency dental care?...17 What is post-stabilization?...18 How do I get medical care after my Primary Care Provider s office is closed?...18 What if I get sick when I m out of town or traveling?...18 What if I m out of the state?...18 What if I m out of the country?...18 What if I need to see a special doctor (specialist)?...18 What is a referral?...19 How soon can I expect to be seen by a specialist?...19 What services do not need a referral?...19 How can I ask for a second opinion?...19 BEHAVIORAL HEALTH...19

5 Page iv How do I get help if I have behavioral (mental) health, alcohol or drug problems? Do I need a referral?...19 PRESCRIPTIONS...20 How do I get my medications?...20 How do I find a network drug store?...20 What if I go to a drug store not in the network?...20 What do I bring with me to the drug store?...20 What if I need my medications delivered to me?...20 Who do I call if I have problems getting my medications?...20 What if I can t get the medication my doctor ordered approved?...20 What if I lose my medication(s)?...20 What if I need durable medical equipment (DME) or other products normally found in a pharmacy?...21 FAMILY PLANNING SERVICES...21 How do I get family planning services?...21 Do I need a referral for this?...21 Where do I find a family planning services provider?...21 FAMILY PLANNING PROVIDERS in the Austin area:...21 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN...26 What is Case Management for Children and Pregnant Women (CPW)?...26 Who can get a case manager?...26 What do case managers do?...26 What kind of help can you get?...26 How can you get a case manager?...26 WHAT IS TEXAS HEALTH STEPS?...26 What services are offered by Texas Health Steps?...26 How and when do I get Texas Health Steps medical and dental checkups for my child?...28 Does my doctor have to be part of Sendero network?...28 Do I have to have a referral?...28 What if I need to cancel an appointment?...28 STAR Member Handbook

6 Page v What if I am out of town and my child is due for a Texas Health Steps checkup?...28 What if I am a migrant farmworker?...28 TRANSPORTATION...28 If I don t have a car, how can I get a ride to a doctor s office?...28 Who do I call for a ride to a medical appointment?...29 How far in advance do I need to call?...29 Can someone I know give me a ride to my appointment and get money for mileage?...29 Who do I call if I have a complaint about the service or staff?...29 What are the hours of operation and limits for transportation services?...29 EYE CARE SERVICES...29 How do I get eye care services?...29 DENTAL SERVICES...30 How do I get dental services for my child?...30 INTERPRETER SERVICES...30 Can someone interpret for me when I talk with my doctor?...30 Who do I call for an interpreter?...30 How far in advance do I need to call?...30 How can I get a face-to-face interpreter in the provider s office?...30 Se Habla Español...30 ATTENTION FEMALE MEMBERS...31 What if I need OB/GYN care?...31 Do I have a right to choose an OB/GYN?...31 How do I choose an OB/GYN?...31 If I do not choose an OB/GYN, do I have direct access?...31 Will I need a referral?...31 Can I stay with my OB/GYN if they are not with Sendero?...31 What if I am pregnant?...31 Who do I need to call?...32 What other services/activities/education does Sendero offer pregnant women? Where can I find a list of birthing centers?... 32

7 Page vi How soon can I be seen after contacting my OB/GYN for an appointment?...32 Can I pick a Primary Care Provider for my baby before the baby is born?...32 How and when can I switch my baby s Primary Care Provider?...32 Can I switch my baby s health plan?...33 How do I sign up my newborn?...33 How and when do I tell my health plan?...33 How and when do I tell my caseworker?...33 Who do I call if I have special health care needs and need someone to help me?...33 ADVANCE DIRECTIVES...33 What if I am too sick to make a decision about my medical care?...33 What are advance directives?...34 How do I get an advance directive?...34 OTHER INFORMATION...34 What happens if I lose my Medicaid coverage?...34 What if I get a bill from my doctor?...34 Who do I call?...34 What information will they need?...35 What do I have to do if I move?...35 What if I have other health insurance in addition to Medicaid?...35 MEMBER RIGHTS AND RESPONSIBILITIES...35 MEMBER RIGHTS...35 MEMBER RESPONSIBILITIES...37 What if I need durable medical equipment (DME) or other products normally found in a pharmacy?...38 COMPLAINT PROCESS...39 What should I do if I have a complaint?...39 Who do I call?...40 Can someone from Sendero help me file a complaint?...40 How long will it take to process my complaint?...40 Requirements and timelines for filing a complaint...40 STAR Member Handbook

8 Page vii Information on how to file a complaint with HHSC once I have gone through the Sendero process:...41 APPEAL PROCESS...41 What can I do if my doctor asks for a service for me that is covered but Sendero denies it or limits it?...41 How will I find out if services are denied?...42 Time frames...43 Can someone from Sendero help me file an appeal?...44 Can I file an appeal with the State?...44 What is an Expedited Appeal?...44 How may I ask for an expedited appeal? Does my request have to be in writing?...45 Who can help me file an expedited appeal?...45 What are the time frames for an expedited appeal?...45 What happens if Sendero denies your request for an expedited appeal?...45 STATE FAIR HEARING...45 Can I ask for a State Fair Hearing?...45 FRAUD AND ABUSE OF THE STAR PROGRAM...46 Do you want to report Waste, Abuse, or Fraud?...46 To report Waste, Abuse, or Fraud...46 To report Waste, Abuse or Fraud, gather as much information as possible...47 INFORMATION THAT MUST BE AVAILABLE ON AN ANNUAL BASIS...47

9 Page 1 IMPORTANT InfoRMATION! Call us: Member Services (English or Spanish) toll-free For hearing impaired: (TDD) toll-free Interpreter Services also available Write us: 2028 E. Ben White Blvd., Suite 400 Austin, Texas Regular Business Hours: 8 a.m 5 p.m. CST, Monday - Friday except for state approved holidays Before 8:00am or after 5:00pm: Call and leave a message. We will return your call the next working day. 24 Hour Behavioral Health Hotline: Call toll-free (English or Spanish) for information on services. You can call this number 24 hours a day, 7 days a week. Other interpretive services available. If there is an emergency or crisis, go to the ER or call Hour Nurse Line: toll-free If you need medical advice or wish to learn more about a medical condition, you can call this number 24 hours a day, 7 days a week. Vision and Eye Care Number: Call toll-free for questions regarding eye exams and glasses Medicaid Managed Care Help Line: Call toll-free TDD STAR Help Line: Call toll-free TDD Dental Care Number: Call toll-free for questions about dental care Pharmacy Help Line: Call toll-free if you need help getting a prescription filled. Non-Urgent Transportation: The Medical Transportation Program can give you a ride if you cannot get a ride to the doctor s office. Call toll-free, Monday - Friday, 8 a.m. to 5 p.m. (CST). Call early to arrange for a ride. Medical Transportation Program Call Center (Scheduling) Central Office Phone Number Document Fax STAR Member Handbook

10 Page 2 SENDERO HealTH Plans and STAR The STAR program in the State of Texas is the Managed Medicaid program. This program provides care to families who would not normally have access to care. The program is administered by the Texas Health and Human Services Commission (HHSC). By choosing (Sendero), we provide STAR health services to you and your children from birth through age 18. Health care through Sendero STAR is available in these central Texas counties: Bastrop Burnet Caldwell Fayette Hays Lee Travis Williamson Sendero is a not-for-profit Health Maintenance Organization (HMO) licensed by the Texas Department of Insurance. By choosing Sendero, you and your child will get all the STAR health benefits plus more: Your own doctor Friendly and confidential staff Access to many hospitals Free health education Free extra benefits Assurance of access to care regardless of nationality, race, religion, origin and gender If you have any questions or concerns about access of care, or feel that you were not allowed access to care because of nationality, race, religion, origin, or gender, please contact Sendero Member Services at as soon as possible. Your concern will be investigated and resolved quickly. The doctor you chose for you and/or your child when you enrolled with Sendero STAR will be your and/or your child s Primary Care Provider (PCP) and will help take care of all your and your child s health care needs.

11 Page 3 First things first. These are a few important things about your and your child s health care: You will receive a Sendero ID card, if you have not already received one Your PCP s name will be on the Sendero ID card. Please check the ID card to make sure the names on it are correct. Get to know you and your child s doctor. Make an appointment with your PCP as soon as possible. Call your PCP for appointments. Tell them you and your child are Sendero STAR Members. Call your PCP whenever you or your child needs health care. Follow your PCP s advice. Carry your Sendero ID card(s) and Your Texas Benefits Medicaid card(s) with you at all times. Use the hospital emergency room only for emergencies. If there is an emergency or crisis, go to the ER or call 911. This Member Handbook answers many questions about Sendero. We hope you read it soon. Keep it in a place where you can find it easily. Please feel free to call or write us if you have any questions. At Sendero we are ready to help you any time during the day or night. We have special services for people who have trouble reading, hearing, seeing, or speak a language other than English or Spanish. If you need this Handbook in a different language, in audio form, larger print, or Braille, let us know and we will get it to you. Just call Sendero Member Services at as soon as possible. Sendero will give these materials to you at no cost. Welcome to! STAR Member Handbook

12 Page 4 YOUR STAR ID CARD You will get a STAR Identification (ID) card after you enroll in Sendero. A sample copy of the Sendero ID card is shown below: Important Information/Información Importante 24/7 Member Services/Departamento de Servicios para Miembros (gratis) TTY for hearing impaired/tty para personas con problemas del oído /7 Behavioral Health Hotline/Linea de Servicios de Salud Mental Vision Services/Servicios para la vista In case of emergency call 911 or go to the closest emergency room. After treatment, call your PCP within 24 hours. 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. NOTICE TO PROVIDER: The member whose name appears on the face of this card is covered by for STAR services. For provider billing or UM questions, The UM FAX number is Submit Professional Claims to:, PO Box 3869, Corpus Christi, TX Pharmacist (Only) Help Desk: BIN: PCN: MCD Rx GRP: SND REV 3/14 FRONT BACK You and each of your children will have a different card. You will not get a new Sendero STAR ID card every month. You will get a new one if you lose your ID card, or if you call us to change your Primary Care Physician (PCP). Reading the Sendero STAR ID card The front of the Sendero STAR ID card shows important information about you and your child, the PCP s name and PCP s phone number. The back of the card shows important phone numbers for help from Sendero Member Services. If you have an emergency, call 911 or go to the nearest emergency room. Using the Sendero STAR ID card Carry your and your child s Sendero STAR ID card with you when you and your children get any health care services. You must show your Sendero STAR ID card each time you get health care services. If you lose your Sendero ID card or move If you lose the Sendero STAR ID card, call us right away at to get a new one. If you move or change phone numbers, call us so we can send you another ID card. We always need to have your correct address and phone number. Your Texas Benefits Medicaid card When you are approved for Medicaid, you will get a Your Texas Benefits Medicaid 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 stripe 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.

13 Page 5 You will get a new Your Texas Benefits Medicaid card every time you change your health plan. If you are not sure if you are covered by Medicaid, you can find out by calling toll free at You can also call 211. 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 The Your Texas Benefits Medicaid card has these facts printed on the front: Your name and Medicaid ID number The name of the Medicaid program you re in if you get your Medicaid services through a health plan. This would be STAR, STAR Health, or STAR+PLUS. The date HHSC made the card for you Facts your drug store will need to bill Medicaid The name of the health plan you re in and the plan s phone number The name of your doctor and drug store if you re in the Medicaid Limited program The back of Your Texas Benefits Medicaid card has a website you can visit and a phone number you can call 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. If you lose the Your Texas Benefits Medicaid card, you can get a new one by calling toll-free at Medicaid Eligibility Verification (Temporary Form 1027-A) If a member loses the Your Texas Benefits Medicaid card and needs quick proof of eligibility, HHSC staff can still generate a Temporary Medicaid Eligibility Verification Form (Form 1027-A). Members must apply for the temporary form in person at an HHSC benefits office. To find the nearest office call 211 (pick a language and then pick option 2). STAR Member Handbook

14 Page 6 ALL about PRIMANY CARE PHYSICIANS What is a Primary Care Provider (PCP)? During the enrollment process, you chose a doctor from our list to be your or your child s PCP. This doctor will make sure that you or your child gets the right care. The PCP will give you and your child regular checkups, write prescriptions for medicines and supplies when you or your child is sick, and tell you if you or your child should see a specialist. To give you the best care possible, your PCP needs to know your and your child s medical history. Your medical records are private and confidential. Only you, your PCP, and other approved providers have a right to see them. If you change doctors, be sure to give your new PCP any information needed about your medical history. Can a clinic be my Primary Care Provider (PCP)? You or your child may select a clinic as your PCP. This can be a Federally Qualified Health Center (FQHC), or a Rural Health Clinic (RHC). If you have questions call Sendero Member Services at What do I need to bring with me to the doctor s appointment? You must take your Sendero ID card, and your Texas Benefits Medicaid card with you when you go to the doctor. If your child is going to the doctor, don t forget your child s ID cards and shot records. How can I change my/my child s Primary Care Provider (PCP)? You may want to change to another PCP if: You are not happy with your PCP s care You need a different kind of doctor to take care of you or your child You move farther away from your PCP Your PCP is no longer a part of Sendero You do not get along with the PCP You can change your PCP by calling toll-free at The Sendero Provider Directory lists all PCPs. You can find it on the Internet at or call us and we will send a copy to you. You will get a new Sendero ID card that shows the date your new PCP can begin to care for you or your child. The new card will show the new PCP s name and phone number.

15 Page 7 When will my Primary Care Provider change become effective? You may change your PCP at any time. If you call to change your Primary Care Provider, before the 15 th of the month, your Primary Care Provider change will happen the first day of the next month. If you call to change your Primary Care Provider after the 15 th of the month, your Primary Care Provider change will happen the first of the following month. EXAMPLE: If you call Sendero to change your Primary Care Provider on February 2 nd, your Primary Care Provider change will happen on March 1 st. If you call to change your Primary Care Provider on January 16 th, the change will happen on March 1 st. 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: 2028 E. Ben White Blvd., Suite 400 Austin, TX Are there any reasons why my request to change Primary Care Provider may be denied? You may not be able to have the PCP you chose if: The PCP you picked is not seeing new patients, or The PCP you picked is no longer a part of Sendero. Can my Primary Care Provider move me to another Primary Care Provider for non-compliance? It is important to follow the PCP s advice. Take part in decisions about your or your child s health care. Your PCP may ask us to assign you or your child to another PCP if you do not follow his or her advice. It may also happen if you and the PCP do not get along or you miss visits without calling to tell the PCP why you weren t there. The PCP must notify us if this occurs. We will contact you and ask that you select another PCP. STAR Member Handbook

16 Page 8 What if I choose to go to another doctor who is not my Primary Care Provider? You may go to any provider who is part of Sendero, if you need: 24-hour emergency care from an emergency room Family Planning services and supplies If you need mental health or substance abuse services you should call the Behavioral Health Hotline at Behavioral Health Services are very private so you do not need the permission from your PCP to get these services. If you need a routine vision exam, you do not need permission from your PCP to get these services. But if you have an eye problem you will need a referral from your PCP. For questions about vision services, call For all other care, you must only see the PCP listed on your Sendero ID card. If you see another PCP, you may have to pay the bill. How do I get medical care after my Primary Care Provider s office is closed? If you or your child gets sick at night or on a weekend and cannot wait to get medical care, call your PCP for advice. Your PCP or another doctor is available by phone 24 hours a day, 7 days a week. If you or your child has a fever or a sore throat and you are not sure what to do, call your PCP s office. What is the Medicaid Limited Program? You may be put in the Limited Program if you do not follow Medicaid rules. It checks how you use Medicaid pharmacy services. Your Medicaid benefits remain the same. If you are put in the Medicaid Limited 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 Option 4. PHYSICIAN INCENTIVE Plan InfoRMATION Physician Incentive Plans: A physician incentive plan rewards doctors for treatments that reduce or limit services for people covered by Medicaid. Right now, Sendero does not have a physician incentive plan.

17 Page 9 CHANGING HEALTH PLANS 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, but not more than once a month. If you are in the hospital, a residential Substance Use Disorder (SUD) treatment facility, or residential detoxification facility for SUD, you will not be able to change health plans until you have been discharged. If you call to change your health plan on or before the 15 th of the month, the change will take place on the first day of the next month. If you call after the 15 th 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? You can change your health plan by calling the Texas STAR or STAR+PLUS Program Helpline at How many times can I change health plans? You can change health plans as many times as you want, but not more than once a month. If you are in the hospital, you will not be able to change health plans until you have been discharged. When will my health plan change be effective? If you call to change your health plan on or before the 15 th of the month, the change will take place on the first day of the next month. If you call after the 15 th 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 STAR Member Handbook

18 Page 10 Can Sendero ask that I get dropped from their plan (for non-compliance, etc.)? Yes, Sendero may request that you be dropped from our health plan if: You let someone else use your Sendero ID card You let someone else use your Texas Benefits Medicaid ID card You do not follow your doctor s advice, for you or your child You keep going to the emergency room for yourself or your child when you do not have a true emergency You cause problems at the doctor s office You make it difficult for your doctor to help you or other people BENEFITS AVAIlable FROM sendero STAR What are my health care benefits? Sendero gives you every covered service that you are entitled to get through Medicaid. You get: Care to help you and your child stay well Needed medical care for adults and children Shots for children under 21 years old Chiropractic services Podiatry (foot doctor) services Laboratory services X-ray services Surgery without staying in the hospital overnight Hospital care 24-hour emergency care from an emergency room Prescription drugs Eye exams and glasses Ear doctor visits and hearing aids Home health services (health care at home) Ambulance services, if you need it Dialysis (help from a machine) for kidney problems Family planning services and supplies (such as birth control) Behavioral (mental) health services Help with substance abuse (such as alcohol or drugs) An adult checkup every year

19 Page 11 How do I get these services? Your or your child s PCP will work with you to make sure you and your child get the care needed. You may call Member Services at at any time you have questions. There may be limitations to these services. Call Member Services for information on any limits. Are there any limits to any covered services? Yes, there are some Medicaid services that have limits. If you have questions about limits on any covered services, call us toll-free at We can let you know if a covered health benefit has a limit. What number do I call to find out about these services? You can call Sendero Member Services toll-free at What services are not covered? The following services, which may not be all services, are not covered by STAR: Acupuncture (healing using needles and pins) Hypnosis Cosmetic surgery (such as a face-lift) Artificial insemination Ear piercing Hospital bereavement Hair transplants Infertility treatments In-vitro fertilization Experimental medicines or procedures Marital counseling Medical testimony and reports Non-authorized services Penile implant Radial keratotomy Respite care Reversal of sterilization Any service that you don t have to have (is not medically necessary) Any service that your PCP does not say is OK Any service you get outside of the United States STAR Member Handbook

20 Page 12 What are my prescription drug benefits? Services include, but are not limited to, the following: Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biologicals; and Drugs and biologicals provided in an inpatient setting. What extra benefits does a member of Sendero get? All eligible Sendero STAR Members can receive the following extra member benefits: 24-hour Nurse Advice line Help finding a ride to doctor appointments $250 of basic dental services for pregnant women Extra $100 towards eye glasses for member 2 years of age and older once every two years One free sports/school physical each year for members 18 years old and younger Free pre-programmed cell phones for women who have a high-risk pregnancy One free home visit for new moms Free one year membership to the Boys and Girls Clubs in Bastrop, Hays, Travis or Williamson counties One free Youth Sports Session at the YMCA of Austin each year for members ages 5-14 in Travis and Williamson counties Free first aid kit and infant thermometer after completing timely post-partum visit Free $10 Academy Sports + Outdoors gift card for completing a New Member Health Assessment form within 45 days of the enrollment date Free Toddler Home Safety Kit after completing required Well-Child visit for certain members Free home baby monitor after completing initial OB appointment for pregnant women within 42 days of member enrollment date Free Newborn Care Kit after completing one Well-Child visit for newborns within 14 days from birth Free $50 GameStop gift card after completing a timely Well-Child/ Adolescent Well-Care visit within 90 days of member enrollment date Free pair of movie passes after completing a timely Well-Child/ Adolescent Well-Care visit within 60 days of a member birthday Free rides to birthing classes for pregnant members Free swim session at the YMCA of Austin for members ages 6 months to 18 years old

21 Page 13 How can I get these benefits? For eyeglasses, call our vision vendor at For an annual sport physical for your child, call the child s PCP to make an appointment. For all other services, call Member Services at What health education does Sendero offer? Sendero has education for members on many different health subjects. There is no charge for Sendero s health education. Health education may include information on: Immunizations Pregnancy Diabetes care Asthma care Bicycle safety Wellness programs and health fairs If you need health education materials in another language, or in another format, call Member Services at What other services can Sendero help me get? Sendero can help you with Women, Infants, and Children, Early Childhood Intervention (ECI), and Supplemental Nutrition Assistance Program (SNAP) also known as Food Stamps. STAR Member Handbook

22 Page 14 HEALTH CARE and OTHER services What does Medically Necessary mean? Medically Necessary means: (1) For members birth through age 20, the following Texas Health Steps services: (a) screening, vision, and hearing services; and (b) other Health Care Services, including Behavioral Health Services, that are necessary to correct or ameliorate a defect or physical or mental illness or condition. A determination of whether a service is necessary to correct or ameliorate a defect or physical or mental illness or condition: (i) must comply with the requirements of the Alberto N., et al. v. Suehs, et al. partial settlement agreements; and (ii) may include consideration of other relevant factors, such as the criteria described in parts (2)(b g) and (3)(b g) of this definition. (2) For members over age 20, non-behavioral health related health care services that are: (a) reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a member, or endanger life; (b) provided at appropriate facilities and at the appropriate levels of care for the treatment of a member s health conditions; (c) consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies; (d) consistent with the diagnoses of the conditions; (e) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; (f) not experimental or investigative; and (g) not primarily for the convenience of the member or provider.

23 Page 15 (3) For members over age 20, behavioral health services that: (a) are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder; (b) are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care; (c) are furnished in the most appropriate and least restrictive setting in which services can be safely provided; (d) are the most appropriate level or supply of service that can safely be provided; (e) could not be omitted without adversely affecting the member s mental and/or physical health or the quality of care rendered; (f) are not experimental or investigative; and (g) are not primarily for the convenience of the member or provider. What is routine medical care? Routine medical care is care that is not an emergency or that does not need urgent treatment (see explanations below). The PCP you chose will help your child with all his/her health care. Your child s PCP will get to know you, arrange regular checkups, and treat your child when he or she is sick. Your PCP will give you prescriptions for medicine, and send your child to a special doctor (specialist) if he/she needs one. It is important that you do what your child s PCP says and take part in decisions made about your child s health care. If you cannot make a decision about your child s health care, you can choose someone else to do it for you. When you need your child to see the PCP, call the PCP at the number on your child s Sendero ID card. Someone in the PCP s office will set a time for you. It is very important that you keep the appointment. Call early to set up visits, and call back if you have to cancel. If more than one child in your family needs to see the doctor, you need a new appointment for each person. How soon can I expect my child to be seen? You should be able to get an appointment for routine care within two (2) weeks. STAR Member Handbook

24 Page 16 What is urgent medical care? Urgent medical care is when your child is sick or hurt and needs treatment as soon as possible to keep your child from getting worse. These are situations when you need to call your child s PCP first: Earache Toothache or baby teething Rash Colds, cough, sore throat, flu or sinus problems Minor sun burn Minor cooking burn Minor headache Broken cast Stitches needing to be removed Medication refills Your child s PCP is available, directly or through other doctors helping to cover the office, 24 hours a day, 7 days a week. How soon can I expect my child to be seen? You can expect your child to be seen for urgent medical care within 24 hours. What is emergency medical care? Emergency medical care is provided for Emergency Medical Conditions and Emergency Behavioral Health Conditions. Emergency Medical Condition means: A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in: 1. placing the patient s health in serious jeopardy; 2. serious impairment to bodily functions; 3. serious dysfunction of any bodily organ or part; 4. serious disfigurement; or 5. in the case of a pregnant woman, serious jeopardy to the health of a woman or her unborn child.

25 Page 17 Emergency Behavioral Health Condition means: Any condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson, possessing average knowledge of medicine and health: 1. Requires immediate intervention or medical attention without which the Member would present an immediate danger to themselves or others; or 2. Which renders the Member incapable of controlling, knowing or understanding the consequences of their actions. Emergency Services and Emergency Care means: Covered inpatient and outpatient services furnished by a provider that is qualified to furnish such services and that are needed to evaluate or stabilize an Emergency Medical Condition or Emergency Behavioral Health Condition, including post-stabilization care services. How soon can I expect to be seen? Go to the nearest hospital if you think you have any of these problems. You may call 911 for help in getting to the hospital emergency room. Emergency Care is available 24 hours a day, 7 days a week. Things like a cold, cough, rash, small cuts, minor burns or bruises are not good reasons to go to the Emergency Room. Are Emergency Dental Services covered? Sendero covers limited emergency dental services for the following: Dislocated jaw Traumatic damage to teeth and supporting structures Removal of cysts Treatment of oral abscess of tooth or gum origin Treatment and devices for craniofacial anomalies Drugs for any of the above conditions Sendero also covers dental services your child gets in a hospital or ambulatory surgical center. This includes services that the doctor provides and other services your child might need, like anesthesia. What do I do if my child needs emergency dental care? During normal business hours, call your child s Main Dentist to find out how to get emergency services. If your child needs emergency dental services after the main dentist s office has closed, call us toll-free at or call 911. STAR Member Handbook

26 Page 18 What is post-stabilization? Post-stabilization care services are services covered by Medicaid that keep your condition stable following emergency medical care. How do I get medical care after my Primary Care Provider s office is closed? If you or your child gets sick at night or on a weekend and cannot wait to get medical care, call your PCP for advice. Your PCP or another doctor is available by phone 24 hours a day, 7 days a week. If you or your child has a fever or a sore throat and you are not sure what to do, call your PCP s office. What if I get sick when I m out of town or traveling? If you need medical care when traveling, call us toll-free and we will help you find a doctor. If you need emergency services while travelling, go to a nearby hospital, then call us toll-free at What if I m out of the state? If you or your child has an emergency while you are out of town or out of state, go to the nearest Emergency Room. When you or your child will be temporarily away from home, you should contact your PCP ahead of time to schedule appointments or obtain prescriptions to last for the duration of your stay. If you or your child gets sick while he or she is out of town -- and it is not an emergency -- he or she will still remain under the care of your PCP. With the exception of emergency care, if you or your child sees an out-of-town doctor you may have to pay. If you or your child leaves the Sendero s service area for an extended period of time, you or your child may be disqualified from STAR or have to enroll in a health plan covering another area within the state of Texas. Keep your and your child s Sendero STAR ID card with you at all times. What if I m out of the country? Medical services performed out of the country are not covered by Medicaid. What if I need to see a special doctor (specialist)? Your PCP will tell you if you or your child needs to see a specialist. Your PCP will make sure that you or your child gets the special care needed. In general, you cannot go to another doctor or get a special service if your PCP does not agree to make a referral.

27 Page 19 What is a referral? A referral is when your PCP sends you to another doctor or service for care. How soon can I expect to be seen by a specialist? You should expect the specialist to give you an appointment within 2 weeks for non-urgent care or within 24 hours for urgent care. What services do not need a referral? You can get some services without going to your PCP first. These include: Emergency care Routine vision care OB/GYN Care Behavioral Health Services Family Planning Services It is good to let your PCP know when you receive other care, but you are not required to. This lets your PCP know all of your or your child s needs. How can I ask for a second opinion? Sendero will pay for a second opinion. Call Member Services at to arrange for a second opinion. The Case Management Department will be glad to help you with this. You will need to call us for authorization before you get a second opinion. BEHAVIORAL HealTH How do I get help if I have behavioral (mental) health, alcohol or drug problems? You can get help for behavioral health, alcohol or drug problems through Sendero. You can go to a mental health provider without a referral from your PCP. The provider you pick must be a provider with Sendero s network. Call the Behavioral Health Hotline on your ID card for help. The phone number is You can call anytime 24 hours a day, seven (7) days a week. Behavioral health services are very private so you do not need permission of your or your child s PCP. Do I need a referral? You can go to a mental health provider without a referral from your PCP. The provider you pick must be a provider with Sendero s network. STAR Member Handbook

28 Page 20 If you or your child has an emergency related to mental health problems or drug or alcohol abuse, go to the nearest hospital emergency room or call 911 for an ambulance. PRESCRIPTIons How do I get my medications? Medicaid pays for most medicine your doctor says you need. Your doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you. How do I find a network drug store? Call Sendero Member Services toll-free if you need help finding a pharmacy or having a prescription filled at What if I go to a drug store not in the network? You may not be able to have your medication filled or you may have to pay out of pocket for the medication. It is best you use a drug store in the network. What do I bring with me to the drug store? Take you or your child s Sendero STAR ID card and Texas Benefits Medicaid ID card with you when you go to the pharmacy. The pharmacy may ask for these cards. What if I need my medications delivered to me? Call Sendero Member Services toll-free if you need help finding a pharmacy that will deliver your medications to you at Who do I call if I have problems getting my medications? Call Sendero Member Services toll-free if you need help finding a pharmacy or having a prescription filled at What if I can t get the medication my doctor ordered approved? If your doctor cannot be reached to approve a prescription, you may be able to get a three-day emergency supply of your medication. Call Sendero Member Services at for help with your medications and refills. What if I lose my medication(s)? Call Sendero Member Services at for help with your medications and refills.

29 Page 21 FAMILY PlannING services How do I get family planning services? Family planning services (such as birth control and counseling) are very private. You do not need to ask your PCP for a referral to get these services or supplies. You may have an annual visit, counseling and tests. You may also get drugs and supplies that prevent pregnancy. You can go to any provider who takes Medicaid/ STAR. To see a list of providers, see page 21 of this Handbook. Do I need a referral for this? You do not need a referral for family planning services. Where do I find a family planning services provider? You can find the locations of family planning providers near you online at or you can call Sendero Member Services at toll-free for help finding a family planning provider. FAMILY PlannING PROVIDERS in the Austin area: CommUnityCare A. K. Black 928 Blackson Ave. Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Thur 7:45 a.m.-4:45 p.m.; Fri 9 a.m.-5 p.m. County Service Area: Travis CommUnityCare Del Valle 3518 FM 973 Del Valle, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Thur 7:45 a.m-4:45 p.m.; Fri 9 a.m-5 p.m. County Service Area: Travis STAR Member Handbook

30 Page 22 Planned Parenthood of Austin - Surgical and Sexual 201 E. Ben White Blvd. Austin, Texas Clinic Phone: (512) Hours of Operation: Mon Fri 8 a.m-6 p.m.; Sat 8 a.m-2:30 p.m. County Service Area: Travis Planned Parenthood of Austin - Family Planning 1823 E. 7th St. Austin, Texas Clinic Phone: (512) Hours of Operation: Mon Fri 8 a.m-6 p.m.; Sat 8 a.m-2:30 p.m. County Service Area: Travis Planned Parenthood of Austin - Surgical and Sexual 9041 Research Blvd, Suite 250 Austin, Texas Clinic Phone: (512) Hours of Operation: Mon Fri 8 a.m-6 p.m.; Sat 8 a.m-2:30 p.m. County Service Area: Travis CommUnityCare East Austin 211 Comal St. Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Fri 8 a.m-4:45 p.m. County Service Area: Travis CommUnityCare Manor 600 W. Carrie Manor St. Manor, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Thur 7:45 a.m-4:45 p.m.; Fri 9 a.m-5 p.m. County Service Area: Travis CommUnityCare Montopolis 1200 B Montopolis Dr. Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Thur 7:45 a.m-4:45 p.m.; Fri 9 a.m-5 p.m. County Service Area: Travis

31 CommUnityCare North Central 1210 W. Braker Ln. Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Fri 7 a.m-6 p.m. County Service Area: Travis CommUnityCare Oak Hill 8656 A Hwy 71 W., Suite C Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Thur 8 a.m-5 p.m.; Fri 9 a.m-5 p.m. County Service Area: Travis CommUnityCare Pflugerville Foothill Farms Loop Pflugerville, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Thur 7:45 a.m-4:45 p.m.; Fri 9 a.m-5 p.m. County Service Area: Travis CommUnityCare Rosewood-Zaragosa 2802 Webberville Rd. Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon 7:45 a.m-4:45 p.m.; Tue, Thur 7:45 a.m-5 p.m; Wed 7:45 a.m 8 p.m.; Fri 9 a.m 5 p.m. County Service Area: Travis CommUnityCare South Austin 2529 S. First St. Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon, Wed 7 a.m-7 p.m.; Tue,Thur 7:45 a.m-7 p.m.; Fri 9 a.m-5 p.m.; Sat 8 a.m-5 p.m. County Service Area: Travis Page 23 STAR Member Handbook

32 Page 24 CommUnityCare Family Wellness Center - UT School of Nursing 2901 North IH 35, Suite 101 Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon, Wed, Thur 8 a.m-5 p.m.; Tue 9 a.m-4:45 p.m. County Service Area: Travis Elgin Community Health Services 204 S. Main Elgin, Texas Agency Name: Community Action Inc, of Hays, Caldwell and Blanco Counties Clinic Phone: (512) Hours of Operation: Mon Fri 8 a.m-5 p.m. County Service Area: Bastrop, Williamson Lockhart Community Health Services 1710 S. Colorado, Suite 115 Lockhart, Texas Agency Name: Community Action Inc, of Hays, Caldwell and Blanco Counties Clinic Phone: (512) Hours of Operation: Mon Fri 8 a.m-5 p.m. County Service Area: Caldwell, Bastrop, Hays Luling Community Health Center 111 South Laurel Street Luling, Texas Agency Name: Community Health Centers of South Central Texas, Inc. Clinic Phone: (830) Hours of Operation: Mon, Wed Fri 8 a.m-5 p.m.; Tue 8 a.m-8 p.m. County Service Area: Caldwell Family Medicine at Lake Aire Medical Center 2423 Williams Drive, Suite 113 Georgetown, Texas Agency Name: Lone Star Circle of Care Clinic Phone: (877) Hours of Operation: Mon Fri 7:30 a.m-7 p.m. County Service Area: Bell, Burnet, Milam, Travis, Williamson

33 Page 25 Lone Star Circle of Care OB/GYN 2300 Round Rock Avenue Round Rock, Texas Agency Name: Lone Star Circle of Care Clinic Phone: (877) Hours of Operation: Mon Fri 7:30 a.m-5 p.m. County Service Area: Bell, Burnet, Milam, Travis, Williamson Lone Star Circle of Care Ben White Health Clinic 1221 W. Ben White Blvd., Suite B200 Austin, Texas Agency Name: Lone Star Circle of Care Clinic Phone: (877) Hours of Operation: Mon Fri 8 a.m-8 p.m.; Sat 9 a.m-1 p.m. County Service Area: Bell, Burnet, Milam, Travis, Williamson Seton-Circle of Care Family Medicine at Texas A&M Health Science Center 3950 North A.W. Grimes Blvd., Suite 301A Round Rock, Texas Agency Name: Lone Star Circle of Care Clinic Phone: (877) Hours of Operation: Mon Fri 8 a.m-8 p.m.; Sat 9 a.m-1 p.m. County Service Area: Bell, Burnet, Milam, Travis, Williamson Dell Children s Circle of Care Adolescent Health at Texas A&M Health Science Center 3950 North A.W. Grimes Blvd., Suite N202 Round Rock, Texas Agency Name: Lone Star Circle of Care Clinic Phone: (877) Hours of Operation: Mon Fri 8 a.m-5 p.m. County Service Area: Bell, Burnet, Milam, Travis, Williamson Seton - Circle of Care Women s Services at Texas A&M Health Science Center 3950 North A. W. Grimes Blvd., Suite N103 Round Rock, Texas Agency Name: Lone Star Circle of Care Clinic Phone: (877) Hours of Operation: Mon Fri 8 a.m-5 p.m. County Service Area: Bell, Burnet, Milam, Travis, Williamson STAR Member Handbook