i Sendero Health Plans

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1 i

2 ii STAR Member Handbook

3 iii TABLE OF CONTENTS PAGE IMPORTANT INFORMATION... 1 SENDERO HEALTH PLANS AND STAR... 2 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 Verification Form 1027-A)... 5 ALL ABOUT PRIMARY CARE PHYSICIANS... 6 What do I need to bring with me to the doctor s appointment?... 6 What is a Primary Care Provider (PCP)?... 6 Can a specialist ever be considered a Primary Care Provider (PCP)?... 6 How can I change my/my child s Primary Care Provider (PCP)?... 6 How can I change my Primary Care Provider?... 6 Can a clinic be my Primary Care Provider (PCP)? (Rural Health Clinic/Federally Qualified Health Center)... 7 How many times can I change my/my child s Primary Care Provider?... 7 When will my Primary Care Provider change become effective?... 7 Are there any reasons why my request to change Primary Care Provider may be denied?... 7 Are there any reasons why a request to change a Primary Care Provider may be denied?... 8 Can my Primary Care Provider move me to another Primary Care Provider for noncompliance?... 8 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 Lock-in Program?... 9 PHYSICIAN INCENTIVE PLAN INFORMATION... 9 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

4 When will my health plan change be effective? Can Sendero ask that I get dropped from their plan (for non-compliance, etc.)? BENEFITS AVAILABLE FROM SENDERO STAR What are my health care benefits? How do I get these services? Are there any limits to any covered services? What number do I call to find out about these services? What services are not covered? What are my prescription drug benefits? What extra benefits do I get as a Member of Sendero? How can I get these benefits? What health education does Sendero offer? What other services can Sendero help me get? What does Medically Necessary mean? What is routine medical care? How soon can I expect my child to be seen? What is Urgent Medical Care? What should I do if my child or I need urgent medical care? How soon can I expect my child to be seen? What is emergency medical care? How soon can I expect to be seen? Are Emergency Dental Services covered? What do I do if my child needs emergency dental care? What is post-stabilization? How do I get medical care after my Primary Care Provider s office is closed? What if I get sick when I m out of town or traveling? What if I m out of the state? What if I m out of the country? What if I need to see a special doctor (specialist)? iv STAR Member Handbook

5 v What is a referral? How soon can I expect to be seen by a specialist? What services do not need a referral? How can I ask for a second opinion? BEHAVIORAL HEALTH How do I get help if I have behavioral (mental) health, alcohol or drug problems? Do I need a referral? What are mental health rehabilitation services and mental health targeted case managements? How do I get these services? PRESCRIPTIONS How do I get my medications? How do I find a network drug store? What if I go to a drug store not in the network? What do I bring with me to the drug store? What if I need my medications delivered to me? Who do I call if I have problems getting my medications? What if I can t get the medication my doctor ordered approved? What if I lose my medication(s)? FAMILY PLANNING SERVICES How do I get family planning services? Do I need a referral for this? Where do I find a family planning services provider? CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN What is Case Management for Children and Pregnant Women (CPW)? Who can get a case manager? What do case managers do? What kind of help can you get? How can you get a case manager? What is Early Childhood Intervention (ECI)?... 30

6 Do I need a referral for this? Where do I find an ECI provider? What is Texas Health Steps? What services are offered by Texas Health Steps? How and when do I get Texas Health Steps medical and dental checkups for my child? Does my doctor have to be part of Sendero network? Do I have to have a referral? What if I need to cancel an appointment? What if I am out of town and my child is due for a Texas Health Steps checkup? What if I am a migrant farmworker? TRANSPORTATION What is MTP? What services are offered by MTP? How to get a ride? Who do I call for a ride to a medical appointment? EYE CARE SERVICES How do I get eye care services? DENTAL SERVICES What dental services does Sendero cover for children? INTERPRETER SERVICES Can someone interpret for me when I talk with my doctor? Who do I call for an interpreter? How far in advance do I need to call? How can I get a face-to-face interpreter in the provider s office? ATTENTION FEMALE MEMBERS What if I need OB/GYN care? Do I have a right to choose an OB/GYN? How do I choose an OB/GYN? If I do not choose an OB/GYN, do I have direct access? Will I need a referral? vi STAR Member Handbook

7 vii How soon can I be seen after contacting my OB/GYN for an appointment? Can I stay with my OB/GYN if they are not with Sendero? What if I am pregnant? How soon can I be seen after contacting my OB/GYN for an appointment? Can I stay with my OB/GYN if they are not with Sendero? Where can I find a list of birthing centers? How soon can I be seen after contacting my OB/GYN for an appointment? Can I pick a Primary Care Provider for my baby before the baby is born? How and when can I switch my baby s Primary Care Provider? Can I switch my baby s health plan? How do I sign up my newborn? How and when do I tell my health plan? How can I receive healthcare after my baby is born (and I am no longer covered by Medicaid)? How and when do I tell my caseworker? Who do I call if I have special health care needs and need someone to help me? ADVANCE DIRECTIVES What if I am too sick to make a decision about my medical care? What are advance directives? How do I get an advanced directive? OTHER INFORMATION What do I have to do if I need help with completing my renewal application? What happens if I lose my Medicaid coverage? What if I get a bill from my doctor? Who do I call? What information will they need? Can my Medicare provider bill me for services or supplies if I am in both Medicare and Medicaid? What do I have to do if I move? What if I have other health insurance in addition to Medicaid?... 42

8 What if I need to update my address or phone number? (For AARP Members Only) MEMBER RIGHTS AND RESPONSIBILITIES MEMBER RESPONSIBILITIES: What if I need durable medical equipment (DME) or other products normally found in a pharmacy? COMPLAINT PROCESS What should I do if I have a complaint? Who do I call? Can someone from Sendero help me file a complaint? How long will it take to process my complaint? What are the requirements and timelines for filing a Complaint? APPEAL PROCESS What can I do if my doctor asks for a service or medicine for me that is covered but Sendero denies it or limit it? How will I find out if services are denied? Can someone from Sendero help me file an Appeal? Can I file an appeal with the State? What is an Expedited Appeal? How do I ask for an Expedited Appeal? Does my request have to be in writing? What are the time frames for an expedited appeal? What happens if Sendero denies your request for an expedited appeal? Who can help me file an expedited appeal? STATE FAIR HEARING Can I ask for a State Fair Hearing? FRAUD AND ABUSE OF THE STAR PROGRAM Do you want to report Waste, Abuse, or Fraud? To report waste, abuse, or fraud, choose one of the following: To report waste, abuse or fraud, gather as much information as possible INFORMATION THAT MUST BE AVAILABLE ON AN ANNUAL BASIS viii STAR Member Handbook

9 IMPORTANT INFORMATION Call us: Write us: Regular Business Hour: Before 8:00am or after 5:00pm: Member Services (English or Spanish) toll-free For hearing impaired: (TTY) toll-free Interpreter Services also available 2028 E. Ben White Blvd., Suite 400 Austin, Texas :00 5:00 CST, Monday through Friday except for state approved holidays 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) with 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 24hours a day, 7 days a week. Vision and Eye Care Number: Ombudsman Managed Care (OMCAT): STAR Help Line: Dental Care Number: Pharmacy Help Line: Non-Urgent Transportation: Call toll-free for questions regarding eye exams and glasses Call toll-free Assistance Team (TTY) Call tollfree (TTY) Call toll-free for questions about dental care Call toll-free if you need help getting a prescription filled. Call toll-free, Monday through Friday, 8:00 a.m. to 5:00 p.m. (CST) 1

10 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 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 (see page 12 of this Handbook) 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 choose 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. STAR Member Handbook

11 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 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!

12 4 YOUR SENDERO 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: 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 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 STAR Member Handbook

13 5 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 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 The Your Texas Benefits Medicaid card has these facts printed on the front: Your name and Medicaid ID number. The date the card was sent to you. The name of the Medicaid program you re in if you get: o Medicare (QMB, MQMB) o Texas Women s health Program (TWHP) o Hospice o STAR Health o Emergency Medicaid, or o Presumptive Eligibility for Pregnant Women (PE). Facts your drug store will need to bill Medicaid. The name of your doctor and drug store if you re in the Medicaid Lock-in program. 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. Medicaid Eligibility Verification (Temporary Verification 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 (pick a language and then pick option 2).

14 ALL ABOUT PRIMARY CARE PHYSICIANS 6 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. 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 information needed about your medical history. Can a specialist ever be considered a Primary Care Provider (PCP)? Yes, to make sure that you keep having care a Specialist can be your PCP when the member has a disability, needs special care or has a long-lasting illness. Contact Sendero if you need help finding a Specialist that can offer the same services as a PCP. How can I change my/my child s Primary Care Provider (PCP)? You should 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 PCP s. 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. How can I change my Primary Care Provider? You should change to another PCP if: STAR Member Handbook

15 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 7 You can change your PCP by calling toll-free at The Sendero Provider Directory lists all PCP s. 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. Can a clinic be my Primary Care Provider (PCP)? (Rural Health Clinic/Federally Qualified Health Center) 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 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 When will my Primary Care Provider change become effective? You may change your PCP at any time. Once the change is made, it will become effective immediately. 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.

16 8 Are there any reasons why a request to change a 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. 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 are, 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. STAR Member Handbook

17 What is the Medicaid Lock-in Program? 9 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. PHYSICIAN INCENTIVE PLAN INFORMATION 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, Sendero does not have a physician incentive plan. CHANGING HEALTH PLANS What if I want to change health plans? You can change your health plan by calling the Texas STAR, STAR Kids, 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? 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

18 have been discharged. 10 When will my health plan change be effective? 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 on or after April 15, your change will take place on June 1 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 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) STAR Member Handbook

19 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 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

20 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 12 What are my prescription drug benefits? You can get unlimited prescriptions through your Medicaid coverage if you go to a pharmacy that takes Members. There are some medications that may not be covered through Medicaid. The pharmacy can let you know which medications are not covered, and can help you find another medication that is covered. You can also ask your doctor about what medications are covered. What extra benefits do I get as a Member of Sendero? All eligible Sendero STAR Members can receive the following extra member benefits: 24-hour nurse line One membership to the Boys & Girls Clubs in Bastrop, Hays, Travis and Williamson counties. Sendero will cover the cost of a summer camp session per calendar year for members that live in Travis County. Both the annual membership and the summer camp are limited to members age of 6 to 18 years old. Limited to one membership payment per member per calendar year and payment for one Summer Camp session per calendar year while a Sendero member. You must present your Sendero Member ID Card when you are signing up for the Boys and Girls Club membership. $500 of basic dental services for pregnant women that are 21 years of age and older. Members can call Denta Quest at Up to $175 for frames and lenses per year for members age 2 and older. This benefit is available once per calendar year. Members who are between the ages of 13 to 18 have a choice of frames and lenses or contacts (standard or disposable). You can receive these benefits at your in network vision doctor s office. $50.00 H-E-B gift card for new members between the ages of 2 weeks to 20 years of age that receive a Texas Health Steps medical checkup within 90 days of the day then joined Sendero. Member must call Member Services to request the extra benefit within 90 days of the visit. If the member completed the visit within 60 days before joining Sendero, the member must provide a completed verification form of the visit from the provider s office. $25.00 H-E-B gift card for existing members between the ages of 1-20 that receive a Texas Health Steps medical checkup within 60 days from their birthday. Member must call Member Services to request the extra benefit within 90 days of the visit. $25.00 H-E-B gift card for new members that complete a New Member STAR Member Handbook

21 13 Assessment within 45 days of when the member joined Sendero. The assessment can be found at the member can also call Member Services and request a copy to be mailed to them. Diaper bag with a package of diapers, first aid kit and infant thermometer for members that give birth to a child while enrolled in Sendero, attend a Sendero Baby Shower and obtain a postpartum visit between the 21st and 56th day following the birth. Member must call Member Services to request the extra benefit within 90 days from visit. Home visit for new mothers that give birth to a child while enrolled in Sendero. The visit will provide guidance to the mother regarding her newborn; answer questions; provide educational materials; facilitate selection of the newborn s PCP, schedule newborn visits; and schedule a postpartum visit The visit must be requested within 21 days from the delivery discharge, member must call Sendero Member Services to request a visit. Limited to 1 home visit per pregnancy Baby monitor for members that complete an initial OB appointment within 42 days from joining Sendero, are a Sendero member through their pregnancy, and complete a post-partum visit within days from delivery. Member must call Member Services to request the extra benefit within 90 days of the post-partum visit. If the member completed the initial OB appointment within 60 days prior to enrolling with Sendero, the member must provide a completed verification form of the visit from the provider s office. Help finding a ride to doctor appointments for STAR members with at risk conditions when state services are not available. Member must request the ride within 2 business days from the date of the appointment by calling Sendero Member Services. Transportation to appointments, stay and meals will be arranged and reimbursed for trips more than 75 miles away from the member s home. Limited to the Travis Service Area which includes Bastrop, Burnett, Caldwell, Fayette, Hays, Lee, Travis and Williamson counties. One sports, summer camp and/ or school physical per calendar year STAR members through age 18. Non-emergency transportation to doctor appointments for members that were not able to receive transportation through the Medical Transportation Program (MTP). Sendero will arrange for members that need a ride in the Capitol Metro service area. Member must call Member Services to request transportation. One swim session per calendar year at the YMCA of Austin for members ages 6 weeks 21 years old. Limited to YMCA of Austin. Member must show their Sendero ID card at the time of the registering for the swim session. Help getting a ride to birthing classes, Sendero s baby shower(s), WIC appointments, and other Sendero health related events for pregnant members in the Travis Service Area. Limited to pregnant women only. One youth sports session per member per season at a participating City of Austin Parks and Recreation Center. STAR members age 2 1/2 18 years of age (Swim sessions excluded). Member must live within the City of Austin,

22 Member must call Member Services to request sports voucher. Sendero will provide a backpack with a $15.00 H-E-B gift card for school supplies for members in grades PK-12.th. One backpack per school year. Member must call Member Services to request backpack. $25.00 H-E-B gift card for newborn STAR members that receive a timely Texas Health Steps medical checkup within 14 days from birth while a Sendero member. Member must call Member Services to request the extra benefit within 90 days of the visit. If the member completed the visit within 60 days before joining Sendero, the member must provide a completed verification form of the visit from the provider s office. Up to $ H-E-B gift card for members that obtain timely prenatal, postpartum visits and get a flu shot during their pregnancy. Member will receive a $25.00 gift card for their 1st, 2nd and 3rd trimester visits. The 1st visit must be within the 1st trimester or within 42 days from enrollment with Sendero. Member can receive a $25.00 gift card for completing their 2nd and 3rd trimester visits. The member must complete the appropriate visit by the end of each trimester. Member can receive $50.00 gift card if postpartum visit is completed within days from delivery. Member can receive a $25.00 gift card once they receive their flu shot during their pregnancy. Member can request gift card(s) by calling Sendero Member Services within 90 days from each date of service or choose one gift card for all the visits; the request must be made within 90 days from postpartum visit. If the member completed the visit within 60 days before joining Sendero, the member must provide a completed verification form of the visit from the provider s office. Home visit and breast feeding kit which includes nursing pads and breast feeding cover. Member must deliver their baby while a Sendero member, must complete a post-partum visit within days from delivery and receive a home visit within days from delivery. Member must call Member Services to request the breast feeding kit. Infant car seat or convertible car seat for pregnant members that completes their initial OB appointment within the first trimester of pregnancy and attend a Sendero Baby Shower. Member must call Member Services to request car seat after they have completed the initial OB visit and attended the Sendero baby shower. If the member completed the initial visit within 60 days prior to enrolling with Sendero, the member must provide a completed verification form of the visit from the provider s office. Free diapers (one box) to pregnant women who complete their initial screenings and prenatal visit within the first trimester. Member can call and request the benefit within 90 days from date of service of prenatal visit or can provide a completed verification form of the visit from the provider s office. Free diapers (one box) to current new moms who complete a post-partum screening questionnaire, and attend a post-partum visit on or between STAR Member Handbook

23 15 days after delivery. Member must call and request the benefit or complete a verification form and send to Sendero within 90 days from date of service of post-partum visit. Booster car seat for members that receive a Texas Health Steps within 90 days from joining Sendero. Member will receive a weight appropriate booster car seat. (Minimum of 40 to 100 lbs.). Member must call and request the benefit within 90 days from date of service. If the member completed the visit within 60 days before joining Sendero, the member must provide a completed verification form of the visit from the provider s office. Toddler nap kit for members between the ages of 1 4. Members must complete a Texas Health Steps within 60 days from their 1 st, 2 nd, 3 rd or 4 th birthday. Members must receive a Texas Health Steps medical checkup within 60 days from birthday. Member needs to call Member Services to request the extra benefit within 90 days of the visit. Sendero will provide up to 750 minutes for Safelink phones for pregnant members that Sendero determines are high-risk pregnancies. Limited to members that have a Safelink phones. Limited to the duration of the pregnancy. Member must request the additional minutes by calling Sendero Member Services. Umbrella stroller upon receiving all the State s and/ or Center for Disease Control and Prevention s (CDC) recommended immunizations and a flu (influenza) injection by either 12, 15, 18, 24 and 36 months of age. Member must call Member Services and request the extra benefit. One year YMCA Membership for Greater Williamson County. Members must be currently enrolled with at the time of the request. One membership per family. Member must live in Williamson County. One YMCA youth sport sessions per calendar year. Members must be between the ages of 5-14 years of age. Members must live in Travis, Hays or Williamson County. Member must go to YMCA and present their Sendero Member ID card. Help for Members with Asthma. High risk members will receive a $20 HEB gift card, an asthma education book at a home visit if they are enrolled in the asthma disease management program. Member can call Sendero Member Services to verify if they qualify to be on the asthma disease management program. Help for Members with Disease Management. High risk members that are enrolled in the disease management program will receive a diabetic cook book at home visit. Member can call Sendero Member Services to verify if they qualify to be on the Disease Management program

24 16 $25.00 H-E-B gift card for STAR members 21 years of age and younger that go to a follow-up visit within 7 days from leaving the hospital for mental health service. Limit to one gift card per fiscal quarter. Member must call Sendero Member Services to request gift card. Safety helmet for new members ages 3 years of age to 18 who receive an initial health assessment or their Texas Health Steps within 90 days from joining Sendero. Member must call and request the benefit within 90 days from the date of service. If the member completed the visits within 60 days before joining Sendero, the member must provide a completed verification form of the visit from the provider s office. Free diapers for newborn and infant members who complete their Texas Health Steps checkups within 1 to 9 months of age. Member must complete two (2) Texas Health Steps checkups within 120 days of birth to receive the first two (2) boxes of diapers. Member must complete 4, 6 and 9 months Texas Health Steps checkups in order to receive an additional two (2) boxes of diapers. Member must request extra benefit within 90 days of each visit. If the member completed one of the two visits within 60 days before joining Sendero, the member must provide a completed verification form of the visit from the provider s office. $25.00 H-E-B gift card for over-the-counter medications that are not covered or listed on the Medicaid formulary. Gift card can be requested every 6 months for members that remain active with. Member must call Member Services and request the extra benefit. For any questions about our extra benefits please contact Sendero Member Services toll-free at You can also see the most up to date list of extra benefits on our website at 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 STAR Member Handbook

25 17 Asthma care 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 WIC, Early Childhood Intervention (ECI), and Supplemental Nutrition Assistance Program (SNAP) also known as Food Stamps. 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 Janek, 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

26 (g) not primarily for the convenience of the member or provider; and 18 (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. What is Urgent Medical Care? Another type of care is urgent care. There are some injuries and illness that are probably not emergencies but can turn into emergencies if they are not treated within 24 STAR Member Handbook

27 hours. Some examples are: 19 Minor burns or cuts Earaches Sore throat Muscle sprains/strains What should I do if my child or I need urgent medical care? For urgent care, you should call your doctor s office even on nights and weekends. Your doctor will tell you what to do. In some cases, your doctor may tell you to go to an urgent care clinic before going. You need to go to a clinic that takes Sendero Medicaid. For help, call us toll-free at You also can call our 24- hour Nurse Help Line at for help getting the care you need. How soon can I expect my child to be seen? You should be able to see your doctor within 24 hours for an urgent care appointment. If your doctor tells you to go to an urgent care clinic, you do not need to call the clinic before going. The urgent care clinic must take Sendero Medicaid. 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 women, serious jeopardy to the health of a woman or her unborn child. 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:

28 20 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 poststabilization 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 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 in a hospital or ambulatory surgical center, including payment for the following: Treatment for dislocated jaw. Treatment for traumatic damage to teeth and supporting structures. Removal of cysts. Treatment of oral abscess of tooth or gum origin. Hospital, physician, and related medical services such as drugs for any of the above conditions. Sendero also covers dental services your child gets in a hospital or ambulatory surgical center including 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 STAR Member Handbook

29 What is post-stabilization? 21 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 all us tollfree 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

30 22 another doctor or get a special service if your PCP does not agree to make a referral. 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 nonurgent 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 STAR Member Handbook

31 you pick must be a provider with Sendero s network. 23 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 for an ambulance. What are mental health rehabilitation services and mental health targeted case managements? Mental health rehabilitation services are given to members with Severe and Persistent Mental Illness (SPMI) or a Severe Emotional Disturbance (SED) as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and who need rehabilitative services decided by either the Adult Needs and Strengths Assessment (ANSA) or the Child and Adolescent Needs and Strengths (CANS). Such as: Adult Day Program Medication Training and Support Crisis Intervention Skills Training and Development Psychosocial Rehabilitative Services Mental health targeted case management are services given to members with SPMI and SED such as: Case management for people who have SED (child, 3 through 17 years of age), which includes routine and intensive case management services. Case management for people who have SPMI (adult, 18 years of age or older). How do I get these services? Call Sendero Member Services toll-free at to help you find mental health rehabilitation services and mental health targeted case management. 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

32 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)? You can call your doctor or Sendero Member Services toll-free at 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 25 of this Handbook. STAR Member Handbook

33 Do I need a referral for this? 25 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 s 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 4:45; Fri 9 5 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 4:45; Fri 9 5 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 4:45 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 4:45; Fri 9 5 County Service Area: Travis CommUnityCare Montopolis 1200 B Montopolis Dr. Austin, Texas 78741

34 26 Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Thur 7:45 4:45; Fri 9 5 County Service Area: Travis CommUnityCare North Central 1210 W. Braker Lane Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Fri 7 6 County Service Area: Travis CommUnityCare Oak Hill 8656 A Hwy 71 West, Suite C Austin, Texas Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon Thur 8 5; Fri 9 5 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 4:45; Fri 9 5 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 4:45; Tue, Thur 7:45 5; Wed 7:45 8; Fri 9 5 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 7; Tue, Thur 7:45 7; Fri 9 5; Sat 8 5 County Service Area: Travis CommUnityCare William Cannon 6801 S. IH-35, Suite 1-E Austin, TX Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) STAR Member Handbook

35 Hours of Operation: Mon-Fri 8-5 County Service Area: Travis 27 CommUnityCare Southeast Health and Wellness Center 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 5; Tue 9 4:45 County Service Area: Travis CommUnityCare Blackstock Health Center 1313 Red River St. Austin, TX Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon-Fri 8-5 (Closed on Wed from 12-2) County Service Area: Travis CommUnityCare David Powell 4614 N.IH-35 Austin, TX Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation Mon, Thur, Fri 8-5 Tues,Wed 8-8 County Service Area: Travis CommUnityCare Rundberg 825 E. Rundberg Lane, Suite B-1 Austin, TX Agency Name: Central Texas Community Health Centers dba CommUnityCare Clinic Phone: (512) Hours of Operation: Mon-Fri 7:10-5 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 5 County Service Area: Bastrop, Williamson Luling Community Health Center 111 South Laurel Street Luling, Texas Agency Name: Community Health Centers of South Central Texas, Inc. Clinic Phone: (830)

36 Hours of Operation: Mon, Wed, Thurs, Fri 8 5; Tue 8 8 County Service Area: Caldwell 28 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 7 County Service Area: Bell, Burnet, Milam, Travis, Williamson 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 5 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 8; Sat 9 1 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 8; Sat 9 1 County Service Area: Bell, Burnet, Milam, Travis, Williamson Seton-Circle of Care Senior 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 5 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 5 County Service Area: Bell, Burnet, Milam, Travis, Williamson STAR Member Handbook

37 Seton Circle of Care Family Medicine at Northwest Research Blvd., Suite 310 Austin, Texas Agency Name: Lone Star Circle of Care Clinic Phone: (877) Hours of Operation: Mon Fri 8 5 County Service Area: Travis CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN 29 What is Case Management for Children and Pregnant Women (CPW)? Need help finding and getting services? You might be able to get a case manager to help you. Who can get a case manager? Children, teens, you adults (birth through age 20) and pregnant women who get Medicaid and: have health problems, or are a high risk for getting health problem s What do case managers do? A case manager will visit with you and then: Find out what services you need. Find services near where you live. Teach you how to find and get other services. Make sure you are getting the services you need. What kind of help can you get? Case managers can help you: Get medical and dental services. Get medical supplies or equipment. Work on school or education issues. Work on other problems.

38 How can you get a case manager? 30 Call the Texas Health Steps at (toll-free) Monday to Friday, 8 a.m. to 8 p.m. To learn more, go to: You can also call Sendero for Case Management toll-free at Monday to Friday, 8a.m. to 5 p.m. You can also go What is Early Childhood Intervention (ECI)? ECI is a statewide program for families with children, birth to three, with disabilities and developmental delays. Information regarding the Early Childhood Intervention (ECI) program can be found on the Texas Department of Assistive and Rehabilitative Services (DARS) website Do I need a referral for this? Yes a referral is needed for ECI services. A referral to ECI can be based on professional judgment or a family s concern. A medical diagnosis or a confirmed developmental delay is not needed to refer. As soon as a delay is suspected, children may be referred to ECI, even as early as birth. To refer a child, from birth to three, call the DARS Inquiries Line at or send an message to dars.inquiries@dars.state.tx.us. Where do I find an ECI provider? You can find a provider by going to the Texas Department of Assistive and Rehabilitative Services (DARS) website or by calling toll-free What is Texas Health Steps? What services are offered by Texas Health Steps? Texas Health Steps is the Medicaid health-care program for children, teens and young adults, birth through age 20. Texas Health Steps gives your child: Free regular medical checkups starting at birth. Fee dental checkups starting at 6 months of age. A case manager who can find out what services your child needs and where to get these services. STAR Member Handbook

39 31 Texas Health Steps checkups: Find health problems before they get worse and are harder to treat. Prevent health problems that make it hard for children to learn and grow like others their age. Help your child have a health smile. When to set up a checkup: You will get a letter from Texas Health Steps telling you when it s time for a checkup. Call your child s doctor or dentist to set up the checkup. Set up the checkup at a time that works best for your family. If the doctor or dentist finds a health problem during a checkup, your child can get the care he or she needs, such as: Eye tests and eyeglasses. Hearing tests and hearing aids. Dental care Other health care. Treatment for other medical conditions. Call Sendero s Member Services (toll-free) or Texas Health Steps (1-877-THSTEPS) (toll-free) if you: Need help finding a doctor or dentist. Need help setting up a checkup. Have questions about checkups or Texas Health Steps. Need help finding and getting other services. If you can t get your child to the checkup, Medicaid may be able to help. Children with Medicaid and their parent can get free rides to and from the doctor, dentist, hospital, or drug store. Houston/Beaumont area: Dallas/Ft. Worth area: All other areas: (1-877-MED-TRIP). How and when do I get Texas Health Steps medical and dental checkups for my child? All of the Sendero PCPs who work with children are also able to offer Texas Health

40 32 Steps services. You may want to talk to your child s PCP first. Don t forget to show your child s Sendero ID Card and Texas Benefits Medicaid ID Card to the PCP. Dental checkups can start at 6 months of age. If the dentist finds a problem, he/ she can also treat the problem in a follow-up visit. If the dentist has to do needed dental treatment at the hospital or someplace other than his/her office, you will need to contact Sendero before the service is done. Call Member Services at Does my doctor have to be part of Sendero network? Your child may go to any Medicaid/STAR provider for Texas Health Steps services. Do I have to have a referral? You do not need a referral from your child s PCP to receive Texas Health Steps services. What if I need to cancel an appointment? Call if you cannot make your appointment. Some PCPs ask patients to call at least 24 hours before their appointment so that another patient can use that time slot. What if I am out of town and my child is due for a Texas Health Steps checkup? If you have moved or are out of town when your child s Texas Health Steps exam is due, call Member Services for assistance at What if I am a migrant farmworker? You can get your checkup sooner if you are leaving the area. TRANSPORTATION MEDICAL TRANSPORTATION PROGRAM (MTP) What is MTP? MTP is an HHSC program that helps with non-emergency transportation to healthcare appointments for eligible Medicaid clients who have no other transportation options. MTP can help with rides to the doctor, dentist, hospital, drug store, and any other place you get Medicaid services. STAR Member Handbook

41 33 What services are offered by MTP? Passes or tickets for transportation such as mass transit within and between cities Air travel Taxi, wheelchair van, and other transportation Mileage reimbursement for enrolled individual transportation participant (ITP). The enrolled ITP can be the responsible party, family member, friend, neighbor, or client. Meals at a contracted vendor (such as a hospital cafeteria) Lodging at a contracted hotel and motel Attendant services (responsible party such as a parent/guardian, etc., who accompanies the client to a healthcare service) How to get a ride? Call MTP Phone Reservations: All requests for transportation services should be made within 2-5 days for your appointment. Exceptions may be authorized in the event of an emergency. Who do I call for a ride to a medical appointment? Call MTP as soon as you know you will need Call MTP as soon as you know you will need a ride. If MTP cannot give you a ride, call Sendero s Member Services at EYE CARE SERVICES How do I get eye care services? If you or child is under the age of 21, you can get an eye exam and prescription glasses. You can have an exam one time every 12 months, and you do not need a referral from your PCP. Children may be able to have additional eye examinations and prescriptions glasses as part of the Texas Health Steps. If you are over the age of 21, you can get an exam and prescription glasses one time every 24 months.

42 DENTAL SERVICES 34 What dental services does Sendero cover for children? Sendero covers emergency dental services in a hospital or ambulatory surgical center, including, but not limited to, payment for the following: Treatment of dislocated jaw. Treatment for traumatic damage to teeth and supporting structures. Removal of cysts. Treatment of oral abscess of tooth or gum origin. Sendero covers hospital, physician, and related medical services for the above conditions. This includes services the doctor provides and other services your child might need, like anesthesia or other drugs. Sendero is also responsible for paying for treatment and devices for craniofacial anomalies. Your child s Medicaid dental plan provides all other dental services including services that help prevent tooth decay and services that fix dental problems. Call your child s Medicaid dental plan to learn more about the dental services they offer. INTERPRETER SERVICES Can someone interpret for me when I talk with my doctor? Yes, Sendero s Member Services will arrange for an interpreter to help you during your visit. Who do I call for an interpreter? Call Sendero s Member Services at How far in advance do I need to call? You will need to call at least 48 hours in advance of your appointment. How can I get a face-to-face interpreter in the provider s office? The interpreter we arrange for you can be someone that comes to the office. This interpreter will be in the doctor s office with you. Let us know if this is what you want. Se Habla Español Sendero has people to help you who speak both Spanish and English. We also have member handouts in Spanish. STAR Member Handbook

43 ATTENTION FEMALE MEMBERS 35 What if I need OB/GYN care? Sendero allows you to pick any OB/GYN, but this doctor must be in the same network as your Primary Care Provider. You have the right to pick an OB/GYN without a referral from your Primary Care Provider. An OB/GYN can give you: One well-woman checkup each year. Care related to pregnancy. Care for any female medical condition. Referral to special doctor within the network. Do I have a right to choose an OB/GYN? Yes, you can choose any OB/GYN from within the same network as your Primary Care Provider. How do I choose an OB/GYN? You can only go to OB/GYNs that are part of the Sendero network. You do not need a referral from your PCP. To choose an OB/GYN, call Member Services at You may also have your OB/GYN doctor be your PCP. If you want to have your OB/GYN doctor be your PCP, call Member Services. If I do not choose an OB/GYN, do I have direct access? If you do not pick a Sendero OB/GYN as your Primary Care Provider, you can still get care from an OB/GYN within the Sendero network. Will I need a referral? You do not need a referral. How soon can I be seen after contacting my OB/GYN for an appointment? If you are pregnant you can be seen by your OBGYN within 14 days, except for high risk pregnancies or new members in their third trimesters an appointment must be offered within five days or immediately if there is an emergency. For preventative health services the OBGYN must offer an appointment within 90 days.

44 Can I stay with my OB/GYN if they are not with Sendero? 36 If your OB/GYN is not in Sendero s Provider Directory, please call our Member Services department at What if I am pregnant? It is very important that you call Sendero to tell us you are pregnant and what doctors you are seeing. Call Member Services at It is very important to start your prenatal care immediately. You should be able to get an appointment within two weeks of your request. Pregnant women will receive case management and health education. A nurse case manager will: Contact you by phone Contact you by mail Provide education about your pregnancy How soon can I be seen after contacting my OB/GYN for an appointment? If you are pregnant you can be seen by your OBGYN within 14 days, except for high risk pregnancies or new members in their third trimesters an appointment must be offered within five days or immediately if there is an emergency. For preventative health services the OBGYN must offer an appointment within 90 days. Can I stay with my OB/GYN if they are not with Sendero? If your OB/GYN is not in Sendero s Provider Directory, please call our Member Services department at Where can I find a list of birthing centers? A birthing center is a health facility, place or institution which is not a hospital or in a hospital and where births are planned to occur away from the mother s residence following a normal, uncomplicated pregnancy. A list of Birthing Centers can be found on the Texas Department of State Health Services website link: How soon can I be seen after contacting my OB/GYN for an appointment? You will be seen within 2 weeks of contacting your OB/GYN for an appointment. STAR Member Handbook

45 Can I pick a Primary Care Provider for my baby before the baby is born? 37 Yes, Call Member Services at and select a Primary Care Provider for your baby. How and when can I switch my baby s Primary Care Provider? If you do not choose a Primary Care Provider for your baby, one will be chosen for you. If you are unhappy with the choice, you may call Member Services and change the Primary Care Provider. Can I switch my baby s health plan? For at least 90 days from the date of birth, your baby will be covered by the same health plan that you are enrolled in. You can ask for a health plan change before the 90 days is up by calling the Enrollment Broker at You cannot change health plans while your baby is in the hospital. How do I sign up my newborn? When your baby is born, call your Texas Department of Human Services caseworker as soon as possible so your baby can get Medicaid. It is also important that you call Member Services at or your Sendero case manager as soon as possible to let us know that your baby is born. You will receive a Texas Benefits Medicaid ID Card for your baby. How and when do I tell my health plan? You should call Sendero as soon possible, at least within 30 days of delivering the baby. How can I receive healthcare after my baby is born (and I am no longer covered by Medicaid)? After your baby is born you may lose Medicaid coverage. You may be able to get some health care services through the Texas Women s Health Program and the Department of State Health Services (DSHS). These services are for women who apply for the services and are approved. Texas Women s Health Program The Texas Women s Health Program provides family planning exams, related health screenings and birth control to women ages 18 to 44 whose household income is at or below the program s income limits (185 percent of the federal poverty level). You must

46 submit an application to find out if you can get services through this program. To learn more about services available through the Texas Women s Health Program, write, call, or visit the program s website: Texas Women s Health Program P.O. Box Midland, TX Phone: Website: Fax: (toll-free) DSHS Primary Health Care Program The DSHS Primary Health Care Program serves women, children, and men who are unable to access the same care through insurance or other programs. To get services through this program, a person s income must be at or below the program s income limits (200 percent of the federal poverty level). A person approved for services may have to pay a co-payment, but no one is turned down for services because of a lack of money. Primary Health Care focuses on prevention of disease, early detection and early intervention of health problems. The main services provided are: Diagnosis and treatment Emergency services Family planning Preventive health services, including vaccines (shots and health education, as well as laboratory, x-ray, nuclear medicine or other appropriate diagnostic services. Secondary services that may be provided are nutrition services, health screening, home health care, dental care, rides to medical visits, medicines your doctor orders (prescription drugs), durable medical supplies, environmental health services, treatment of damaged feet (podiatry services), and social services. You will be able to apply for Primary Health Care services at certain clinics in your area. To find a clinic where you can apply, visit the DSHS Family and Community Health Services Clinic Locator at To learn more about services you can get through the Primary Health Care program, , call, or visit the program s website: STAR Member Handbook

47 Website: Phone: (512) DSHS Expanded Primary Health Care Program The Expanded Primary Health Care program provides primary, preventive, and screening services to women age 18 and above whose income is at or below the program s income limits (200 percent of the federal poverty level). Outreach and direct services are provided through community clinics under contract with DSHS. Community health workers will help make sure women get the preventive and screening services they need. Some clinics may offer help with breast feeding. You can apply for these services at certain clinics in your area. To find a clinic where you can apply, visit the DSHS Family and Community Health Services Clinic Locator at To learn more about services you can get through the DSHS Expanded Primary Health Care program, visit the program s website, call, or Website: Phone: (512) Fax: (512) PPCU@dshs.state.tx.us DSHS Family Planning Program The Family Planning Program has clinic sites across the state that provide quality, lowcost, and easy-to-use birth control for women and men. To find a clinic in your area visit the DSHS Family and Community Health Services Clinic Locator at To learn more about services you can get through the Family Planning program, visit the program s website, call, or Website: Phone: (512) Fax: (512) PPCU@dshs.state.tx.us How and when do I tell my caseworker?

48 Call your caseworker as soon as possible after your baby is born. 40 Who do I call if I have special health care needs and need someone to help me? You or your child may need more health and other services because of complex or chronic conditions. There may be times when Sendero may allow a special doctor (specialist) to be your child s. Call Member Services at for more information on special services that Sendero has for you or your child. A case manager will call you back to talk about these special needs. ADVANCE DIRECTIVES What if I am too sick to make a decision about my medical care? Sometimes people are too sick to make decisions about their health care. If this happens, how will a doctor know what you want? You can make an advance directive, which is a letter that tells people what you want to happen if you get very sick. One kind of advance directive is a living will, which tells your doctor what to do if you are too sick to tell him or her. The other kind is a durable power of attorney, which lets a friend or family member (who you choose) make decisions for you. Any advance directive you make starts when you get very sick and will last until you change or cancel it. If you would like more information about advance directives, call Member Services at What are advance directives? Accidents or serious illness can happen suddenly without any warning. The best way to prepare is to have your wishes put in writing. Advance directives are written legal papers (or forms) that speak for you when you cannot. They are living wills that tell doctors and family members your wishes in a medical emergency. If you cannot speak for yourself, an advance directive will tell them about what you want, or don t want. For example, how you feel about care that is needed to keep you alive, such as: being resuscitated if your heart stops or if you stop breathing breathing machines, tube feedings, life support, or organ donation You can change or cancel advance directives at any time. STAR Member Handbook

49 How do I get an advanced directive? 41 You can get forms online and learn more at Click on Learn about DADS Click on Publications, and then Click on Advance Directives If you have questions, your doctor can give you more information. You can also call Sendero s Member Services at OTHER INFORMATION What do I have to do if I need help with completing my renewal application? If you need help with completing your renewal application you can call (if you can t connect, call ). After you pick a language, press 1. What happens if I lose my Medicaid coverage? If you lose Medicaid coverage but get it back again within six (6) months you will get your Medicaid services from the same health plan you had before losing your Medicaid coverage. You will also have the same Primary Care Provider you had before. What if I get a bill from my doctor? You should never get a bill from your doctor. Who do I call? If you get a bill from a doctor, call Member Services at , and we will call the provider s office. We will help explain your benefits. What information will they need? When you call us, please have you or your child s ID card and the provider s bill available. Member Services will need this information to help you. Can my Medicare provider bill me for services or supplies if I am in both Medicare and Medicaid? You cannot be billed for Medicare cost-sharing, which includes deductibles, coinsurance, and co-payments that are covered by Medicaid.

50 What do I have to do if I move? 42 As soon as you have your new address, give it to the local HHSC benefits office and Sendero Member Services department at Before you get Medicaid services in your new area, you must call Sendero, unless you need emergency services. You will continue to get care through Sendero until HHSC changes your address. What if I have other health insurance in addition to Medicaid? Medicaid and Private Insurance You are required to tell Medicaid staff about any private health insurance you have. You should call the Medicaid Third Party Resources hotline and update your Medicaid case files if: Your private health insurance is canceled You get new insurance coverage You have general questions about third party insurance You can call the hotline toll-free at If you have other insurance you may still qualify for Medicaid. When you tell Medicaid staff about your other health insurance, you help make sure Medicaid only pays for what your other health insurance does not cover. IMPORTANT: Medicaid providers cannot turn you down for services because you have private health insurance as well as Medicaid. If providers accept you as a Medicaid patient, they must also file with your private health insurance company. What if I need to update my address or phone number? (For AARP Members Only) The adoptive parent or permanency care assistance caregiver should contact the DFPS regional adoption assistance eligibility specialist assigned to his or her case. If the parent or caregiver doesn t know who the assigned eligibility specialist is, they can contact the DFPS hotline, , to find out. The parent or caregiver should contact the adoption assistance eligibility specialist to assist with the address change. STAR Member Handbook

51 MEMBER RIGHTS AND RESPONSIBILITIES 43 MEMBER RIGHTS: 1. You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to: a. Be treated fairly and with respect. b. Know that your medical records and discussions with your providers will be kept private and confidential. 2. You have the right to a reasonable opportunity to choose a health care plan and primary care provider. This is the doctor or health care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to: a. Be told how to choose and change your health plan and your primary care provider. b. Choose any health plan you want that is available in your area and choose your primary care provider from that plan. c. Change your primary care provider. d. Change your health plan without penalty. e. Be told how to change your health plan or your primary care provider. 3. You have the right to ask questions and get answers about anything you do not understand. That includes the right to: a. Have your provider explain your health care needs to you and talk to you about the different ways your health care problems can be treated. b. Be told why care or services were denied and not given. 4. You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to: a. Work as part of a team with your provider in deciding what health care is best for you. b. Say yes or no to the care recommended by your provider. 5. You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid, and get a timely response to complaints, appeals and fair hearings. That includes the right to: a. Make a complaint to your health plan or to the state Medicaid program about your health care, your provider or your health plan. b. Get a timely answer to your complaint. c. Use the plan s appeal process and be told how to use it. d. Ask for a fair hearing from the state Medicaid program and get information e. about how that process works. 6. You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to: a. Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need.

52 44 b. Get medical care in a timely manner. c. Be able to get in and out of a health care provider s office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act. d. Have interpreters, if needed, during appointments with your providers and when talking to your health plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information. e. Be given information you can understand about your health plan rules, including the health care services you can get and how to get them. 7. You have the right to not be restrained or secluded when it is for someone else s convenience, or is meant to force you to do something you do not want to do, or is to punish you. 8. You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service. 9. You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services. MEMBER RESPONSIBILITIES: 1. You must learn and understand each right you have under the Medicaid program. That includes the responsibility to: a. Learn and understand your rights under the Medicaid program. b. Ask questions if you do not understand your rights. c. Learn what choices of health plans are available in your area. 2. You must abide by the health plan s and Medicaid s policies and procedures. That includes the responsibility to: a. Learn and follow your health plan s rules and Medicaid rules. b. Choose your health plan and a primary care provider quickly. c. Make any changes in your health plan and primary care provider in the ways established by Medicaid and by the health plan. d. Keep your scheduled appointments. e. Cancel appointments in advance when you cannot keep them. f. Always contact your primary care provider first for your non- emergency medical needs. g. Be sure you have approval from your primary care provider before going to a specialist. h. Understand when you should and should not go to the emergency room. 3. You must share information about your health with your Primary Care Provider and learn about service and treatment options. That includes the responsibility to: a. Tell your primary care provider about your health. STAR Member Handbook

53 b. Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated. c. Help your providers get your medical records. 4. You must be involved in decisions relating to service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility to: a. Work as a team with your provider in deciding what health care is best for you. b. Understand how the things you do can affect your health. c. Do the best you can to stay healthy. d. Treat providers and staff with respect. e. Talk to your provider about all of your medications. If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at You also can view information concerning the HHS Office of Civil Rights online at What if I need durable medical equipment (DME) or other products normally found in a pharmacy? Some durable medical equipment (DME) and products normally found in a pharmacy are covered by Medicaid. For all members, Sendero pays for nebulizers, ostomy supplies, and other covered supplies and equipment if they are medically necessary. For children (birth through age 20), Sendero also pays for medically necessary prescribed over-the-counter drugs, diapers, formula, and some vitamins and minerals. Call Sendero s Member Services at for more information about these benefits. COMPLAINT PROCESS What should I do if I have a complaint? We want to help. If you have a complaint, please call us toll-free at to tell us about your problem. A Sendero Member Services Advocate can help you file a complaint. Just call Most of the time, we can help you right away or at the most within a few days. Once you have gone through the Sendero complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free If you would like to make your complaint in writing, please send it to the following address: 45

54 Texas Health and Human Services Commission Health Plan Operations - H-320 P.O. Box Austin, TX ATTN: Resolution Services 46 If you can get on the Internet, you can send your complaint in an to: HPM_Complaints@hhsc.state.tx.us. We will send you a letter to let you know we received the complaint. This letter will be sent within five (5) days of receiving your complaint. We will send you a form to complete and mail to us. We will not follow-up on your complaint unless you put it in writing. We will not punish you for filing a complaint. Your doctor may file a complaint for you. We will not punish you or your doctor for filing a complaint. Most of the time, we can help you right away or at the most within a few days. At the most, we will respond with an answer to your complaint within thirty (30) days of receipt. If you are not happy with the way we help you, you can call us and appeal. Sendero wants to help you get the best health care for your family. If you have questions about how to file a complaint, an appeal, or need additional help, call us tollfree at We will be glad to help. Call us: Member Services Write to us: ATTN: Member Advocate 2028 E. Ben White Blvd., Suite 400 Austin, Texas All complaints are reviewed to make sure that there is follow-up. They are also reviewed to make sure that timely answers are given. You also have the right to meet with a Complaints Appeal Panel. This panel is made up of doctors and others who will hear your complaint and make a decision. Who do I call? Please call Sendero s Member Services toll-free at STAR Member Handbook

55 Can someone from Sendero help me file a complaint? 47 Yes, either one of Sendero Member Services agents can help you or the Quality Improvement Manager can help you file a complaint. How long will it take to process my complaint? Sendero will send you a letter telling you about our decision. You will receive this letter within 30 days after we receive your complaint. Our letter will tell you the medical or plan benefit reason for our decision. If you have a complaint about an emergency or hospital stay, you will have a decision in one business day. What are the requirements and timelines for filing a Complaint? You can file a complaint at any time either by calling the Sendero Member Services department at or by writing Sendero at: 2028 E. Ben White Blvd., Suite 400 Austin, TX Information on how to file a complaint with HHSC once I have gone through the Sendero process: Once you have gone through the Sendero complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free If you would like to make your complaint in writing, please send it to the following address: Texas Health and Human Services Commission Health Plan Operations - H-320 PO Box Austin, TX ATTN: Resolution Services If you can get on the Internet, you can send your complaint in an to: HPM_Complaints@hhsc.state.tx.us. APPEAL PROCESS What can I do if my doctor asks for a service or medicine for me that is covered but Sendero denies it or limit it? There may be times when the Sendero Medical Director denies these services. When this occurs, Sendero will send you a Notice of Action in writing of our decision. You may

56 48 appeal this decision. To appeal these medical decisions, call Sendero s Member Services at In order to ensure continuity of currently authorized services you must file the appeal on or before the later of: 10 days following Sendero s mailing of the notice of Action, or the intended effective date of the proposed Action. You or your provider may appeal verbally or in writing. If a request for an appeal is received verbally, you or your provider will need to put the appeal in writing. If your provider sends us the appeal, you will need to sign that request. We will send you a letter within five (5) days of receiving your appeal, to let you know that we did receive it. We will complete the appeal review within thirty (30) days. If we need more time to review the appeal, we will send you a letter telling you why we need more time. You have the option of asking Sendero to extend the appeal time up to 14 calendar days. How will I find out if services are denied? Sendero will notify you in writing within 3 days of the Medical Director denying the request. We will send you a letter explaining why the decision was made and how to appeal the decision. You or a person acting on your behalf (i.e.: doctor, relative, friend, lawyer, or any other person), have the right to Sendero s internal appeal process. You can either call the Sendero Member Services Coordinator at for help in completing the appeal request form or you can fill out and send in the enclosed appeal request form by mail to: Attn: Member Advocate / Compliance Director 2028 E. Ben White Blvd., Suite 400 Austin, Texas Toll-free phone: All appeal requests must be submitted on this form. If there is any other information you would like for Sendero to consider when reviewing your appeal, please include it with this form. Sendero must have this completed form within 30 days of the date on this notice to move forward with your appeal. We will send you a letter letting you know when Sendero has received your appeal (along with a copy of the appeal form if you have asked for an appeal by phone), within one week of the appeal form arriving in our office. Appeals are reviewed by a doctor who was not involved in the original denial decision. You will receive a response to your appeal within thirty (30) calendar days of receipt of the appeal. If the decision results in stopping or reducing current services and you want them to keep going, you must ask for an extension of the services and file the appeal on or before ten (10) days after the date of this notice or the date the notice says your STAR Member Handbook

57 49 services will end, whichever is later. If you request that services continue while your appeal is pending, you need to know that you may have to pay for these services if the decision on your appeal upholds Sendero s first decision. If the decision on your appeal reverses our first decision, Sendero will pay for the services you received while your appeal was pending. You must complete Sendero s internal appeals process before you can ask for a Medicaid fair hearing from the State If you or your doctor feels that this denial of services will seriously jeopardize the member s health, you or your doctor may request an expedited appeal. You may obtain an expedited appeal by contacting Sendero s Senior Care Coordinator toll-free Sendero s expedited appeal process must be completed prior to requesting an expedited fair hearing. Once an expedited appeal has been requested and is determined to be an urgent situation, a decision is made within three (3) business days. If your appeal relates to an ongoing emergency or denial of continued hospitalization Sendero will complete the investigation and resolution of the appeal within one (1) business day after receiving your request for an expedited appeal. Expedited appeals can be extended up to fourteen (14) calendar days if you or your authorized representative or Sendero (with HHSC approval) determine if there is a need for additional information that would best serve the member s interest. If you disagree with Sendero s decision, you have the right to ask for a Medicaid fair hearing from the Texas Health and Human Services Commission (HHSC). You may represent yourself at the fair hearing, or name someone else to be your representative. This could be a doctor, relative, friend, lawyer or any other person. You may name someone to represent you by writing a letter to Sendero telling us the name of the person that you want to represent you. If you want to challenge a decision made by Sendero, you or your representative must ask for the Medicaid fair hearing within 120 days from the date of the notice. If you do not ask for the fair hearing by this date, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should write or call: Attn: Fair Hearing Coordinator / Member Advocate 2028 E. Ben White Blvd., Suite 400 Austin, Texas Toll-free phone: If you believe that waiting for a hair fearing will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you or your representative may ask for an expedited fair hearing by writing or calling Sendero. To qualify for an

58 expedited fair hearing through HHSC, you must first complete Sendero s internal appeals process. 50 Time frames If you ask for a fair hearing (1) within 10 days after the date of the notice or (2) the intended effective date of the action, you may be able to keep getting the service or benefit that is being terminated, suspended, or reduced by Sendero, at least until the fair hearing decision is made. If you do not request a fair hearing by this date, the service or benefit will be terminated, suspended, or reduced. If you lose you fair hearing appeal, Sendero may be able to collect from you the costs of providing the service or benefit to you while the appeal was pending. If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most hearings are held by telephone. You can also contact the HHSC Hearings Officer if you would like the hearing to be held inperson. During the hearing, you or your representative can tell why you need the service or why you disagree with Sendero s action. You have the right to examine, at a reasonable time before the date of the fair hearing, the contents of your case file and any documents to be used by Sendero at the hearing. At least one week before the hearing, Sendero will send you all the documents to be used at the hearing. HHSC will give you a final decision within 90 days from the date you asked for the hearing. You may qualify for free or low cost legal services. A list of legal aid providers that may be able to help you is included. Can someone from Sendero help me file an Appeal? Yes, please contact Sendero s Member Services at Can I file an appeal with the State? You have the right to appeal to the State, once you have exhausted Sendero s appeal process. If you do not agree with our decision, you may ask for a State Fair Hearing. You must make the request in writing for a Fair Hearing within one hundred and twenty (120) days from the date on the health plan s letter with the decision. If you do not request a hearing within 120 days, you lose your right to a hearing. See information below about how to ask for a State Fair Hearing. STAR Member Handbook

59 What is an Expedited Appeal? 51 An Expedited Appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health. How do I ask for an Expedited Appeal? Call Member Services at to request an expedited appeal. Does my request have to be in writing? You may request an expedited appeal orally or in writing. Attn: Fair Hearing Coordinator / Member Advocate 2028 E. Ben White Blvd., Suite 400 Austin, Texas Toll-free phone: What are the time frames for an expedited appeal? We will review your case and get back to you no later than 3 working days after we receive your request. What happens if Sendero denies your request for an expedited appeal? You may discuss your request for an expedited appeal with the Medical Director if there are questions. Requests for expedited appeal are very serious. We want to make sure you or your child receive the care that is medically necessary. Who can help me file an expedited appeal? If you need assistance in filling this appeal, contact Member Services at and they will contact a Member Advocate to help you. The Member Advocate will have a decision within 3 days after the day the Expedited Appeal was received. STATE FAIR HEARING Can I ask for a State Fair Hearing? If you, as a member of the health plan, disagree with the health plan s decision, you have the right to ask for a fair hearing. You must exhaust Sendero s appeal process

60 52 before requesting a State Fair Hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 120 days of the date on the health plan s letter with the decision. If you do not ask for the fair hearing within 120 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at 2028 E. Ben White Blvd., Suite 400, Austin, TX or call You have the right to keep getting any service the health plan denied or reduced, at least until the final hearing decision is Made if you ask for a fair hearing by the later of (1) 10 calendar days following the MCO s mailing of the health plan s letter with the decision, or (2) the day the health plan s letter says your service will be reduced or end. If you do not request a fair hearing by this date, the service the health plan denied will be stopped. If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing. FRAUD AND ABUSE OF THE STAR PROGRAM Do you want to report Waste, Abuse, or Fraud? Let us know if you think a doctor, dentist, pharmacist at a drug store, other health care providers, or a person getting benefits is doing something wrong. Doing something wrong could be waste, abuse or fraud, which is against the law. For example, tell us if you think someone is: Getting paid for services that weren t given or necessary Not telling the truth about a medical condition to get medical treatment. Letting someone else use their Medicaid ID. Using someone else s Medicaid ID. Not telling the truth about the amount of money or resources he or she has to get benefits STAR Member Handbook

61 To report waste, abuse, or fraud, choose one of the following: 53 Call the OIG Hotline at ; Visit Under the box labeled I WANT TO click Report Waste, Abuse, and Fraud to complete the online form; or You can report directly to your health plan: Attn: Compliance Officer 2028 E. Ben White Blvd., Suite 400 Austin, TX Toll-free phone: Confidential line toll-free To report waste, abuse or fraud, gather as much information as possible. When reporting about a provider (a doctor, dentist, counselor, etc.) include: o Name, address, and phone number of provider o Name and address of the facility (hospital, nursing home, home health agency, etc.) o Medicaid number of the provider and facility, if you have it o Type of provider (doctor, dentist, therapist, pharmacist, etc.) o Names and phone numbers of other witnesses who can help in the investigation o Dates of events o Summary of what happened When reporting about someone who gets benefits, include: o The person s name o The person s date of birth, Social Security Number, or case number if you have it o The city where the person lives o Specific details about the waste, abuse or fraud INFORMATION THAT MUST BE AVAILABLE ON AN ANNUAL BASIS As a member of Sendero you can ask for and get the following information each year Information about network providers at a minimum primary care doctors, specialists, and hospitals in our service area. This information will include names, addresses, telephone numbers, and languages spoken (other than English) for each network provider, plus identification of providers that are not accepting new patients.

62 54 Any limits on your freedom of choice among network providers. Your rights and responsibilities Information on complaint, appeal and fair hearing procedures. Information about benefits available under the Medicaid program, including amount, duration and scope of benefits. This is designed to make sure you understand the benefits to which you are entitled. How you get benefits including authorization requirements. How you get benefits, including family planning services, from out-of-network providers and/or limits to those benefits. How you get after hours and emergency coverage and/or limits to those kinds of benefits, including: o What makes up emergency medical conditions, emergency services and post-stabilization services? o The fact that you do not need prior authorization from your Primary Care Provider for emergency care services. o How to get emergency services, including instructions on how to use the telephone system or its local equivalent. o The addresses of any places where providers and hospitals furnish emergency services covered by Medicaid. o A statement saying you have a right to use any hospital or other settings for emergency care o Post-stabilization rules. Policy on referrals for specialty care and for other benefits you cannot get through your Primary Care Provider Sendero s practice guidelines. STAR Member Handbook

63 55 If you, or someone you re helping, have questions about, you can get help and information in your preferred language. You can ask for an interpreter, large print, Braille or recorded information. will give these and other aids and services to help you understand free of charge. To talk with an interpreter, call Customer Care at For hearing impaired, call (TTY line).

64 56 STAR Member Handbook