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What
is STAR Medicaid Managed Care?
Who
may enroll in the STAR Medicaid Managed Care Program?
How
do I receive my healthcare in the STAR Medicaid Managed Care
Program?
What
benefits do I receive if I enroll in the STAR Medicaid Managed
Care Program?
What
area is the STAR Medicaid Managed Care Program offered in?
How
do I change my primary care provider (PCP)?
How
do I change my health plan?
Where
does my child receive their dental services?
What
if I move out of the STAR, STAR+PLUS, or NorthSTAR service
delivery areas?
Are
there any services in STAR that do not require a referral?
How
do I get a referral for specialty care?
What
if I or my child needs transportation to a health care
appointment?
What
if I have problems with my Health Plan?
What
is Urgent Care?
What
do I do when I have an urgent medical need?
When
should I seek Emergency Care?
What
should I do if I need emergency care?
What
is external quality review?
Why
does Medicaid Managed Care need external quality review?
How
does this work in the State of Texas?
Who
is the enrollment contractor for Medicaid managed care?
What
is meant by managed care "enrollment?"
How
does a Medicaid recipient enroll in managed care?
Who
can tell Medicaid recipients about the health plans and
primary care providers that are available?
Will
the MAXIMUS enrollment counselor recommend a specific health
plan?
Which
of the areas within the BMC would an interested party contact
for information about the STAR Program, such as how it works,
the population served, etc.?
Who
should a STAR member contact if they are changing their
address and moving to a different, non-STAR location?
How
are marketing materials approved and how are marketing
violations reported and resolved?
What
is an example of a monitoring activity that the Customer
Service section would perform?
Can
a member contact the BMC for assistance in getting a problem
with their MCO resolved?
What
is the roll-out schedule for future Medicaid managed care
areas?
What
is STAR Medicaid Managed Care?
The State of Texas has selected certain
counties to have a Medicaid managed care program called STAR
(which stands for State of Texas Access Reform.) The
STAR program offers Medicaid services to members, except in a
different way, called managed care. You will have to
choose a health plan.
In the STAR Medicaid Managed Care Program:
-
You use providers that are in a group
called the "provider network."
-
You choose a doctor, called a Primary Care
Provider (PCP) who works with you to keep you healthy and
gets you to other doctors, services, and specialists.
The PCP is your medical home.
-
You will receive a STAR ID from your
health plan. You must show your STAR ID card with
your Medicaid Certification Letter (Form 3087) when you go
to a health care appointment.
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Who
may enroll in the STAR Medicaid Managed Care Program?
You MAY enroll in the STAR program or choose
to say in regular Medicaid if you are receiving Supplemental
Security Income (SSI) (NOTE: Persons receiving SSI and
living in the Southeast Region cannot enroll in the STAR
program.)
You MUST enroll in the STAR program if:
-
You receive cash assistance (TANF); or
-
You are pregnant; or
-
You or your children have limited income;
and
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You live in a STAR program service
delivery area.
You MAY NOT enroll in the STAR program if:
-
You are receiving Medicare.
-
You are in foster care.
-
You live in a long-term care facility
(i.e., nursing home or group home).
-
You are on the Medically Needy Program.
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How
do I receive my healthcare in the STAR Medicaid Managed Care
Program?
You may receive your healthcare in one of two
ways:
-
The first way is through a Health
Maintenance Organization (HMO), which is an organization
that provides health services to its members also called a
health plan. You will become a member of an HMO,
carry a health plan ID card, and get a member handbook.
You will choose a doctor, called your Primary Care
Provider (PCP). You will use only providers in the
HMO group of providers called a "Network."
A special booklet, called a "Provider
Directory," lists providers in the HMO's network.
You will always have a PCP to see you. Your PCP will
also be called your "medical home."
-
The second way is though Primary Care Case
Management (PCCM). The PCCM health plan is called
the Texas Health Network (THN). It is not available
in all of the STAR service delivery areas. You will
become a member of THN, carry a health plan ID card, and
get listings of PCPs and hospitals. You will choose
a doctor (PCP). Your PCP can refer you to any
Medicaid specialist who is willing to see you as a
patient. You will always have a doctor (PCP) to see
you. Your PCP will also be called your "medical
home."
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What
benefits do I receive if I enroll in the STAR Medicaid Managed
Care Program?
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You and your children will receive
unlimited prescriptions.
-
You may received extra
"value-added" services from your health plan
beyond what is available to you under Medicaid. Some
examples of value-added services are adult dental services
and diapers for newborns.
-
Adults receive one physical exam per year,
not covered in regular Medicaid. Children (under 21
years of age) received regular check-ups medical exams and
dental services through Texas Health Steps.
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What
area is the STAR Medicaid Managed Care Program offered in?
If you live in one of the following areas, you
may be eligible to enroll in the STAR Medicaid Managed Care
Program:
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El Paso (El Paso, Hudspeth, Culberson
Counties)
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Lubbock (Lubbock, Lamb, Hale, Floyd,
Crosby, Garza, Lynn, Terry, Hockley Counties)
-
San Antonio (Bexar, Kendall, Comal,
Medina, Atascosa, Wilson, Guadalupe Counties)
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Dallas (Dallas, Ellis, Kaufman, Rockwall,
Hunt, Collin, Navarro Counties)
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Houston (Harris, Fort Bend, Montgomery,
Waller, Brazoria, Galveston Counties)
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Fort Worth (Tarrant, Wise, Denton, Parker,
Hood, Johnson Counties)
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Austin (Travis, Burnet, Blanco, Hays,
Caldwell, Bastrop, Lee, Williamson Counties)
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Southeast Region of Texas (Chambers,
Hardin, Jefferson, Liberty, Orange Counties)
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How
do I change my primary care provider (PCP)?
You can change your PCP up to four times a
year. Call your health plan and tell them you want to
change your PCP.
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How
do I change my health plan?
You can change your managed care health plan
when you need to (as often as every 30 days). Call the
STAR helpline as 1-800-964-2777 to make health plan changes.
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Where
does my child receive their dental services?
To get children's dental services, go to any
Medicaid dental provider. To find out about dental
providers in your area, call the Medicaid hotline at
1-800-252-8263. Sometimes, health plans may offer
"value-added" dental services for adults. To
find out more about these services, call your health plan.
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What
if I move out of the STAR, STAR+PLUS, or NorthSTAR service
delivery areas?
Be sure to report the change of address by calling 2-1-1. For help with accessing medical services please call your current health plan. For any other assistance, please call the Medicaid Managed Care Helpline at 1-866-566-8989.
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Are
there any services in STAR that do not require a referral?
Yes, you do not need a doctor's referral if
you need one of the following services:
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Family Planning
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Obstetrician (Ob) or gynecology services (GYN)
- you must choose providers in your health plan's network.
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Emergency Care
-
Behavioral Health (mental health, drug
and/or alcohol dependency services) - you must choose
providers in your health plan's network.
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How
do I get a referral for specialty care?
You can get a referral for a specialist from
your PCP.
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What
if I or my child needs transportation to a health care
appointment?
Call the Medical Transportation Program at
1-877-633-8747 toll-free.
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What
if I have problems with my Health Plan?
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Discuss your problem with your PCP.
He or she may be able to help you get what you need.
-
If your PCP cannot help you, contact the
member or customer services department at your HMO health
plan. Explain the problem and ask for help.
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If your problem is not fixed, file a
complaint with the HMO. Your member services
handbook should tell you how to do this.
-
If you have tried these steps and are
still having problems getting the medical services you
need, call Starlink at 1-866-566-8989 toll-free.
They can help you if you are not sure what your next step
should be.
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What
is Urgent Care?
Urgent Care is when your medical need is
URGENT, but your condition is not life-threatening.
Examples of urgent medical needs are:
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Your ear hurts.
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You have a rash.
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You have a cold, cough, sore throat,
and/or flu.
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Your back hurts.
-
Your cast is broken.
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Your stitches need to be taken out.
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You need more medicine.
-
Your tooth hurts.
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What
do I do when I have an urgent medical need?
Call your PCP. Tell the staff what
symptoms you have and that you need urgent care. Ask
them for an appointment as soon as possible. If the PCP
staff decides you need immediate attention, you will be
referred to a hospital. Even if it is after hours or on
a weekend, call your PCP's office. Someone should answer
the phone.
Call the Nurse Hotline at your Health Plan.
The number is in the Member Handbook. Ask for the nurse.
Tell the nurse you have an urgent medical need. The
nurse will give you advice on what to do.
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When
should I seek Emergency Care?
You should seek emergency care if your
condition is life-threatening; if you have serious pain; of if
serious harm could come to you without immediate medical
attention.
Examples of when to go to the emergency room
are:
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Someone may die.
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Someone may lose an arm or leg.
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Someone has bad chest pains.
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Someone cannot breath or is choking.
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Someone has passed out or is having a
seizure.
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Someone is sick from poison or a drug
overdose.
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Someone has a broken bone.
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Someone is bleeding a lot.
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Someone has been attacked (raped, stabbed,
shot).
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Someone suddenly cannot move their arms,
legs, and/or head.
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What
should I do if I need emergency care?
Go to the nearest hospital if you think you
have any of the problems listed above. You may call 911
for assistance in getting to the hospital emergency room.
Remember that your PCP or Health Plan hotline
have staff available 24 hours a day, 7 days a week to help
you. Call them to get help.
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What is external
quality review?
This is an independent entity that tracks, analyzes and
reports on the quality of the Medicaid managed care system.
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Why does Medicaid
Managed Care need external quality review?
This function is Federally mandated.
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How does this
work in the State of Texas?
Since 1997, the
State has contracted with Texas Health Quality Alliance (THQA)
for the external quality review. They also perform quality
improvement studies and maintain an analytical data resource
on services provided. THQA activities include:
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Who is the
enrollment contractor for Medicaid managed care?
MAXIMUS
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What is meant by
managed care "enrollment?"
A Medicaid recipient enrolls in managed care by choosing a
health plan and a primary care provider.
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How does a
Medicaid recipient enroll in managed care?
The recipient can enroll in one of three ways: 1) over the
phone by calling MAXIMUS, the enrollment broker; 2) through
the mail, by submitting an enrollment form (available from
MAXIMUS); or 3) in person, at any local Dept of Human Services
office or Social Security office which has a MAXIMUS outreach
counselor.
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Who can tell
Medicaid recipients about the health plans and primary care
providers that are available?
MAXIMUS enrollment counselors can do this.
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Will the MAXIMUS
enrollment counselor recommend a specific health plan?
No. The enrollment counselor will explain the services
offered by each health plan in the Medicaid recipient’s area
and the recipient will choose the plan based on their needs.
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Which of the
areas within the BMC would an interested party contact for
information about the STAR Program, such as how it works, the
population served, etc.?
The Customer Services Section can provide information about
program operations, services, and the different populations
served.
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Who should a STAR
member contact if they are changing their address and moving
to a different, non-STAR location?
The member should contact the Department of Human Services
(DHS) at their old and new location and they should inform
their MCO of the plan to move.
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How are marketing
materials approved and how are marketing violations reported
and resolved?
The Customer Service section is responsible for
review/approval of all MCO marketing materials. Additional
responsibilities include: Interpretation of marketing
policies, investigation, and resolution of alleged marketing
violations.
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What is an
example of a monitoring activity that the Customer Service
section would perform?
The section conducts MCO telephone line monitoring wherein
for a specified period of time "spot-check" calls
are made to MCO toll free line. The MCOs are notified of
findings, asked to submit a corrective action plan (CAP) and
the Customer Services staff works with MCOs on implementation
of their CAPs.
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Can a member
contact the BMC for assistance in getting a problem with their
MCO resolved?
The member is encouraged to contact their health plan first
for resolution of any problems. If they are not successful in
getting a resolution resolved at the plan level, they can
contact the Medicaid Hotline at 1 (800) 252-8263 for
assistance. In certain instances, the BMC participates in the
resolution of issues raised by the member.
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What
is the roll-out schedule for future Medicaid managed care
areas?
The 76th Legislature, House Bill 2896, placed
a moratorium on the roll-out of Medicaid managed care.
According to this legislation, the moratorium will expire at
the end of current legislative session, if no further action
is taken by the legislature. Any changes in roll-out status
will be provided in updates to this question.
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