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Managed Medicaid

Texas Managed Medicaid is comprised of several parts:
Star Medicaid, Star +Plus, CHIP, TX Perinatal, and Foster Kids Program.

STAR Medicaid
GHN is contracted with Aetna, Community First, Superior, and THN/PCCM (for rural counties).

STAR +Plus Medicaid
GHN is contracted with Amerigroup, Molina and Superior.

CHIP
GHN is contracted with Aetna, Community First, and Superior.

Foster Kids
GHN is contracted with Superior.

TX Perinatal
GHN is contract with Community First and Superior.


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.) Guadalupe County is required to be in the STAR program. The STAR program offers Medicaid services to members, except in a different way, called managed care. The STAR program is designed for individuals who do not qualify for CHIP, qualify for Medicaid, and are under 65. Recipients will have to choose a health plan, such as Aetna, Community First, or Superior.

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.

You MAY enroll in the STAR program or choose to say in regular Medicaid if you are receiving Supplemental Security Income (SSI).

You MUST enroll in the STAR program if your approved for Medicaid and:

•	You receive cash assistance (TANF); or
•	You are pregnant; or
•	You or your children have limited income; and
•	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.

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, it is available in Guadalupe County. 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. Your PCP will also be called your "medical home."

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.

For assistance with transportation to a health care appointment, call the Medical Transportation Program at 1-877-633-8747 toll-free.


What is STAR+PLUS?
STAR+PLUS is a Texas Medicaid managed care program designed to provide health care, acute and long-term services and support through a managed care system. STAR+PLUS is designed for Medicaid recipients over age 65 and those with disabilities.

Participants of STAR+PLUS choose a health plan (HMO) from those available in their county, and receive Medicaid services through those health plans. GHN is contracted with Amerigroup, Superior, Molina, and (THN) PCCM for STAR+PLUS.

Service coordination is the main feature of STAR+PLUS. Medicaid clients, their family and providers work together to help clients coordinate health, long-term and other community support services.

Who Qualifies for STAR+PLUS?
Enrollment in STAR+PLUS is required for Medicaid recipients who live in a STAR+PLUS service area and fit one or more of the following criteria:

•	People who have a physical or mental disability and qualify for supplemental security income (SSI) benefits or for Medicaid due to low income.
•	People who qualify for Community-Based Alternative 1915(c) waiver services.
•	People age 21 or older who can receive Medicaid because they are in a Social Security Exclusion program and meet financial criteria for 1915(c) waiver services.
•	People age 21 or older who are receiving supplemental security income. Enrollment in STAR+PLUS is voluntary for:
•	Children under age 21 receiving supplemental security income (SSI). The following people cannot participate in the STAR+PLUS program:
•	Residents of nursing facilities.
•	STAR+PLUS members who have been in a nursing facility for more than 120 days
•	Clients of Medicaid 1915(c) waiver services, except for Community-Based Alternative services.
•	Residents of Intermediate Care Facilities for the Mentally Retarded (ICF-MR).
•	Clients not eligible for full Medicaid benefits, such as Frail Elderly program members, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, Qualified Disabled Working Individuals and undocumented aliens.
•	People not eligible for Medicaid.
•	Children in state foster care.

What does this mean for Dual Eligibles?
The term “dual eligible” refers to someone who is enrolled in both Medicaid and Medicare.
STAR+PLUS will not change how dual eligible members receive Medicare services.

STAR+PLUS members who are not dual eligibles (which means they only receive Medicaid services) are required to choose a health plan and a primary care provider. These members receive all of their services, including acute and long-term services, from their STAR+PLUS health plan.

Dual eligible members choose a STAR+PLUS health plan but do not choose a primary care provider because they receive acute care from their Medicare providers. The STAR+PLUS health plan only provides Medicaid long-term services and support to these dual eligible members.

“Medicaid is the State and Federal cooperative venture that provides medical coverage to eligible needy persons. The purpose of Medicaid in Texas is to improve the health of people who might otherwise go without medical care for themselves and their children. Medicaid is different in every state. HHSC's Medicaid Office is responsible for statewide oversight of the Texas Medicaid Program.” (copied from Medicaid website)

Use the website http://www.hhsc.state.tx.us/medicaid/index.html to find the Consumer Guide to Better Health Care. This informational guide will explain the services provided by Medicaid, Medicaid Managed Care, the Children’s Health Insurance Program (CHIP), and Children’s Medicaid as well as how to access those programs and services.

Health Human Services Commission encourages you to:
See a primary care provider regularly for routine and urgent care;
Seek preventive care, especially for your children;
Take your prescription medicine according to your doctor’s instructions;
Use the emergency room only for “true” emergencies; and
Make healthy choices for yourself and your family.

As in any publication, information is always changing. Please use the toll-free numbers to make sure that any information you are using is still correct.

Helpful Toll-Free Phone Numbers

Medicaid Hotline
1-800-252-8263 (TDD 1-800-735-2989) for information
about Medicaid services, pharmacy issues, Medicaid rights,
and Medicaid complaints and fair hearings

Local Health and Human Services Office
(830) 379-6525
314 S. Saunder
Seguin, Texas 78155

STARLink
1-866-566-8989 (TDD 1-866-222-4306) for problems
or concerns about the STAR or STAR+PLUS Programs, or
general Medicaid Managed Care.

Texas Health Steps (THSteps) and Case Management
for Children and Pregnant Women
1-877-847-8377 (TDD 1-800-735-2989) for information
about the Texas Health Steps Program and case management
for children under 21 years of age.

Texas Health and Human Services Commission
Ombudsman Office
1-888-877-787-8999 (TDD 1-888-425-6889) for information
about qualifying for Medicaid, ID forms, and address
changes, programs for elders and persons with disabilities
offered, or to locate the local Texas Health and Human
Services Commission office nearest you.

Medical Transportation Program
1-877-633-8747 (TDD 1-800-735-2989) for information
about medical transportation in the Medicaid and Medicaid
Managed Care programs.

Medicare Hotline
1-800-633-4227 for policy and benefit information.

TMHP Medicaid Hotline
Texas Medicaid & Healthcare Partnership
1-800-335-8957 for information about the Medically
Needy Program or Medicaid billing questions.

Social Security Administration
1-800-772-1213 (TDD 1-800-325-0778) for information
about Social Security Supplemental Income or to locate the
Social Security Office nearest to you.

STAR Helpline
1-800-964-2777 (TDD 1-800-267-5008) for information about enrollment in a STAR or STAR+PLUS Managed Care health plan and general information about Medicaid
Managed Care.

Information obtained from the 2007 Edition A Consumer Guide to Better Health Care

http://www.hhsc.state.tx.us/medicaid/index.html

 

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Call 2-1-1 2-1-1 is the national abbreviated dialing code for free access to health and human services information in your community. Callers from outside of Texas and those on cellular phones will have to call their 2-1-1 Area Information Center directly. HHSC Benefits Offices 314 S. Saunders Seguin, Texas 78155 Call 2-1-1 or visit the www.yourtexasbenefits.com site to find the HHSC benefits office closest to you.