Medicaid managed care nursing facility member handbook required critical elements



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HHSC Uniform Managed Care manual

CHAPTER


PAGE

HHSC Uniform Managed Care Manual
3.30

of


MEDICAID MANAGED CARE

NURSING FACILITY MEMBER HANDBOOK
REQUIRED CRITICAL ELEMENTS

Effective Date

November 1, 2016

Version 2.1







DOCUMENT HISTORY LOG

STATUS1

DOCUMENT

REVISION2

EFFECTIVE

DATE

DESCRIPTION3

Baseline

2.0

March 1, 2015

Initial version Uniform Managed Care Manual, Chapter 3.30 “Medicaid Managed Care Nursing Facility Member Handbook Critical Elements”

Revision

2.1

November 1, 2016

Version 2.2 applies to contracts issued as a result of HHSC RFP numbers 529-10-0020, 529-12-0002, and 529-13-0042.

Section II. is modified to clarify the date to be used.

Section III. C. is modified to change “Medicaid Managed Care Helpline” to “Ombudsman Managed Care Assistance Team” and to update the phone numbers.

Section III. D. is modified to change "Your Texas Benefits Medicaid Card" to "Your Texas Benefits (YTB) Medicaid ID Card".

Section III. I. "Healthcare and Other Services" is modified to add language regarding the end of NorthSTAR in the Dallas Service Area.

Section III. N. “Reporting Abuse, Neglect, and Exploitation” is added and all subsequent subsections are re-lettered.

Section IV. is modified to clarify the date to be used.

Attachment A "Your Texas Benefits Medicaid Card" is renamed "Your Texas Benefits (YTB) Medicaid ID Card" and to add language regarding the YTB website.

Attachment O "Where do I find a family planning services provider?" is modified to update the URL.

Attachment BB “Reporting Abuse, Neglect, or Exploitation (ANE)” is added and subsequent attachments are re-lettered.















1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions.

2 Revisions should be numbered according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.

3 Brief description of the changes to the document made in the revision.


Applicability of Chapter 3.4

This chapter, and its requirements, applies to Managed Care Organizations (MCOs) participating in the STAR+PLUS Program.



Section II. Modified by Version 2.1



Required Critical Elements

Page Number
  1. GENERAL INSTRUCTIONS TO MCO





The Nursing Facility (NF) Member Handbook may not be combined with the STAR+PLUS Member Handbook.




The NF Member Handbook must be written at or below a 6th grade reading level in English and in Spanish. Additionally, the NF Member Handbook must be written in the languages of other Major Population Groups if directed by HHSC. The handbook must also be written using the style and preferred terms of the Consumer Information Tool Kit which can be found at http://www.hhsc.state.tx.us/medicaid/CommunicationsResources.shtml.




This table is to be completed and attached to the NF Member Handbook when submitted for approval. Include the page number of the location for each required critical element.




The following items must be included in the handbook but not necessarily in this order (unless specified):




II. FRONT COVER

     

The front cover must include, at a minimum:




  • MCO name

     

  • MCO logo

     

  • Program logo (STAR+PLUS)

     

  • The words “STAR+PLUS NURSING FACILITY MEMBER HANDBOOK”

     

  • Member Services Hotline number

     

  • Month/year of the first available distribution date for the handbook (may be placed on front or back cover)

     

III. CONTENTS

     

A. Table of Contents

     

The NF Member Handbook must include a table of contents.




B. Introduction

     

This must include information about the MCO's health plan (benefits and eligibility information). The MCO must inform the Member that Member Services is available to provide help. In addition, the MCO must explain that the NF Member Handbook is available in audio, larger print, Braille, other language, etc., when a Member requests it or when the MCO identifies a Member who needs it. (This information should be located within the first three pages of the NF Member Handbook.)




C. Phone Numbers

     

The following information should be located within the first three pages of the NF Member Handbook.





  • Section III. C. Modified by Version 2.1
    Toll-Free Member Services Line. Information must include the following explanations:

     

  • Regular business hours (8 a.m. to 5 p.m. local time for Service Area, Monday through Friday, excluding state-approved holidays)

     

    • For after-hours and weekend coverage, an answering service or other similar mechanism, that allows callers to obtain information from a live person, must be used

     

  • Member Services Line. Information must include the following:

     

    • How to access all covered services – including what to do in an emergency or crisis

     

    • Availability of information in English and Spanish

     

    • Availability of interpreter services through Member Services line

     

    • TTY Line for hearing-impaired

     

     

  • Behavioral Health and Substance Abuse Services Line. Information must include the following:

     

    • 24 hours a day, 7 days a week, toll-free number

     

    • How to access services – including what to do in an emergency or crisis

     

    • Availability of information in English and Spanish

     

    • Availability of interpreter services

     

    • Other Important Health Plan Quick Reference Phone Numbers and what they are used for (these are a minimum and MCO must include all applicable items below; MCO may also want to include phone numbers unique to its plan):

     

  • Nurse Line

     

  • Eye care

     

  • Ombudsman Managed Care Assistance Team 1-866-566-8989

     

  • STAR+PLUS Program Help Line

     

  • Dental Contractors

     

  • Non-emergency ambulance transportation

     

D. Member Identification (ID) Cards

     


    • Section III. D. Modified by Version 2.1
      Information about (insert MCO name) ID card, including

     

    • Sample ID card

     

    • How to read it

     

    • How to use it

     

    • How to replace it if lost

     

  • Information about Your Texas Benefits (YTB) Medicaid ID Card. (MCO will use HHSC’s provided language – Attachment A.)

     

  • Information about temporary verification form - Form 1027-A (how to use it).

     

E. Primary Care Providers

     

The following questions must be included and answered in the handbook:




  • What is a Primary Care Provider?

     

  • Will I be assigned a Primary Care Provider if I have Medicare?

     

  • How do I see my Primary Care Provider if s/he does not visit my nursing home?

     

  • How can I change my Primary Care Provider?

     

  • When will my Primary Care Provider change become effective?

     

  • What is the Medicaid Lock-in Program? (MCO will use HHSC’s provided language – Attachment B)

     

Note: For STAR+PLUS Members who are covered by Medicare, no Primary Care Provider will be assigned




F. Physician Incentive Plan Information (MCO will use HHSC’s provided language – Attachment C)

     

G. Changing Health Plans

     

The following questions must be included and answered in the handbook:




  • What if I want to change health plans? (MCO will use HHSC’s provided language – Attachment D)

     

  • Who do I call?

     

  • How many times can I change health plans?

     

  • When will my health plan change become effective?

     

  • Can (insert MCO name) ask that I get dropped from their health plan (for non-compliance, etc.)?

     

H. Benefits

     

The following questions must be included and answered in the handbook:




  • What are my health care benefits?

     

    • How do I get these services?

     

    • Are there any limits to any covered services?

     

  • What are Long-Term Services and Supports (LTSS)?

     

    • What are my Nursing Facility LTSS benefits?

     

  • How would my benefits change if I moved into the community?

     

  • What are my Acute Care benefits?




    • How do I get these services?

     

  • What number do I call to find out about these services?

     

  • What services can I still get through regular Medicaid but are not covered by (insert MCO name)?




    • Preadmission Screening and Resident Review PASRR - PASRR is a federal requirement to help determine whether an individual is not inappropriately placed in a nursing home for long term care.

     

    • Hospice

     

    • Behavioral Health (BH) services in Dallas Service Area

     

  • What are my prescription drug benefits?

Non-Duals Only

     

  • What extra benefits do I get as a Member of (insert MCO name)?

     

    • How can I get these benefits?

     

  • What health education classes does (insert MCO name) offer?

     


Section III. I. Modified by Version 2.1
I. Health Care and Other Services

     

The following questions must be included and answered in the handbook:




  • What does Medically Necessary mean? Both Acute Care and Behavioral Health (MCO will use HHSC’s provided language – Attachment E)

     

  • What is routine medical care?

     

    • How soon can I expect to be seen?

     

    • Are non-emergency dental services covered? (MCO will use HHSC’s provided language – Attachment F)

     

  • What is emergency medical care? (MCO will use HHSC’s provided language – Attachment G)

     

  • How soon can I expect to be seen?

     

  • Do I need a prior authorization?

     

  • Are Emergency Dental Services Covered? (MCO will use HHSC’s provided language- Attachment H)

     

  • What is post stabilization? (MCO will use state provided language – Attachment I)

     

  • What if I get sick when I am out of the facility/or traveling out of town? (MCO will use HHSC’s provided language- Attachment J)

     

    • What if I am out of the state?

     

    • What if I am out of the country? (MCO will use HHSC’s provided language- Attachment K)

     

  • What if I need to see a special doctor (specialist)?

     

    • 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?

     

    • How do I get help if I have behavioral health issues, mental health, alcohol, or drug problems? (This question applies to all STAR+PLUS MCOs. Attachment L is HHSC’s required language for the MCOs in the Dallas Service Area only. However, Attachment L should no longer be used beginning January 1, 2017. Effective January 1, 2017, NorthSTAR will be discontinued and MCOs in the Dallas Service Area will be responsible for Medicaid Behavioral Health Services consistent with all other Service Areas.)

     

    • Do I need a referral?

     

    • What are mental health rehabilitation services and mental health targeted case management?

     

      • How do I get these services?

     

    • How do I get my medications? (MCO will use HHSC’s provided language – Attachment M)

     

    • What if I also have Medicare?

     

    • 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? (MCO will use HHSC’s provided language – Attachment N)

     

    • What if I lose my medication(s)?

     

  • How do I get family planning services? (MCOs that do not provide family planning must submit alternative language for HHSC’s approval.)

     

    • Do I need a referral for this?

     

    • Where do I find a family planning services provider? (MCO will use HHSC’s provided language – Attachment O)

     

          • What is Service Coordination? (MCO will use HHSC’s provided language – Attachment P)

     

    • What will a Service Coordinator do for me?

     

    • How can I talk with a Service Coordinator?

     

Note: Include information and phone number for Service Coordination

     

          • What transportation services does the [insert MCO name] provide? (MCO will use HHSC’s provided language – Attachment Q)

     

    • What services are offered?

     

    • Who do I call for a ride to a medical appointment?

     

          • How do I get eye care 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?

     

          • What if I need OB/GYN care? (MCO will use HHSC’s provided language – Attachment R)

     

    • Do I have the 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?

     

    • How soon can I be seen after contacting my OB/GYN for an appointment? (Accessing requirements for perinatal care is within 2 weeks of request.)

     

    • Can I stay with my OB/GYN if they are not with (insert MCO name)?

     

          • What if I am too sick to make a decision about my medical care?

     

            • What are advance directives?

     

            • How do I get an advance directive?

     

          • What happens if I lose my Medicaid coverage? (MCO will use HHSC’s provided language – Attachment S)

     

          • What if I get a bill from my Nursing Facility?

     

            • Who do I call?

     

            • What information will they need?

            • What is Applied Income, and what are my responsibilities? (MCO will use HHSC’s provided language – Attachment T)

     

          • Can my Medicare provider bill me for services or supplies if I am in both Medicare and Medicaid? (MCO will use HHSC’s provided language – Attachment U)




          • What do I have to do if I move? (MCO will use HHSC’s provided language (MCO will use HHSC’s provided language – Attachment V)

     

          • What if I have other health insurance in addition to Medicaid? (MCO will use HHSC’s provided language – Attachment W)

     

          • What are my rights and responsibilities? (MCO will use HHSC’s provided language – Attachment X)

     

J. Complaint Process

     

The following questions must be included and answered in the handbook:




          • What should I do if I have a Complaint? (Optional HHSC provided language – Attachment Y)

     

    • Who do I call? (Include at least one toll-free telephone number)

     

    • Can someone from (insert MCO name) help me file a Complaint?

     

    • How long will it take to process my Complaint?

     

    • What are the requirements and timeframes for filing a Complaint?

     

    • Information on how to file a Complaint with HHSC, once I have gone through the (insert MCO name) Complaint process.

     

K. Appeal Process

     

The following questions must be included and answered in the handbook:




          • What can I do if my doctor asks for a service or medicine for me that’s covered but (insert MCO name) denies it or limits it?

     

          • How will I find out if services are denied?

     

    • Timeframes for the Appeals process – including option to extend up to 14 calendar days if a Member asks for an extension; or the MCO shows that there is a need for more information and how the delay is in the Member’s interest. If the MCO needs to extend, the Member must receive written notice of the reason for delay.

     

    • When does a Member have the right to ask for an Appeal – include option for the request of an Appeal for denial of payment for services in whole or in part.

     

    • Include notification to Member that in order to ensure continuity of current authorized services, the Member must file the Appeal on or before the later of: 10 calendar days following the MCO’s mailing of the notice of the Action or the intended effective date of the proposed Action.

     

    • Every oral Appeal received must be confirmed by a written, signed Appeal by the Member or his or her representative, unless an Expedited Appeal is requested.

     

              1. Can someone from (insert MCO name) help me file an Appeal?

     

              1. Information informing Members that they can request a State Fair Hearing any time during or after the health plan’s Appeals process.

     

L. Expedited MCO Appeal

     

The following questions must be included and answered in the handbook:




          • What is an Expedited Appeal? (MCO will use HHSC’s provided language Attachment Z)

     

          • How do I ask for an Expedited Appeal?

     

          • Does my request have to be in writing? (must be accepted orally or in writing)

     

          • What are the timeframes for an expedited appeal?

     

          • What happens if the MCO denies the request for an Expedited Appeal?

     

          • Who can help me file an Expedited Appeal?

     

M. State Fair Hearing (MCO will use HHSC’s provided language – Attachment AA)

     


Section III. N. Added by Version 2.1
N. Reporting Abuse, Neglect, and Exploitation

     

How do I report suspected abuse, neglect, or exploitation? (MCO will use HHSC's provided language – Attachment BB.)

     

O. Fraud Information

     

The following question must be included and answered in the handbook:




          • Do you want to report Waste, Abuse, or Fraud? (MCO will use HHSC’s provided language – Attachment CC)

     

P. Information That Must Be Available on an Annual Basis (MCO will use HHSC’s provided language – Attachment DD)

     

      1. Back Cover

     

Month and year of the first available distribution date for the handbook can be on the front or back cover.

     

Section IV. Modified by Version 2.1

R
Attachment A “Your Texas Benefits (YTB) Medicaid ID Card” Modified by Version 2.1
EQUIRED LANGUAGE


ATTACHMENT A

Your Texas Benefits (YTB) Medicaid ID Card

When you are approved for Medicaid, you will get a YTB Medicaid ID card. This plastic card will be your everyday Medicaid ID card. You should carry and protect it just like your driver’s license or a credit card. The card has a magnetic strip that holds your Medicaid ID number. Your doctor can use the card to find out if you have Medicaid benefits when you go for a visit.

You will be issued one card, and will only receive a new card in the event your card is lost or stolen. If your Medicaid ID card is lost or stolen, you can get a new one by calling toll-free 1-855-827-3748, or by going online to print a temporary card at www.YourTexasBenefits.com.

If you are not sure if you are covered by Medicaid, you can find out by calling toll-free at 1-800-252-8263. You can also call 2-1-1. 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 1-800-252-8263.

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 program you’re in if you get:

    • Medicare (QMB, MQMB)

    • Texas Women’s health Program (TWHP)

    • Hospice

    • STAR Health

    • Emergency Medicaid, or

    • 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 (www.YourTexasBenefits.com) and a phone number you can call toll-free (1-800-252-8263) 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.


Your Texas Benefits Medicaid website: www.YourTexasBenefits.com

Adult Medicaid clients can now see their available health information online by visiting www.YourTexasBenefits.com.

You can:


  • View your benefit and case information

  • View, print, and order Medicaid ID cards.

  • View and set up your, or your families, Texas Health Steps Alerst and email notifications.

  • Choose whether or not to share your available health information.

  • View available health information such as:

    • Health events

    • Prescription drugs

    • Past Medicaid visits

    • Lab information

    • Vaccination information

To access the portal, visit YourTexasBenefits.com.

  • To get started, you will need to: Click "View my case"

  • Follow the steps for setting up an account or logging in.

  • Once you have logged in, click on the "Medicaid" tab in the upper right part of the screen.

  • Find your case

  • Click on "View Services and Health History" tab

If you have questions, call 1-855-827-3748 or email ytb-card-support@hpe.com


La tarjeta de Medicaid de Your Texas Benefits

Cuando lo aprueban para recibir Medicaid, usted recibirá una tarjeta de Medicaid de Your Texas Benefits. Esta tarjeta de plástico será su tarjeta de identificación de Medicaid de todos los días. Debe llevarla y protegerla como lo haría con la licencia de manejar o una tarjeta de crédito. La tarjeta tiene una cinta magnética con su número de identificación de Medicaid. El doctor puede usar la tarjeta para saber si usted tiene beneficios de Medicaid cuando vaya a una cita.

Solo le entregarán una tarjeta, y solo recibirá una tarjeta nueva si la pierde o se la roban. Si pierde o le roban la tarjeta de identificación de Medicaid, puede obtener una nueva llamando gratis al 1-855-827-3748.

Si no está seguro de que tiene cobertura de Medicaid, puede llamar gratis al 1-800-252-8263 para saberlo. También puede llamar al 211. Primero, escoja un idioma y después escoja la opción 2.

Su historia médica es una lista de los servicios médicos y medicamentos que usted recibió por medio de Medicaid. La divulgamos a los doctores de Medicaid para ayudarles a decidir qué atención médica necesita usted. Si no quiere que los doctores vean su historia médica por medio de una red segura en Internet, llame gratis al 1-800-252-8263.

La tarjeta de Medicaid de Your Texas Benefits tiene impreso en el frente estos datos:



  • Su nombre y número de identificación de Medicaid.

  • La fecha en que le enviaron la tarjeta.

  • El nombre del programa de Medicaid en que está inscrito si recibe:

    • Medicare (QMB, MQMB)

    • Programa de Salud para la Mujer de Texas (TWHP)

    • Cuidado de hospicio

    • STAR Health

    • Medicaid de emergencia, o

  • Elegibilidad Condicional para Mujeres Embarazadas (PE).

  • La fecha en que la HHSC hizo la tarjeta para usted.

  • La información que la farmacia necesita para cobrar a Medicaid.

  • El nombre y teléfono del plan de salud en que está inscrito.

  • El nombre de su doctor y de su farmacia si está en el Programa Medicaid Lock-in Limitado de Medicaid.

El dorso de la tarjeta de Medicaid de Your Texas Benefits tiene un sitio web al que puede ir (www.yourtexasbenefits.com) y un número de teléfono al que puede llamar (1-800-252-8263) si tiene preguntas sobre la nueva tarjeta.

Si se le olvida la tarjeta, el doctor, dentista o farmacéutico puede usar el teléfono o Internet para asegurarse de que usted recibe beneficios de Medicaid.



Your Texas Benefits Medicaid website: www.YourTexasBenefits.com

Los clientes mayores de edad de Medicaid pueden ahora ver la información disponible sobre su salud en línea. Visite www.YourTexasBenefits.com.

Usted podrá:


  • Ver información sobre sus beneficios y su caso

  • Ver, imprimir y ordenar tarjetas de Medicaid

  • Ver y configurar alertas y notificaciones por correo electrónico de Pasos Sanos de Tejas para usted y su familia

  • Elegir si desea o no compartir información sobre su salud

  • Ver información sobre su salud disponible, incluyendo:

    • Acontecimientos en su salud

    • Recetas médicas

    • Visitas anteriores de Medicaid

    • Resultados de laboratorio

    • Información sobre vacunas

Para acceder al portal, visite YourTexasBenefits.com:

  • Haga clic en "Ver mi caso"

  • Siga los pasos para crear una cuenta o entrar al sistema

  • Una vez que haya entrado al sistema, haga clic en la etiqueta de "Medicaid" en la parte superior derecha de la pantalla

  • Localice su caso

  • Haga clic en "Ver Servicios e Historial de Salud"

Si tiene preguntas, llame al 1-855-827-3748, o email ytb-card-support@hpe.com

REQUIRED LANGUAGE
ATTACHMENT B



What is the Medicaid Lock-in Program?

You may be placed 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 placed 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 [insert MCO name].  

¿Qué es el Programa Lock-in de Medicaid?

Si usted no sigue las reglas de Medicaid, puede que le asignen al Programa Lock-in. Este programa revisa cómo utiliza los servicios de farmacia de Medicaid. Sus beneficios de Medicaid no cambian. Cambiar a una MCO diferente no cambiará su estado en el programa.

Para evitar que lo pongan en el Programa Lock-in de Medicaid:


  • Escoja una farmacia en particular y úsela todo el tiempo.

  • Asegúrese de que su doctor de cabecera, dentista primario o los especialistas a los que le envían, sean los únicos doctores que le receten medicamentos.

  • No obtenga el mismo tipo de medicamento de diferentes doctores.

Para más información, [insert MCO name].

REQUIRED LANGUAGE
ATTACHMENT C
Physician Incentive Plans Planes de incentivos para doctores

If the MCO offers a physician incentive plan that rewards providers, including nursing facilities, for providing services to Members in the most cost-effective manner:

(Insert name of MCO) rewards doctors for treatments that are cost-effective for people covered by Medicaid. You have the right to know if your primary care provider (main doctor) is part of this physician incentive plan. You also have a right to know how the plan works. You can call (insert toll-free telephone number) to learn more about this.

(Insert name of MCO) premia a los doctores cuyos tratamientos reducen o limitan los servicios prestados a las personas cubiertas por Medicaid. Usted tiene el derecho de saber si su proveedor de cuidado primario (doctor de cabecera) participa en el plan de incentivos para doctores. También tiene el derecho de saber cómo funciona el plan. Puede llamar gratis al (insert toll-free telephone number) para más información.


If the MCO does not offer a physician incentive plan that rewards providers, including nursing facilities, for providing services to Members in the most cost-effective manner:
A physician incentive plan rewards doctors for treatments that are cost-effective for people covered by Medicaid. Right now, (insert name of MCO) does not have a physician incentive plan.
Un plan de incentivos para doctores premia a los doctores cuyos tratamientos reducen o limitan los servicios prestados a las personas cubiertas por Medicaid. En este momento, (insert name of MCO) no tiene un plan de incentivos para doctores.
OPTIONAL LANGUAGE


ATTACHMENT D

What if I want to change health plans?

You can change your health plan by calling the STAR+PLUS Program Helpline at 1-800-964-2777. You can change health plans as often as you want, but not more than once a month.



If you are in the hospital, a residential Substance Use Disorder (SUD) treatment facility, or residential detoxification facility for SUD, you will not be able to change health plans until you have been discharged.

If you call to change your health plan on or before the 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.



¿Qué hago si quiero cambiar de plan de salud?

Puede cambiar su plan de salud llamando a la Línea de Ayuda de STAR+PLUS de Texas al 1-800-964-2777. Usted puede cambiar su plan de salud siempre que quiera, pero no más de una vez al mes.

Si está en el hospital, un centro de tratamiento residencial para trastornos por uso de sustancias (SUD), o centro residencial de desintoxicación para SUD, no puede cambiar de plan de salud hasta que lo den de alta.

Si llama para cambiar de plan de salud el día 15 del mes o antes, el cambio entrará en vigor el día primero del mes siguiente. Si llama después del 15 del mes, el cambio entrará en vigor el día primero del segundo mes siguiente. Por ejemplo:

 Si llama el día 15 de abril o antes, el cambio entrará en vigor el 1 de mayo.

 Si llama después del 15 de abril, el cambio entrará en vigor el 1 de junio.



REQUIRED LANGUAGE
ATTACHMENT E
Medically Necessary means:
(1) For Members age 21 and over, non-behavioral health related health care services that are:

(a) reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a Member, or endanger life;

(b) provided at appropriate facilities and at the appropriate levels of care for the treatment of a Member’s health conditions;

(c) consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies;

(d) consistent with the diagnoses of the conditions;

(e) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;

(f) not experimental or investigative; and

(g) not primarily for the convenience of the Member or provider; and


(2) For Members age 21 and over, 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.


[Insert MCO name] will determine medical necessity for Nursing Facility Add-on Services and Acute Care Services only. Nursing Facility Add-on Services include, but are not limited to emergency dental services, physician-ordered rehabilitative services, customized power wheel chairs, and audio communication devices.

Médicamente necesario significa:
(1) Para los miembros mayores de 20 años, servicios no relacionados con la salud mental y abuso de sustancias que:

(a) son razonables y necesarios para evitar enfermedades o padecimientos médicos, detectar a tiempo enfermedades, hacer intervenciones o para tratar padecimientos médicos que provoquen dolor o sufrimiento, para prevenir enfermedades que causen deformaciones del cuerpo o que limiten el movimiento, que causen o empeoren una discapacidad, que provoquen enfermedad o pongan en riesgo la vida del miembro;

(b) se prestan en instalaciones adecuadas y al nivel de atención adecuado para el tratamiento del padecimiento médico del miembro;

(c) cumplen con las pautas y normas de calidad de atención médica aprobadas por organizaciones profesionales de atención médica o por departamentos del gobierno;

(d) son acordes con el diagnóstico del padecimiento;

(e) son lo menos invasivos o restrictivos posible para permitir un equilibrio de seguridad, efectividad y eficacia;

(f) no son experimentales ni de estudio; Y

(g) no son principalmente para la conveniencia del miembro o proveedor; y


(2) Para miembros mayores de 20 años, servicios de salud mental y abuso de sustancias que:

(a) son razonables y se necesitan para diagnosticar o tratar los problemas de salud mental o de abuso de sustancias, o para mejorar o mantener el funcionamiento o para evitar que los problemas de salud mental empeoren;

(b) cumplen con las pautas y normas clínicas aceptadas en el campo de la salud mental y el abuso de sustancias;

(c) se prestan en el lugar más adecuado y menos restrictivo y en donde hay un ambiente seguro;

(d) se prestan al nivel más adecuado de servicios que puedan prestarse sin riesgos;

(e) no se pueden negar sin verse afectada la salud mental o física del miembro o la calidad de la atención prestada;

(f) no son experimentales ni de estudio; Y

(g) no son principalmente para la conveniencia del miembro o proveedor.


[Insert MCO name] solo determinará la necesidad médica de servicios adicionales de centros para convalecientes y servicios de atención de casos agudos. Los servicios adicionales de centros para convalecientes son, entre otros, servicios dentales de emergencia, servicios de rehabilitación ordenados por un doctor, sillas de ruedas eléctricas personalizadas y aparatos de comunicación por audio.


REQUIRED LANGUAGE


ATTACHMENT F

Are non-emergency dental services covered?

(Insert MCO’s name) is not responsible for paying for routine dental services provided to Medicaid Members.

(Insert MCO’s name) is responsible, however, for paying for treatment and devices for craniofacial anomalies.

¿Están cubiertos los servicios dentales que no son de emergencia?

(Insert MCO’s name) no es responsable de pagar los servicios dentales periódicos que reciben los miembros de Medicaid.

Sin embargo, (Insert MCO’s name) es responsable de pagar el tratamiento y los aparatos para anomalías craneofaciales.

REQUIRED LANGUAGE

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