Driscoll Children’s Health Plan

Transcript

Page 1 Driscoll Children’s Health Plan Call us: Se Habla Español Write us: Regular Business Hours: Before 8:00 or after 5:00 24 Hour Behavioral Health Hotline Member Services 1-877-220-6376(toll-free) For hearing impaired: 1-800-855-2880 (TTY) toll-free Interpreter Services also available Driscoll Children's Health Plan P.O. Box 6609 Corpus Christi, TX 78466-6609 8:00 – 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. 1-888-244-4142 (English or Spanish) with information on services. Other interpretive services available. If there is an emergency or crisis, go to the ER or call 9-1-1. Vision and Eye Care Number 1-866-838-7614 for questions about eye exams and glasses Dental Care Number 1-866-561-5892 for questions about dental care STAR Help Line 1-800-964-2777 STARLink Call 1-866-566-8989 for help to get services. This is a state wide helpline. Hearing Impaired call the TDD#: 1-866-222-4306 Pharmacist Help Call 1-800-252-8263 (toll-free) if you need help getting a prescription filled. Line Non-Urgent Transportation Driscoll Children’s Health Plan The Medical Transportation Program can give you a ride if you can not get a ride to the doctor’s office. Call 1-877-633-8747, Monday through Friday, 8:00 a.m. to 5:00 p.m. (CST). Call early to arrange for a ride. Medicaid/STAR Member Handbook sygdom.info Page 2 Welcome! Welcome to Driscoll Children's Health Plan By choosing the Driscoll Children’s Health Plan (DCHP), your child will get all the STAR/Medicaid health benefits – plus more. • • • • • Your own doctor Friendly and confidential staff Access to Driscoll Children’s Hospital and many other hospitals Free health education for children of any age Assurance of access to care regardless of nationality, race, religion, origin and gender If you have any questions or concerns about access of care, and feel that you were not allowed access to care because of nationality, race, religion, origin, or gender, please contact DCHP Member Services at 1-877-220-6376 as soon as possible. Your concern will be investigated and resolved quickly. The doctor you chose when you enrolled with DCHP will be your child's Primary Care Provider (PCP) and will help take care of all your child’s health care needs. First things first. These are a few important things about your child's health care. • • • • • • • • You will receive a DCHP ID card, if you have not already received one. Your PCP’s name will be on the DCHP ID card. Please check the ID card to make sure the names on it are correct. Get to know your and your child’s doctor. Make an appointment with your PCP as soon as possible. Call your PCP for appointments. Tell them you or your child is a DCHP STAR member. Call your PCP whenever you or your child needs health care. Follow your PCP’s advice. Carry your or your child's DCHP ID card with you at all times. Use the hospital emergency room only for emergencies. This Member Handbook answers many questions about DCHP. 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 DCHP 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 member materials, including this handbook, are needed in a different way due to reading, seeing or language problems, notify Member Services at 1-877-2206376 as soon as possible. DCHP will provide these materials to you at no cost. Again, Welcome! Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 3 Contents Page Driscoll Children's Health Plan and Important Phone Numbers.............................. 1 Welcome to Driscoll Children's Health Plan ............................................................ 2 DCHP Identification Card (ID Card) ....................................................................... Reading the DCHP ID Card ................................................................................... Using the DCHP ID Card ....................................................................................... If you lose your ID Card or move ........................................................................... Medicaid Identification Form 3087 .......................................................................... Medicaid Eligibility Verification (Temporary Form) ................................................. What do I need to bring with me to the Doctor’s Appointments .............................. Your and Your Child’s Primary Care Provider (PCP) ............................................. How do I change by PCP ........................................................................................ When will my PCP change become effective.......................................................... Can a Clinic be PCP ............................................................................................... How many times can I change my PCP.................................................................. Reasons why your request to change PCP may be denied.................................... Can my PCP request that I be changed to another PCP for non-compliance ........ What if I choose to go to another doctor who is not my PCP .................................. Physician Incentive Plan Information ...................................................................... Changing health plans ............................................................................................ Can DCHP request that I get disenrolled from their plan ........................................ What are my health care benefits ........................................................................... How do I obtain these services ............................................................................... What services are not covered by STAR ................................................................ What Extra Benefits does a member of DCHP get ................................................. How do I get these Value Added services .............................................................. How do I get help if I have behavioral (mental) health or drug problems ................ What if I need OB/GYN care ................................................................................... What if I am or my child is Pregnant ....................................................................... Can I pick a PCP for my babe before the baby is born ........................................... How and when can I switch my baby’s PCP ........................................................... Can I switch my baby’s health plan......................................................................... How do I sign up my newborn................................................................................. What about family planning services....................................................................... What services are offered by THSteps ................................................................... How and when do I get THSteps medical and dental checkups for my child.......... Do I have to have a referral..................................................................................... 5 5 6 6 6 9 9 9 9 9 10 10 10 10 10 11 11 11 12 12 12 13 13 14 14 15 15 15 15 15 15 16 16 17 Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 4 Contents What if I need to cancel an appointment................................................................. What if I am out of town and my child is due for a THSteps exam.......................... What Health Education classes does DCHP offer .................................................. How do I get eye care services ............................................................................... Interpreter Services................................................................................................. Prescription Coverage............................................................................................. What does Medically Necessary mean ................................................................... What is routine medical care and how do I get it .................................................... What is urgent medical care and how do I get it ..................................................... What is emergency care ......................................................................................... What is post stabilization care................................................................................. How do I get medical care after my PCP’s office is closed ..................................... If you or your child becomes sick when out of town or traveling ............................. Getting a ride to the doctor’s office ......................................................................... Referrals to a special doctor ................................................................................... Children with Special Health Care Needs ............................................................... What if I am too sick to make a decision about my medical care............................ What happens if I lose my Medicaid/STAR eligibility .............................................. If you get a bill from your doctor.............................................................................. What do I do if I move ............................................................................................. What if I have other health insurance in addition to Medicaid/STAR ...................... Services that require prior authorization ................................................................. How will I be notified if services are denied ............................................................ Can I appeal when we have not paid a claim.......................................................... Can I file an appeal with the State .......................................................................... Expedited Appeal .................................................................................................... State Fair Hearing ................................................................................................... Complaints .............................................................................................................. Fraud and Abuse of the STAR Program ................................................................. Information that must be available on an annual basis ........................................... Member Rights and Responsibilities....................................................................... Family Planning Providers ...................................................................................... Driscoll Children’s Health Plan Page 17 17 17 17 18 18 18 20 20 20 22 22 22 22 23 23 24 24 25 25 25 25 26 27 27 27 28 28 29 30 31 34 Medicaid/STAR Member Handbook Page 5 Driscoll Children’s Health Plan and STAR The STAR program in the State of Texas is the Managed Medicaid program. This provides care to families who would not normally have access to care. By choosing the Driscoll Children’s Health Plan (DCHP), we can provide STAR health services to you and your children. Health care through DCHP STAR is available in these south Texas counties: • • • • • • Aransas Bee Calhoun • • • Jim Wells Kleberg Nueces Refugio San Patricio Victoria DCHP is a not-for-profit Health Maintenance Organization (HMO) licensed by the Texas Department of Insurance. Your STAR ID Card You will get a STAR Identification (ID) card after you enroll in DCHP. A copy of the DCHP ID card is shown below. Information about you or your child PCP name and phone number Important Information/Información importante Member Services (toll-free)/ Departamento de Servicios para Miembros (gratis) STAR/Medicaid Member Name: John Doe Member ID#: 000-00-0000-01 Effective Date: 01/01/2006 PCP: Joe B. Doctor PCP Phone #: (361) 000-0000 Effective Date of PCP: 01/01/2006 TTY for hearing impaired/TTY para personas con problemas del oído 24 Hour Behavioral Health Hotline/Linea de Servicios de Salud Mental Vision Services/Servicios para la vista Prescription Drugs In case of emergency call 911 or go to the closest emergency room. After treatment, call your PCP within 24 hours. 1-877-220-6376 1-800-855-2880 1-888-244-4142 1-866-838-7614 1-800-252-8263 En caso de emergencia, llame al 911 ó vaya a la sala de emergencias más cercana. Después de recibir tratamiento, llame al PCP dentro de las 24 horas. NOTICE TO PROVIDER: The member whose name appears on the face of this card is covered by Driscoll Children’s Health Plan for STAR services. For provider billing or UM questions, 1-877-324-3627. The toll free UM FAX is 1-866-7415650. Submit Claims to: DCHP STAR, P.O. Box 3668, Corpus Christi, TX 78463-3668. STAR prescription drug is covered by the STAR Prescription Drug Benefit with the State of Texas Customer Service Phone #: 1-877-220-6367 CAREMARK Help Desk: 1-800-345-5413 BIN: 004336 PCN: ADV Rx GRP: RX 4020 Rev 06 Each of you and your children will have a different card. You will not get a new DCHP STAR card every month. You will get a new one if you lose your ID, or if you call us to change your Primary Care Physician (PCP). Reading the DCHP STAR ID Card The front of the DCHP STAR ID card shows important information about you or your child, the PCP’s name and PCP’s phone number. The back of the card shows important phone numbers for emergencies or other help from DCHP Member Services. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 6 Using the DCHP STAR ID Card Carry your and your child’s DCHP STAR ID Card with you when you and your child gets any health care services. You must show your STAR ID Card each time for any health service. If you lose an ID Card or Move If you lose the DCHP STAR ID Card, call us right away at 1-877-220-6376 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. Medicaid Identification Form 3087 You will get a Medicaid ID Form 3087 in the mail each month as long as your are eligible for Medicaid. The Medicaid form tells providers about you and the services that you can get each month. Because you are now in the STAR Program, the form will look different than your regular Medicaid form. You will see the STAR Program logo (Texas STAR) on the top right hand side of your form. This will tell providers that you are part of the STAR Program. The form has a “Good Through” date in the top right hand box. This means the Medicaid form is good through the last day of the month printed in this box. It will also list your name and the names of any other family members who are part of your Medicaid case. As a member of the STAR Program, your Medicaid form will show your Health Plan below each name listed on the form. If you are under 21, you will also see a reminder under your name if you have a Texas Health Steps (EPSDT) checkup due. You will need to call your PCP or Health Plan to arrange for a checkup. The Medicaid form also shows that adults can get more than three prescriptions each month. Be sure to take your Medicaid form to the pharmacy when you need to get a prescription filled. In addition, the form has the following information: Date Run – This is the date the form was printed. BIN – This information is used for pharmacy services. BP – This is a code that tells where you live. TP – This is the type program for your case. Cat – This is your case category. Case No. – This is your case number. ID No. – This is your Medicaid number. Name – This is your full name as listed with Medicaid. Date of Birth – This is your birth date listed with Medicaid by month, day and year. Sex – This shows if you are female (F) or male (M). Eligibility Date – This is the beginning date of your eligibility. TPR – This shows if you have other insurance. A “P” means you have private insurance and an “M” means you are eligible for Medicare. Medicare No. – This is your Medicare Number, if you have one. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 7 Be sure to read the back of the Medicaid form. It also gives you more information about the form. There is also a box that has specific information for providers. You must take your Medicaid form and your DCHP ID card with you when you get any health care services. You will need to show your Medicaid form and DCHP ID card each time you need services. If you lose your Medicaid form, contact your local HHSC Eligibility Office for another one. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 8 Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 9 Medicaid Eligibility Verification (Temporary Form) If you lose your Medicaid ID Form 3087, you may get a temporary Medicaid form. Contact the STAR Help Line at 1-800-964-2777 for more information. All About PCPs What do I need to bring with me to the Doctor’s appointments? You must take your DCHP ID card, and your Medicaid ID Form 3087 with you when you go to the doctor. If your child is going to the doctor, don’t forget your child’s shot records. You and your child’s Primary Care Physician (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 check-ups, write prescriptions for medicines and supplies when you or your child is sick, and tell you if you or your child should see a specialist. To give you the best care possible, your PCP needs to know your and your child’s medical history. Your medical records are private and confidential. Only you, your PCP, and other approved providers have a right to see them. If you change doctors, be sure to give your new PCP any information needed about your medical history. How do I change by Primary Care Provider (PCP)? You may want to change to another PCP if: • You are not happy with your PCP’s care • You need a different kind of doctor to take care of your child • You move farther away from your PCP • Your PCP is no longer a part of DCHP’s network • You do not get along with the PCP. You can change your PCP by calling toll-free at 1-877-220-6376. The DCHP Provider Directory lists all PCPs. You will get a new 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. When will my PCP change become effective? You may change your PCP at anytime. If you call BEFORE the 15th of the month, the change will become effective immediately. If you call AFTER the 15th of the month, the Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 10 PCP will not change until the first of the next month. If you see the new PCP before the change, you will have to pay the bill. Can a Clinic be by PCP? You or your child may select a clinic as your PCP. This can be a Federally Qualified Health Center (FQHC), or a Rural Health Clinic (RHC). If you have questions call Member Services at 1-877-220-6376. How many times can I change my PCP? You may change your or your child’s PCP up to four (4) times every year. Reasons why your request to change PCP may be denied. You may not be able to have the PCP you chose if: • The PCP you picked is not seeing new patients • The PCP you picked is no longer a part of DCHP • You have already changed PCPs more than four (4) times in one year Can my PCP request that I be changed to another PCP 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 PCP? You may go to any provider who is part of DCHP, 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 1-888-244-4142. 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 1-866-838-7614. For all other care, you must only see the PCP listed on your ID Card. If you see another PCP, you may have to pay the bill. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 11 Physician Incentive Plan Information You have a right to know if your or your child’s PCP is participating in a Physician Incentive Plan through Driscoll Children's Health Plan. You may call Member Services at 1-877-220-6376. Changing Health Plans What if I want to change health plans? If you or your child is not in the hospital, you can change your health plan by calling the Texas STAR Program Helpline at 1-800-964-2777. You can change health plans as many times as you want, but not more than once a month. If you or your child are in the hospital, you will not be able to change health plans until you have been discharged. When will my Health Plan change become 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 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 1st. If you call after April 15, your change will take place on June 1st. Can Driscoll Children's Health Plan request that I get disenrolled from their plan (for non-compliance, etc.)? Yes, Driscoll Children's Health Plan may request that you be disenrolled from our health plan. DCHP may request for your disenrollment if: • • • • • • You let someone else use your DCHP ID Card; You let someone else use your Medicaid ID Form 3087; You do not follow your doctor’s advise, for you or your child; You keep going to the emergency room for yourself or your child when you do not have a true emergency; You cause problems at the doctor’s office; or You make it difficult for your doctor to help you or other people. If there are changes in your health plan, you will be sent a letter. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 12 Benefits Available From DCHP STAR What are my health care benefits? Driscoll Children's Health Plan 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 (through the Vendor Drug Program) • Eye exams and glasses; • Ear doctor visits and hearing aids; • Home health Services (health care at home); • Ambulance Services, if you need it; • Dialysis (help from a machine) for kidney problems; • Family planning services and supplies (such as birth control); • Behavioral (mental) health services; • Help with substance abuse (such as alcohol or drugs); • An adult checkup every year. How do I obtain these services? Your or your child’s PCP will work with you to make sure your child gets the care needed. You may call Member Services at 1-877-451-6889 at any time you have questions. There may be limitations to these services. Call Member Services for information on limits. What services are not covered by STAR? 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; Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 13 • • • • • • • • • • • • • • • • • • Ear piercing Hospital bereavement; Hair transplant; Infertility treatment; In-vitro fertilization; Experimental medicines or procedures; Marital counseling; Medical testimony and reports; Non-authorized services; Obesity services; Obesity surgery; Penile implant; Radial keratotomy; Respite care; Reversal of sterilization; Any services that you don’t have to have (is not medically necessary); Any service that your PCP does not say is “OK”; or, Any service you get outside of the United States. What Extra Benefits does a Member of Driscoll Children's Health Plan get? All eligible Driscoll Children's Health Plan members will receive the following Value Added services: • • • Eyeglasses with a retail value up to $100 every 24 months; Temporary cell phones for members who are pregnant; or Home visits to new mothers to offer help and answer questions about yourself or the new baby. How can I get these Value Added services? For eyeglasses, contact our vision vendor at 1-866-838-7614. For temporary cell phones, contact Member Services at 1-877-220-6376. To arrange for home visit after giving birth, you will be contacted by our case manager. If you have questions of the case manager, contact Member Services at 1-877-2206376. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 14 Behavioral (Mental) Health Services How do I get help if I have behavioral (mental) health or drug problems? You can get help for behavioral (mental) health problems and/or substance (drug) abuse. You can go to a mental health provider without a referral from your PCP. The provider you pick must be a provider with Driscoll Children's Health Plan’s Behavioral Health network. Call the Behavioral Health Hotline on your ID card for help. The phone number is 1-888-244-4142. 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. If you or your child has an emergency related to mental health problems or drug or alcohol abuse, go to the nearest hospital emergency room or call 911 for an ambulance. Attention Female Members What if I need OB/GYN care? You have the right to select an OB/GYN without a referral from your PCP. Driscoll Children's Health Plan has limited your selection of an OB/GYN to the same network as your PCP. The access to health care services of an OB/GYN includes: • • • • One well-woman checkup each year Care related to pregnancy Care for any female medical condition Referral to special doctor within the network What happens if I don’t choose an OB/GYN? You are not required to choose an OB/GYN doctor (doctor for women’s health). But, if you are pregnant you should choose an OB/GYN doctor to take care of you. How do I choose an OB/GYN? You can only go to OB/GYNs that are part of the Driscoll Children's Health Plan. You do not need a referral from your PCP. To choose an OB/GYN, call Member Services at 1-877-220-6376. 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 at 1-877-220-6376. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 15 What if I am or my child is Pregnant? It is very important that you call Driscoll Children's Health Plan to tell us you are pregnant and what doctors you are seeing. Call Member Services at 1-877-220-6376. 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; • Help you find an OB/GYN doctor; and • Give you a temporary cell phone for use while you are pregnant. Can I pick a PCP for my baby before the baby is born? Yes. Call Member Services at 1-877-220-6376 and select a PCP for your baby. How and when can I switch my baby’s PCP? If you do not choose a PCP for your baby, one will be chosen for you. If you are unhappy with the choice, you may call Member Services and change the PCP. Can I switch my baby’s health plan? Your baby will be assigned to the same health plan that you are enrolled with for at least 90 days from date of birth. You can request a plan change prior to the 90 days if both health plans agree with transfer. If your baby is in the hospital, plan changes are not permitted until the baby is discharged. How do I sign up my newborn? When your baby is born, call your Texas Department of Human Services caseworker so your baby can get Medicaid. It is also important that you call Member Services or your Case Manager to let us know that your baby is born. You will receive a Medicaid ID Form 3087 that says “Newborn Call Plan”. This means the baby is enrolled in the mother’s health plan for at least 90 days from the date of birth. 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 have drugs and supplies that prevent pregnancy. You can go to any provider who takes Medicaid/STAR. To see a list of providers, see page 34. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 16 Texas Health Steps What is Texas Health Steps? Texas Health Steps (THSteps) is a special health care program for children under 21. THSteps is for children’s health checkups. These checkups are important and should be set up within 45 days of becoming a Driscoll Children's Health Plan member. Even if a child looks and feels well, he or she may still have a problem. What services are offered by THSteps? Texas Health Steps can help in many ways. Some of the things done in a THSteps medical checkup are: • • • • • • Physical exam, measuring height and weight; Hearing and eye check; Checking for a good diet; Shots (when needed); Blood tests (when needed) TB test Children under age 21 can get dental care. This care includes: • • • • • • Fillings Getting teeth pulled Crowns Root canals Teeth cleaning every 6 months, and Getting wisdom teeth pulled. If you are age 21 or older, Medicaid/STAR will cover your dental care only if it is an emergency that puts your life in danger. How and when do I get Texas Health Steps (THSteps) medical and dental checkups for my child? All of the Driscoll Children's Health Plan PCPs who work with children are also able to offer THSteps services. You may want to talk to your child’s PCP first. Don’t forget to show your Driscoll Children's Health Plan ID card and Medicaid ID Form 3087 to your PCP. Dental checkups can be received every 6 months beginning at 12 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 some place other than his/her office, you will need to contact Driscoll Children's Health Plan before the service is done. Call Delta Dental for information about dental treatment at 1-866-561-5892. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 17 Does my doctor have to be with my Health Plan? Your child may go to any Medicaid/STAR provider for THSteps services. Do I have to have a referral? You do not need a referral from your child’s PCP to receive THSteps services. What if I need to cancel an appointment? Call and make an appointment for each family member who needs to be seen. 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 THSteps exam? If you have moved or are out of town when your child’s THSteps exam is due, call Member Services for assistance at 1-877-220-6376. Other Coverage and Services What Health Education classes does Driscoll Children's Health Plan offer? DCHP has education for members on many different health subjects. There is no charge for DCHP’s health education. Health education may include information on: • Immunizations • Special diets for diabetes • Asthma care • Bicycle safety • Wellness programs and health fairs If you need health education materials in another language, or in another format, call Member Services at 1-877-220-6376. How do I get eye care services? If you or your 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. Children may be able to have additional eye examinations and prescription glasses as part of the Texas Health Steps. For information about eye care and where you can find an eye doctor, call 1888-268-2664. If you are over the age of 21, you can get an eye exam and prescription glasses one time every 24 months. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 18 Interpreter Can someone interpret for me when I talk with my doctor? Yes. Call Member Services at 1-877-220-6376. We will arrange for an interpreter to help you during your visit. 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 Espanol – DCHP has people to help you who speak both Spanish and English. We also have member handouts in Spanish. Prescription Coverage How Do I Get My Prescriptions? Driscoll Children's Health Plan does not provide your prescription drugs. These drugs are covered by the STAR Prescription Drug Benefit (PDB). You can take your or your child’s prescription to any pharmacy taking part in the STAR PDB. Try to always use the same pharmacy to get more personal service. Take your or your child’s Driscoll Children's Health Plan STAR ID card with you when you go to the pharmacy. The pharmacy can make sure you or your child is a STAR member. The pharmacy may ask for the ID card. Call the STAR PDB if you need help finding a pharmacy or have problems getting prescriptions filled. Their number is 1-800-252-8263. Health Care and Other Services What does Medically Necessary mean? Medically Necessary means: (1) Health Care Services that are: Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 19 (a) reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/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) are not experimental or investigative; and (g) are not primarily for the convenience of the Member or Provider; and (2) Behavioral Health Services that are: (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. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 20 What is routine medical care and how do I get it? The PCP you chose will help you or your child with all your health care. Your or your child’s PCP will get to know you, arrange regular checkups, and treat you when you or your child are sick. Your PCP will give you prescriptions for medicine, and send you or your child to a special doctor (specialist) if you need one. It is important that you do what your or your child’s PCP says and take part in decisions made about your or your child’s health care. If you cannot make a decision about your or your child’s health care, you can choose someone else to do it for you. When you need to see your PCP, call your PCP at the number on your or your child’s Driscoll Children's Health Plan ID card. Someone in the PCP’s office will set a time for you. It is very important that you keep your appointment. Call early to set up visits, and call back if you have to cancel. If more than one member of your family needs to see the doctor, you need a new appointment for each person. You should be able to get an appointment for routine care within two (2) weeks. What is Urgent medical care and how do I get it? Urgent medical care is when you or your child are sick or hurt and need treatment as soon as possible to keep you or your child from getting worse. These are situations when you need to call your PCP first: • • • • • • • • • • • Earache Toothache or baby teething Rash Colds, cough, sore throat, flu or sinus problems Minor sun burn Minor cooking burn Chronic back pain Minor headache Broken cast Stitches needing to be removed Medication refills Your PCP is available, directly or through other doctors helping to cover the office, 24 hours a day, 7 days a week. You can expect to be seen for urgent medical care within 24 hours. Emergency Care What is emergency medical care? Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 21 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. You or your child has an EMERGENCY medical need if: • you think your or your child’s condition is life threatening; • you or your child has serious pain; or • serious harm could come to you or your child without immediate medical attention. If you or your child has an emergency, go to the closest Emergency Room right away or call 9-1-1. Examples of when to go to the emergency room are: • • • • • • • • • • • • • Someone may die without immediate medical attention; Someone has bad chest pains; Someone cannot breathe or is choking; Someone has passed out or is having a seizure; Someone is sick from poison or a drug overdose; Someone has a broken bone; Someone is bleeding a lot; Someone has been attacked (raped, stabbed, shot, beaten); Someone is about to deliver a baby; Someone has a serious injury to the arm, leg, hand, foot, or head; Someone has a severe burn; Someone has a severe allergic reaction or has an animal bite; or Someone has trouble controlling behavior and without treatment is dangerous to self or others. Go to the nearest hospital if you think you or your child has any of these problems. You may call 911 for help in getting to the hospital emergency room. Emergency care is available 24 hours a day, 7 days a week. A cold, cough, rash, small cuts, minor burns or bruises are not good reasons to go to the Emergency Room. If you go to the ER, be sure to call you PCP within 24 hours, or as soon as your child is medically stable. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 22 What is post stabilization? Post-stabilization care services are Medicaid covered services that you receive following emergency medical care in order to keep your condition stable. How do I get medical care after my PCP’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. If you or your child becomes sick when out of town or traveling If you or your child gets sick while you are out of town or out of state, call your PCP at the phone number listed on the front of your DCHP STAR ID card. You may also call Member Services at the number on the back of your ID card. If you or your child has an emergency while you are out of town or out of state, go to the nearest ER. 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 or your child’s 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-oftown doctor you may have to pay. If you or your child leaves the Driscoll Children’s Health Plan 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. Driscoll Children's Health Plan does not cover any care outside of the United States. Keep your and your child’s DCHP ID card with you at all times. Transportation If I don’t have a car, how can I get a ride to a doctor’s office? If you need a ride to a doctor’s office, you can get help from the Texas Department of Health Medical Transportation Program (MTP). Call MTP as soon as you know you will need a ride. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 23 Who do I call for a ride to a medical appointment? You must call at least two days before your visit. If your visit is on Monday, call MTP by Thursday the week before. They may be able to give you a ride even in the evening or on the weekend. If you need to know more or need a ride to the doctor, call this number: Medical Transportation Program (MTP) 1-877-633-8747 Can someone I know give me a ride to my appointment and get money for mileage? The Medical Transportation Program (MTP) also can help with money for gas for someone who drives you to an appointment. These drivers can be your family members, neighbors, or other volunteers. Please call the MTP at 1-877-633-8747 for more information. Who do I call if I have a complaint about the service or staff? If you have a complaint about the service or staff, call MTP at 1-877-633-8747, or call Member Services at 1-877-220-6376. What are the hours of operation and limitations for transportation services? The MTP hours of operation are 8:00 a.m. to 5:00 p.m., Monday – Friday except for state holidays. You will need to call them 2 days before you need the ride. Call MTP for any limitations on transportation services. Referrals to Specialists Referrals to a Special Doctor Your PCP will tell you if you or your child needs to see a specialist. Your PCP will make sure that you or your child gets the special care needed. In general, you cannot go to another doctor or get a special service if your PCP does not agree to make a referral. A referral is when your PCP sends you to another doctor or service for care. You should expect the specialist to give you an appointment within 2 weeks for non-urgent care or within 24 hours for urgent care. Who do I call if I have special health care needs and need someone to assist me? You or your child may need more health and other services because of a complex or chronic conditions. There may be times when DCHP may allow a special doctor (Specialist) to be your child’s PCP. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 24 Call Member Services at 1-877-220-6376 for more information on special services that DCHP has for you or your child. A Case Manager will call you back to talk about these special needs. Services that 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 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 request a second opinion? Driscoll Children's Health Plan will pay for a second opinion. Call Member Services at 1-877-220-6376 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. 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 1-877-220-6376. Other Information What happens if I lose my Medicaid/STAR eligibility? If you lose Medicaid/STAR eligibility but become eligible again within six (6) months or less, you will automatically be re-enrolled in the same Health Plan you were enrolled in Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 25 prior to losing your Medicaid/STAR eligibility. You will also be re-enrolled with the same PCP you had before. If you get a bill from your PCP or other Doctor You should never get a bill from your PCP or DCHP doctor. If you get a bill from your PCP or other Doctor, call DCHP Member Services at 1-877220-6376, and someone will call the provider’s office. We will help explain your benefits. When you call us, please have your child’s ID card and the provider’s bill available. DCHP Member Services will need this information to help you. What do I do if I move? Report your new address as soon as possible to the local HHSC Eligibility Office and the DCHP Member Services Department at 1-877-220-6376. You must call DCHP before getting any services in your new area unless it is an emergency. You will continue to get care through DCHP until the address is changed unless you have moved out of the service delivery area. What if I have other health insurance in addition to Medicaid/STAR? As a condition of Medicaid/STAR eligibility, you are required to report all insurance information to the program. If your private health insurance is canceled, if you have obtained new insurance coverage, or if you have general questions regarding third party insurance, you should call the Medicaid Third Party Resources (TPR) hotline so that you can update your records and get answers to your questions. You can call the TPR hotline toll-free at 1-800-846-7307. Having other insurance does not affect whether or not you qualify for Medicaid/STAR. Reporting other insurance is necessary to ensure that Medicaid remains the payer of last resort. IMPORTANT: Medicaid providers cannot refuse to see you because you have private health insurance as well as Medicaid/STAR. If providers accept you as a Medicaid patient, they must also file with your private health insurance company. Services That Require Prior Authorization There are some services that will require your PCP or other provider to contact DCHP and obtain permission for you or your child to receive the service. Some of these services are: • All admissions to a hospital (except in an emergency situation, where notifying DCHP within 24 hours of admission is required) Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 26 • • • • • • • • • Admission to a rehabilitation center Outpatient surgery Rehabilitation therapy (physical therapy, speech therapy and occupational therapy) Home health services, including home intravenous therapy Referral to a Specialist physician other than an OB/GYN or Mental Health physician Durable Medical Equipment services that cost over $300 Use of ambulance for medical transportation (not emergency transport) Request for services by a provider who does not have a contract with DCHP Other forms of medical treatment (such as hypnosis, massage therapy) To call for authorization, you or your physician may call the Member Services number 1-877-220-6376, Monday through Friday, 8:00 a.m. until 5:00 p.m., CST. If there is no authorization for the service, you may have to pay for it. You have a right to know the cost of any service before you or your child receives that service. If you agree to get services that DCHP does not cover or authorize, you may have to pay for them. Your or your child’s hospital stay is reviewed everyday. Services may be reviewed after they are delivered or paid. What can I do if the Health Plan denies or limits my doctor’s request for a covered service? There may be times when the DCHP Medical Director denies these services. When this occurs, you may appeal this decision. To appeal these medical decisions, call Member Services at 1-877-220-6376. How will I be notified if services are denied? You will be sent a letter telling you of the denial of services. You have ten (10) days from the date on the denial letter or the date of requested service to send us an appeal. 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. If you need more than ten (10) days to appeal, you may ask for more time. You may have fourteen (14) more days to file the appeal. 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. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 27 If you wish to appeal a denial of a service that is not a covered benefit, then you will need to file a complaint. See page 28 to see how to file a complaint. Can I appeal when we have not paid a claim? Yes, you may submit an appeal in writing. If the claim was not paid because the service was not a covered benefit, you will need to file a complaint. See page 28 on how to file a complaint. Can someone from Driscoll Children's Health Plan help me file an appeal? Yes. Contact Member Services at 1-877-220-6376. Can I file an appeal with the State? You have the right to appeal to the state at any time during or after the plan’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 ninety (90) days of the date on the notice of action. If you do not request a hearing within 90 days, you lose your right to a hearing. See information below about how to ask for a State Fair Hearing. What is an Expedited Fair Hearing (Appeal)? An expedited fair hearing is when the HMO is required to make a decision quickly based on your health status and taking the time for a standard appeal could jeopardize your life or health. How may I request an Expedited Appeal? Call the DCHP Medical Management Department to request an expedited appeal. The number is 1-877-455-1053. You may request an expedited appeal verbally, or in writing. If you need assistance in filing this appeal, contact Member Services at 1-877220-6376 and they will contact a Member Advocate to help you. We will review your case and get back to you within one day after we receive your request. What happens if we deny 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. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 28 State Fair Hearing You have the right to ask for a State Fair Hearing at any time during or after the plan’s appeal process. If you do not agree with your plan’s decision, you may ask for a Fair Hearing from the State. You have 90 days from the date on the letter to request a Fair Hearing. You have the right to continue any service you are now receiving pending the final hearing decision provided you request the hearing within ten days from receipt of the hearing notice from your health plan. If you do not request a Fair Hearing within ten days from receipt of the hearing notice, your service being appealed will be discontinued. If you do not request a hearing within 90 days, you lose your right to a hearing. You can request a Fair Hearing by contacting the Health and Human Services Commission (HHSC) at 1-800-252-8263 or by mailing to: Texas Health and Human Services Commission Appeals Division, Fair Hearings Y-613 P.O. Box 149030 Austin, Texas 78714 You do not have a right to a Fair Hearing if Medicaid does not cover the service you requested. If you ask for a Fair Hearing, you will get a letter from the hearing officer. The letter will tell you the date and time of the hearing. The letter will tell you what you need to know to get ready for the hearing. The hearing can be held by telephone and you can explain why you asked for this service. You can also ask the hearing officer to review the information you send in and make a decision. HHSC will give you a final decision within 90 days from the date you asked for the hearing. Complaints What should I do if I have a complaint? We want to help. If you have a complaint, please call us at 361-653-7689 or toll-free at 1-877-220-6376 to tell us about your problem. A Driscoll Children's Health Plan Member Advocate can help you file a complaint, just call 1-877-220-6376. Most of the time, we can help you right away or at the most within a few days. You can also complain to the Health and Human Services Commission by calling toll-free at 1-800252-8263. 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 Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 29 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. 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. Driscoll Children’s Health Plan wants to help you get the best healthcare for your family. If you have questions about how to file a complaint, an appeal, or need additional help, call us toll-free at 1-877-220-6376. We will be glad to help. Call us: Driscoll Children’s Health Plan DCHP Member Services 1-877-220-6376 Write to us: Driscoll Children’s Health Plan ATT: Executive Director of QI 615 N Upper Broadway, Suite 1621 Corpus Christi, TX 78401 All complaints are reviewed to make sure that there is follow-up. They are also reviewed to make sure that timely answers are given. Fraud and Abuse of the STAR program FRAUD AND ABUSE If you suspect a client (a person who receives benefits) or a provider (e.g., doctor, dentist, counselor, etc.) has committed waste, abuse or fraud, you have a responsibility and a right to report it. How do I report someone who is misusing/abusing the Programs? To report waste, abuse or fraud, gather as much information as possible. You can report providers / clients directly to your health plan at: Driscoll Children's Health Plan ATT: Compliance Officer 615 N Upper Broadway, Suite 1621 Corpus Christi, Texas 78401 Phone Number: 1-877-220-6376 Or if you have access to the Internet go to HHSC OIG website at http://www.hhs.state.tx.us and select “Reporting Waste, Abuse and Fraud”. The site provides information on the types of waste, abuse and fraud to report. If you do not Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 30 have Internet access and prefer to talk to a person, call the Office of Inspector General (OIG) Fraud Hotline at 1-800-436-6184, or you may send a written statement to the following OIG addresses: To report providers, use this address: To report clients, use this address: Office of Inspector General Medicaid Provider Integrity/Mail Code 1361 P.O. Box 85200 Austin, TX 78708-5200 Office of Inspector General General Investigations/Mail Code 1362 P.O. Box 85200 Austin, TX 78708-5200 o When reporting a provider (e.g., doctor, dentist, counselor, etc.) provide the following: • Name, address, and phone number of provider; • Name and address of the facility (hospital, nursing home, home health agency, etc.); • Medicaid number of the provider and facility is helpful; • Type of provider (physician, physical therapist, pharmacist, etc.); • Names and the number of other witnesses who can aide in the investigation; • Dates of events; and • Summary of what happened. o When reporting a client (a person who receives benefits) provide the following: • The person’s name; • The person’s date of birth, social security number, or case number if available; • The city where the person resides; and • Specific details about the waste, abuse or fraud. Information That Must Be Available On An Annual Basis As a member of Driscoll Children's Health Plan you can ask for and receive the following information each year: • • • • Names, addresses, telephone numbers, and languages spoken (other than English) by network providers, and identification of providers that are not accepting new patients. The information provided will be, at a minimum, on primary care physicians, specialists, and hospitals in the member’s service area. Any restrictions on the member’s freedom of choice among network providers. Member rights and responsibilities. Information on complaint, appeal and fair hearing procedures. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 31 • • • • • • • • • • • • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that members understand the benefits to which they are entitled. How to get benefits including authorization requirements. How members may get benefits, including family planning services, from out-ofnetwork providers and/or limits to those benefits. How after hours and emergency coverage are provided and/or limits to those benefits, including: What makes up emergency medical conditions, emergency services and poststabilization services; The fact that prior authorization is not required for emergency care services; How to obtain emergency services, including use of the 911 telephone system or its local equivalent. The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services covered under the contract; The member has a right to use any hospital or other settings for emergency care; and Post-stabilization rules. Policy on referrals for specialty care and for other benefits not furnished by the member’s primary care provider. MCO’s practice guidelines. Member Rights and Responsibilities What are my rights and responsibilities? As a member of DCHP Medicaid/STAR, you have rights and responsibilities. If you have any questions or concerns, please call us. We are here to help. You can call us toll-free at 1-877-220-6376. MEMBER RIGHTS: 1. To respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to: a. be treated fairly and with respect; and b. know that your medical records and discussions with your providers will be kept private and confidential. 2. To a reasonable opportunity to choose a health care plan and primary care provider (the doctor or health care provider you will see most of the time and who will coordinate your care) and to change to another plan or provider in a reasonably easy manner. That includes the right to: a. be informed of 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; Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 32 d. change your health plan without penalty; and e. be educated about how to change your health plan or your primary care provider. 3. To ask questions and get answers about anything you don’t 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; and b. be told why care or services were denied and not given. 4. To consent 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; and b. say yes or no to the care recommended by your provider. 5. To utilize each available complaint and appeal process through the managed care organization and through Medicaid, and receive 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. access the plan’s appeal process and the procedures for doing so; and d. request a fair hearing from the state Medicaid program and request information about the process for doing so. 6. 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 in order to obtain any needed emergency or urgent care; b. get medical care in a timely manner; c. be able to get in and out of a health care provider’s office, including barrier free access for persons with disabilities or other conditions limiting 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, assist with a disability, or help you understand the information; and e. be given an explanation you can understand about your health plan rules, including the health care services you can get and how to get them. 7. To not be restrained or secluded when doing so is for someone else’s convenience, or is meant to force you to do something you don’t want to do, or to punish you. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 33 MEMBER RESPONSIBILITIES: 1. To 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 don’t understand your rights; and c. learn what choices of health plans are available in your area. 2. To abide by the health plan and Medicaid policies and procedures. That includes the responsibility to: a. learn and follow your health plan 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 can’t 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; and h. understand when you should and shouldn’t go to the emergency room. 3. To share information relating to your health status with your primary care provider and become fully informed about service and treatment options. That includes the responsibility to: a. tell your primary care provider about your health; b. talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated; and c. help your providers get your medical records 4. To actively participate in decisions relating to service and treatment options, make personal choices, and take action to maintain your health. 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; and d. treat providers and staff with respect. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 34 Family Planning Providers Clinics for Aransas County: South Texas Family Planning & Health Corporation Rockport Family Planning Clinic 1004 Main Street Rockport, Texas 78382 Phone: (361) 729-7512 Fax: No number on file Hours: 8am – 6:30pm, Mon-Thurs.; 9am – 1pm, Fri. Clinics for Bee County: South Texas Manning & Health Corporation Beeville Family Planning Clinic 1400 W. Corpus Christi, Suite #4 Beeville, Texas 78102 Phone: (361) 358-2974 Fax: (361) 358-5820 Hours: 8am – 6:30pm, Mon-Thurs.; 9am – 1pm, Fri. Clinics for Calhoun County: Calhoun County Health Department 117 West Ash Port Lavaca, Texas 77979 Phone; (316) 552-9721 Fax: No number on file Hours: 8am – 6pm, Mon-Fri; 10am – 2pm, Sat. Clinics for Jim Wells County: Planned Parenthood of San Antonio and South Central Texas Planned Parenthood of San Antonio and South Central Texas – Alice Center 313 E. 1st Street Alice, Texas 78332 Phone: (361) 664-0831 Fax: No number on file Hours: 8:30am – 5:30pm, Wed; 8am – 5pm, Tues, Thurs, Fri; 10am – 7pm, Mon Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 35 Clinics for Kleberg County: South Texas Family Planning & Health Corporation Kingsville Family Planning Clinic 1001 W. Corral Kingsville, Texas 78363 Phone: (361) 595-1929 Fax: No number on file Hours: 8am – 6:30pm, Mon-Tues; 10am – 7pm, Wed; 8am – 5pm, Thurs, Fri. Planned Parenthood of San Antonio and South Central Texas Planned Parenthood of San Antonio and South Central Texas – Kingsville Center 1028 S. 14th Street Kingsville, Texas 78363 Phone: (361) 592-2649 Fax: No number on file Hours: 8am – 5pm, Mon, Wed-Fri; 10am – 7pm, Tues. Clinics for Nueces County: Corpus Christi-Nueces County Public Health District Robstown Clinic 710 East Main Robstown, Texas 78380 Phone: (361) 767-5241 Fax: No number on file Hours: 8am – 12pm, Mon; 7:30am – 4pm, Tues; 7:30am – 6:30pm, Wed; 7:30am – 4:30pm, Fri. South Texas Family Planning & Health Corporation Robstown Family Planning Clinic 15 Pat Shutter, #121 Robstown, Texas 78380 Phone: (361) 387-6996 Fax: No number on file Hours: 8am – 6:30pm, Mon-Tues, Thurs; 8am – 12pm, Fri; 9am – 1pm, Sat. South Texas Family Planning & Health Corporation Corpus Christi Family Planning Clinic 4455 South Padre Island Drive, #30 Corpus Christi, Texas 78411 Phone: (361) 883-0619 Fax: No number on file Hours: 8am – 7pm, Mon, Tues; 8:30am – 5:30pm, Wed; 10am – 7pm, Thurs; 8:30am – 5pm, Fri; 9am – 1pm, Sat. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 36 Planned Parenthood of South Texas, Inc. Dillon Lane Clinic 4410 Dillon Land, Suite 1 Corpus Christi, Texas 78415 Phone: (361) 855-9107 Fax: No number on file Hours: 8:30am – 5pm, Mon, Wed, Fri; 8:30am – 8pm, Tues; 10am – 1pm, Sat. Corpus Christi-Nueces County Public Health District CCNC PHD Case Management 1702 Horne Road Corpus Christi, Texas 78416 Phone: (361) 851-7256 Fax: No number on file Hours: 7:30am – 6:30pm, Mon; 7:30am – 4:30pm, Tues, Wed; 8am – 11am, Thurs. Corpus Christi-Nueces County Public Health District Flour Bluff Clinic 1456 Waldron Road Corpus Christi, Texas 78418 Phone: (361) 851-7256 Fax: No number on file Hours: 10am – 6pm Wed. Clinics for Refugio County: No clinics are listed for this county Clinics for San Patricio County: San Patricio County Health Department Ingelside Branch 2681 San Angelo Ingelside, Texas 78362 Phone (512) 776-3591 Fax: No number on file Hours: 8am – 5pm, Mon-Fri. San Patricio County Health Department Mathis Clinic 600 North Frio Mathis, Texas 78368 Phone: (512) 547-3328 Fax: No number on file Hours: 8am – 5pm, Mon-Fri Driscoll Children’s Health Plan Medicaid/STAR Member Handbook Page 37 San Patricio Health Department Sinton Clinic 313 North Rachal Sinton, Texas 78387 Phone: (512) 364-6208 Fax: No number on file Hours: 8am – 5pm, Mon-Fri South Texas Family Planning & Health Corporation Sinton Family Planning Clinic 301 S. San Patricio Street Sinton, Texas 78387 Phone: (361) 364-3306 Fax: No number on file Hours: 9am – 6p, Mon, Tues, Thurs; 8am – 5pm, Fri. Clinics for Victoria County: UTMB Regional Maternal & Child Health Program RM&CHP UTMB Victoria 2603 Hospital Drive Victoria, Texas 77901-5748 Phone: (361) 576-2110 Fax: No number on file Hours: 8am – 7pm, Mon; 8am – 5pm, Tues-Fri. Driscoll Children’s Health Plan Medicaid/STAR Member Handbook