STAR MEMBER HANDBOOK - Sendero Health Plans

Page vWhat if I am out of town and my child is due for a Texas Health Steps checkup? ...29What if I am a migrant farmworker? ...................................................................29How do I get dental services for my child? .........................................................29TRANSPORTATION ...........................................................................................30If I don’t have a car, how can I get a ride to a doctor’s office? ............................30Who do I call for a ride to a medical appointment? .............................................30How far in advance do I need to call? .................................................................30Can someone I know give me a ride to my appointment andget money for mileage? .................................................................................30Who do I call if I have a complaint about the service or staff? .............................30What are the hours of operation and limits for transportation services? ..............30INTERPRETER SERVICES .................................................................................31Can someone interpret for me when I talk with my doctor? ................................31Who do I call for an interpreter? .........................................................................31How far in advance do I need to call? .................................................................31How can I get a face-to-face interpreter in the provider’s office? ........................31Se Habla Español ...............................................................................................31ATTENTION FEMALE MEMBERS .......................................................................31What if I need OB/GYN care?..............................................................................31Do I have a right to choose an OB/GYN? .............................................................31How do I choose an OB/GYN? ............................................................................32If I do not choose an OB/GYN, do I have direct access? ......................................32Will I need a referral? .........................................................................................32Can I stay with my OB/GYN if they are not with Sendero? ...................................32What if I am pregnant? ......................................................................................32Who do I need to call? ........................................................................................32What other services/activities/education does Sendero offer pregnant women? ... 32Where can I find a list of birthing centers? ............................................................ 33How soon can I be seen after contacting my OB/GYN for an appointment? .........33Can I pick a Primary Care Provider for my baby before the baby is born? ............33How and when can I switch my baby’s Primary Care Provider? ..........................33Sendero Health Plans

Page viiTime frames ......................................................................................................44Can someone from Sendero help me file an appeal? ..........................................44Can I file an appeal with the State? ....................................................................44What is an expedited appeal?.............................................................................44How may I ask for an expedited appeal? Does my requesthave to be in writing? ....................................................................................45Who can help me file an expedited appeal? ........................................................45What are the time frames for an expedited appeal? ............................................45What happens if Sendero denies your request for an expedited appeal? .............45STATE FAIR HEARING .......................................................................................46Can I ask for a State Fair Hearing? .....................................................................46FRAUD AND ABUSE OF THE STAR PROGRAM ..................................................47How do I report someone who is misusing/abusing the programs or services? .... 47FRAUD AND ABUSE ..........................................................................................47Do you want to report waste, abuse, or fraud? ...................................................47To report waste, abuse, or fraud ........................................................................48To report waste, abuse or fraud, gather as much information as possible. ..........48INFORMATION THAT MUST BE AVAILABLE ON AN ANNUAL BASIS ................48Sendero Health Plans

Page 1IMPORTANT INFORMATION!Call us:Member Services (English or Spanish)1-855-526-7388 toll-freeFor hearing impaired:1-800-855-2880 (TDD) toll-freeInterpreter Services also availableWrite us:Sendero Health Plans2028 E. Ben White Blvd., Suite 510Austin, Texas 78741Regular Business Hours: 8:00–5:00 CST, Monday through Fridayexcept for state approved holidaysBefore 8:00am or after 5:00pm: Call and leave a message. We will returnyour call the next working day.24 Hour Behavioral Health Hotline: Call 1-888-287-5402 toll-free(English or Spanish) with information on services.You can call this number 24 hours a day,7 days a week. Other interpretive services available.If there is an emergency or crisis,go to the ER or call 9-1-1.24 Hour Nurse Line 1-855-880-7019 toll-freeIf you need medical advice or wish to learnmore about a medical condition, you cancall this number 24 hours a day, 7 days a week.Vision and Eye Care Number: Call 1-877-615-7730 toll-free for questionsregarding eye exams and glassesMedicaid Managed Care Help Line: Call 1-866-566-8989 toll-freeTDD 1-866-222-4306STAR Help Line:Call 1-800-964-2777 toll-freeTDD 1-866-222-4306Dental Care Number:Call 1-855-526-7388 toll-free for questionsabout dental carePharmacy Help Line:Call 1-855-526-7388 toll-free if you needhelp getting a prescription filled.Non-Urgent Transportation The Medical Transportation Program can giveyou a ride if you cannot get a ride to thedoctor’s office. Call 1-877-633-8747 toll-free,Monday through Friday, 8:00 a.m. to 5:00 p.m.(CST). Call early to arrange for a ride.Medical Transportation ProgramCall Center (Scheduling) 1-877-633-8747Central Office Phone Number 1-512-706-4900Document Fax 1-210-646-3257STAR Member Handbook

Page 2SENDERO HEALTH PLANS AND STARThe STAR program in the State of Texas is the Managed Medicaid program.This program provides care to families who would not normally have access tocare. The program is administered by the Texas Health and Human ServicesCommission (HHSC).By choosing Sendero Health Plans (Sendero), we provide STAR health servicesto you and your children from birth through age 18. Health care through SenderoSTAR is available in these central Texas counties:BastropBurnetCaldwellFayetteHaysLeeTravisWilliamsonSendero is a not-for-profit Health Maintenance Organization (HMO) licensedby the Texas Department of Insurance.By choosing Sendero, you and your child will get all the STAR health benefits—plus more: Your own doctor Friendly and confidential staff Access to many hospitals Free health education Free extra benefits (see page 12 of this Handbook) Assurance of access to care regardless of nationality,race, religion, origin and genderIf you have any questions or concerns about access of care, or feel that youwere not allowed access to care because of nationality, race, religion, origin, orgender, please contact Sendero Member Services at 1-855-526-7388 as soon aspossible. Your concern will be investigated and resolved quickly.The doctor you chose for you and/or your child when you enrolled with SenderoSTAR will be your and/or your child’s Primary Care Provider (PCP) and will helptake care of all your and your child’s health care needs.Sendero Health Plans

Page 3First things first. These are a few important things about your and your child’shealth care: You will receive a Sendero ID Card, if you have not already received one Your PCP’s name will be on the Sendero ID Card. Please checkthe ID Card to make sure the names on it are correct. Get to know you and your child’s doctor. Make anappointment with your PCP as soon as possible. Call your PCP for appointments. Tell them you andyour child are Sendero STAR members. Call your PCP whenever you or your child needs health care Follow your PCP’s advice.Carry your Sendero ID Card(s) and Your Texas Benefits Medicaid Card(s) withyou at all times. Use the hospital emergency room only for emergencies.If there is an emergency or crisis, go to the ER or call 9-1-1.This Member Handbook answers many questions about Sendero.We hope you read it soon. Keep it in a place where you can find it easily.Please feel free to call or write us if you have any questions. At Sendero we areready to help you any time during the day or night. We have special services forpeople who have trouble reading, hearing, seeing, or speak a language otherthan English or Spanish. If you need this Handbook in a different language, inaudio form, larger print, or Braille, let us know and we will get it to you. Just callSendero Member Services at 1-855-526-7388 as soon as possible. Sendero willgive these materials to you at no cost.Welcome to Sendero Health Plans!STAR Member Handbook

Page 4YOUR STAR ID CARDYou will get a STAR Identification (ID) card after you enroll in Sendero. A samplecopy of the Sendero ID Card is shown below:FRONTBACKYou and each of your children will have a different card. You will not get a newSendero STAR ID Card every month. You will get a new one if you lose your IDCard, or if you call us to change your Primary Care Physician (PCP).Reading the Sendero STAR ID CardThe front of the Sendero STAR ID Card shows important information about youand your child, the PCP’s name and PCP’s phone number. The back of the cardshows important phone numbers for help from Sendero Member Services. If youhave an emergency, call 911 or go to the nearest emergency room.Using the Sendero STAR ID CardCarry your and your child’s Sendero STAR ID Card with you when you and yourchildren get any health care services. You must show your Sendero STAR ID Cardeach time you get health care services.If you lose your Sendero ID Card or moveIf you lose the Sendero STAR ID Card, call us right away at 1-855-526-7388 toget a new one. If you move or change phone numbers, call us so we can send youanother ID Card. We always need to have your correct address and phone number.Your Texas Benefits Medicaid CardWhen you are approved for Medicaid, you will get a Your Texas Benefits MedicaidCard. This plastic card will be your everyday Medicaid ID Card. You should carryand protect it just like your driver’s license or a credit card. The card has amagnetic stripe that holds your Medicaid ID number. Your doctor can use the cardto find out if you have Medicaid benefits when you go for a visit.Sendero Health Plans

Page 7When will my Primary Care Provider change become effective?You may change your PCP at any time. If you call to change your Primary CareProvider, before the 15 th of the month, your Primary Care Provider change willhappen the first day of the next month. If you call to change your Primary CareProvider after the 15 th of the month, your Primary Care Provider change willhappen the first of the following month.EXAMPLE: If you call Sendero to change your Primary Care Provider onFebruary 2 nd , your Primary Care Provider change will happen on March 1 st .If you call to change your Primary Care Provider on January 16 th , the changewill happen on March 1 st .How many times can I change my/my child’s Primary Care Provider?There is no limit on how many times you can change your or your child’s PrimaryCare Provider. You can change Primary Care Providers by calling us toll-free at1-855-526-7388 or writing to:Sendero Health Plans2028 E. Ben White Blvd., Suite 510Austin, TX 78741Are there any reasons why my request to change Primary Care Providermay be denied?You may not be able to have the PCP you chose if:The PCP you picked is not seeing new patients, orThe PCP you picked is no longer a part of Sendero.Can my Primary Care Provider move me to another Primary Care Providerfor non-compliance?It is important to follow the PCP’s advice. Take part in decisions about your or yourchild’s health care. Your PCP may ask us to assign you or your child to anotherPCP if you do not follow his or her advice. It may also happen if you and the PCPdo not get along or you miss visits without calling to tell the PCP why you weren’tthere. The PCP must notify us if this occurs. We will contact you and ask that youselect another PCP.STAR Member Handbook

Page 9CHANGING HEALTH PLANSWhat if I want to change health plans?You can change your health plan by calling the Texas STAR or STAR+PLUSProgram Helpline at 1-800-964-2777. You can change health plans as often asyou want, but not more than once a month.If you are in the hospital, a residential Substance Use Disorder (SUD) treatmentfacility, or residential detoxification facility for SUD, you will not be able to changehealth plans until you have been discharged.If you call to change your health plan on or before the 15 th of the month, thechange will take place on the first day of the next month. If you call after the 15 thof the month, the change will take place the first day of the second month afterthat. For example: If you call on or before April 15, your change will take place on May 1. If you call after April 15, your change will take place on June 1.Who do I call?You can change your health plan by calling the Texas STAR or STAR+PLUSProgram Helpline at 1-800-964-2777.How many times can I change health plans?You can change health plans as many times as you want, but not more than oncea month. If you are in the hospital, you will not be able to change health plansuntil you have been discharged.When will my health plan change be effective?If you call to change your health plan on or before the 15 th of the month, thechange will take place on the first day of the next month. If you call after the 15 thof the month, the change will take place the first day of the second month afterthat. 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 1STAR Member Handbook

Page 10Can Sendero ask that I get dropped from their plan (for non-compliance, etc)?Yes, Sendero may request that you be dropped from our health plan if: You let someone else use your Sendero ID Card You let someone else use your Texas Benefits Medicaid ID Card You do not follow your doctor’s advice, for you or your child You keep going to the emergency room for yourself oryour child when you do not have a true emergency You cause problems at the doctor’s office You make it difficult for your doctor to help you or other peopleBENEFITS AVAILABLE FROMSENDERO STARWhat are my health care benefits?Sendero gives you every covered service that you are entitled to getthrough Medicaid.You get:Care to help you and your child stay wellNeeded medical care for adults and childrenShots for children under 21 years oldChiropractic servicesPodiatry (foot doctor) servicesLaboratory servicesX-ray servicesSurgery without staying in the hospital overnightHospital care24-hour emergency care from an emergency roomPrescription drugsEye exams and glassesEar doctor visits and hearing aidsHome health services (health care at home)Ambulance services, if you need itDialysis (help from a machine) for kidney problemsFamily planning services and supplies (such as birth control)Behavioral (mental) health servicesHelp with substance abuse (such as alcohol or drugs)An adult checkup every yearSendero Health Plans

Page 11How do I get these services?Your or your child’s PCP will work with you to make sure you and your child getthe care needed. You may call Member Services at 1-855-526-7388 at any timeyou have questions. There may be limitations to these services. Call MemberServices for information on any limits.Are there any limits to any covered services?Yes, there are some Medicaid services that have limits. If you have questionsabout limits on any covered services, call us toll-free at 1-855-526-7388.We can let you know if a covered health benefit has a limit.What number do I call to find out about these services?You can call Sendero Member Services toll-free at 1-855-526-7388.What services are not covered?The following services, which may not be all services, are not covered by STAR:Acupuncture (healing using needles and pins)HypnosisCosmetic surgery (such as a face-lift)Artificial inseminationEar piercingHospital bereavementHair transplantsInfertility treatmentsIn-vitro fertilizationExperimental medicines or proceduresMarital counselingMedical testimony and reportsNon-authorized servicesPenile implantRadial keratotomyRespite careReversal of sterilizationAny service that you don’t have to have (is not medically necessary)Any service that your PCP does not say is “OK”Any service you get outside of the United StatesSTAR Member Handbook

Page 12What extra benefits do I get as a member of Sendero?All eligible Sendero STAR members will receive the followingvalue added services:24-hour Nurse Advice lineHelp finding a ride to doctor appointmentsExtra $100 towards eye glassesFree sports physicals for members 18 years old and youngerFree pre-programmed cell phones for women who havea high-risk pregnancy$250 of basic dental services for pregnant womenFree membership to the Boys and Girls Club of the Austin AreaFree Youth Sports Session at the YMCA of AustinFree diaper bag, diapers, first aid kit, and infant thermometerafter completing timely post-partum visitFree $10 Academy gift card for completing a new memberHealth Assessment form$25 for over the counter pharmacy itemsFree home visits for new momsHow can I get these benefits? For eyeglasses, call our vision vendor at 1-877-615-7730. For an annual sports physical for your child, callthe child’s PCP to make an appointment. For all other services, call Member Services at 1-855-526-7388.What health education does Sendero Health Plans offer?Sendero has education for members on many different health subjects. Thereis no charge for Sendero’s health education. Health education may includeinformation on:ImmunizationsPregnancyDiabetes careAsthma careBicycle safetyWellness programs and health fairsIf you need health education materials in another language, or in another format,call Member Services at 1-855-526-7388.Sendero Health Plans

Page 13What other services can Sendero help me get?Sendero can help you with WIC, Early Childhood Intervention (ECI), andSupplemental Nutrition Assistance Program (SNAP) also known as Food Stamps.How can I find out about WIC (Women, Infants, and Children)? WIC has been offering support to families in Texas for more than 20 years. WIC helps mothers, babies and children be healthier. WIC is for good health. At WIC, you can get answers to your healthquestions. WIC helps mothers make feeding choices for their babies. WICalso gives breastfeeding support, childhood shots, and children’s checkups. WIC teaches how to eat healthy. You can go to a class or get oneon-onehelp. WIC can help you learn how to make healthy mealsfor your family. WIC provides dairy foods like milk, cheese, eggs,and also cereal and juice. WIC families get monthly suppliesof foods high in protein, iron, vitamin C, and calcium. WIC is another way to do something good for your family. It’s easyto find out if you can get WIC. If you are pregnant, breastfeeding,or have children under the age of five (5), call 1-800-942-3678and speak to someone in the WIC office to learn more.HEALTH CARE AND OTHER SERVICESWhat does medically necessary mean?Medically necessary means:(1) For members birth through age 20, the followingTexas Health Steps services:(a) screening, vision, and hearing services; and(b) other health care services, including behavioral healthservices, that are necessary to correct or ameliorate a defector physical or mental illness or condition. A determinationof whether a service is necessary to correct or amelioratea defect or physical or mental illness or condition:(i) must comply with the requirements of the Alberto N., etal. v. Suehs, et al. partial settlement agreements; and(ii) may include consideration of other relevantfactors, such as the criteria described in parts(2)(b–g) and (3)(b–g) of this definition.STAR Member Handbook

Page 14(2) For members over age 20, non-behavioral healthrelated health care services that are:(a) reasonable and necessary to prevent illnesses or medicalconditions, or provide early screening, interventions,and/or treatments for conditions that cause sufferingor pain, cause physical deformity or limitations infunction, threaten to cause or worsen a handicap, causeillness or infirmity of a member, or endanger life;(b) provided at appropriate facilities and at the appropriate levelsof care for the treatment of a member’s health conditions;(c) consistent with health care practice guidelines andstandards that are endorsed by professionally recognizedhealth care organizations or governmental agencies;(d) consistent with the diagnoses of the conditions;(e) no more intrusive or restrictive than necessary to provide aproper 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(3) For members over age 20, behavioral health services that are:(a) are reasonable and necessary for the diagnosis ortreatment of a mental health or chemical dependencydisorder, or to improve, maintain, or prevent deteriorationof functioning resulting from such a disorder;(b) are in accordance with professionally accepted clinical guidelinesand standards of practice in behavioral health care;(c) are furnished in the most appropriate and least restrictivesetting in which services can be safely provided;(d) are the most appropriate level or supply ofservice that can safely be provided;(e) could not be omitted without adversely affecting the member’smental 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.Sendero Health Plans

Page 15What is routine medical care?Routine medical care is care that is not an emergency or that does not needurgent treatment (see explanations below).The PCP you chose will help your child with all his/her health care. Your child’sPCP will get to know you, arrange regular checkups, and treat your childwhen he or she is sick. Your PCP will give you prescriptions for medicine,and send your child to a special doctor (specialist) if he/she needs one. It isimportant that you do what your child’s PCP says and take part in decisionsmade about your child’s health care. If you cannot make a decision aboutyour child’s health care, you can choose someone else to do it for you. Whenyou need your child to see the PCP, call the PCP at the number on your child’sSendero ID Card. Someone in the PCP’s office will set a time for you. It isvery important that you keep the appointment. Call early to set up visits,and call back if you have to cancel. If more than one child in your familyneeds to see the doctor, you need a new appointment for each person.How soon can I expect my child to be seen?You should be able to get an appointment for routine care within two (2) weeks.What is urgent medical care?Urgent medical care is when your child is sick or hurt and needs treatment assoon as possible to keep your child from getting worse. These are situations whenyou need to call your child’s PCP first:EaracheToothache or baby teethingRashColds, cough, sore throat, flu or sinus problemsMinor sun burnMinor cooking burnMinor headacheBroken castStitches needing to be removedMedication refillsYour child’s PCP is available, directly or through other doctors helping to coverthe office, 24 hours a day, 7 days a week.How soon can I expect my child to be seen?You can expect your child to be seen for urgent medical care within 24 hours.STAR Member Handbook

Page 16What is emergency medical care?Emergency Medical CareEmergency medical care is provided for emergency medical conditions andemergency behavioral health conditions.Emergency medical condition means:A medical condition manifesting itself by acute symptoms of recent onset andsufficient severity (including severe pain), such that a prudent layperson, whopossesses an average knowledge of health and medicine, could reasonablyexpect 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; or5. In the case of a pregnant women, serious jeopardy tothe health of a woman or her unborn child.Emergency behavioral health condition means:Any condition, without regard to the nature or cause of the condition,which in the opinion of a prudent layperson, possessing average knowledgeof medicine and health:1. requires immediate intervention and/or medicalattention without which the member would present animmediate danger to themselves or others; or2. which renders the member incapable of controlling, knowingor understanding the consequences of their actions.Emergency services and emergency care means:Covered inpatient and outpatient services furnished by a provider that is qualifiedto furnish such services and that are needed to evaluate or stabilize an emergencymedical condition and/or emergency behavioral health condition, including poststabilizationcare services.How soon can I expect to be seen?Go to the nearest hospital if you think you have any of these problems. You maycall 9-1-1 for help in getting to the hospital emergency room. Emergency care isavailable 24 hours a day, 7 days a week.Things like a cold, cough, rash, small cuts, minor burns or bruises are not goodreasons to go to the Emergency Room.Sendero Health Plans

Page 17Are emergency dental services covered?Sendero covers limited emergency dental services for the following:Dislocated jawTraumatic damage to teeth and supporting structuresRemoval of cystsTreatment of oral abscess of tooth or gum originTreatment and devices for craniofacial anomaliesDrugs for any of the above conditionsSendero also covers dental services your child gets in a hospital or ambulatorysurgical center. This includes services that the doctor provides and other servicesyour child might need, like anesthesia.What do I do if my child needs emergency dental care?During normal business hours, call your child’s main dentist to find out how to getemergency services. If your child needs emergency dental services after the maindentist’s office has closed, call us toll-free at 1-855-526-7388 or call 9-1-1.What is post-stabilization?Post-stabilization care services are services covered by Medicaid that keep yourcondition stable following emergency medical care.How do I get medical care after my Primary Care Provider’soffice is closed?If you or your child gets sick at night or on a weekend and cannot wait to getmedical care, call your PCP for advice. Your PCP or another doctor is available byphone 24 hours a day, 7 days a week. If you or your child has a fever or a sorethroat and you are not sure what to do, call your PCP’s office.What if I get sick when I’m out of town or traveling?If you need medical care when traveling, call us toll-free 1-855-526-7388and we will help you find a doctor.If you need emergency services while travelling, go to a nearby hospital,then call us toll-free at 1-855-526-7388.STAR Member Handbook

Page 18What if I’m out of the state?If you or your child has an emergency while you are out of town or out of state, goto the nearest Emergency Room.When you or your child will be temporarily away from home, you should contactyour PCP ahead of time to schedule appointments or obtain prescriptions to lastfor the duration of your stay. If you or your child gets sick while he or she is out oftown—and it is not an emergency—he or she will still remain under the careof your PCP. With the exception of emergency care, if you or your child sees anout-of-town doctor you may have to pay. If you or your child leaves the Sendero’sservice area for an extended period of time, you or your child may be disqualifiedfrom STAR or have to enroll in a health plan covering another area within the stateof Texas. Keep your and your child’s Sendero STAR ID Card with you at all times.What if I’m out of the country?Medical services performed out of the country are not covered by Medicaid.What if I need to see a special doctor (specialist)?Your PCP will tell you if you or your child needs to see a specialist. Your PCP willmake sure that you or your child gets the special care needed. In general, youcannot go to another doctor or get a special service if your PCP does not agree tomake a referral.What is a referral?A referral is when your PCP sends you to another doctor or service for care.How soon can I expect to be seen by a specialist?You should expect the specialist to give you an appointment within 2 weeks fornon-urgent care or within 24 hours for urgent care.What services do not need a referral?You can get some services without going to your PCP first. These include:Emergency careRoutine vision careOB/GYN CareBehavioral Health ServicesFamily Planning ServicesIt is good to let your PCP know when you receive other care, but you are notrequired to. This lets your PCP know all of your or your child’s needs.Sendero Health Plans

Page 19How can I ask for a second opinion?Sendero will pay for a second opinion. Call Member Services at 1-855-526-7388to arrange for a second opinion. The Case Management Department will be gladto help you with this. You will need to call us for authorization before you get asecond opinion.BEHAVIORAL HEALTHHow do I get help if I have behavioral (mental) health,alcohol or drug problems?You can get help for behavioral health, alcohol or drug problems throughSendero. You can go to a mental health provider without a referral fromyour PCP. The provider you pick must be a provider with Sendero’s network.Call the Behavioral Health Hotline on your ID Card for help. The phone numberis 1-888-287-5402. You can call anytime 24 hours a day, seven (7) daysa week. Behavioral health services are very private so you do not needpermission of your or your child’s PCP.Do I need a referral?You can go to a mental health provider without a referral from your PCP.The provider you pick must be a provider with Sendero’s network.If you or your child has an emergency related to mental health problems ordrug or alcohol abuse, go to the nearest hospital emergency room or call 911for an ambulance.STAR Member Handbook

Page 20PRESCRIPTIONSHow do I get my medications?Medicaid pays for most medicine your doctor says you need. Your doctor will writea prescription so you can take it to the drug store, or may be able to send theprescription for you.What are my prescription drug benefits?Services include, but are not limited to, the following: Outpatient drugs and biologicals; including pharmacy-dispensedand provider-administered outpatient drugs and biologicals; and Drugs and biologicals provided in an inpatient setting.How do I find a network drug store?Call Sendero Member Services toll-free if you need help finding a pharmacyor having a prescription filled, at 1-855-526-7388.What if I go to a drug store not in the network?You may not be able to have your medication filled or you may have to payout of pocket for the medication. It is best you use a drug store in the network.What do I bring with me to the drug store?Take you or your child’s Sendero STAR ID Card and Texas Benefits Medicaid ID Cardwith you when you go to the pharmacy. The pharmacy may ask for these cards.What if I need my medications delivered to me?Call Sendero Member Services toll-free if you need help finding a pharmacythat will deliver your medications to you, at 1-855-526-7388.Who do I call if I have problems getting my medications?Call Sendero Member Services toll-free if you need help finding a pharmacyor having a prescription filled, at 1-855-526-7388.What if I can’t get the medication my doctor ordered approved?If your doctor cannot be reached to approve a prescription, you may be able toget a three-day emergency supply of your medication.Sendero Member Services at 1-855-526-7388 for help with your medicationsand refills.Sendero Health Plans

Page 21What if I lose my medication(s)?You can call your doctor or Sendero Member Services toll-free at1-855-526-7388.What if I need durable medical equipment (DME) or other products normallyfound in a pharmacy?Some durable medical equipment (DME) and products normally found in apharmacy are covered by Medicaid. For all members, Sendero pays for nebulizers,ostomy supplies, and other covered supplies and equipment if they are medicallynecessary. For children (birth through age 20), Sendero also pays for medicallynecessary prescribed over-the-counter drugs, diapers, formula, and somevitamins and minerals.Call Sendero Member Services at 1-855-526-7388 for more information aboutthese benefits.EYE CARE SERVICESHow do I get eye care services?If you or your child is under the age of 21, you can get an eye exam andprescription glasses. You can have an exam one time every 12 months, and youdo not need a referral from your PCP. Children may be able to have additional eyeexaminations and prescription glasses as part of the Texas Health Steps. If youare over the age of 21, you can get an eye exam and prescription glasses onetime every 24 months.For information about eye care and where you can find an eye doctor,call 1-877-615-7730.STAR Member Handbook

Page 22FAMILY PLANNING SERVICESHow do I get family planning services?Family planning services (such as birth control and counseling) are very private.You do not need to ask your PCP for a referral to get these services or supplies.You may have an annual visit, counseling and tests. You may also get drugs andsupplies that prevent pregnancy. You can go to any provider who takes Medicaid/STAR. To see a list of providers, see page 23 of this Handbook.Do I need a referral for this?You do not need a referral for family planning services.Where do I find a family planning services provider?You can find the locations of family planning providers near you online athttp://www.dshs.state.tx.us/famplan/locator.shtm, or you can call Sendero at1-855-526-7388 toll-free for help finding a family planning provider.Sendero Health Plans

Page 23FAMILY PLANNING PROVIDERS in the Austin area:CommUnityCare A. K. Black928 Blackson Ave.Austin, Texas 78752Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9740Hours of Operation: Mon–Thur 7:45–4:45; Fri 9–5County Service Area: TravisCommUnityCare Del Valle3518 FM 973Del Valle, Texas 78617Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9060Hours of Operation: Mon–Thur 7:45–4:45; Fri 9–5County Service Area: TravisCommUnityCare East Austin211 Comal St.Austin, Texas 78702Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9200Hours of Operation: Mon–Fri 8–4:45County Service Area: TravisCommunityCare Manor600 W. Carrie Manor St.Manor, Texas 78653Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9780Hours of Operation: Mon–Thur 7:45–4:45; Fri 9–5County Service Area: TravisCommUnityCare Montopolis1200 B Montopolis Dr.Austin, Texas 78741Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9800Hours of Operation: Mon–Thur 7:45–4:45; Fri 9–5County Service Area: TravisSTAR Member Handbook

Page 24CommUnityCare North Central1210 W. Braker LaneAustin, Texas 78758Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9300Hours of Operation: Mon–Fri 7–6County Service Area: TravisCommUnityCare Northeast Austin7112 Ed Bluestein Blvd., Suite 155Austin, Texas 78723Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9300Hours of Operation: Mon 7:45–4:45; Tue, Wed, Thur 7:45–6; Fri 9–6County Service Area: TravisCommUnityCare Oak Hill8656 A Hwy 71 West, Suite CAustin, Texas 78735Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9820Hours of Operation: Mon–Thur 8–5; Fri 9–5County Service Area: TravisCommUnityCare Pflugerville15822 Foothill Farms LoopPflugerville, Texas 78660Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9840Hours of Operation: Mon–Thur 7:45–4:45; Fri 9–5County Service Area: TravisCommUnityCare Rosewood-Zaragosa2802 Webberville Rd.Austin, Texas 78702Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9400Hours of Operation: Mon 7:45–4:45; Tue, Thur 7:45–5; Wed 7:45–8; Fri 9–5County Service Area: TravisSendero Health Plans

Page 25CommUnityCare South Austin2529 S. First St.Austin, Texas 78704Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 978-9500Hours of Operation: Mon & Wed 7–7; Tue, Thur 7:45–7; Fri 9–5; Sat 8–5County Service Area: TravisCommUnityCare Family Wellness Center - UT School of Nursing2901 North IH 35, Suite 101Austin, Texas 78722Agency Name: Central Texas Community Health Centers dba CommUnityCareClinic Phone: (512) 232-3900Hours of Operation: Mon, Wed, Thur 8–5; Tue 9–4:45County Service Area: TravisElgin Community Health Services204 S. MainElgin, Texas 78621Agency Name: Community Action Inc, of Hays, Caldwell and Blanco CountiesClinic Phone: (512) 281-5520Hours of Operation: Mon–Fri 8–5County Service Area: Bastrop, WilliamsonLockhart Community Health Services1710 S. Colorado, Suite 115Lockhart, Texas 78644Agency Name: Community Action Inc, of Hays, Caldwell and Blanco CountiesClinic Phone: (512) 398-3494Hours of Operation: Mon–Fri 8–5County Service Area: Caldwell, Bastrop, HaysLuling Community Health Center111 South Laurel StreetLuling, Texas 78648Agency Name: Community Health Centers of South Central Texas, Inc.Clinic Phone: (830) 672-6511Hours of Operation: Mon, Wed, Thur, Fri 8–5; Tue 8–8County Service Area: CaldwellSTAR Member Handbook

Page 26Family Medicine at Lake Aire Medical Center2423 Williams Drive, Suite 113Georgetown, Texas 78628Agency Name: Lone Star Circle of CareClinic Phone: (877) 800-5722Hours of Operation: Mon–Fri 7:30–7County Service Area: Bell, Burnet, Milam, Travis, WilliamsonLone Star Circle of Care OB/GYN2300 Round Rock AvenueRound Rock, Texas 78681Agency Name: Lone Star Circle of CareClinic Phone: (877) 800-5722Hours of Operation: Mon–Fri 7:30–5County Service Area: Bell, Burnet, Milam, Travis, WilliamsonLone Star Circle of Care Ben White Health Clinic1221 W. Ben White Blvd., Suite B200Austin, Texas 78704Agency Name: Lone Star Circle of CareClinic Phone: (877) 800-5722Hours of Operation: Mon–Fri 8–8; Sat 9–1County Service Area: Bell, Burnet, Milam, Travis, WilliamsonSeton-Circle of Care Family Medicine at Texas A&M Health Science Center3950 North A.W. Grimes Blvd., Suite 301ARound Rock, Texas 78665Agency Name: Lone Star Circle of CareClinic Phone: (877) 800-5722Hours of Operation: Mon–Fri 8–8; Sat 9–1County Service Area: Bell, Burnet, Milam, Travis, WilliamsonDell Children’s Circle of Care Adolescent Healthat Texas A&M Health Science Center3950 North A.W. Grimes Blvd., Suite N202Round Rock, Texas 78665Agency Name: Lone Star Circle of CareClinic Phone: (877) 800-5722Hours of Operation: Mon–Fri 8–5County Service Area: Bell, Burnet, Milam, Travis, WilliamsonSendero Health Plans

Page 27Seton - Circle of Care Womens’ Services atTexas A&M Health Science Center3950 North A. W. Grimes Blvd., Suite N103Round Rock, Texas 78665Agency Name: Lone Star Circle of CareClinic Phone: (877) 800-5722Hours of Operation: Mon–Fri 8–5County Service Area: Bell, Burnet, Milam, Travis, WilliamsonCASE MANAGEMENT FOR CHILDRENAND PREGNANT WOMENWhat is Case Management for Children and Pregnant Women (CPW)?Case Management for Children & Pregnant Women provides services to childrenwith a health condition/health risk, birth through 20 years of age and to high-riskpregnant women of all ages.This program will help you and/or your children get help accessing medical, social,educational, and other health-related services. If you want to request these services: Fax a completed referral form to Texas Health Steps SSU at 512-533-3867 Call Texas Health Steps toll-free at 1-877-847-8377 (1-877-THSTEPS)Monday through Friday, 8 a.m. to 8 p.m., Central Standard Time Contact a case manager directlyWhat kind of services would my child or I get?You would have access to: Medical and dental services Medical supplies or equipment Work on school or educational issues Other servicesFor more information, go to http:/www.dshs.state.tx.us/caseman/default.shtmon the Internet where you will find information on nutrition, physical and mentalhealth care, well-child care, and financial assistance programs. These programsare targeted to children and families in the general public as well as families withchildren with disabilities or special medical conditions.STAR Member Handbook

Page 28TEXAS HEALTH STEPSWhat is Texas Health Steps?Texas Health Steps (THSteps) is a special health care program for children under21. Texas Health Steps is for children’s health checkups. These checkups areimportant and should be set up within 45 days of becoming a Sendero member.Even if a child looks and feels well, he or she may still have a problem.What services are offered by Texas Health Steps?Texas Health Steps can help in many ways. Some of the things done in a TexasHealth Steps medical checkup are:Physical exam, measuring height and weightHearing and eye checkChecking for a good dietShots (when needed)Blood tests (when needed)TB testChildren under age 21 can get dental care. This care includes:FillingsGetting teeth pulledCrownsRoot canalsTeeth cleaning every 6 monthsGetting wisdom teeth pulledIf you are age 21 or older, Medicaid/STAR will cover your dental careonly if it is an emergency that puts your life in danger.Sendero Health Plans

Page 29How and when do I get Texas Health Steps medical and dental checkupsfor my child?All of the Sendero PCPs who work with children are also able to offer Texas HealthSteps services. You may want to talk to your child’s PCP first. Don’t forget to showyour child’s Sendero ID Card and Texas Benefits Medicaid ID Card to the 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-upvisit. If the dentist has to do needed dental treatment at the hospital or someplace other than his/her office, you will need to contact Sendero before theservice is done. Call Member Services at 1-855-526-7388.Does my doctor have to be part of Sendero network?Your child may go to any Medicaid/STAR provider for Texas Health Steps services.Do I have to have a referral?You do not need a referral from your child’s PCP to receive Texas Health Steps services.What if I need to cancel an appointment?Call 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 least24 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 aTexas Health Steps checkup?If you have moved or are out of town when your child’s Texas Health Steps examis due, call Member Services for assistance at 1-855-526-7388.What if I am a migrant farmworker?You can get your checkup sooner if you are leaving the area.How do I get dental services for my child?Your child’s Medicaid dental plan provides dental services including services thathelp prevent tooth decay and services that fix dental problems. Call your child’sMedicaid dental plan to learn more about the dental services they offer.Sendero Health Plans covers emergency dental services your child gets in ahospital or ambulatory surgical center. This includes services the doctor providesand other services your child might need like anesthesia.STAR Member Handbook

Page 30TRANSPORTATIONIf 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 TexasDepartment of Health Medical Transportation Program (MTP) by calling1-877-633-8747 (toll-free).Who do I call for a ride to a medical appointment?Call MTP as soon as you know you will need a ride. If MTP cannot give you a ride,call Sendero Member Services at 1-855-526-7388.How far in advance do I need to call?You must call at least two days before your visit. If your visit is on Monday, callMTP by Thursday the week before. They may be able to give you a ride even inthe evening or on the weekend. If you need to know more or need a ride to thedoctor, call this number: 1-877-633-8747.Can someone I know give me a ride to my appointment and get moneyfor mileage?The Medical Transportation Program (MTP) also can help with money for gas forsomeone who drives you to an appointment. These drivers can be your familymembers, neighbors, or other volunteers. Please call the MTP at 1-877-633-8747for 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 Sendero Member Services at 1-855-526-7388.What are the hours of operation and limits for transportation services?The MTP hours of operation are 8:00 a.m. to 5:00 p.m., Monday–Friday except forstate holidays. You will need to call them at least 2 days before you need the ride.Call MTP for any other limitations on transportation services.Sendero Health Plans

Page 31INTERPRETER SERVICESCan someone interpret for me when I talk with my doctor?Yes, Sendero Member Services will arrange for an interpreter to help youduring your visit.Who do I call for an interpreter?Call Sendero Member Services at 1-855-526-7388.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. Thisinterpreter will be in the doctor’s office with you. Let us know if this is what you want.Se Habla Español —Sendero has people to help you who speak both Spanishand English. We also have member handouts in Spanish.ATTENTION FEMALE MEMBERSWhat if I need OB/GYN care?Sendero Health Plans allows you to pick any OB/GYN, whether that doctor is in thesame network as your Primary Care Provider or not.You have the right to pick an OB/GYN without a referral from your Primary CareProvider. An OB/GYN can give you:One well-woman checkup each yearCare related to pregnancyCare for any female medical conditionReferral to special doctor within the networkDo I have a right to choose an OB/GYN?Yes, you can choose any OB/GYN from within the same network as yourPrimary Care Provider.STAR Member Handbook

Page 32How do I choose an OB/GYN?You can only go to OB/GYNs that are part of the Sendero network. You do notneed a referral from your PCP. To choose an OB/GYN, call Member Services at1-855-526-7388. You may also have your OB/GYN doctor be your PCP. If youwant to have your OB/GYN doctor be your PCP, call Member Services.If I do not choose an OB/GYN, do I have direct access?If you do not pick a Sendero OB/GYN as your Primary Care Provider, you can stillget care from an OB/GYN within the Sendero network.Will I need a referral?You do not need a referral.Can I stay with my OB/GYN if they are not with Sendero?If your OB/GYN is not in Sendero’s provider directory, please call our MemberServices department at 1-855-526-7388.What if I am pregnant?It is very important that you call Sendero to tell us you are pregnant and whatdoctors you are seeing. Call Member Services at 1-855-526-7388. It is veryimportant to start your prenatal care immediately. You should be able to get anappointment within two weeks of your request. Pregnant women will receive casemanagement 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 Give you a temporary pre-programmed cell phone for use whileyou are pregnant and you are determined to be at high riskWho do I need to call?Please call the Sendero Member Services department at 1-855-526-7388.What other services/activities/education does Sendero offerpregnant women?Sendero offers classes for women who are going to have a baby. These classesteach you how to care for a baby before and after it is born. To learn more, callour Member Services department at 1-855-526-7388.Sendero Health Plans

Page 33Where can I find a list of birthing centers?A birthing center is a health facility, place or institution which is not a hospitalor in a hospital and where births are planned to occur away from the mother’sresidence following a normal, uncomplicated pregnancy. A list of Birthing Centerscan be found on the Texas Department of State Health Services website link:http://www.dshs.state.tx.us/HFP/apps.shtm#directorybirthHow soon can I be seen after contacting my OB/GYN for an appointment?You will be seen within 2 weeks of contacting your OB/GYN for an appointment.Can I pick a Primary Care Provider for my baby before the baby is born?Yes. Call Member Services at 1-855-526-7388 and select a Primary CareProvider for your baby.How and when can I switch my baby’s Primary Care Provider?If you do not choose a Primary Care Provider for your baby, one will be chosenfor you. If you are unhappy with the choice, you may call Member Servicesand change the Primary Care Provider.Can I switch my baby’s health plan?For at least 90 days from the date of birth, your baby will be covered by the samehealth plan that you are enrolled in. You can ask for a health plan change beforethe 90 days is up by calling the Enrollment Broker at 1-800-964-2777.You cannot change health plans while your baby is in the hospital.How do I sign up my newborn?When your baby is born, call your Texas Department of Human Servicescaseworker as soon as possible so your baby can get Medicaid. It is alsoimportant that you call Member Services at 1-855-526-7388 or your Senderocase manager as soon as possible to let us know that your baby is born.You will receive a Texas Benefits Medicaid ID Card for your baby.How and when do I tell my health plan?You should call Sendero as soon possible, at least within 30 daysof delivering the baby.How and when do I tell my caseworker?Call your caseworker as soon as possible after your baby is born.STAR Member Handbook

Page 34Who do I call if I have special health care needs and need someone to help me?You or your child may need more health and other services because of complex orchronic conditions. There may be times when Sendero may allow a special doctor(specialist) to be your child’s PCP.Call Member Services at 1-855-526-7388 for more information on specialservices that Sendero has for you or your child. A case manager will callyou back to talk about these special needs.ADVANCE DIRECTIVESWhat 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 thishappens, how will a doctor know what you want? You can make an advancedirective, which is a letter that tells people what you want to happen if you getvery sick. One kind of advance directive is a living will, which tells your doctorwhat to do if you are too sick to tell him or her. The other kind is a durablepower of attorney, which lets a friend or family member (who you choose) makedecisions for you. Any advance directive you make starts when you get very sickand will last until you change or cancel it.If you would like more information about advance directives, callMember Services at 1-855-526-7388.What are advance directives?Accidents or serious illness can happen suddenly without any warning. Thebest way to prepare is to have your wishes put in writing. Advance directivesare written legal papers (or forms) that speak for you when you cannot. Theyare “living wills” that tell doctors and family members your wishes in a medicalemergency. If you cannot speak for yourself, an advance directive will tell themabout what you want, or don’t want.For example, how you feel about care that is needed to keep you alive, such as:being resuscitated if your heart stops or if you stop breathingbreathing machines, tube feedings, life support, or organ donationYou can change or cancel advance directives at any time.How do I get an advanced directive?You can get forms online and learn more at www.dads.state.tx.us.Click on “Learn about DADS”Click on “Publications,” and thenClick on “Advance Directives”If you have questions, your doctor can give you more information.You can also call Sendero Member Services at 1-855-526-7388.Sendero Health Plans

Page 35OTHER INFORMATIONWhat happens if I lose my Medicaid coverage?If you lose Medicaid coverage but get it back again within six (6) monthsyou will get your Medicaid services from the same health plan you had beforelosing your Medicaid coverage. You will also have the same Primary Care Provideryou had before.What if I get a bill from my doctor?You should never get a bill from your a doctor.Who do I call?If you get a bill from a doctor, call Sendero Member Services at 1-855-526-7388,and we will call the provider’s office. We will help explain your benefits.What information will they need?When you call us, please have you or your child’s ID Card and the provider’s billavailable. Sendero Member Services will need this information to help you.What do I have to do if I move?As soon as you have your new address, give it to the local HHSC benefits officeand Sendero Health Plans Member Services department at 1-855-526-7388.Before you get Medicaid services in your new area, you must call Sendero, unlessyou need emergency services. You will continue to get care through Sendero untilHHSC changes your address.What if I have other health insurance in addition to Medicaid?Medicaid and Private InsuranceYou are required to tell Medicaid staff about any private health insurance youhave. You should call the Medicaid Third Party Resources hotline and updateyour Medicaid case file if:Your private health insurance is canceledYou get new insurance coverageYou have general questions about third party insuranceYou can call the hotline toll-free at 1-800-846-7307.If you have other insurance you may still qualify for Medicaid. When youtell Medicaid staff about your other health insurance, you help make sureMedicaid only pays for what your other health insurance does not cover.STAR Member Handbook

Page 36IMPORTANT: Medicaid providers cannot turn you down for services because you haveprivate health insurance as well as Medicaid. If providers accept you as a Medicaidpatient, they must also file with your private health insurance company.MEMBER RIGHTS AND RESPONSIBILITIESWhat are my rights and responsibilities?MEMBER RIGHTS and RESPONSIBILITIESMEMBER RIGHTS:1. You have the right to respect, dignity, privacy, confidentialityand nondiscrimination. That includes the right to:a. Be treated fairly and with respect.b. Know that your medical records and discussions withyour providers will be kept private and confidential.2. You have the right to a reasonable opportunity to choose a healthcare plan and Primary Care Provider. This is the doctor or healthcare provider you will see most of the time and who will coordinateyour care. You have the right to change to another plan or providerin a reasonably easy manner. That includes the right to:a. Be told how to choose and change your healthplan and your Primary Care Provider.b. Choose any health plan you want that is available in your areaand choose your Primary Care Provider from that plan.c. Change your Primary Care Provider.d. Change your health plan without penalty.e. Be told how to change your health planor your Primary Care Provider.3. You have the right to ask questions and get answers aboutanything you do not understand. That includes the right to:a. Have your provider explain your health care needsto you and talk to you about the different waysyour health care problems can be treated.b. Be told why care or services were denied and not given.4. You have the right to agree to or refuse treatment and activelyparticipate in treatment decisions. That includes the right to:a. Work as part of a team with your provider indeciding what health care is best for you.b. Say yes or no to the care recommended by your provider.Sendero Health Plans

Page 375. You have the right to use each complaint and appeal processavailable through the managed care organization andthrough Medicaid, and get a timely response to complaints,appeals and fair hearings. That includes the right to:a. Make a complaint to your health plan or to the state Medicaidprogram about your health care, your provider or your health plan.b. Get a timely answer to your complaint.c. Use the plan’s appeal process and be told how to use it.d. Ask for a fair hearing from the state Medicaid programand get information about how that process works.6. You have the right to timely access to care that does not have anycommunication or physical access barriers. That includes the right to:a. Have telephone access to a medical professional 24 hours a day,7 days a week to get any emergency or urgent care you need.b. Get medical care in a timely manner.c. Be able to get in and out of a health care provider’soffice. This includes barrier free access for people withdisabilities or other conditions that limit mobility, inaccordance with the Americans with Disabilities Act.d. Have interpreters, if needed, during appointments with yourproviders and when talking to your health plan. Interpreters includepeople who can speak in your native language, help someonewith a disability, or help you understand the information.e. Be given information you can understand aboutyour health plan rules, including the health careservices you can get and how to get them.7. You have the right to not be restrained or secluded when it isfor someone else’s convenience, or is meant to force you todo something you do not want to do, or is to punish you.8. You have a right to know that doctors, hospitals, and others who carefor you can advise you about your health status, medical care, andtreatment. Your health plan cannot prevent them from giving you thisinformation, even if the care or treatment is not a covered service.9. You have a right to know that you are not responsible for paying forcovered services. Doctors, hospitals, and others cannot require youto pay copayments or any other amounts for covered services.STAR Member Handbook

Page 38MEMBER RESPONSIBILITIES:1. You must learn and understand each right you have under theMedicaid program. That includes the responsibility to:a. Learn and understand your rights under the Medicaid program.b. Ask questions if you do not understand your rights.c. Learn what choices of health plans are available in your area.2. You must abide by the health plan’s and Medicaid’s policiesand procedures. That includes the responsibility to:a. Learn and follow your health plan’s rules and Medicaid rules.b. Choose your health plan and a Primary Care Provider quickly.c. Make any changes in your health plan and Primary Care Providerin the ways established by Medicaid and by the health plan.d. Keep your scheduled appointments.e. Cancel appointments in advance when you cannot keep them.f. Always contact your Primary Care Provider firstfor your non-emergency medical needs.g. Be sure you have approval from your PrimaryCare Provider before going to a specialist.h. Understand when you should and shouldnot go to the emergency room.3. You must share information about your health withyour Primary Care Provider and learn about service andtreatment options. That includes the responsibility to:a. Tell your Primary Care Provider about your health.b. Talk to your providers about your health careneeds and ask questions about the different waysyour health care problems can be treated.c. Help your providers get your medical records.4. You must be involved in decisions relating to service andtreatment options, make personal choices, and take action tokeep yourself healthy. That includes the responsibility to:a. Work as a team with your provider in decidingwhat health care is best for you.b. Understand how the things you do can affect your health.c. Do the best you can to stay healthy.d. Treat providers and staff with respect.e. Talk to your provider about all of your medications.Sendero Health Plans

Page 39If you think you have been treated unfairly or discriminated against, call the U.S.Department of Health and Human Services (HHS) toll-free at 1-800-368-1019.You also can view information concerning the HHS Office of Civil Rights online atwww.hhs.gov/ocr.COMPLAINT PROCESSWhat should I do if I have a complaint?We want to help. If you have a complaint, please call us toll-free at1-855-526-7388 to tell us about your problem. A Sendero Member ServicesAdvocate can help you file a complaint. Just call 1-855-526-7388. Most of thetime, we can help you right away or at the most within a few days.Once you have gone through the Sendero complaint process, you can complainto the Health and Human Services Commission (HHSC) by calling toll-free1-800-566-8989. If you would like to make your complaint in writing, pleasesend it to the following address:Texas Health and Human Services CommissionHealth Plan Operations - H-320P.O. Box 85200Austin, TX 78708-5200ATTN: Resolution ServicesIf you can get on the Internet, you can send your complaint in an email to:HPM_Complaints@hhsc.state.tx.us.We will send you a letter to let you know we received the complaint. This letterwill be sent within five (5) days of receiving your complaint. We will send you aform to complete and mail to us. We will not follow-up on your complaint unlessyou 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 doctorfor filing a complaint.Most of the time, we can help you right away or at the most within a few days.At the most, we will respond with an answer to your complaint within thirty (30)days of receipt. If you are not happy with the way we help you, you can call usand appeal.STAR Member Handbook

Page 40Sendero wants to help you get the best health care for your family. If you havequestions about how to file a complaint, an appeal, or need additional help,call us toll-free at 1-855-526-7388. We will be glad to help.Call us: Sendero Health PlansMember Services1-855-526-7388Write to us: Sendero Health PlansATTN: Member Advocate2028 E. Ben White Blvd., Suite 510Austin, Texas 78741All complaints are reviewed to make sure that there is follow-up. They are alsoreviewed to make sure that timely answers are given.You also have the right to meet with a Complaints Appeal Panel. This panel ismade up of doctors and others who will hear your complaint and make a decision.Who do I call?Please call Sendero Member Services toll-free at 1-855-526-7388.Can someone from Sendero help me file a complaint?Yes, either one of Sendero Member Services agents can help you or the QualityImprovement Manager can help you file a complaint.How long will it take to process my complaint?Sendero will send you a letter telling you about our decision. You will receive thisletter within 30 days after we receive your complaint. Our letter will tell you themedical or plan benefit reason for our decision. If you have a complaint about anemergency or hospital stay, you will have a decision in one business day.Requirements and timelines for filing a complaintYou can file a complaint at any time either by calling the Sendero MemberServices department at 1-855-526-7388 or by writing to Sendero at:2028 E. Ben White Blvd., Suite 510Austin, TX 78741Sendero Health Plans

Page 41Information on how to file a complaint with HHSC once I have gone throughthe Sendero process:Once you have gone through the Sendero complaint process, you can complainto the Health and Human Services Commission (HHSC) by calling toll-free1-866-566-8989. If you would like to make your complaint in writing, pleasesend it to the following address:Texas Health and Human Services CommissionHealth Plan Operations - H-320PO Box 85200Austin, TX 78708-5200ATTN: Resolution ServicesIf you can get on the Internet, you can send your complaint in an email to:HPM_Complaints@hhsc.state.tx.us.What can I do if my doctor asks for a service for me that is covered butSendero denies it or limits it?There may be times when the Sendero Medical Director denies these services.When this occurs, Sendero will send you a Notice of Action in writing of ourdecision. You may appeal this decision. To appeal these medical decisions, callMember Services at 1-855-526-7388. In order to ensure continuity of currentlyauthorized services, you must file the appeal on or before the later of: 10 daysfollowing Sendero’s mailing of the notice of Action, or the intended effectivedate of the proposed Action. You or your provider may appeal verbally or inwriting. If a request for an appeal is received verbally, you or your provider willneed to put the appeal in writing. If your provider sends us the appeal, you willneed to sign that request.We will send you a letter within five (5) days of receiving your appeal, to let youknow 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 tellingyou why we need more time. You have the option of asking Sendero to extend theappeal time up to 14 calendar days.How will I find out if services are denied?Sendero will notify you in writing within 3 days of the Medical Director denying therequest. We will send you a letter explaining why the decision was made and howto appeal the decision.STAR Member Handbook

Page 42You or a person acting on your behalf (i.e.: doctor, relative, friend, lawyer, or anyother person), have the right to Sendero’s internal appeal process. You can eithercall the Sendero Member Services Coordinator at 1-855-526-7388 for help incompleting the appeal request form or you can fill out and send in the enclosedappeal request form by mail to:Sendero Health PlansAttn: Member Advocate / Compliance Director2028 E. Ben White Blvd., Suite 510Austin, Texas 78741Toll-free phone: 1-855-895-0475All appeal requests must be submitted on this form. If there is any otherinformation you would like for Sendero to consider when reviewing your appeal,please include it with this form. Sendero must have this completed formwithin 30 days of the date on this notice to move forward with your appeal.We will send you a letter letting you know when Sendero Health Plans hasreceived your appeal (along with a copy of the appeal form if you have asked foran appeal by phone), within one week of the appeal form arriving in our office.Appeals are reviewed by a doctor who was not involved in the original denialdecision. You will receive a response to your appeal within thirty (30) calendardays of receipt of the appeal.If the decision results in stopping or reducing current services and you want themto keep going, you must ask for an extension of the services and file the appealon or before ten (10) days after the date of this notice or the date the notice saysyour services will end, whichever is later. If you request that services continuewhile your appeal is pending, you need to know that you may have to pay forthese services if the decision on your appeal upholds Sendero Health Plans’ firstdecision. If the decision on your appeal reverses our first decision, Sendero HealthPlans will pay for the services you received while your appeal was pending. Youmay ask for a Medicaid fair hearing from the State any time during or after theappeal process unless you have asked for an expedited appeal.If you or your doctor feels that this denial of services will seriously jeopardizethe member’s health, you or your doctor may request an expedited appeal. Youmay obtain an expedited appeal by contacting Sendero Health Plans’ Senior CareCoordinator toll-free at 1-855-297-9191. All Sendero Health Plans’ expeditedappeal processes must be used prior to requesting an expedited fair hearing.Once an expedited appeal has been requested and is determined to be an urgentsituation, a decision is made within three (3) business days.Sendero Health Plans

Page 43If your appeal relates to an ongoing emergency or denial of continuedhospitalization Sendero Health Plans will complete the investigation and resolutionof the appeal within one (1) business day after receiving your request for anexpedited appeal.Expedited appeals can be extended up to fourteen (14) calendar days if you oryour authorized representative or Sendero Health Plans (with HHSC approval)determine if there is a need for additional information that would best serve themember’s interest.If you disagree with Sendero Health Plans’ decision, you have the right to ask fora Medicaid fair hearing from the Texas Health and Human Services Commission(HHSC). You may represent yourself at the fair hearing, or name someone else tobe your representative. This could be a doctor, relative, friend, lawyer or any otherperson. You may name someone to represent you by writing a letter to SenderoHealth Plans telling us the name of the person that you want to represent you.If you want to challenge a decision made by Sendero Health Plans, you or yourrepresentative must ask for the Medicaid fair hearing within 90 days fromthe date of the notice. If you do not ask for the fair hearing by this date, youmay lose your right to a fair hearing. To ask for a fair hearing, you or yourrepresentative should write or call:Sendero Health PlansAttn: Fair Hearing Coordinator / Member Advocate2028 E. Ben White Blvd., Suite 510Austin, Texas 78741Toll-free phone: 1-855-895-0475If you believe that waiting for a hair fearing will seriously jeopardize your life orhealth, or your ability to attain, maintain, or regain maximum function, you or yourrepresentative may ask for an expedited fair hearing by writing or calling SenderoHealth Plans. To qualify for an expedited fair hearing through HHSC, you must firstcomplete Sendero Health Plans’ internal appeals process.STAR Member Handbook

Page 44Time framesIf you ask for a fair hearing (1) within 10 days after the date of the notice or(2) the intended effective date of the action, you may be able to keep gettingthe service or benefit that is being terminated, suspended, or reduced by SenderoHealth Plans, at least until the fair hearing decision is made. If you do not requesta fair hearing by this date, the service or benefit will be terminated, suspended,or reduced. If you lose you fair hearing appeal, Sendero Health Plans may be ableto collect from you the costs of providing the service or benefit to you while theappeal was pending.If you ask for a fair hearing, you will get a packet of information letting you knowthe date, time and location of the hearing. Most hearings are held by telephone.You can also contact the HHSC Hearings Officer if you would like the hearing tobe held in-person. During the hearing, you or your representative can tell why youneed the service or why you disagree with the Sendero Health Plans’ action.You have the right to examine, at a reasonable time before the date of the fairhearing, the contents of your case file and any documents to be used by SenderoHealth Plans at the hearing.At least one week before the hearing, Sendero Health Plans will send you allthe documents to be used at the hearing.HHSC will give you a final decision within 90 days from the date you askedfor the hearing.You may qualify for free or low cost legal services. A list of legal aid providersthat may be able to help you is included.Can someone from Sendero help me file an appeal?Yes. Contact Member Services at 1-855-526-7388.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’sappeal process. If you do not agree with our decision, you may ask for a StateFair 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 within90 days, you lose your right to a hearing. See information below about how to askfor a State Fair Hearing.What is an expedited appeal?An expedited appeal is when the health plan has to make a decision quickly basedon the condition of your health, and taking the time for a standard appeal couldjeopardize your life or health.Sendero Health Plans

Page 45How may I ask for an expedited appeal? Does my request haveto be in writing?Call Sendero Member Services at 1-855-526-7388 to request an expeditedappeal. You may request an expedited appeal orally or in writing.Sendero Health PlansAttn: Fair Hearing Coordinator / Member Advocate2028 E. Ben White Blvd., Suite 510Austin, Texas 78741Toll-free phone: 1-855-895-0475Who can help me file an expedited appeal?If you need assistance in filing this appeal, contact Member Services at1-855-526-7388 and they will contact a Member Advocate to help you. Wewill review your case and get back to you no later than 3 working days after wereceive your request.What are the time frames for an expedited appeal?We will review your case and get back to you no later than 3 working days afterwe receive your request.What happens if Sendero denies your request for an expedited appeal?You may discuss your request for an expedited appeal with the Medical Director ifthere are questions. Requests for expedited appeal are very serious. We want tomake sure you or your child receive the care that is medically necessary.STAR Member Handbook

Page 46STATE FAIR HEARINGCan I ask for a State Fair Hearing?If you, as a member of the health plan, disagree with the health plan’s decision,you have the right to ask for a fair hearing. You may name someone to representyou by writing a letter to the health plan telling them the name of the personyou want to represent you. A doctor or other medical provider may be yourrepresentative. If you want to challenge a decision made by your health plan, youor your representative must ask for the fair hearing within 90 days of the dateon the health plan’s letter with the decision. If you do not ask for the fair hearingwithin 90 days, you may lose your right to a fair hearing. To ask for a fair hearing,you or your representative should either send a letter to the health plan at2028 E. Ben White Blvd., Suite 510, Austin, TX 78741 or call 1-855-526-7388.You have the right to keep getting any service the health plan denied orreduced, at least until the final hearing decision is made if you ask for a fairhearing by the later of: (1) 10 days from the date you get the health plan’sdecision letter, or (2) the day the health plan’s letter says your service will bereduced or end. If you do not request a fair hearing by this date, the service thehealth plan denied will be stopped.If you ask for a fair hearing, you will get a packet of information letting youknow the date, time and location of the hearing. Most fair hearings are held bytelephone. At that time, you or your representative can tell why you need theservice the health plan denied.HHSC will give you a final decision within 90 days from the date you askedfor the hearing.Sendero Health Plans

Page 47FRAUD AND ABUSE OF THESTAR PROGRAMHow do I report someone who is misusing/abusingthe programs or services?FRAUD AND ABUSEDo you want to report waste, abuse, or fraud?Let us know if you think a doctor, dentist, pharmacist at a drug store, other healthcare providers, or a person getting benefits is doing something wrong. Doingsomething wrong could be waste, abuse or fraud, which is against the law.For example, tell us if you think someone is: Getting paid for services that weren’t given or necessary Not telling the truth about a medical condition to get medical treatment Letting someone else use their Medicaid ID Using someone else’s Medicaid ID Not telling the truth about the amount of money orresources he or she has to get benefitsTo report waste, abuse, or fraud, choose one of the following: Call the OIG Hotline at 1-800-436-6184; Visit https://oig.hhsc.state.tx.us/ and pick “Click Here to ReportWaste, Abuse, and Fraud” to complete the online form; or You can report directly to your health plan:– MCO’s name– MCO’s office/director address– MCO’s toll-free phone numberSTAR Member Handbook

Page 48To report waste, abuse or fraud, gather as much information as possible.When reporting about a provider (a doctor, dentist, counselor, etc.) include:– Name, address, and phone number of provider– Name and address of the facility (hospital, nursinghome, home health agency, etc.)– Medicaid number of the provider and facility, if you have it– Type of provider (doctor, dentist, therapist, pharmacist, etc.)– Names and phone numbers of other witnesseswho can help in the investigation– Dates of events– Summary of what happenedWhen reporting about someone who gets benefits, include:– The person’s name– The person’s date of birth, Social SecurityNumber, or case number if you have it– The city where the person lives– Specific details about the waste, abuse or fraudINFORMATION THAT MUST BE AVAILABLEON AN ANNUAL BASISAs a member of Sendero you can ask for and get the followinginformation each year: I nformation about network providers—at a minimum primarycare doctors, specialists, and hospitals in our service area. Thisinformation will include names, addresses, telephone numbers, andlanguages spoken (other than English) for each network provider, plusidentification of providers that are not accepting new patients. Any limits on your freedom of choice among network providers Your rights and responsibilities Information on complaint, appeal and fair hearing procedures Information about benefits available under the Medicaid program,including amount, duration and scope of benefits. This is designed tomake sure you understand the benefits to which you are entitled. How you get benefits including authorization requirements How you get benefits, including family planning services, fromout-of-network providers and/or limits to those benefitsSendero Health Plans

Page 49 How you get after hours and emergency coverage and/or limits to those kinds of benefits, including:– What makes up emergency medical conditions,emergency services and post-stabilization services– The fact that you do not need prior authorization from yourPrimary Care Provider for emergency care services– How to get emergency services, including instructions on howto use the 911 telephone system or its local equivalent– The addresses of any places where providers and hospitalsfurnish emergency services covered by Medicaid– A statement saying you have a right to use anyhospital or other settings for emergency care– Post-stabilization rules Policy on referrals for specialty care and for other benefitsyou cannot get through your Primary Care Provider Sendero Health Plan’s practice guidelinesSTAR Member Handbook