C—1110  Medical Information

C—1111  State Medicaid Agencies

TANF and Medical Programs

For links to all State Medicaid Agencies, go to www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.html.

C—1112  Services Under the Texas Medical Assistance Program

TANF and Medical Programs

Benefits provided through health insuring agent:

• In-patient hospital services*
• Out-patient hospital services*
• Laboratory and x-ray services
• Physician's services
• Podiatrist's services
• Optometric services*
• Ambulance services*
• Family planning services*
• Home health services limited to nurse and home health aid visits*
• Medicare Part A deductible and coinsurance when benefits would otherwise be payable under Medical Assistance and Medicare Part B deductible and coinsurance for assigned claims only
• Chiropractic treatment — limited to Medicare Part B deductible and coinsurance for assigned claims only
• Eyeglasses*
• Rural health clinics*

Services provided through contract or by direct vendor payments from HHSC:

• Nursing care skilled and intermediate care. Skilled care is limited to recipients age 21 and over. Medicare SNF coinsurance.*
• Active treatment for recipients/patients of any age in licensed and approved section of institutions for mental retardation.*
• In-patient hospital care for recipients/patients age 65 and older in contracted mental hospitals and state (tuberculosis) hospitals.*
• Texas Health Steps screening program and limited dental treatment for eligible individuals under age 21.
• Prescriptions limited to no more than three covered per month if over 18. Unlimited if 18 and under.
• Prior authorized hearing aid services.*
• Primary home care for recipients age 18 and over.*
• Other medical transportation.

*With limitations — see appropriate provider manuals for details.

The benefits of this program do not extend to:

• Inmates in a public institution. (Recipients in approved medical units in certain contracted institutions are eligible for vendor payments made by the Texas Health and Human Services Commission.)
• Special shoes or other supportive devices for the feet or walking aids.
• Services in military medical facilities, Veteran's Administration facilities, or United States Public Health Service Hospitals.
• Care and treatment related to any condition for which benefits are provided or are available under Workman's Compensation laws.
• Dental care and services except certain oral surgery or that provided under Texas Health Steps (THSteps).
• Any services or supplies provided in connection with a routine physical examination except family planning services.
• Any care or services payable under Title XVIII (Medicare).
• Any service provided by an immediate relative of the recipient or member of the recipient's household.
• Any services or supplies that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of the malformed body member.
• Custodial care.
• Any services provided to the recipient after a Utilization Review or medical review finding that such services are not medically necessary.
• Any services or supplies that are payable through a third party.
• Any service or supplies not specifically provided by the Texas Medical Assistance Program.

Disclaimer: This list is for convenient reference and does not have the effect of law, regulation, or policy. If there is a conflict between this list and law, regulations, and policy, the latter will prevail. If there is a question, use the appropriate provider manuals or filed releases for clarification.

C—1113  Qualified Provider Procedures for Presumptive Eligibility Determinations

TP 42–Pregnant Women Presumptive

Presumptive eligibility provides temporary limited medical coverage for pregnant women to ensure early access to prenatal care.

A Health and Human Services Commission (HHSC)-approved qualified provider determines presumptive eligibility for pregnant women. To be eligible:

• Pregnancy must be verified.
• The family's self-declared income must be less than 185% of the Federal Poverty Income Limits (FPIL). No verification is required.
• The pregnant woman must meet the Temporary Assistance for Needy Families (TANF) citizenship alien status requirements.
• The pregnant woman must meet the TANF residency requirements.

Coverage begins the day the qualified provider makes the determination and ends when HHSC makes the final Medicaid determination.

Medicaid services during the presumptive eligibility period are limited to those that are medically necessary. These services do not include labor, delivery, inpatient services or THSteps medical and dental services. To receive regular medical coverage HHSC must determine eligibility through the regular application process.

Qualified providers issue Form H1266, Notice of Presumptive Eligibility for Pregnant Women. These women receive a Your Texas Benefits Medicaid card annotated with "PE" in the top right corner.

Related Policy
Processing Presumptive Eligibility Applications, A-124

C—1114  Guidelines for Providing Retroactive Coverage for Children and Medical Programs

Medical Programs

When determining retroactive eligibility for children and pregnant women, use the following decision table and the applicable income chart.

Chart One, March 2011 through February 2012

For pregnant women, use the 185% FPIL amount from the above chart.

Chart Two, March 2012 through February 2013

C—1115  Immunization Terms

TANF and Medical Programs

Immunization by inoculation or vaccination protects against childhood diseases. Except for tetanus, these diseases are contagious. Encourage individuals to follow the Texas Department of Health's recommended schedule found on Form H1012, Immunization Record. If a child is on an alternate schedule refer to A-2125, Immunizations.

The following are descriptions of the diseases and symptoms associated with immunizations.

• Diphtheria — An acute, bacterial illness that causes a sore throat and a fever and sometimes causes more serious or even fatal complications.
• Haemophilus Influenza Type b — A bacterium that can cause meningitis and pneumonia and infect other body systems such as blood, joints, bones and soft tissue under the skin, throat, and the covering of the heart.
• Hepatitis A — An infection of the liver caused by the Hepatitis A virus.
• Hepatitis B — An infection of the liver caused by the Hepatitis B virus.
• Measles — An acute, highly contagious viral disease involving the respiratory tract that causes a characteristic rash, fever, runny nose, sore eyes, and cough.
• Mumps — An acute viral disease mainly of childhood. It is characterized by a swelling of the parotid (salivary) glands on one or both sides and may cause fever, headache, and difficulty swallowing may develop.
• Pertussis (Whooping Cough) — An acute highly contagious respiratory disease characterized by a severe attack of coughing that ends in a characteristic "whoop" as breath is drawn in.
• Poliomyelitis (Polio – once known as "infantile paralysis") — An infectious disease and may lead to extensive paralysis of the muscles.
• Rubella (German Measles) — A viral infection characterized by a mild fever, swollen glands in the neck and a rash that lasts up to three days.
• Tetanus (Lockjaw) — A very serious disease of the central nervous system caused by an infection of a wound that makes a person unable to open his/her mouth or swallow and causes muscle spasms in the jaw, neck, leg or other muscles.
• Varicella (Chickenpox) — A highly contagious viral infection which presents as a generalized, itchy, vesicular rash. The rash begins as smooth, red spots which develop into blisters that last three to four days before forming crusty scabs.

C—1116  Type Programs

TANF, Medical Programs

TANF

Medical Programs – Texas Works

Medical Programs - Department of Family and Protective Services

Medicaid Programs - Medicaid for the Elderly and People with Disabilities

C—1117  Managed Care Plans

TANF and Medical Programs

STAR-Bexar Service Area

(Counties: Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson)

STAR-Dallas Service Area

(Counties: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall)

STAR-El Paso Service Area

(Counties: El Paso and Hudspeth)

STAR-Harris Service Area

(Counties: Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller, Wharton)

STAR-Hidalgo Service Area

(Counties: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, Zapata)

STAR-Jefferson Service Area

(Counties: Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker)

STAR-Lubbock Service Area

(Counties: Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher, Terry)

STAR-Nueces Service Area

(Counties: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio, Victoria)

STAR-Tarrant Service Area

(Counties: Denton, Hood, Johnson, Parker, Tarrant, Wise)

STAR-Travis Service Area

(Counties: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis, Williamson)

NorthSTAR-Dallas Service Area

(Counties: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall)

STAR-Medicaid RSA West Texas Service Area

(Counties: Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallas, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, LaSalle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Young, Zavala)

STAR-Medicaid RSA Northeast Texas Service Area

(Counties: Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt, Wood)

STAR-Medicaid RSA Central Texas Service Area

(Counties: Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Miliam, Mills, Robertson, San Saba, Somervell, Washington)

STAR+PLUS – Bexar Service Area

(Counties: Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson)

STAR+PLUS – Dallas Service Area

(Counties: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall)

STAR+PLUS – El Paso Service Area

(Counties: El Paso and Hudspeth)

STAR+PLUS – Harris Service Area

(Counties: Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller, Wharton)

STAR+PLUS – Hidalgo Service Area

(Counties: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, Zapata)

STAR+PLUS – Jefferson Service Area

(Counties: Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker)

STAR+PLUS – Lubbock Service Area

(Counties: Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher, Terry)

STAR+PLUS – Nueces Service Area

(Counties: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio, Victoria)

STAR+PLUS – Tarrant Service Area

(Counties: Denton, Hood, Johnson, Parker, Tarrant, Wise)

STAR+PLUS – Travis Service Area

(Counties: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis, Williamson)

STARHealth – Statewide

Dental – Statewide

Note: Each region has a designated representative who managed care plan staff contact to resolve issues related to eligibility, county code assignment and other concerns for individuals enrolled in managed care. The plan representative has the same access to individual record information as a medical provider.

Related Policy
Managed Care, A-821.2
Releasable Information for Medicaid Providers and Their Contractors, B-1230
Office of the Ombudsman, B-1420

C—1118  Texas Health Steps Quick Reference Guide and Recipient Enrollment Script

TP 43, TP 44, TP 45, TP 47, TP 48

MMC/THSteps QUICK REFERENCE GUIDE STAR+PLUS (Dual Eligibles)

Did I verify the caller's identity?

8 Steps to VERIFICATION and ENROLLMENT

• Medicaid ID No. or SSN
• Name
• Address
• Primary Language Spoken in Home
• Phone No.
• DOB
• Third-Party Resources (Private Insurance)
• Pregnancy

POINTS OF EDUCATION

• Introduction (Name, program)
• Medicaid Managed Care Enrollment-Medicaid Managed Care Recipients

1. Explain Managed Care
2. Explain that STAR+PLUS for dual eligibles is for LONG TERM CARE Services only
3. Explain recipients will continue to use your doctors and hospitals as before.
4. Explain your doctor's office will continue to bill Medicare and Medicaid for your visit, you do not need to show your STAR+PLUS Health Plan ID card.
5. Explain that dual eligibles will still get their prescription drugs through Medicare.
6. Explain the enrollment will be effective in 15-45 days and traditional Medicaid is in effect until then
7. Enroll recipient. Give health plan's member services phone number.
8. Explain they will receive an ID card from the health plan with the phone number on it.
9. STAR+PLUS plan changes, call the STAR+PLUS HelpLine

For more information on drug coverage for dual eligibles:

If you are on Medicare and Medicaid, you will continue to use Medicare for your regular health care needs and all prescription drugs. You will use STAR+PLUS only for your Medicaid long-term service and support needs. Enrollment in STAR+PLUS will not change the way you use Medicare.

Recipient Enrollment Script for STAR+PLUS Dual Eligibles
Expanded (11/06)

Introduction

Standard Greeting to include your name, program and purpose for calling. For example: Hello, may I speak with [case name]: Hello, Mr/Mrs_______________________. My name is _________________.

Did I verify the caller's identity?

8 Steps to VERIFICATION and ENROLLMENT

• Medicaid ID No. or SSN-Do you have your Medicaid ID form handy? Will you read the number that appears on your letter to the left of your name.
• Name-Is this your name?
• Address-Are you still living at this address?
• Primary Language Spoken in Home-Document what language
• Phone No. -Is this the correct phone number?
• DOB-Is this your DOB?
• Third Party Resources (Private Insurance)-Does your child have any private health insurance?
• Pregnancy-Are you or anyone in your home pregnant at this time?
• Special Health Care Questions-3 questions for each adult:

Health Plan Information-STAR+PLUS for Dual Eligibles in Harris, Harris Expansion, Travis, Nueces and Bexar Service Areas

1. Explain Managed Care STAR + PLUS "Let me tell you a little about the STAR+PLUS program. STAR+PLUS is a managed care program that provides Medicaid long-term services and supports in your area. Long-term services and supports may include personal attendant services, adaptive aids, adult foster home service, assisted living, nursing services, and medical supplies. There are different STAR+PLUS health plans in your area that will provide these services. You must choose a STAR+PLUS health plan for your long-term services and supports, or a plan will be chosen for you. You will not choose a primary care provider.
2. Explain that STAR+PLUS for dual eligibles is for long-term services and supports ONLY. For STAR+PLUS members who are also on Medicare, STAR+PLUS only provides long-term services and supports. You will use Medicare for your regular health care needs and prescription drugs, just as you did before.
3. Explain recipients will continue to use your doctors and hospitals as before.You will continue to go to your regular Medicare doctor for general health care needs. STAR+PLUS also does not affect the way you receive hospital services.
4. Explain your doctor's office will continue to bill Medicare and Medicaid for your visit, you do not need to show your STAR+PLUS Health Plan ID card. Because STAR+PLUS only includes long-term services and supports, make sure you bring your Medicare card with you to all of your doctor visits. You do not need to bring your STAR+PLUS health plan ID card.
5. Explain that dual eligibles will still get prescription drugs through Medicare. You will continue to use your Medicare Part D plan for all of your prescription drugs. STAR+PLUS does not include prescriptions.
6. Enroll recipient. Give health plan's member services phone number. Have you received a STAR+PLUS enrollment packet? The packet has an enrollment form for you to choose a health plan, as well as other program information and the health plan provider directories. Have you already enrolled? If not, I will be glad to help you enroll today!
7. Explain the enrollment will be effective in 15-45 days and traditional Medicaid is in effect until then. Once your enroll, it may take up to 45 days before you get a Medicaid ID care that show your STAR+PLUS health plan. Until you get a Medicaid ID with your STAR+PLUS health plan on it, you will get Medicaid services the same way you do now.
8. Explain they will receive an ID card from the health plan with the phone number on it. You will also get an ID card from the health plan you chose. The health plan ID card will have a phone number for you to call with any questions.
9. STAR+PLUS plan changes, call the STAR+PLUS HelpLine. In the STAR+PLUS program you may change health plans at any time. Just call the STAR+PLUS HelpLine. The phone number is 1-800-964-2777.
10. Summary
    • Any Questions regarding your benefits?
    • Provide your name

C—1119  Health Care Orientation Quick Reference Guide and Enrollment Script

TP 43, TP 44, TP 47, TP 48

MMC/THSteps QUICK SCRIPT REFERENCE GUIDE STAR/PCCM Expansion/FFS/STAR+PLUS (except for Dual Eligibles)

Effective 11/1/06

STEPS TO VERIFICATION and ENROLLMENT

Verification

• Medicaid ID No. or SSN
• Name
• Address
• Phone No.
• DOB

Enrollment

• Third Party Resources (Private Insurance)
• Pregnancy
• Primary Language Spoken in Home
• Special Health Care Questions-STAR Only

If all family members are over 21, only provide information from the first five bullets below and MTP as appropriate.

15 Steps to EDUCATION

• Introduction (Name, program, Health Care Orientation) (Face to face HCO's should receive "Helpful Toll-free Number" Handout)
• Medicaid Managed Care Enrollment-Medicaid Managed Care Recipients

1. Explain Managed Care and PCP
2. Explain about PCP / emergency rooms
3. Explain about specialist and referrals.
4. Explain about preventive health check-ups
5. Explain the STAR/STAR+PLUS enrollment will be effective in 15-45 days and traditional Medicaid is in effect until then. PCCM Expansion area recipients are automatically enrolled.
6. Enroll recipient. Give health plan's member services phone number.
7. Explain they will receive an ID card from the health plan. (Except PCCM)
8. Other education is provided as necessary (i.e., TP40 education script, newborn education).
9. Managed Care changes– Plan and/or PCP how often, who to call to make changes
10. NorthSTAR script-Dallas SA only

• Medicaid Program Knowledge – don't pay bills, what Medicaid covers, excluding SSI recipients
• Medicaid ID Form- monthly 8x11 sheet, THSteps Medical and Dental check-up due reminder, STAR plan under name, PCCM PCP under name, must see PCP for routine care.
• Maintaining Eligibility – reading mail, sending back information, getting check-ups
• THSteps Program Knowledge - under age 21 – preventive check-ups, medical and dental
• Check-up Schedule & Components – when check up is due and what happens at check-up
• Medical and Dental Providers – Give choices/handout or we can have a list mailed, immediate call 1-877-847-8377.
• How to Schedule an Appointment – offer to help or give the toll free number; keeping/canceling appts
• Case Management for Children/Pregnant Women– health risk or health condition, trouble finding services, CMI Script
• Medical Transportation - available benefit, call for transportation assistance
• CHIP – any uninsured children in the household?
• WIC –Pregnant Women or child in the family who is under 5
• Summary -HCO Provided, Enrollment information, Dr. No., Verify address and phone, assistance scheduling appointment.

Health Care Orientation/Enrollment Script STAR/PCCM Expansion/FFS/STAR+PLUS (except for Dual Eligibles)

Expanded (Effective 11/1/06)

Introduction

Standard Greeting to include your name, program and purpose for calling. For example: Hello, may I speak with [case name]: Hello, Mr/Mrs_______________________. My name is _________________. Since your child/children are new to Medicaid, a state law requires that you received what is known as a Health Care Orientation. This will only take a few minutes and I will give you some valuable information about how to use your child's/children's Medicaid benefits. Your Health and Human Services Commission caseworker is likely to follow up with you to make sure you have received this information.

Did I verify the caller's identity?

8 Steps to VERIFICATION and ENROLLMENT

• Medicaid ID No. or SSN-Do you have your Medicaid ID form handy? Will you read the number that appears on your letter to the left of your child's name.
• Name-Is this the name of your child?
• Address-Are you still living at this address.
• Primary Language Spoken in Home-Ask and Document what language
• Phone No. -Is this the correct phone number?
• DOB-Is this your child's date of birth?
• Third Party Resources (Private Insurance)-Does your child have any private health insurance?
• Pregnancy-Are you or anyone in your home pregnant at this time?
• Special Questions: Ask at initial enrollment only

15 Steps to EDUCATION

Health Plan Information-Only for Managed Care Areas

1. Explain Managed Care and Primary Care Provider. STAR/STAR+PLUS: "Let me tell you a little about the STAR/STAR+PLUS program. The STAR/STAR+PLUS program is the Medicaid Managed Care program plans in your area." Managed care means that you will receive your Medicaid services through a health plan. You only have 30 days from the date you are certified to select a health plan and a primary care provider. The primary care provider can be a doctor, specially trained nurse, clinic or health center. If you don't choose, the STAR/STAR + PLUS program will pick a health plan and primary care provider for you. The primary care provider is available 24 hours a day, 7 days a week to coordinate care for you and/or your child/children. Have you received an enrollment packet? This is a large white envelope with the different health plan booklets, enrollment form and instructions. Have you already enrolled? If not, I will be glad to help you enroll today! (or change plan if they have been defaulted) PCCM Expansion: "Let me tell you a little about the PCCM program. The PCCM program is the Medicaid managed care program in your area." The PCCM program will send you a welcome letter and a member handbook for your child/children. The Medicaid ID Form will show you a Primary Care Provider called a PCP. The PCP can be a doctor, specially trained nurse, clinic or health center. The PCP is available 24/7 to coordinate care for your child/children.
2. Explain about primary care providers and emergency rooms. Your child's primary care provider is the one you contact first when your child/children needs/need any kind of medical health care. Unless it is an emergency, you should contact your primary care provider before you take your child to the emergency room. An emergency would be a problem or condition, including severe pain that is so serious that waiting for routine care might result in serious harm. In an emergency, you may not have time to contact the primary care provider, in that case, call 911 or take your child to the nearest emergency room.
3. Explain referrals: Referrals to specialists for both STAR/STAR+PLUS and PCCM Expansion recipients must be obtained through the primary care provider. However, families do not need a referral for the following services: Family Planning, Eye Care, Behavioral Health and THSteps medical/dental check-ups. The primary care provider will refer your child/children to specialists or hospitals when needed.
4. Preventive check-ups: THSteps: Recipients under 21 are eligible for preventive medical and dental checks-ups through THSteps program no matter what service delivery system is in their area. STAR/STAR+PLUS: Adults get one annual preventive exam per year. PCCM Expansion: Adults will receive services currently eligible in traditional Medicaid.
5. Tell the family the effective date of the enrollment: Once you enroll in a health plan, it will take 15-45 days before you get a Medicaid ID card that shows your new health plan choice. You will get Medicaid services the same way you do now until you get that new Medicaid ID (meaning they can still seek care from any Medicaid provider). PCCM Expansion recipients are automatically enrolled.
6. Enroll family if they are in a STAR/STAR+PLUS area. Once the family has enrolled, provide them with the name and phone number of their health plan and the primary care provider. If the family is in the PCCM Expansion area, PCCM will send you a welcome letter and a member handbook for your child/children. The Medicaid ID form will list the primary care provider for your (child/children). You will need to contact the PCCM helpline if you want to change their primary care provider. (For pregnant women, go to #8)
7. Explain the recipients will receive a Medicaid ID Form each month. STAR/STAR+PLUS: After the recipient is enrolled in the STAR/STAR+PLUS program, the name of the plan and plan phone number will be listed on the Medicaid ID form. The recipient will also receive a member ID card from the plan (except in the PCCM expansion area). PCCM Expansion: If the recipient is enrolled in the PCCM plan, the provider name and plan phone number will be listed on the Medicaid ID form.
8. Pregnant Women: If applicable, expand education to include TP40 (pregnant women) I information.
   STAR/STAR+PLUS: Pregnant woman - ask "Are you currently seeing a provider for your prenatal care?" Inform - Pregnant women must choose a plan and primary care provider within 15 days from their Medicaid application. The enrollment will take effect as soon as the recipient is found eligible for Medicaid. All efforts will be made to expedite the enrollment. If that is not possible, the enrollment will be effective within 15-45 days. Remind the recipient the importance of selecting a plan for herself and the baby since the recipient will not be able to change the baby's plan until the baby is three months old. After the baby is born, the recipient should call the plan to pick a primary care provider for the baby. Explain when the STAR Program is effective for pregnant women. If the pregnant woman's Medicaid is certified before the 10th of the month, the enrollment is effective the first day of the certification month (retroed). If the pregnant woman's Medicaid is certified after the 10th of the month, the enrollment is effective the first day of the month following the certification date (prospective).
   
   PCCM Expansion: SAVERR/TIERS automatically establishes an enrollment in PCCM for all mandatory recipients at certification. Enrollments are prospective. (Depends on certification date and state cutoff). Direct recipient to contact PCCM to change PCP for herself and/or newborn.
   
   Note for Pregnant Women: If a pregnant woman has 12 weeks or less remaining in her pregnancy (third trimester), she may choose to remain with her current OB/GYN for the remainder of her pregnancy, delivery, and postpartum checkup, even if the OB/GYN does not participate with the chosen health plan.
9. Changes:
   STAR/STAR+PLUS recipients can change their primary care provider up to 4 times a year; they can have unlimited changes in health plan (however, there are time restrictions – each health plan change can take 15-45 days). Call the STAR helpline to change the health plan and call the health plan directly to request a primary care provider change. PCCM expansion recipients need to call the PCCM helpline to change their PCP.

Medicaid Program Knowledge

• Medicaid pays for you or your child's care when they go to the doctor, if they are in the hospital, if they go to the dentist and if they go to a specialist. It will also pay for prescriptions, shots, transportation to any Medicaid covered service, and for behavioral health services. It also pays for preventive medical and dental checkups for children under age 21 through the Texas Health Steps program even when they are not sick.
• Medicaid only pays providers like doctors, dentists, specialists and hospitals. You should not get any bills. However, if you get a bill don't pay it. First call the provider and find out why they did not send the bill to Medicaid. Make sure your provider has the Medicaid ID number needed for billing. If the recipient is on STAR/STAR+PLUS direct them to call their health plan. If they are in PCCM Expansion, direct them to call the PCCM helpline. If they are on fee for service direct them to call the number on the back of Medicaid ID Form for Billing questions 1-888-834-7406.

Medicaid ID Form-Process

• Ask the family if they have received their Medicaid ID form. If not, explain it is a form they will receive once a month as long as they are on Medicaid. Describe the Medicaid ID form. Explain it is sometimes called a card but it is actually a letter sized sheet of paper. STAR/STAR+PLUS: The STAR or STAR+PLUS logo will be on the top right side of the Medicaid ID form. Their STAR or STAR+PLUS health plan will also be listed on the form. PCCM Expansion: PCCM logo will be listed on the top right corner of the Medicaid ID form.
• Remind the family to take the Medicaid ID form to the doctor, dentist, pharmacy or every time they are obtaining a Medicaid service.
• Explain to the family if they do not receive their Medicaid ID form in the next couple of weeks, to contact their local HHSC office.
• Explain to the family a reminder message is noted on the Medicaid ID form when the child's THSteps Medical and/or Dental check-up is due. It is located directly under the recipient's name. Remind the family that even when the message comes off the Medicaid ID form that the child is eligible for all necessary medical and dental services except the check-up.

Maintaining Eligibility

• Follow up with any paper work you get from the Health and Human Services Commission (also called HHSC). HHSC reviews your case from time to time, usually every 6 months and so it is very important to complete the paperwork to keep your child/children on Medicaid.
• It is a requirement to get your health care orientation (we are providing that right now) and for your children to receive their THSteps preventive check-ups to avoid having to go to the office for a face to face interview or to be required to return follow-up information at your review.

THSteps Program Knowledge

• THSteps is Medicaid for people in Texas under age 21. It includes regularly scheduled medical and dental check-ups to make sure your children are growing up healthy, as well as when your children are sick. Regular check-ups find health problems while they are still small and easily treated.

Check-up Schedule & Components

• Explain to the family when each child is due for a medical check-up according to their date of birth following the periodicity schedule. Give the family a wallet card, Check-ups and a Whole Lot More brochure and the Visits to the Doctor/Dentist brochure if in person.
• Explain that the children are eligible for a dental check-up beginning age 1 and every 6 months thereafter.
• Review components of both the medical and dental check-up for each child by age (see attached chart)
• Remind the family if a medical or dental problem is found during the check-up THSteps and is medically necessary, Medicaid will cover the follow up treatment.
• Your child/children may receive an excused absence from school for medical and dental appointments

Dental Providers

• Do you have a dentist who accepts Medicaid?
• Provide list of at least three providers in the individual's area so they can choose. A list can be mailed upon request. If family wants a list immediately request they call the helpline.

Medical Providers
PCCM / Traditional Medicaid

• Have you checked with your PCP to see if he/she will do the THSteps medical check-up? You can get a THSteps check-up from any THSteps provider if your PCP does not do the check-ups. It is important to have a medical home for your child. A medical/dental home is when you have a provider who treats your child regularly, who knows your child's health condition and has the responsibility for keeping your child's medical records and for coordinating medical care. If you family needs help finding a THSteps provider call the THSteps helpline at 1-877-847-8377. It is open 8 a.m. to 8 p.m. Central time. It is a free call.

Managed Care

• Encourage family to go to PCP for THSteps Check-up if provider does check-up
• Explain if PCP doesn't do THSteps Check-up call Plan for THSteps provider
• If enrollment into STAR has not processed yet, they can use any Medicaid provider for service until the enrollment is effective.

Scheduling the Appointment

• If the family has already chosen a THSteps Medical, Dental or Case Management Provider ask if they would like help scheduling an appointment. If they say yes and would like do a three way call with the provider's office, please process if your phone is capable or ask them to call the Customer Care Center for assistance.
• If they have not yet chosen a provider tell the family we would be happy to help them schedule an appointment when they choose a provider by calling the THSteps helpline at 1-877-847-8377.

Case Management for Children and Pregnant Women (CPW)-see the special services script

Medical Transportation Program (MTP)

• Explain the Medical Transportation Program is available for all Medicaid covered services to those with full Medicaid (not QMB, SLMB) that do not have any other means of transportation.
• Call at least 2 days before appt. and be prepared with your name, Medicaid ID, doctor's name, phone, address, date and time of appointment.

Three Ways to travel:

• If you don't have a car and you don't have anyone else to drive you, the Medical Transportation Program will help. This may be by bus tokens;
• If you don't have a car and don't have gas money to pay someone else, the Medical Transportation Program can pay for someone to take you.
• If you have a car, but no gas money, the Medical Transportation Program can pay you gas reimbursement by the mile.
• Call 1-877-MED TRIP or 1-877-633-8747

Children's Health Insurance Program (CHIP)

• If anyone in household is under age 19 does not have health insurance, explain they may be eligible for some type of state funded health insurance. The may call 1 800-647-6558 to apply for CHIP and Children's Medicaid.

WIC (Women, Infant, and Children's Program)

• Explain WIC is a supplemental nutrition education program to provide nutritious foods to help women, infants and children improve on their nutrition. If you are receiving Medicaid, you are income eligible for the program, but will have to complete a nutritional screening to receive benefits.
• If pregnant or a postpartum woman, or a child in household under 5 lives in the household, give the parent the 1-800-942-3678 number to locate their nearest WIC office to them.

Summary

• Any Questions regarding THSteps or Medicaid?
• Inform individual that they have received a "Health Care Orientation"
• Verify individual information, phone number, migrant status, any other children in the household
• If enrolled, recap enrollment information include PCP and health plan.
• Follow up questions about having a medical or THSteps appointment or scheduled a medical or THSteps appointment since certification date (on list).
• Provide toll free number for future assistance. Thank the person for their time.
• If in person, provide literature and "Helpful Toll Free Number" handout.

Medical Check-up components include:

Dental Check-up Components include*:

* Emergency dental services are available at any age (do not require a check on ID)

C—1120  IRS Tax Code

All Programs

§7213. Unauthorized Disclosure of Information

1. Returns and Return Information
   1. Federal employees and other persons — It shall be unlawful for any officer or employee of the United States or any person described in section 6103(n) (or an officer or employee of any such person), or any former officer or employee, willfully to disclose to any person, except as authorized in this title, any return or return information [as defined in section 6103(b)]. Any violation of this paragraph shall be a felony punishable upon conviction by a fine in any amount not exceeding $5,000, or imprisonment of not more than 5 years, or both, together with the costs of prosecution, and if such offense is committed by any officer or employee of the United States, he shall, in addition to any other punishment, be dismissed from office or discharged from employment upon conviction for such offense.
   2. State and other employees — It shall be unlawful for any person [not described in paragraph (1)] willfully to disclose to any person, except as authorized in this title, any return or return information (as defined in section 6103(b)] acquired by him or another person under subsection (d), (i)(3)(B)(i), (1), (6), (7), (8), (9), (10), (12), or (15) or (16) or (m)(2), (4), (5), (6), or (7) of section 6103. Any violation of this paragraph shall be a felony punishable by a fine in any amount not exceeding $5,000, or imprisonment of not more than 5 years, or both, together with the cost of prosecution.
   3. Other persons — It shall be unlawful for any person to whom any return or return information [as defined in section 6103(b)] is Disclosed in any manner unauthorized by this title thereafter willfully to print or publish in any manner not provided by law any such return or return information. Any violation of this paragraph shall be a felony punishable by a fine in any amount not exceeding $5,000, or imprisonment of not more than 5 years, or both, together with the cost of prosecution.
   4. Solicitation — It shall be unlawful for any person willfully to offer any item of material value in exchange for any return or return information [as defined in 6103(b)] and to receive as a result of such solicitation any such return or return information. Any violation of this paragraph shall be a felony punishable by a fine in any amount not exceeding $5,000, or imprisonment of not more than 5 years, or both, together with the cost of prosecution.
   5. Shareholders — It shall be unlawful for any person to whom return or return information [as defined in 6103(b)] is disclosed pursuant to the provisions of 6103(e)(1)(D)(iii) willfully to disclose such return or return information in any manner not provided by law. Any violation of this paragraph shall be a felony punishable by a fine in any amount not exceeding $5,000, or imprisonment of not more than 5 years, or both, together with the cost of prosecution.

§7213A. Unauthorized Inspection of Returns or Return Information

1. Prohibitions
   1. Federal employees and other persons — It shall be unlawful for
      1. any officer or employee of the United States, or
      2. any person described in section 6103(n) or an officer willfully to inspect, except as authorized in this title, any return or return information.
   2. State and other employees — It shall be unlawful for any person not described in paragraph (1)] willfully to inspect, except as authorized by this title, any return information acquired by such person or another person under a provision of section 6103 referred to in section 7213(a)(2).
2. Penalty
   1. In general — Any violation of subsection (a) shall be punishable upon conviction by a fine in any amount not exceeding $1,000, or imprisonment of not more than 1 year, or both, together with the costs of prosecution.
   2. Federal officers or employees — An officer or employee of the United States who convicted of any violation of subsection (a) shall, in addition to any other punishment, be dismissed from office or discharged from employment.
3. Definitions — For purposes of this section, the terms "inspect," "return," and "return information" have respective meanings given such terms by section 6103.

§7431 Civil damages for unauthorized disclosure of returns and return information

1. In General
   1. Inspection or disclosure by employee of United States — If any officer or employee of the United States knowingly, or by reason of negligence, inspects or discloses any return or return information with respect to a taxpayer in violation of any provision of section 6103, such taxpayer may bring a civil action for damages against the United States in a district court of the United States
   2. Inspection or disclosure by a person who is not an employee of United States — If any person who is not an officer or employee of the United States knowingly, or by reason of negligence, inspects or discloses any return or return information with respect to a taxpayer in violation of any provision of section 6103, such taxpayer may bring a civil action for damages against such person in a district court of the United States.
2. Exceptions — No liability shall arise under this section with respect to any inspection or disclosure
   1. which results from good faith, but erroneous, interpretation of section 6103, or
   2. which is requested by the taxpayer.
3. Damages — In any action brought under subsection (a), upon a finding of liability on the part of the defendant, the defendant shall be liable to the plaintiff in an amount equal to the sum of
   1. the greater of
      1. $1,000 for each act of unauthorized inspection or disclosure of a return or return information with respect to which such defendant is found liable, or
      2. the sum of
         1. the actual damages sustained by the plaintiff as a result of such unauthorized inspection or disclosure, plus
         2. in the case of a willful inspection or disclosure or an inspection or disclosure which is the result of gross negligence, punitive damages, plus
   2. the costs of the action.
4. Period for Bringing Action — Notwithstanding any other provision of law, an action to enforce any liability created under this section may be brought, without regard to the amount in controversy, at any time within 2 years after the date of discovery by the plaintiff of the unauthorized inspection or disclosure.
5. Notification of Unlawful Inspection and Disclosure — If any person is criminally charged by indictment or information with inspection or disclosure of a taxpayer's return or return information in violation of
   1. paragraph (1) or (2) of section 7213(a);
   2. section 7213A(a); or
   3. subparagraph (B) of section 1030(a)(2) of title 18, United States Code, the Secretary shall notify such taxpayer as soon as practicable of such inspection or disclosure.
6. Definitions — For purposes of this section, the terms inspect, inspection, return, and return information have the respective meanings given such terms by section 6103(b).
7. Extension to Information Obtained Under Section 3406 — For purposes of this Section
   1. any information obtained under section 3406 [including information with respect to any payee certification failure under subsection (d) thereof] shall be treated as return information, and
   2. any inspection or use of such information other than for purposes of meeting any requirement under section 3406 or (subject to the safeguards set forth in 6103) for purposes permitted under section 6103 shall be treated as a violation of section 6103.

For purposes of subsection (b), the reference to section 6103 shall be treated as including a reference to section 3406.

C—1130  EBT Charts and Guides

C—1131  Advisor Guide for Explaining EBT

TANF and SNAP

Instruct the cardholder to read Form H1185, Welcome to Your Lone Star Card, and be prepared to ask questions about any Electronic Benefit Transfer (EBT) issuance procedures he does not understand. Advisors must also explain:

• procedures for Lone Star Card issuance and personal identification number (PIN) issuance/self-selection to access benefits including:
  • primary cardholder and secondary cardholder (including how to establish a secondary cardholder);
  • how access is limited to a person with both the card and the PIN;
  • that there is no charge for using the Lone Star Card for food account purchases; and
  • that to obtain benefits they need to have a card, PIN and available benefits.
• when applicants will be able to use their initial benefits, if certified, and explain the availability of monthly benefits as specified in Form H1184, Benefit Issuance Schedule.
• how and where to use the Lone Star Card including:
  • how to make a purchase (and/or cash withdrawal for TANF), availability of receipts and the need to save EBT receipts to keep track of account balance(s);
  • how to identify stores accepting Supplemental Nutrition Assistance Program (SNAP)/Lone Star Cards and how to ask store personnel if the store provides TANF cash-back services; and
  • the TANF cash-back policy. See B-239.1, Advisor Interview Requirements for Client Training.
• card/PIN security including:
  • how to keep their benefits secure;
  • what to do if a card is lost or stolen or the PIN is compromised; and
  • that HHSC will not replace benefits used before a card is reported lost or stolen to the Lone Star help desk.
• the dormant account policy. If the cardholder does not access the EBT account for a limited number of consecutive months, the individual's benefits become dormant. Individuals may still access benefits in their EBT account. See B-361, Dormant Account Policy.
• procedures when moving out of Texas including the:
  • use of the Lone Star Card to access:
    • TANF at retailers in other states; or
    • SNAP benefits at retailers; and
  • recommendation to withdraw all available cash benefits from the cash account before leaving the state.

    Note: HHSC may mail a benefit conversion warrant (full month's TANF benefit only) to the household's new address if the:

    • cardholder cannot find a retailer that accepts the Lone Star Card; and
    • household moved out of state on or after the first of the month but before accessing that month's TANF benefits. See B-331, Cancelling Benefits in EBT Accounts.

C—1132  Issuance Staff Guide for EBT Issuance and Client Training

TANF and SNAP

After you receive Form H1172, EBT Card/Pin Issuance and Data Entry Request, authorizing an initial Lone Star card and PIN to the primary cardholder, take the following actions:

• Issue and briefly explain the:
  • Lone Star card;
  • card sleeve;
  • Form H1183, EBT Pocket Guide;
  • PIN packet, if applicable;
  • Form H1184, Benefit Issuance Schedule; and
  • second cardholder form.
• If you give the Lone Star card to someone other than the primary card holder, then:
  • explain the use of each item to the person receiving the card;
  • place a registration sticker on the card; and
  • if applicable, mail the PIN packet to the primary cardholder.
• If you mail the Lone Star card to the primary cardholder, then:
  • place a registration sticker on the card;
  • place the card in the card mailer;
  • mail the card and all training materials to the primary cardholder in the EBT mailing envelope; and
  • if applicable, mail the PIN packet separately.

  Note: The PIN packet is a self mailing envelope that must be addressed and mailed separately from the card.

• Explain:
  • the importance of saving the last receipt for the current account balance(s);
  • card registration, if required;
  • the requirement for the primary cardholder to sign the back of the card;
  • how to protect the card and what to do if it is lost or stolen; and
  • how to protect the PIN and what to do if it is compromised.
• Advise the individual to call the toll-free Lone Star help desk (1-800-777-7EBT or 1-800-777-7328) if they have problems accessing benefits or additional questions.

C—1140  TANF and SNAP Overpayment Determination Chart

C—1141  Timely Reported

TANF and SNAP

When the individual reports a change timely (i.e., individual reported within 10 days of knowing of the change), use B-600, Changes, B-732, Errors After Certification, and the following chart to determine the first month of overpayment.

Note: The first month of overpayment can be no later than two months from the month the change occurred.

C—1142  Untimely Reported

TANF and SNAP

When the individual fails to report a change timely (i.e., does not report a change later discovered by HHSC or untimely reports a change), use B-600, Changes, B-732, Errors After Certification, and the following chart to determine the first month of overpayment.

Note: The first month of overpayment can be no later than two months from the month the change occurred.