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Table of Contents STAR PROGRAM TABLE OF CONTENTS INTRODUCTION PRIMARY CARE PROVIDERS PHYSICIAN INCENTIVE PLAN INFORMATION CHANGING HEALTH PLANS

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STAR PROGRAM

Table of Contents

TABLE OF CONTENTS

INTRODUCTION

About Managed Care ... 1

Important Telephone Numbers and Information ... 1

El Paso First Premier Plan Identification Card ... 3

Your Texas Benefits Medicaid Card ... 5

PRIMARY CARE PROVIDERS What do I need to bring with me to my doctor’s appointment? ... 9

What is a Primary Care Provider?... 9

How can I change my Primary Care Provider? ... 9

Can a specialist ever be considered a Primary Care Provider? ... 10

Can a clinic (RHC/FQHC) be my Primary Care Provider? ... 10

How do I pick a new Primary Care Provider? ... 10

How many times can I change my/my child’s Primary Care Provider? ... 11

When will my Primary Care Provider change become effective? ... 11

Reasons why a request to change a Primary Care Provider may be denied ... 11

Can my Primary Care Provider request that I be changed to another Primary Care Provider? ... 11

What if I pick to go to another doctor who is not my Primary Care Provider? ... 12

What is the Medicaid Lock-in Program? ... 12

PHYSICIAN INCENTIVE PLAN INFORMATION ... 13

CHANGING HEALTH PLANS What if I want to change health plans? Who do I call? ... 13

How many times can I change health plans? ... 13

When will my health plan change become effective? ... 13

Can El Paso First Premier Plan request that I leave their plan? ... 13

BENEFITS What are my Medicaid Health Care Benefits? ... 14

How do I obtain these services? ... 14

Are there any limits to any covered service? ... 15

What services are Not Covered by Medicaid? ... 15

What are my prescription drug benefits? ... 15

What extra benefits do I get as a Member of El Paso First Premier Plan? ... 16

How do I get these benefits? ... 16

What health education classes does El Paso First Health Plans offer? ... 16

What other services can El Paso First Health Plans help me with? ... 17

HEALTH CARE AND OTHER SERVICES What does “Medically Necessary” mean? ... 18

What is routine medical care? ... 19

What is urgent medical care? ... 19

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Are Emergency Dental Services covered by the health plan? ... 21

What do I do if I need Emergency Dental Care? / What do I do if my child needs Emergency Dental Care? ... 22

What is post-stabilization? ... 22

How do I get medical care after my Primary Care Provider’s office is closed? ... 22

Extended and After Hours Night Clinics ... 22

What if I get sick when I am out of town or traveling? ... 24

What if I am out of state? ... 24

What if I am out of the country? ... 24

What if I need to see a special doctor (specialist)? ... 24

What is a referral? ... 24

What services do not need a referral? ... 25

How can I request a second opinion? ... 25

How do I request authorization for specialty medical services? ... 25

How do I get help if I have behavioral (mental) health or substance (drug) abuse problems? ... 25

What are mental health rehabilitation services and mental health targeted case management?... 26

How do I get my medications? ... 26

What if I need durable medical equipment (DME) or other products normally found in a pharmacy? ... 27

How do I get family planning services? ... 27

Case Management for Children and Pregnant Women ... 27

What is Early Childhood Intervention (ECI)? ... 28

What is Texas Health Steps? ... 28

What services are offered by Texas Health Steps? ... 28

How and when do I get Texas Health Steps medical and dental checkups for my child? ... 29

Does my doctor have to be part of the El Paso First Health Plans network? ... 29

Do I have to have a referral? ... 30

What if I need to cancel an appointment? ... 30

What if I am out of town and my child is due for a Texas Health Steps exam? ... 30

What if I am a Migrant Farm Worker? ... 30

Medical Transportation Program (MTP) ... 30

How do I get eye care services? ... 31

How do I get dental services for my child? ... 31

Can someone interpret for me when I talk with my doctor? ... 31

What if I need OB/GYN care? ... 31

How do I pick an OB/GYN? ... 32

Can I stay with my OB/GYN if they aren’t with El Paso First? ... 32

What if I am pregnant? ... 32

What other services or activities does El Paso First Health Plans, Inc. offer pregnant women? ... 33

What services will El Paso First provide me and my baby when I deliver? ... 33

Can I pick a Primary Care Provider before my baby is born? ... 33

Can I switch my baby’s health plan? ... 34

How do I sign up my newborn baby? ... 34

How can I receive healthcare after my baby is born (and I am no longer covered by Medicaid)? ... 34

Who do I call if I have special health care needs and need someone to help me? ... 35

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What if I am too sick to make a decision about my medical care? ... 36

What happens if I lose my Medicaid coverage? ... 38

What if I get a bill from my doctor? ... 39

What do I have to do if I move? ... 39

What if I have other insurance in addition to Medicaid? ... 39

RIGHTS AND RESPONSIBILITIES Member Rights and Responsibilities ... 40

COMPLAINTS PROCESS What should I do if I have a complaint? ... 42

How long will it take to process my complaint? ... 42

Can someone from El Paso First help me file a complaint? ... 43

APPEAL PROCESS What can I do if my doctor asks for a service or medicine for me that’s covered but El Paso First denies it or limits it? ... 43

How will I find out if services are denied? ... 43

What are the timeframes for the appeal process? ... 44

When do I have a right to ask for an appeal? ... 44

Can I continue to receive my medical services that El Paso First has already approved? ... 44

Does my appeal have to be in writing? ... 44

Can someone from El Paso First help me file an appeal? ... 45

What is a Fair Hearing and when can I request one? ... 45

EXPEDITED EL PASO FIRST APPEAL What is an expedited appeal? ... 45

How do I request an expedited appeal? ... 45

Does my request have to be in writing? ... 45

What are the timeframes for an expedited appeal? ... 45

What happens if El Paso First denies the request for an expedited appeal? ... 46

Who can help me file an expedited appeal? ... 46

STATE FAIR HEARING Can I ask for a State Fair Hearing? ... 46

FRAUD AND ABUSE Do you want to report Waste, Abuse, or Fraud? ... 47

INFORMATION THAT MUST BE AVAILABLE ON A YEARLY BASIS ... 48

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Member Handbook

MEMBER HANDBOOK

Introduction to El Paso First Premier Plan’s STAR Program

Thank you for choosing El Paso First!

El Paso First Health Plans, Inc. is happy to welcome you to our El Paso First Premier Plan family. Your child will get covered benefits and services from doctors, hospitals and other medical care providers who are part of the El Paso First network of providers. El Paso First Health Plans Inc. and El Paso First Premier Plan, work in partnership with you to provide for you and your families’ health care needs.

El Paso First is a Health Maintenance Organization that provides services to people eligible for the health plan. El Paso First Health Plans will provide or arrange for covered services to be

available to members enrolling in the health plan.

About Managed Care

El Paso First Premier Plan is a managed health care program. Managed care allows you to pick your child’s primary care provider. This primary care provider could be a doctor, nurse practitioner, or a physician assistant. For this handbook, we will call the primary care provider “doctor or primary care provider (PCP).”

The biggest advantage of managed care is that your child will have his/her own doctor. This doctor makes sure your child gets all the health care they need. It is not up to you to find the services and arrange for those services. You have a doctor who will give you the information you need to make good choices about your child’s treatment.

Important Telephone Numbers and Information

EL PASO FIRST HEALTH PLANS, INC.

1145 Westmoreland Dr.

El Paso, Texas 79925

915-532-3778 or 1-877-532-3778

Monday – Friday, during regular business hours 8 a.m. to 5 p.m., Mountain Time

excluding state approved holidays. Call center hours of operation are 7 a.m. to 5 p.m.

After Hours Answering Service

If you call after regular business, weekend, and holiday hours, El Paso First will still answer your phone call. We have bilingual staff working during the evening hours that can give you the infor-mation you need, or take your message and have someone from our Member Services

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Member Services Helpline

If you need help understanding or reading this Member Handbook, call the Member Services

Helpline at 915-532-3778 or 1-877-532-3778. This number is avail able 24 hours a day 7 days a

week. Our Member Services staff is made up of highly qualified and trained people, fluent in both English and Spanish. They will gladly help you understand this handbook.

Our Member Services Department can also:

n Explain what services are covered

n Help you pick a Primary Care Provider if you do not have one

n Help you find a Primary Care Provider close to your home

n Help you change your Primary Care Provider

n Help send new ID cards

n Tell you what you need to do when you move out of the area

n We will transfer members to 211 to change your address or phone number

n Explain how to get free transportation services

n Listen to your complaints and concerns

n Tell you about classes, health fairs, and other special events in your area

If you need the Member Handbook in audio, larger print, Braille, or another language, just call the

El Paso First Health Plans, Inc. Member Services Helpline at 915-532-3778 or 1-877-532-3778

to request it.

In case of emergency call 911 or go to the closest emergency room. After treatment, call your

Primary Care Provider within 24 hours or as soon as possible.

Behavioral Health and Substance Abuse Helpline/Drug and Alcohol Treatment

El Paso First also has mental health and drug abuse services. If you need help, our phone

number is 915-532-3778 or “Toll-Free” 1-877-532-3778.

Sometimes you might need help with a personal or family problem. If you have an emergency and you need help, please call our crisis line at “Toll-Free” 1-877-377-6147. You can get behavioral health or substance abuse help when you need it. This line is open 24 hours a day, 7 days a week. A qualified and trained person, fluent in both English and Spanish, will be there

to help you.

NOTICE OF SPECIAL TOLL-FREE COMPLAINT NUMBER

TO MAKE A COMPLAINT ABOUT A PRIVATE PSYCHIATRIC HOSPITAL, CHEMICAL DEPENDENCY TREATMENT CENTER, OR PSYCHIATRIC OR CHEMICAL DEPENDENCY SERVICES AT A GENERAL HOSPITAL, CALL:

1-800-832-9623

Your complaint will be referred to the state agency that regulates the hospital or chemical dependency treatment center.

Interpreter Services

Interpreter services are available through our Member Services Department. Call 915-532-3778

if you are in El Paso or 1-877-532-3778.

TTY Line for the Hearing Impaired

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Transportation

For free transportation to a doctor’s appointment, call the El Paso First Member Services Help

Line at 915-532-3778 or 1-877-532-3778.

Other helpful numbers:

n The STAR Program Helpline number is 1-800-964-2777.

n The Medical Transportation Program Helpline number is 1-877-633-8747.

n For questions regarding Eye Care Services, please call 915-532-3778 or 1-877-532-3778.

n Medicaid Managed Care Helpline 1-866-566-8989; Medicaid Managed Care Helpline

TDD# 1-866-222-4306.

n For pharmacy information, please call El Paso First at 915-532-3778 or 1-877-532-3778.

n For questions about Dental Services call:

DentaQuest 1-800-516-0165 or MCNA Dental 1-800-494-6262

n Finding Help in Texas, please call 2-1-1.

El Paso First Premier Plan Identification Card

When you become a member of El Paso First Premier Plan, you will get an El Paso First Premier Plan ID card. This card will show important information about you, and the name and phone num ber of your primary care provider (PCP). Carry your ID card and the Your Texas Benefits Medicaid Card with you at all times. You must show both when you get medical care or medicine.

You will not get a new El Paso First Premier Plan ID card every month. El Paso First Premier Plan will mail you a new ID card when:

n You change your Primary Care Provider

n Your Primary Care Provider’s address or phone number changes

n You get a new address or phone number

If you lose your ID card, you will need to ask for a new one. Call El Paso First Health Plans, Inc.

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Your El Paso First Premier Plan ID card shows:

n The Name of the Health Plan – El Paso First Premier Plan n Member Name – This is your name

n Member Number – This is your Medicaid ID Number

n DOB – This is your birth date

n Name, address, and phone number of your Primary Care Provider –

This is your Primary Care Provider’s information. You should call your Primary Care Provider for all medical needs.

n The back of the ID card has important information for you and your Primary Care Provider.

Remember to call the Primary Care Provider listed on the front of your card for appoint-ments. Call your Primary Care Provider before going to a special doctor (specialist). It also has information on Behavioral (mental) Health and Substance Abuse Helpline

1-877-377-6147. You can call this number 24 hours a day if you have questions or

prob-lems about behavioral (mental) health and substance abuse (such as alcohol or drugs) and it also tells you what to do in an emergency. Be sure to read the back of your card. There is important information which will be used by your Primary Care Provider and other health care providers.

n The front of the ID card also has some important phone numbers. Member Services

Helpline (915-532-3778 or 1-877-532-3778) – You can call this number 24 hours a day

if you have questions or problems about El Paso First Premier Plan or El Paso First Health Plans, Inc. Call this number if you want to change your Primary Care Provider. Remember to show the Your Texas Benefits Medicaid Card and El Paso First Premier Plan ID card whenever you go to the doctor or get any other health care.

If you lose your card or did not get one, call El Paso First Health Plans, Inc. Member Services

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Your Texas Benefits Medicaid Card

When you are approved for Medicaid, you will get a Your Texas Benefits Medicaid Card. This plastic card will be your everyday Medicaid ID card. You should carry and protect it just like your driver’s license or a credit card. The card has a magnetic stripe that holds your Medicaid ID num-ber. Your doctor can use the card to find out if you have Medicaid benefits when you go for a visit. You will only be issued one card, and will only receive a new card in the event of the card being lost or stolen. If your Medicaid ID card is lost or stolen, you can get a new one by calling toll-free

1-855-827-3748.

If you are not sure if you are covered by Medicaid, you can find out by calling toll-free at

1-800-252-8263. You can also call 2-1-1. First pick a language and then pick option 2.

Your health history is a list of medical services and drugs that you have gotten through Medicaid. We share it with Medicaid doctors to help them decide what health care you need. If you don’t want your doctors to see your health history through the secure online network, call toll-free at

1-800-252-8263.

The Your Texas Benefits Medicaid card has these facts printed on the front:

n Your name and Medicaid ID number.

n The date the card was sent to you.

n The name of the Medicaid program you’re in if you get:

— Medicare (QMB, MQMB)

— Texas Women’s health Program (TWHP) — Hospice

— STAR Health

— Emergency Medicaid, or

— Presumptive Eligibility for Pregnant Women (PE).

n Facts your drug store will need to bill Medicaid.

n The name of your doctor and drug store if you’re in the Medicaid Lock-in program.

The back of the Your Texas Benefits Medicaid card has a website you can visit

www.YourTexas-Benefits.com and a phone number you can call toll-free 1-800-252-8263 if you have questions

about the new card.

If you forget your card, your doctor, dentist, or drug store can use the phone or the Internet to make sure you get Medicaid benefits.

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Information about the Temporary Verification Form 1027-A

The HHSC form 1027-A is called the Temporary Verification Form. It is to provide members who are eligible or may be eligible for Medicaid with a document verifying their eligibility. This form is only issued out when one of the following situations occurs:

n Has had his or her Medicaid eligibility related to foster care/adoption

n Has not had a Medicaid client number assigned

n His or her current Medicaid card has not been issued

n Has been lost or not accessible

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Client Eligibility

4

4.9.1 Medicaid Eligibility Verification (Form H1027-A)

Te xa s D ep ar tm en t of H um an S er vi ce s/ Fo rm 1 02 7-A / 1-20 00 N am e of P ha rm ac y/ N om br e de la F ar m ac ia Ea ch p er so n lis te d be lo w h as a pp lie d fo r an d is e lig ib le f or M ED IC A ID B EN EF IT S fo r th e da te s in di ca te d be lo w , bu t ha s no t ye t re ce ive d a cli ent nu mb er. Do n ot su bmit a cl ai m u nt il yo u ar e gi ve n a cl ie nt n um be r. P ha rm ac is ts h av e 90 d ay s fr om t he d at e th e nu m be r is is su ed t o fil e cl ea n cl ai m s. H ow ev er , c he ck y ou r pr ov id er m an ua l b ec au se ot he r pr ov id er s m ay h av e di ffe re nt fi lin g de ad lin es . C al l t he e lig ib ili ty w or ke r na m ed b el ow if y ou h av e no t be en g iv en t he c lie nt n um be r( s) w it hi n 15 d ay s. Ea ch p er so n lis te d be lo w is e lig ib le fo r M ED IC A ID B EN EF IT S fo r da te s in di ca te d be lo w . T he M ed ic ai d Id en ti fic at io n fo rm is lo st o r la te . T he c lie nt n um be r m us t ap pe ar o n al l cl ai m s fo r he al th s er vi ce s. BIN

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ST A R /S TA R +P LU S H EA LT H P LA N IN FO R M A TI O N IN FO RM AC IÓ N D EL PL AN D E SA LU D S TA R/ ST AR +P LU S Pl an N am e an d M em be r S er vi ce s To ll-Fr ee T el ep ho ne N o. N om br e de l P la n y el Te lé fo no d e Se rv ic io s pa ra M iem br os pa ra Lla m ar Gr at is Po r es te m ed io c er tif ic o, b aj o pe na p er ju rio y /o f ra ud e, q ue l os c lie nt es n om br ad os a rri ba h em os pe rd id o, n o he m os r ec ib id o o po r ot ra r az ón n o te ne m os e n nu es tro p od er l a Id en tif ic ac ió n pa ra M ed ic ai d (F or m a 30 87 ) de l c or rie nt e m es . S ol ic ité y r ec ib í e st a Co nfi rm ac ió n de E le gi bi lid ad M éd ic a (F or m a 10 27 -A ) pa ra c om pr ob ar n ue st ra e le gi bi lid ad p ar a M ed ic ai d du ra nt e el p er io do c ub ie rto es pe ci fic ad o ar rib a. C om pr en do q ue u sa r est a co nf irm ac ió n pa ra o bt en er b en ef ic io s (s er vi ci os o ar tíc ul os ) d e M ed ic ai d pa ra a lg un a pe rs on a no n om br ad a ar rib a co m o be ne fic ia rio c on st itu ye fr au de e s ca st ig ab le p or u na m ul ta y /o la c ár ce l. AD VE RT EN CI A: Si ust ed ac ep ta be ne fic io s de M ed ic ai d (s er vi ci os o ar tíc ul os ), ot or ga y c on ce de a l e st ad o de T ex as e l d er ec ho a re ci bi r p ag os po r l os s er vi ci os o a rtí cu lo s de o tra s co m pa ñí as de s eg ur os y o tra s fu en te s re sp on sa bl es , h as ta c om pl et ar la c an tid ad q ue s e re qu ie re p ar a cu br ir lo qu e h ay a ga st ad o M ed ic ai d. O ff ic e A dd re ss a nd T el ep ho ne N o. / O fic in a y Te lé fo no D at e Dat e THI S FOR M C OV ERS ON LY T HE D A TE S SH OW N B EL O W . I T IS N OT V A LI D F O R A N Y DA Y S BE FOR E O R A FT ER THE SE DA TE S. ES TA F O R M A ES V ÁL ID A S O LA M EN TE E N L AS F EC H AS IN D IC AD AS A B AJ O . N O E S V ÁL ID A N I A N TE S N I D ES PU ÉS D E E S TA S F EC H AS . W O R K ER S IG N A TU R E x SU P ER VI SO R S IG N A TU R E x N am e of D oc to r/ N om br e de l D oc to r Ve rif ic at io n M et ho d

Lo ca l D C U

SA VE R R D ire ct In qu iry

R eg io na l P ro ce du re

S. O . D CU ( A & D Sta ff) On ly ) MEDICAR E CLAIM NO. N Ú M . D E R EC LA M O D E M ED IC AR E W or ke r B JN Su pe rv is or * B JN *o r A ut ho riz ed L ea d W or ke r /* o Tr ab aj ad or E nc ar ga do EL IG IB IL IT Y D A TE S PE R IO D O D E E LE G IB IL ID AD Th ro ug h/ H ast a S ig na tu re –C lie nt o r R ep re se nt at iv e/ Fi rm a– Cl ie nt e o Re pr es en ta nt e D at e/ Fe cha N am e of W or ke r (t yp e) / N om br e de l T ra ba ja do r N am e of S up er vi so r* ( ty pe )/ N om br e de l S up er vi so r* Fr om / D es de eb y ce rt ify , u nd er p en al ty o f p er ju ry a nd /o r f ra ud , t ha t th e ab ov e cl ie nt (s ) ha ve lo st , h av e no t iv ed , or h av e no a cc es s to t he M ed ic ai d Id en ti fic at io n (F or m 3 0 87 ) fo r th e cu rr en t m on th . I r eq ue st ed a nd r ec ei ve d Fo rm 1 02 7-A , M ed ic ai d El ig ib ili ty V er ifi ca ti on , to u se a s pr oo f of ib ili ty fo r t he d at es s ho w n ab ov e. I un de rs ta nd t ha t us in g th is fo rm t o ob ta in M ed ic ai d be ne fit s vi ce s or s up pl ie s) f or p eo pl e no t lis te d ab ov e is f ra ud a nd i s pu ni sh ab le b y fin e an d/ or is on m en t. M ED ICA ID E LI G IB IL IT Y VE R IF IC A TI O N C O N FI R M AC IÓ N D E EL EG IB IL ID AD P AR A M ED IC AI D C LI EN T N O . C LI EN TE N Ú M. TI O N : If yo u ac ce pt M ed ic ai d be ne fit s (s er vi ce s or lie s) , y ou g iv e an d as si gn to th e st at e of T ex as y ou r t o re ce iv e pa ym en ts fo r t ho se s er vi ce s or s up pl ie s ot he r in su ra nc e co m pa ni es an d ot he r lia bl e ce s, up to th e am ou nt ne ed ed to co ve r w ha t ic ai d sp en t. D A TE O F B IR TH FE C H A D E N AC IM IE N TO El ig ib ili ty V er ifi ed C LI EN T N A M E N O M B R E D EL C LI EN TE

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Section 4 Fo rm 10 27 -A /P ag e 2 El c lie nt e de M ed ic ai d no t ie ne q ue p ag ar c ue nt as m éd ic as q ue M ed ic ai d de be pa ga r. E s m uy im po rt an te q ue u st ed d ig a in m ed ia ta m en te a s u m éd ic o, a l h os pi ta l, a la f ar m ac ia , y a ot ro s pr ov ee do re s de s er vi ci os m éd ic os q ue u st ed t ie ne M ed ic ai d. S i no l es d ic e qu e tie ne M ed ic ia d, p ue de q ue u st ed t en ga q ue p ag ar es ta s cu en ta s. S i us te d re ci be u na c ue nt a de u n do ct or , un h os pi ta l, u ot ro pr ov ee do r de s er vi ci os m éd ic os , pr eg un te p or q ué le m an dó la c ue nt a. S i t od av ía le m an da n un a cu en ta , lla m e al n úm er o di re ct o de M ed ic ai d al 1 -8 0 0 -2 5 2 -8 2 6 3 pa ra p ed ir ayu da . S i M ed ic ai d no v a a pa ga r l a cu en ta o s i s e ni eg an lo s be ne fic io s de M ed ic ai d (lo s se rv ic io s o lo s ar tíc ul os ), u st ed p ue de p ed ir po r es cr ito u na au di en ci a im pa rc ia l. La d ire cc ió n y el n úm er o de te lé fo no a pa re ce n en la c ar ta q ue re ci bi ó. N O TA : La s cl ín ic as d e pl an ifi ca ci ón f am ili ar y lo s ot ro s pr ov ee do re s of re ce n gr at is ex ám en es f ís ic os , an ál is is d e la bo ra to rio , m ét od os a nt ic on ce pt iv os ( in cl us iv e la es te ril iz ac ió n) y c on se je ría s ob re lo s an tic on ce pt iv os . P R O VI D ER IN FO R M A TI O N / IN FO R M AC IO N P AR A EL P R O VE ED O R O nl y th os e pe op le li st ed u nd er “ C LI EN T N AM E” h av e M ed ic ai d co ve ra ge . Pa ym en t is a llo w ed O N LY f or s er vi ce s re ce iv ed d ur in g th e el ig ib ili ty d at es r ef le ct ed o n th e fr on t of t hi s fo rm . P LE A SE N O TE : P ay m en t of F am ily P la nn in g S er vi ce s is a va ila bl e w ith ou t th e co ns en t of t he c lie nt ’s p ar en t or s po us e. C on fid en tia lit y is r eq ui re d. F am ily p la nn in g dr ug s, s up pl ie s, a nd s er vi ce s ar e ex em pt f ro m t he p re sc rip tio n dr ug a nd “ LI M IT ED ” re st ric tio ns . K ey t o te rm s th at m ay a pp ea r on t hi s fo rm : LI M IT ED — Ex ce pt fo r f am ily p la nn in g se rv ic es , a nd fo r T ex as H ea lth S te ps (E PS D T) , m ed ic al s cr ee ni ng , d en ta l, an d he ar in g ai d se rv ic es , t he c lie nt is li m ite d to s ee in g th e do ct or an d/ or l im ite d to u si ng t he p ha rm ac y na m ed o n th e fo rm f or d ru gs o bt ai ne d th ro ug h th e Ve nd or D ru g Pr og ra m . In t he e ve nt o f an e m er ge nc y m ed ic al co nd iti on a s de fin ed b el ow , th e “L IM IT ED ” re st ric tio n do es n ot a pp ly . EM ER G EN C Y — Th e cl ie nt i s lim ite d to c ov er ag e fo r an e m er ge nc y m ed ic al c on di tio n. T hi s m ea ns a m ed ic al c on di tio n (in cl ud in g em er ge nc y la bo r an d de liv er y) m an ife st in g its el f by a cu te s ym pt om s of s uf fic ie nt s ev er ity ( in cl ud in g se ve re p ai n) s uc h th at a p ru de nt la yp er so n (w ho p os se ss a n av er ag e kn ow le dg e of h ea lth a nd m ed ic in e) w ou ld th in k th at th e ab se nc e of im m ed ia te m ed ic al a tt en tio n co ul d re as on ab ly b e ex pe ct ed to re su lt in (1 ) p la ci ng th e pa tie nt ’s h ea lth in s er io us je op ar dy , (2 ) se rio us im pa irm en t to b od ily f un ct io ns , or ( 3 ) se rio us d ys fu nc tio n of a ny b od ily o rg an o r pa rt . H O SP IC E — Th e cl ie nt is in h os pi ce a nd w ai ve s th e rig ht t o re ce iv e se rv ic es r el at ed t o th e te rm in al c on di tio n th ro ug h ot he r M ed ic ai d pr og ra m s. If a c lie nt c la im s to ha ve c an ce le d ho sp ic e, c al l t he lo ca l h os pi ce a ge nc y or D H S t o ve rif y. Q M B — Th e M ed ic ai d ag en cy is p ro vi di ng c ov er ag e of M ed ic ar e pr em iu m s, d ed uc tib le , an d co in su ra nc e lia bi lit ie s, b ut t he c lie nt is n ot e lig ib le f or r eg ul ar M ed ic ai d be ne fit s. M Q M B — Th e M ed ic ai d ag en cy is p ro vi di ng r eg ul ar M ed ic ai d co ve ra ge a s w el l a s co ve ra ge o f M ed ic ar e pr em iu m s, d ed uc tib le s, a nd c oi ns ur an ce li ab ili tie s. P E — M ed ic ai d co ve rs o nl y fa m ily p la nn in g an d m ed ic al ly n ec es sa ry o ut pa tie nt s er vi ce s. ST A R /S TA R +P LU S H EA LT H P LA N — Th e cl ie nt is e nr ol le d in t he M ed ic ai d M an ag ed C ar e pr og ra m a nd is a ss ig ne d to t he h ea lth p la n na m ed o n th e fo rm . N O TE T O P H A R M A C Y: M ed ic ai d w ill p ay fo r m or e th an t hr ee p re sc rip ti on s ea ch m on th fo r an y M ed ic ai d cl ie nt w ho is u nd er a ge 2 1, o r liv es in a n ur si ng fa ci lit y, or h as t he S TA R /S TA R +P LU S H ea lt h P la n, o r ge ts s er vi ce s th ro ug h th e C om m un it y Li vi ng A ss is ta nc e an d Su pp or t Se rv ic es ( C LA SS ), C om m un it y-B as ed A lt er na ti ve s (C B A ) an d ot he r no n-SS I co m m un it y-ba se d w ai ve r pr og ra m s. C lie nt s w it h M ed ic ar e w ho a re e nr ol le d in S TA R +P LU S m ay b e lim it ed t o th re e pr es cr ip ti on s pe r m on th . M ed ic ai d cl ie nt s do n ot h av e to p ay b ill s th at M ed ic ai d sh ou ld p ay . It i s ve ry im po rt an t th at y ou t el l yo ur d oc to r, h os pi ta l, dr ug s to re , an d ot he r he al th c ar e pr ov id er s rig ht a w ay th at y ou h av e M ed ic ai d. if y ou d o no t te ll th em t ha t y ou h av e M ed ic ai d, y ou m ay h av e to p ay t he se b ill s. I f yo u ge t a bi ll fr om a d oc to r, ho sp it al , o r ot he r he al th c ar e pr ov id er , a sk t he p ro vi de r w hy t he y ar e bi lli ng y ou . If yo u st ill g et a b ill , ca ll th e M ed ic ai d ho tl in e at 1 -8 00 -2 52 -8 26 3 fo r he lp . If M ed ic ai d w ill n ot p ay t he b ill o r if M ed ic ai d be ne fit s (s er vi ce s an d su pp lie s) a re de ni ed , yo u m ay r eq ue st a f ai r he ar in g by w rit in g to t he a dd re ss o r ca lli ng t he te le ph on e nu m be r lis te d on t he le tt er y ou g et . N O TE : Fa m ily p la nn in g cl in ic s an d ot he r pr ov id er s gi ve f re e ph ys ic al e xa m s, la b te st s, bi rt h co nt ro l m et ho ds (i nc lu di ng st er ili za ti on ), an d co nt ra ce pt iv e co un se lin g.
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Primary Care Providers

PRIMARY CARE PROVIDERS

What do I need to bring with me to my doctor’s appointment?

When you need to see your child’s Primary Care Provider, call his or her office ahead of time and make an appointment for a visit. You will not have to wait long if you do this.

When you call, be ready to tell the receptionist about your child’s health problem or question. It is important that you be on time to your child’s appointments. If you need to cancel an appoint-ment with your child’s Primary Care Provider, please call the Primary Care Provider’s office as far in advance as possible.

If your child has a medical problem that needs attention the same day, call his/her Primary Care Provider immediately. Your child’s Primary Care Provider will tell you what you need to do.

You must take the Your Texas Benefits Medicaid Card and your El Paso First Premier Plan

ID Card with you when you get any healthcare services.

What is a Primary Care Provider?

Your main health care provider in non-emergency situations

Your child’s Primary Care Provider is the first person to call when your child has a health problem or you have a question about his/her health. Your child’s Primary Care Provider will provide the care your child needs or direct you to someone else who can help you.

Your Primary Care Provider’s role is to:

n Provide preventive care and teach healthy lifestyle choices

n Identify and treat common medical conditions

n Make referrals to medical specialists when necessary

The following are some examples of the services your Primary Care Provider can provide for your child:

n Check-ups that help your child stay healthy

n Vaccines that prevent disease

n Treatment for common health problems

n Make arrangements for your child to get medical tests or treatment when needed

n Make arrangements for your child to see a specialist (special doctor) when needed

n Help you make decisions about your child’s health care, such as whether or not he/she

should have an operation

How can I change my Primary Care Provider?

If you decide later that the Primary Care Provider you chose for yourself or for your baby does not meet your needs, you may call anytime to pick a different one.

To change your Primary Care Provider, call the El Paso First Member Services Line at

915-532-3778 or 1-877-532-3778. A Member Services Representative will help you make the change.

We will do everything we can to help you find a doctor that is right for you. Our Member Services Representative will also tell you when you can start seeing your new Primary Care Provider.

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Please do not change to a new Primary Care Provider without telling El Paso First. If you go to a new Primary Care Provider without telling us, the services may not be covered.

If your Primary Care Provider decides to leave El Paso First and you are under treatment, we will arrange for your continued treatment with your Primary Care Provider until your treatment is complete or you have chosen a new Primary Care Provider that is qualified to treat your condition and is acceptable to you.

Can a specialist ever be considered a Primary Care Provider?

Yes! If you are a woman, you may pick an obstetrician (OB) or gynecologist (GYN) as your

Primary Care Provider. Call El Paso First Health Plans at 1-877-532-3778 to find an OB/GYN

Provider that is also a Primary Care Provider.

You will need to pick a Primary Care Provider for each eligible family Member. You can pick from:

n Pediatricians (they only see children)

n General/family practice (they see all ages)

n Internal medicine (they usually see adults)

n OB/GYNs (they see women)

n Federally Qualified Health Centers/ Rural Health Clinics (RHC/FQHC)

Can a clinic (RHC/FQHC) be my Primary Care Provider?

Yes! El Paso First Health Plans lets you pick a clinic as your Primary Care Provider. If you have any questions, call El Paso First Health Plans at 1-877-532-3778.

How do I pick a new Primary Care Provider?

To pick a new Primary Care Provider, follow these simple steps:

n Look at the El Paso First Health Plans, Inc.’s Primary Care Provider Directory.

n See who speaks your language.

n See who has an office in your neighborhood or if the Primary Care Provider’s

office is close enough for you to travel to.

n Pick your Primary Care Provider.

Once you pick a Primary Care Provider, call El Paso First Health Plans, Inc. Member Services

Helpline at 915-532-3778 or 1-877-532-3778. An El Paso First Premier Plan ID card will be sent

to you with the name and phone number of your Primary Care Provider.

Remember if you do not pick a Primary Care Provider, a Primary Care Provider will be picked for you. You can always call and pick a new Primary Care Provider if you don’t want the one we selected for you.

Be sure to keep your El Paso First Health Plans, Inc. Provider Directory. If you lose it, you may

call the El Paso First Health Plans, Inc. Member Services Helpline at 915-532-3778 or

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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 primary care provider. You can change primary care providers by calling us toll-free at 1-877-532-3778 or writing to:

El Paso First Health Plans

Member Services / Enrollment 1145 Westmoreland Dr.

El Paso, Texas 79925

When will my Primary Care Provider change become effective?

Your change will not happen right away; it may take about a month. You will get a new El Paso First Premier Plan ID card at the beginning of the month (that your change takes place) with your new Primary Care Provider’s name on it. If you need care before you get your new card, call the Primary Care Provider on your current card. If you call on or before the 15th of the month, your change will take place on the first day of the next month. If you call after the 15th of the month, your change will take place the first day of the second month after that. For example:

n If you call on or before April 15, your change will take place on May 1.

n If you call after April 15, your change will take place on June 1.

Reasons why a request to change a

Primary Care Provider may be denied:

n The Primary Care Provider you want is not taking new patients.

n The Primary Care Provider you want to change to is not part of El Paso First Premier Plan.

Can my Primary Care Provider request

that I be changed to another Primary Care Provider?

A provider may ask that you pick another Primary Care Provider if:

n You often miss visits without calling your Primary Care Provider to say you won’t be there.

n You don’t follow your Primary Care Provider’s advice.

n You and the provider do not get along. n You miss a lot of appointments.

If your Primary Care Provider requests a change, you will get a letter in the mail. You will be able to pick a new Primary Care Provider. If you do not pick a new Primary Care Provider, one will be picked for you.

Remember, for you to get the best health care, your Primary Care Provider needs to know your medical information. Your medical information is private: only you, your Primary Care Provider, and other authorized people can see them. If you change your Primary Care Provider, be sure to give your new Primary Care Provider any information so you can get the best care possible.

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What if I pick to go to another doctor

who is not my Primary Care Provider?

Please do not change to a new Primary Care Provider without telling El Paso First.

If you go to a new Primary Care Provider without telling us, the services may not

be covered.

But, you may go to any provider who takes Medicaid if you need:

n 24-hour emergency care from an emergency room

n Texas Health Steps

n Family Planning services and supplies

If you need mental health or substance abuse services you should call the Behavioral Health number on your ID card. That number is 1-877-377-6147. Behavioral Health Services are very private so you do not need the permission of your Primary Care Provider to get these services.

If you need a routine vision exam, you do not need a referral. But if you have an eye problem,

get a referral from your Primary Care Provider. Pick a Vision Provider from the El Paso First Health Plans, Inc. Provider Directory. You must pick a provider from El Paso First Health Plans, Inc. Directory.

If your Primary Care Provider sends you to another Primary Care Provider, he/she must give you medical care. If you see another doctor that your Primary Care Provider didn’t send you to, you may have to pay your medical bills yourself. If you have questions about what providers you can

see call the Member Services Helpline. The number is 915-532-3778 or 1-877-532-3778.

What is the Medicaid Lock-in Program?

You may be put in the Lock-in Program if you do not follow Medicaid rules. It checks how you use Medicaid pharmacy services. Your Medicaid benefits remain the same. Changing to a different MCO will not change the Lock-In status.

To avoid being put in the Medicaid Lock-in Program:

n Pick one drug store at one location to use all the time.

n Be sure your main doctor, main dentist, or the specialists they refer you to are the only

doctors that give you prescriptions.

n Do not get the same type of medicine from different doctors.

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Physician Incentive Plan

Changing Health Plans

PHYSICIAN INCENTIVE PLAN INFORMATION

Physician Incentive Plans

El Paso First rewards doctors for treatments that reduce or limit services for people covered by Medicaid. You have the right to know if your primary care provider (main doctor) is part of this physician incentive plan. You also have a right to know how the plan works. You can call El Paso

First at 915-532-3778 or toll free at 1-877-532-3778 to learn more about this.

CHANGING HEALTH PLANS

What if I want to change health plans? Who do I call?

You may decide to leave El Paso First Premier Plan to pick a different plan. If you want to change, call the Texas STAR Program Helpline. Their number is 1-800-964-2777.

How many times can I change health plans?

You can change your health plan by calling the Texas STAR or STAR+PLUS Program Helpline

at 1-800-964-2777. You can change health plans as often as you want, but not more than once

a month.

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

When will my health plan change become effective?

If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that.

For example:

n If you call on or before April 15, your change will take place on May 1.

n If you call after April 15, your change will take place on June 1.

Can El Paso First Premier Plan request that I leave their plan?

You may have to leave El Paso First Premier Plan if:

n You let someone else use your El Paso First Premier Plan ID card;

n You let someone else use Your Texas Benefits Medicaid Card;

n You don’t follow your doctor’s advice;

n You keep going to the emergency room when you do not have a true emergency;

n You cause problems at the doctor’s office; or,

n You make it difficult for your doctor to help you or other people.

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Benefits

BENEFITS

What are my Medicaid Health Care Benefits?

El Paso First Premier Plan gives you every covered service that you are entitled to get through Medicaid and sometimes more!

You get:

n 24-hour emergency care from an emergency room;

n A checkup every year;

n Behavioral (mental) health services;

n Birthing center services;

n Chiropractic (back doctor) services;

n Dialysis (help from a machine) for kidney problems;

n Durable medical equipment and supplies (wheelchairs);

n Ear doctor visits and hearing aids;

n Family planning services and supplies (such as birth control);

n Foot doctor services;

n Help with substance abuse (such as alcohol or drugs);

n Home health services (health care at home);

n Hospital care with an “OK” from El Paso First Health Plans, Inc.;

n Human Papillomavirus (HPV) vaccine is a benefit for males who are 9 through

26 years of age;

n Laboratory services;

n Mastectomy and breast reconstruction procedures;

n Needed medical care for adults and children;

n Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas

Health Steps medical checkup for children 6 months through 35 months of age;

n Prenatal care;

n Primary care services to help you stay well;

n Shots for children under 21 years old;

n Specialty physician services;

n Surgery without staying in the hospital overnight;

n The use of an ambulance, if you need it;

n Therapies – physical, speech, and occupational;

n Transplantation of organs and tissues (such as heart or kidney);

n Vision (eye exams and glasses);

n X-ray services.

How do I obtain these services?

Your Primary Care Provider together with El Paso First Premier Plan can help you receive these services. Whenever you have a question about your health care services, call El Paso First

Member Services Department at 915-532-3778 or 1-877-532-3778, anytime between 7 a.m. to

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Are there any limits to any covered service?

Some services may require prior authorizations. For information on services that require prior

authorization please call El Paso First Member Services Department at 915-532-3778 or

1-877-532-3778.

What services are Not Covered by Medicaid?

There are health services that are not covered by Medicaid. The following are some examples:

n Any service that you don’t need to have (is not medically necessary):

n Any service that your Primary Care Provider does not say is “OK”; or,

n Any service you get outside of the United States.

n Artificial insemination;

n Autopsies;

n Biofeedback therapy;

n Cosmetic surgery (such as a face-lift);

n Dentures or endosteal implants for adults;

n Ear piercing;

n Experimental medicines or procedures;

n Hair transplant;

n Healing using needles and pins (Acupuncture);

n Hospital bereavement;

n Hypnosis;

n Infertility treatment;

n Intersex surgery;

n Intragastric balloon for obesity;

n In-vitro fertilization;

n Marital counseling;

n Mastectomy for diagnosis of fibrocystic disease in the absence of documented risk factors;

n Medical documents and reports;

n Penile implant;

n Respite care;

n Reversal of sterilization;

n Non-authorized services.

What are my prescription drug benefits?

You get unlimited prescriptions through your Medicaid coverage if you go to a pharmacy in the El Paso First network. There are some medications that may not be covered through Medicaid. An El Paso First pharmacy can let you know which medications are not covered, or help you find another medication that is covered. You can also ask your doctor or clinic about what medications are covered, and what is best for you.

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What extra benefits do I get as a

Member of El Paso First Premier Plan?

El Paso First members can receive the following value added services:

n Welcome Packet: A $25 value of over-the-counter items if the request form is completed

and mailed back within 30 days of enrollment.

n Gifts of a digital thermometer, an emergency aid booklet (per family per year) and a school

supply kit for new Members if requested within 30 days of receiving welcome packet.

n Free calls or texts from El Paso First for related health activities. One free cell phone per

household from the Lifeline Assistance Program for those who qualify.

n $15 gift card for health items for Members age 20 and younger completing a timely Texas

Health Steps visit.

n Up to $25 for any sport registration activity fee, once every 12 months.

n 4 extra food counseling services, above the Medicaid benefit, for Members age 20

and younger.

n Help getting a ride to doctor visits or health classes for Members who need a ride.

n Extra dental services up to $295 (initial checkup, x-rays, and a routine cleaning) for

Members age 21 and older through Project Vida.

n Up to $125 above the Medicaid benefit for contact lenses, lenses, and frames.

n 1 free car seat per pregnancy for pregnant Members who complete a pregnancy class at

El Paso First.

n $10 gift card for health related items for pregnant Members completing one pregnancy visit

within 30 days of enrollment.

n Home visits to high risk pregnant Members.

n $15 gift card for health items for postpartum Members completing one postpartum visit

within 21-56 days after delivery.

How do I get these benefits?

For more information on how to get these benefits please call the El Paso First Member Services

Help Line at 915-532-3778 or 1-877-532-3778.

What health education classes does

El Paso First Health Plans offer?

Our health education classes are prepared with your family’s health in mind. If you or your child has asthma, diabetes or you are pregnant, one of our nurse case managers will be happy to register you and your child in some of our classes. For information about our health education classes,

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What other services can El Paso First Health Plans help me with?

El Paso First Health Plans wants to link you to quality healthcare and social services. This is the goal of the El Paso First Outreach Coordinators/Promotoras. The El Paso First Premier Plan Outreach Coordinators/Promotoras teach you how to use El Paso First Premier Plan services. They can visit you at home, talk to you on the phone or send you information by mail. They can help you with things like:

n How to pick a Primary Care Provider

n Transportation Services

n How to use El Paso First Premier Plan Services

n How to use your Member Handbook

n Texas Health Steps

n Early Childhood Intervention (ECI) case management/service coordination

n DSHS Case Management for Children and Pregnant Women / DSHS Targeted Case

Management

n Preventive, Urgent and Emergent Care

n Visits to Specialists

n Complaint and Appeal Procedures

n Disenrollment Procedures

El Paso First Premier Plan Outreach Coordinators/Promotoras can provide you with resources to help you get food, housing, clothing and utility services.

El Paso First will also try to help you get other services you may need such as, but not limited to:

n Living arrangements

n Employment

n Job training

n Food

n Access to public schools

For more information, please call Member Services at 915-532-3778 or 1-877-532-3778.

We also invite our members to visit our office located at 1145 Westmoreland Dr., El Paso, TX 79925. Our Resource Center is inside our office—we have a selection of health information brochures and applications. You can also call our Member Services Department to request an application or health information by mail.

Please call the Member Services Department at 915-532-3778 or 1-877-532-3778, for more

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Health Care & Other Services

HEALTH CARE AND OTHER SERVICES

What does “Medically Necessary” mean?

Medically Necessary means:

(1) For Members birth through age 20, the following Texas Health Steps services: (a) screening, vision, and hearing services; and

(b) other Health Care Services, including Behavioral Health Services, that are necessary to correct or ameliorate a defect or physical or mental illness or condition. A determination of whether a service is necessary to correct or ameliorate a defect or physical or mental illness or condition:

(i) must comply with the requirements of the Alberto N., et al. v. Suehs, et al. partial

settlement agreements; and

(ii) may include consideration of other relevant factors, such as the criteria described in parts (2)(b-g) and (3)(b-g) of this definition.

(2) For Members over age 20, non-behavioral health related health care services that are: (a) reasonable and necessary to prevent illnesses or medical conditions, or provide early

screening, interventions, or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a member, or endanger life;

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

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

(d) consistent with the diagnoses of the conditions;

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

(f) not experimental or investigative; and

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

(3) Behavioral health services (that for Members birth through age 20 are not available through Texas Health Steps) that are:

(a) are reasonable and necessary for the diagnosis or treatment of a mental health or chemi-cal dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder;

(b) are in accordance with professionally accepted clinical guidelines and standards of prac-tice in behavioral health care;

c) are furnished in the most appropriate and least restrictive setting in which services can be safely provided;

(d) are the most appropriate level or supply of service that can safely be provided;

(e) could not be omitted without adversely affecting the member’s mental and/or physical health or the quality of care rendered;

(f) are not experimental or investigative; and

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What is routine medical care?

Routine medical care involves regular checkups by your Primary Care Provider and treatment by him or her when you are sick. During these regular visits, your Primary Care Provider can give you prescriptions for medicine, and send you to a special doctor (specialist) if you need one. It is important that you do what your Primary Care Provider says and that you take part in deci-sions made about your health care. If you cannot make a decision about your health care, you can pick some one else to do it for you.

How soon can I expect to be seen?

When you need to see your Primary Care Provider, call the Primary Care Provider at the number on your El Paso First Premier Plan ID card. Someone in the Primary Care Provider’s office will set a time for you. It is very important that you keep your appointment. Call early to set up visits, and call back if you need to cancel. If more than one member of your family needs to see the doc-tor, you need an appointment for each person.

Your doctor is available 24 hours a day either in person or by telephone. If your doctor is not available, he or she will have another doctor available for you. This includes weekends and holi days. For routine medical care, your Primary Care Provider should see you within two weeks. If you have a condi tion that needs medical attention the same day, your Primary Care Provider can help you with that.

What is Urgent Medical Care?

Another type of care is urgent care. There are some injuries and illnesses that are probably not emergencies but can turn into emergencies if they are not treated within 24 hours. Some exam-ples are:

n Minor burns or cuts

n Earaches

n Sore throat

n Muscle sprains/strains

What should I do if my child or I need urgent medical care?

For urgent care, you should call your doctor’s office even on nights and weekends. Your doctor will tell you what to do. In some cases, your doctor may tell you to go to an urgent care clinic. If your doctor tells you to go to an urgent care clinic, you don’t need to call the clinic before going.

You need to go to a clinic that takes El Paso First Medicaid. For help, call at 915-532-3778 or

toll-free at 1-877-532-3778.

How soon can I expect to be seen?

You should be able to see your doctor within 24 hours for an urgent care appointment. If your doctor tells you to go to an urgent care clinic, you do not need to call the clinic before going. The urgent care clinic must take El Paso First Medicaid.

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What is Emergency Medical Care?

Emergency medical care is provided for Emergency Medical Conditions and Emergency

Behavioral Health Conditions.

Emergency Medical Condition means:

A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in:

(1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions;

(3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or

(5) in the case of a pregnant women, serious jeopardy to the health of a woman or her unborn child.

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 knowledge of medicine and health:

(1) requires immediate intervention and/or medical attention without which the Member would present an immediate danger to themselves or others; or

(2) which renders the Member incapable of controlling, knowing or understanding the conse-quences of their actions.

Emergency Services and Emergency Care means:

Covered inpatient and outpatient services furnished by a provider that is qualified to furnish such services and that are needed to evaluate or stabilize an Emergency Medical Condition and/or Emergency Behavioral Health Condition, including post-stabilization care services.

You have an EMERGENCY medical need if you think your condition is life threatening, if you

have serious pain or if serious harm could come to you without immediate medical attention. Examples of when to go to the emergency room are:

n Someone may die.

n Someone has bad chest pains.

n Someone cannot breathe or is choking.

n Someone has a severe burn.

n Someone has passed out or is having a seizure.

n Someone is sick from poison or a drug overdose.

n Someone has a broken bone.

n Someone is bleeding a lot.

n Someone has been attacked (raped, stabbed, shot, beaten).

n Someone is about to deliver a baby.

n Someone has a serious injury to the arm, leg, hand, foot, or head.

n Someone has a severe allergic reaction or has an animal bite.

n Someone has trouble controlling behavior and without treatment is dangerous

(27)

STAR PROGRAM

How soon can I expect to be seen?

Go to the nearest hospital if you think you have any of these problems. You may call 911 for

assistance in getting to the hospital emergency room. Emergency room doctors will handle

a true emergency immediately. They will continue treatment until the patient is out of danger.

If you go to a hospital emergency room for a true emergency, you must call your child’s doctor,

clinic, or El Paso First at 915-532-3778 or 1-877-532-3778, as soon as you can. If you are not

able to make the phone call, a family member or friend may call for you. If the nearest hospital is not an El Paso First contracted hospital, you may be moved to an El Paso First contracted

hospital when strong enough.

When people who are not in serious danger go to an emergency room, they often have to wait a long time for treatment. In most cases they can get the treatment they need more quickly at their doctor’s office or at one of El Paso First’s Night Clinics. El Paso First pays for all visits to your Primary Care Provider and to our Night Clinics. For more information about our Night Clinics,

please call our Member Services Department at 915-532-3778 or 1-877-532-3778.

If you have an emergency when you are traveling outside the service area, you are still covered for emergency care, even when you are outside of the state of Texas. If you have an emergency situation outside the state of Texas, go to the closest hospital. Then call your Primary Care Provider and El Paso First as soon as possible. El Paso First will cover your emergency room treatment outside of the state as long as it is a true emergency.

Services provided outside of the United States

are not covered benefits of the Medicaid Program.

Most medical problems do not need emergency care. You should call your Primary Care Provider

whenever you have one of the following problems.

n Ear ache

n Toothache or baby teething

n Rash

n Colds, cough, sore throat, flu, or sinus problems

n Minor sunburn

n Minor cooking burn

n Chroni

References

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