DentaQuest / Superior Health Plan Training 2016 STAR Health (Foster Care) STAR + PLUS STAR Value Added Services Advantage by Superior (Medicare)

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Raymond Clifton Tucker
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1 DentaQuest / Superior Health Plan Training 2016 STAR Health (Foster Care) STAR + PLUS STAR Value Added Services Advantage by Superior (Medicare) SHP_201237

2 Agenda STAR Health (Foster Care) STAR + PLUS STAR Pregnant Women Value Added Service (VAS) Advantage by Superior (Medicare) 2

3 STAR Health Children and Young Adults are Eligible when they are: In Foster care In Kinship placement (Placed with a family Member or a close friend to the family) Young adults who choose to remain in a paid foster care placement through the month of their 22nd birthday Medicaid for Transitional Foster Care Youth (MTFCY) Young adults who aged out of the foster care system at age 18 through the month of their 21 st birthday. Former Foster Care in Higher Education (FFCHE) STAR Health coverage may be provided from age 21 through the month of Member s 23 rd birthday Must be in Foster Care on their 18 th birthday Must be enrolled in an institution of higher education or technical school in Texas Newborns born to STAR Health Moms (exception: FFCHE) 3

4 STAR Health Eligibility Members are STAR Health Eligible upon removal from the home Members can access services with one of the following: 2085-B Form- Designation of Medical Consenter- used as eligibility Superior STAR Health ID card Your Texas Benefits (YTB) Medicaid card *Please note: If a member has the 2085-B Form but is not in the DentaQuest or Superior system, the member is still eligible for services. 4

5 2085-B Form-Designation of Medical Consenter 5

6 STAR Health ID Cards 6

7 STAR Health Benefits Statewide program STAR Health members receive the same benefits as Medicaid members 7

8 STAR Health Pre-Appeals Process There may be times when a member s health care provider may request services that do not meet medical necessity. In order to minimize service denials, we are committed to the unique nature of foster children. DentaQuest will be responsible for contacting the provider, medical consenter, and/or DFPS to request any additional, related information to help the approval of the service or with the development of other care options to meet the Member s needs. DentaQuest will make a decision on a service authorization within 3 days. This process can be extended up to 14 days if more information is needed. 8

9 Reporting Abuse If you suspect abuse or neglect of a child, report it immediately! Call: or 911 9

10 Health Passport Health Passport helps authorized users access health information for STAR Health Members such as: health history current health status and health problems Registration is fast and easy. Just go to to register For assistance or questions in accessing Health Passport, please contact the Health Passport Help Desk at: or by at 10

11 Health Passport Advantage Health Passport provides helpful information including: Note: Prescriptions a list of prescriptions that were filled at the pharmacy Lab results Immunizations Allergies Visit History (Medicaid claims for 2 years prior to STAR Health enrollment) Health Care Service Plans for those who receive Service Management and health summaries are located under the forms section Caregivers who are NOT medical consenters cannot access Health Passport Medical Consenters who are not DFPS staff cannot access behavioral health notes Health Passport is not available to some MTFCY and all FFCHE Members 11

12 Confidentiality and Communication Superior will ensure coordination and sharing of child s health information between Caregivers, Medical Consenters, DFPS workers, Courts and all health care providers (as appropriate) to guarantee that all Member s health care needs are met. DentaQuest and STAR Health, by law, will keep Member s health records and medical information private. All discussions with doctors or other health care providers will be kept private. We will always make sure that any sharing of medical information will meet all State and Federal confidentiality laws and HIPAA regulations. 12

13 STAR Health Reminders Caregivers can: Receive form 2085 (B or C) and the Superior ID Card Request information regarding a Member by providing the DFPS ID Number Medicaid ID Number Members demographics NOT authorize any services without consent from the Medical Consenter NOT request a PCP change NOT have access to the Health Passport (unless the Caregiver is also the Medical Consenter) 13

14 STAR Health Reminders Continued Medical Consenters can: Be up to 4 different people in the child s life Authorize any service for a child (Medical Consenter must be contacted before any service is given to the child) Request any information from us by providing the child s DFPS ID Number Medicaid ID Number Members demographics Request medical records from a provider Make a PCP change on behalf of the Member Have access to the Health Passport (read-only rights) Be a part of the Pre-Appeals, Appeals and State Fair Hearing process 14

15 STAR + PLUS STAR+PLUS was created specifically to serve the elderly and persons with disabilities, typically known as the aged, blind and disabled population (ABD) Goal-to achieve a seamless continuum of care by integrating acute and comprehensive care Long-Term Services and Support (LTSS) in a managed care environment Promotes delivery of home and community-based- services Superior HealthPlan is responsible for coordinating acute and LTSS through the use of a Service Coordinator Service Coordination is the cornerstone of the STAR+PLUS model 15

16 STAR + PLUS Members Mandatory Population Supplemental Security Income (SSI) eligible adult clients (ages 21 and over) Medical Assistance Only (MAO) Clients who qualify for 1915 (c) Nursing Facility Waiver (limited number) Dual Eligibles - those individuals who are covered by Medicare and receive dental benefits or dental value added services Voluntary Population SSI Children under the age of 21 Children (under the age of 21) who are Medicaid eligible because they are in a Social Security Exclusion Program 16

17 STAR + PLUS Service Areas Recipients must reside in a STAR+PLUS service area: Bexar Dallas Hidalgo Lubbock Nueces 17

18 STAR + PLUS ID Cards 18

19 STAR + PLUS Value Added Services STAR+PLUS Eligible population: Medicaid Only (non-dual eligible) > 21 years Benefit Limit: $250 maximum per calendar year Covered Value Added Services Evaluation: D0120, D0140, D0150, D0170 X-Rays: D0220, D0230, D0270, D0272, D0274, D0330 Cleanings: D1110, D1204, D1206 *Non-covered services are the member s responsibility 19

20 STAR + PLUS Waiver Benefits STAR+PLUS Eligible population: Medicaid Waiver and Dual Waiver Adult Members Benefit Limit: $5000 maximum per individual service plan year Covered Waiver Dental Services Treatment of injuries to the teeth or supporting structures Dentures and the cost of fitting and preparation Preventative procedures that are required to prevent the imminent loss of teeth Exhaust Value Added Benefits before accessing those services through the waiver benefits 20

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22 STAR + PLUS Additional Information IF Anesthesia (other than IV sedation) is given while performing dental services AND/OR services are provided IN an inpatient/outpatient setting: Medicare pays for anyone that is Dual Eligible (not enrolled in Advantage by Superior). No authorization is required by Superior. Medicaid Only Member Anesthesia services and facility are authorized by and billed directly to Superior & must be performed by a network provider. Providers can visit to determine Participating Providers/Facilities and to view authorization procedures Report any signs of Abuse or Neglect to Adult Protective Services at or Medical Transportation Program provides transportation to dental appointments Medical Transportation Program doesn t transport members 17 years or younger who are not accompanied by a parent or legal guardian 22

23 STAR Value Added Service Service Areas: Bexar El Paso Hidalgo Lubbock Nueces Travis Medicaid Rural Service Area Central Medicaid Rural Service Area Northeast Medicaid Rural Service Area West 23

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26 STAR ID Cards 26

27 STAR Value Added Service STAR Eligible population: STAR Pregnant Women > 21 years Benefit Limit: $250 maximum per calendar year Covered Value Added Services Evaluation: D0120, D0140, D0150, D0170 X-Rays: D0220, D0230, D0270, D0272, D0274, D0330 Cleanings: D1110, D1204, D

28 Advantage by Superior (Medicare) Superior Health Plan is a Special Needs Plan (HMO SNP) for Medicare Superior contracts with Center for Medicaid/Medicare Services (CMS) Program approved Counties (not Service Area) Bexar County Nueces County Dallas Rockwall Collin 28

29 Medicare Advantage ID Cards 29

30 Medicare Advantage Value Added Dental Benefits Medicare Advantage Eligible population: Dual Eligible Members enrolled in a Medicare SNP Covered Value Added Services Annual Benefit 2 Cleanings per year 2 Oral Exams per year 1 Dental X-Ray per year *Note: Services are excluded form the maximum Comprehensive Benefit Limit: $750 maximum per calendar year for comprehensive services $0 Co-pay No UM review 30

31 Questions 31

Superior HealthPlan Hospital Training. SHP_2013158 Hospital Orientation Presentation

Superior HealthPlan Hospital Training SHP_2013158 Hospital Orientation Presentation Introductions & Agenda Presenter Introductions About Superior HealthPlan Eligibility Medical Management CHIP Perinate