Benefits Overview STAR+PLUS (Medicaid Only) STAR+PLUS Health-care Benefits How to Get These Services Primary Care Service Coordination
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1 Overview STAR+PLUS (Medicaid Only) Here is a summary of the benefits you get as an Amerigroup member living in the community. If you live in a nursing facility, please refer to the separate Overview for STAR+PLUS Nondual Nursing Facility residents. STAR+PLUS Health-care You get benefits from Amerigroup for acute care such as doctor visits, hospitalizations, prescriptions, and behavioral health services, and you also can get long-term services and supports. You may not need long-term services and supports right now, but Amerigroup will provide these benefits if you need them in the future. If you do need long-term services and supports benefits, the kind of benefits you can get is based on your category of Medicaid eligibility. There are three Medicaid eligibility levels which are listed below: Other Community Care (OCC) basic coverage Community First Choice (CFC) mid-level coverage Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) highest level of coverage for members with complex needs How to Get These Services Your primary care provider will help you get the acute care you need. Your service coordinator will help you get long-term services and supports. STAR+PLUS members with intellectual disabilities or related conditions who do not qualify for Medicare and who receive services through the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF-IID) program or an Intellectual or Developmental Disability (IDD) Waiver will be covered for acute care services only under STAR+PLUS. Long-term services and supports will be provided through the Texas Department of Aging and Disability Services (DADS). The ICF-IID program is the Medicaid program serving individuals with intellectual disabilities or related conditions who receive care in intermediate care facilities other than a state supported living center. IDD Waiver means the Community Living Assistance and Support Services Waiver program (CLASS), the Deaf-Blind with Multiple Disabilities Waiver program (DBMD), the Home and Community-Based Services Waiver program (HCBS), or the Texas Home Living Waiver program (TxHmL). Primary Care Maintaining good physical health is important. With Amerigroup, you go to one main person for your health care. He or she can be a doctor, a nurse practitioner, or a physician's assistant. This person is called your primary care provider. Amerigroup has a network of doctors and nurses who assist our members. To find a provider in your area, use the Find a Doctor search tool. Service Coordination We will assign you a personal service coordinator if you ask for one. We also will provide you with a personal service coordinator if we find you need one after we look at your health and support needs. A service coordinator works as a team with you and your primary care provider to arrange all the services that you need to receive, including services from specialists and behavioral health providers if needed. A service coordinator helps make sure all your different health-care needs are met.
2 If you think you need a service coordinator, call toll-free at the number below for your service area Monday through Friday from 8 a.m. to 5 p.m. local time. STAR+PLUS members with intellectual disabilities or related conditions who receive services through the ICF-IID program or an IDD Waiver should call Bexar , ext El Paso , ext Harris and Jefferson , ext Lubbock , ext Tarrant , ext Travis , ext West Medicaid Rural Service Area , ext If you are deaf or hard of hearing, call 711. Long-term Services and Supports Some people need help with everyday tasks, like eating or light housekeeping duties, fixing meals, or personal care. Some people have needs that would qualify them to be in a facility, but they want to stay at home. If you have no one to help you at home, Amerigroup can help. Call Amerigroup to ask for help. We will send a service coordinator to your home to see what help you need. With your agreement, the service coordinator will talk to your doctors. Then, the service coordinator will tell you about the help we can help get for you. If you agree, the service coordinator will help get the services started. And our service coordinator will call you to see how well you are doing with the services. To get any long-term services and supports, you must talk to your service coordinator first. Long-term services and supports will be provided through the Texas Department of Aging and Disability Services (DADS) for STAR+PLUS members with intellectual disabilities or related conditions who receive services through the ICF-IID program or an IDD Waiver. If you do need long-term services and supports benefits, the kind of benefits you can get is based on your category of Medicaid eligibility. The basic category of coverage is called Other Community Care (OCC). The next higher level is Community First Choice (CFC). The third category for members with more complex medical needs is called HCBS STAR+PLUS Waiver (SPW). An overview of these benefits by type and category of coverage is shown below. Long-term Services and Supports Other Community Care (OCC) Community First Choice (CFC) HCBS STAR+PLUS Waiver (SPW) Primary home care/personal assistance services Day activity and health services (DAHS) Consumer-directed attendant care Nursing services (in home) N/A N/A Amerigroup* Acquisition, maintenance, and enhancement of skills services Emergency response services (emergency call button) N/A Amerigroup* Amerigroup* N/A Amerigroup* Amerigroup*
3 Long-term Services and Supports (continued) Other Community Care (OCC) Community First Choice (CFC) HCBS STAR+PLUS Waiver (SPW) Dental services N/A N/A Amerigroup* Home-delivered meals N/A N/A Amerigroup* Minor home modifications N/A N/A Amerigroup* Adaptive aids N/A N/A Amerigroup* Durable medical equipment N/A N/A Amerigroup* Medical supplies N/A N/A Amerigroup* Physical, occupational, and speech therapy N/A N/A Amerigroup* Adult foster care/personal home care N/A N/A Amerigroup* Assisted living N/A N/A Amerigroup* Transition assistance services (for members leaving a nursing facility) $2,500 maximum Respite (with or without self-directed models) N/A N/A Amerigroup* N/A N/A Amerigroup* Dietitian/nutritional service N/A N/A Amerigroup* Transportation assistance Cognitive rehabilitation therapy N/A N/A Amerigroup* Financial management services N/A N/A Amerigroup* Support consultation/management N/A Amerigroup* Amerigroup* Employment assistance N/A N/A Amerigroup* Supported employment N/A N/A Amerigroup* * Call a service coordinator or Member Services to find out if you qualify for services. Dental Care Amerigroup members age 20 and younger can get dental benefits through the Medicaid dental plan they choose. The dental plans available are: DentaQuest MCNA Dental HCBS STAR+PLUS Waiver members should contact their service coordinator directly or through Member Services at (TTY 711) about needed dental services. Pharmacy Adults and children can get as many prescriptions as their doctor thinks are needed. You may go to any pharmacy that takes Amerigroup to have your prescription filled. Since Amerigroup covers your prescriptions, you need to take your Amerigroup ID card and the Your Texas Medicaid card with you when you get your prescriptions.
4 If you do not know if a drugstore takes Amerigroup, ask the pharmacist. You can also use the Find a Doctor search tool or call Member Services at Vision Care Amerigroup members do not need a referral from their primary care provider for eye care benefits. Members age 20 and younger get a vision exam and medically necessary frames and lenses once every 12 months. Members age 21 and older get a vision exam and medically necessary frames and lenses once every 24 months. Please call Superior Vision of Texas at for help finding a network eye doctor (optometrist) in your area. Rides Assistance If you need transportation for medical appointments, call the Texas Health and Human Services Commission (HHSC). MTP will help you get to your doctor appointments and to the hospital for scheduled tests or surgery. Call MTP at least 48 hours before your appointment. The sooner you call, the easier it should be for you to get transportation. You can call MTP toll-free from 8 a.m. to 5 p.m. Monday through Friday at for the Dallas/Fort Worth area for the Houston/Beaumont area, or call for all other areas. Amerigroup provides nonemergency ambulance transportation for members who require this service. To get nonemergency ambulance transportation, your doctor must contact us to arrange for these services. Value-added As an Amerigroup member, you also get additional benefits, including: 24-hour Nurse HelpLine nurses available 24 hours a day, 7 days a week for your urgent medical issues and health-care questions Transportation assistance to get to your medical appointments when medical transportation services are not available Enhanced vision benefits Additional 200 one-time cellphone minutes with free health-related text messages if you qualify An extra 8 hours of respite services for families and caregivers of members Smoking/tobacco cessation help with personal coaching Taking Care of Baby and Me program for pregnant women and new mothers Pest control services every 3 months Personal disaster plan and first aid kit after completing a plan online Gift cards for achieving health goals or getting certain checkups or screenings like Texas Health Steps and and pregnancy checkups, or cholesterol and diabetic screenings
5 Personal exercise kit A welcome home safety kit for members moving from a nursing facility back into the community Dental hygiene kit Nutritional dietary support after getting out of a hospital or nursing facility For members age 21 and older Not available for HCBS STAR+PLUS Waiver members Specific benefit details, including exclusions and limitations, can be found in the member handbook. To find out more about these benefits, call your service coordinator or Member Services at (TTY 711). We will find out about your needs and which services you can get. Amerigroup members in the Medicaid Rural Service Area are served by Amerigroup Insurance Company; all other Amerigroup members in Texas are served by Amerigroup Texas, Inc. WEB-TX
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Preauthorization Requirements * (as of January 1, 2016)
OFFICE VISITS Primary Care Office Visits Primary Care Home Visits Specialist Office Visits No Specialist Home Visits PREVENTIVE CARE Well Child Visits and Immunizations Adult Annual Physical Examinations
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