NorthSTAR MEMBER INFORMATION AND PROVIDER DIRECTORY. Libro de Miembros y Directorio de Proveedores

Transcription

1 Si necesita esta información en españo soamente, por favor ame: For: En os Condados: Coin, Daas, Eis, Hunt, Kaufman, Navarro and Rockwa Counties If your Provider is not isted, pease ca: Si usted no ve a su Proveedor en este Directorio, por favor ame a: TDD: Aparato de teecomunicaciones para personas sordas: Visit our website at: NorthSTAR NorthSTAR MEMBER INFORMATION AND PROVIDER DIRECTORY Libro de Miembros y Directorio de Proveedores 06/01/15 DA4B-0615

2 VaueOptions NorthSTAR Member Information CONTENTS Who is VaueOptions? 2 Where is VaueOptions? 2 Am I eigibe to enro in the VaueOptions NorthSTAR Program? 2 How do I enro in VaueOptions NorthSTAR? 3 How much wi I pay for NorthSTAR Services? 3 Are there other Heath Insurance Programs my Chidren or I may quaify for? 3 How do I get Menta Heath or Substance Abuse Services? 3 What if I need Emergency Care? 4 What if I Need to be Admitted to a Hospita? 4 What if I am away from home and need Routine or Emergency Care? 4 How can I find a Provider? 4 How do I get a Referra to another Provider? 4 What if I have no way to get to my Provider? 4 How Do I Cance or Change an Appointment? 5 What are Medicay Necessary Services? 5 What Services or Benefits does VaueOptions offer me in NorthSTAR if I am Medicaid-Eigibe? 5 If I am not Medicaid-Eigibe, what Services does VaueOptions offer me? 5 Can I get Prescription Drugs? 6 How much wi I pay for Prescriptions? 6 Are there any Benefit Limits or Excuded Services? 6 What if I am unhappy with my care or your service? 7 What is a Compaint, and how do I make one? 7 What is an Appea, and how do I fie one? 7 How do I get a Fair Hearing? 7 Can I be Disenroed from NorthSTAR? 8 What if I move? 8 What is Fraud and Abuse? 8 What are My Rights? 8 What are My Responsibiities in My Recovery? 9 Do You offer Prevention or Education Programs? 9 What about Programs for Famiy Members? 9 Are there any Sef-Hep or Consumer-Run Programs? 9 What are Advance Directives? 9 How can I find other Community Resources? 11 What are My Privacy Rights? 11 What if I don t understand the information in this book? 13 What does that Word Mean? 13 How to Read Our Provider Listings 15 Pharmacy Listing 16 Provider/Faciity Listing Provider Index 37 Cinic Index 39 Pease note: This ist is current as of 06/01/15. Every day VaueOptions is adding more providers to serve NorthSTAR enroees. If you do not see your provider isted, pease ca the ACCESS LINE at and we wi give you the atest provider information from VaueOptions. 1

3 VaueOptions NorthSTAR Member Information Wecome to VaueOptions V aueoptions manages the NorthSTAR program for the State. NorthSTAR serves Coin, Daas, Eis, Hunt, Kaufman, Navarro, and Rockwa counties (the NorthSTAR area). We manage pubicy funded menta heath and substance abuse services for peope who ive in the NorthSTAR area, to make sure that you get the best care and service. We aso make sure that everyone who is heping you is working together. Our services are cose to you and easy to use. This handbook wi te you about VaueOptions and NorthSTAR. If there are words or phrases in this handbook that you do not understand, there is a hepfu ist to te you what they mean on page 13. If you have questions or comments about your services, or in case of emergency, you can ca: VaueOptions to free ACCESS LINE 24 Hours A Day, 7 Days a Week TDD Visit our website at WHO IS VALUEOPTIONS? VaueOptions is icensed as a Heath Maintenance Organization (HMO) by the Texas Department of Insurance (TDI). We are a specia kind of HMO that manages programs for menta heath and substance abuse services. This type of HMO is caed a Behaviora Heath Organization (BHO). In 1999, the State of Texas created new programs to provide better heath care to ow income famiies. The physica heath pan is caed STAR, and NorthSTAR is the menta heath and substance abuse pan. VaueOptions understands menta heath and substance abuse probems, and we are here to hep you with any probems you may have. VaueOptions has a ot of experience in more than 24 other states and Tarrant and Harris Counties with increasing the quaity of menta heath and substance abuse care and improving access to needed services for peope who get their services through pubic programs. Pease ca us if you have any questions or need to get care. VaueOptions Mission Statement is to: Empower the consumers we serve within their communities, Ensure the provision of integrated, highquaity, cuturay competent, communitybased menta heath and substance abuse treatment services, Enrich the ives of those we serve by providing services when they are needed in a manner that is respectfu and cost-efficient, and Assist consumers in achieving the success that they deserve. VaueOptions beieves that persons who have a menta iness and/or a substance abuse probem can, with treatment, get we enough to have meaningfu ives in their communities. This idea is caed Recovery. There is information at the end of the member handbook section of this book about Recovery. There is aso a workbook to hep you make your own recovery pan. You can aso find information about your diagnosis and tips for getting and staying we on our NorthSTAR Achieve Soutions website. Cick on the Achieve Soutions ink at www. vaueoptions.com/northstar. VaueOptions does not discriminate against anyone on the basis of race, reigion, gender, age, disabiity or sexua orientation. The decision to provide services is based on the cinica and psychosocia needs of the individua and what wi best assist his or her recovery. WHERE IS VALUEOPTIONS? We are as cose as your teephone. Ca the to free ACCESS LINE at or TDD Our phone ines are staffed 24 hours a day, 7 days a week with icensed behaviora heathcare cinicians. Our quaified and hepfu staff wi answer questions about your benefits, what behaviora heath services you want, or who woud be a good provider of menta heath or substance abuse services for you. You can aso tak to a cinician if you or a famiy member is having a menta heath or substance abuse crisis. Our customer services staff who answer our ACCESS LINE can aso hep persons who need information interpreted into another anguage. VaueOptions centra office ocation and maiing address is: VaueOptions 1199 S. Betine Road, Suite 100 Coppe, TX AM I ELIGIBLE TO ENROLL IN THE VALUEOPTIONS NORTHSTAR PROGRAM? You are eigibe to enro in the NorthSTAR program if you ive in the NorthSTAR area and meet any of the criteria isted beow. MEDICAID-ELIGIBLE INDIVIDUALS If you beieve that you may be eigibe for one of the foowing programs, contact your oca office of the Texas Department of Human Services. To find the nearest office, ook in your teephone book or ca VaueOptions Customer Service at Temporary Assistance to Needy Famiies (TANF) s Temporary Assistance to Needy Famiies (TANF) Chidren Pregnant Women Medica Assistance Ony (MAO) Pregnant women whose famiy income is beow 185% of the Federa Poverty Leve Newborns chidren under age one born to MAO Mothers Expansion Chidren and Federa Mandate Chidren(MAO) Disabed or Bind Individuas receiving Suppementa Security Income (SSI) with or without Medicare Chidren who are ineigibe for Suppementa Security Income (SSI) for reasons other than disabiity. Persons of a ages who quaify for NorthSTAR-eigibe Medicaid types are automaticay enroed in NorthSTAR by Maximus, the state s enroment broker. They may not choose to remain in fee-for-service Medicaid. State or Federa Adoption Subsidy NON-MEDICAID-ELIGIBLE INDIVIDUALS If you do not receive Medicaid, you are eigibe to enro in the NorthSTAR program if you reside in the NorthSTAR area and meet the criteria isted beow. Individuas who have income at or beow 200% of the Federa Poverty Leve (FPL) and fit into one of the foowing groups: Individuas who meet the Texas Department of State Heath Services (TDSHS) menta heath target popuation definition s or Youth with a substance abuse or chemica dependency diagnosis Individuas who are in one of the groups isted above are eigibe for covered services that are medicay necessary. 2

4 VaueOptions NorthSTAR Member Information HOW DO I ENROLL IN VALUEOPTIONS NORTHSTAR? Maximus, the State s enroment broker for STAR and NorthSTAR wi enro Medicaid-eigibe individuas, who quaify for NorthSTAR eigibe Medicaid types, in NorthSTAR. The State wi et Maximus know when you are approved for Medicaid, and Maximus wi enro you in NorthSTAR. If you are a Medicaid-eigibe individua and have a question about your enroment you may ca Maximus at , or you may ca VaueOptions at or TDD Within five days after enroment, you wi be sent an enroment package that wi incude a wecome etter and this handbook and provider directory, Non-Medicaid-eigibe individuas may enro in NorthSTAR at any of our enroment sites by competing a short form that tes us about your income (a financia assessment form). To find the enroment site nearest you ca VaueOptions Access Line at or TDD Non-Medicaid members may obtain a Member Handbook and Provider Directory at their provider site or by caing VaueOptions to free at HOW MUCH WILL I PAY FOR NorthSTAR SERVICES? Medicaid-Eigibe Individuas receive approved covered services at no cost. If you are not Medicaid-eigibe, you may pay a fee based on your income and abiity to pay. If you have questions about what you might have to pay, ask your provider or ca VaueOptions at or TDD VaueOptions cannot pay for services that are not covered by the NorthSTAR program. If you receive services that are not pre-approved by VaueOptions, you may have to pay for them, except for emergency behaviora heathcare. If you are receiving benefits that are covered by another insurance pan (such as Medicare or private insurance), those insurance pans must pay before VaueOptions pays. If you receive a bi for services, pease contact the other insurance pan about paying for those services. You must use NorthSTAR network providers in order for VaueOptions to pay for services. Some services must be pre-approved by VaueOptions in order to be paid for by NorthSTAR. ARE THERE OTHER HEALTH INSURANCE PROGRAMS MY CHILDREN OR I MAY QUALIFY FOR? CHIP and Medicaid Chidren whose famiies have incomes beow 133% of the Federa Poverty Leve (FPL) and who have imited resources may quaify for Medicaid. The State of Texas aso has a program caed CHIP (Chidren s Heath Insurance Program) to insure ow-income chidren from birth through age 19 who do not quaify for Medicaid. CHIP has both physica and behaviora heath benefits. The income imit for CHIP is 200% of the FPL. Non-Medicaid-eigibe chidren who are eigibe for NorthSTAR are probaby aso eigibe for CHIP. You can appy for both CHIP and Medicaid in the same appication. Appy onine at www. yourtexasbenefits.com, by phone by caing 211 or (to free), or in person. You can ocate the cosest office by caing 211 or You can aso ocate a oca service agency that can hep you appy by caing those numbers. STAR and STAR-Pus STAR is the state s managed Medicaid pan that in the NorthSTAR area covers persons with TANF Medicaid benefits for heath services other than behaviora heath. Behaviora heath services are sti covered for STAR recipients under NorthSTAR in the seven county NorthSTAR region. (In other parts of the state, STAR and STAR-Pus aso provide behaviora heath coverage.) Aged, bind, or disabed persons who receive Suppementa Security Income (SSI) are eigibe for the STAR-Pus program, even if they aso receive Socia Security Disabiity Insurance (SSDI) payments. Ony chidren who receive SSI can opt out of STAR-Pus. Maximus, the enroment broker for STAR, STAR-Pus, and NorthSTAR, wi send Medicaid recipients appropriate information about the program they must sign up for as we as about the various pans in our area that they may choose among. Both STAR and STAR-Pus provide benefits for the Medicaid members who receive them by providing a primary care physician in a medica famiy home and access to unimited prescriptions through those pans. The Affordabe Care Act (ACA) You and your famiy may aso be abe to get heath insurance at ow or no cost through the Affordabe Care Act (ACA) Marketpace. You can appy onine at or by caing If you wish to appy in person or to find an agency that wi hep you appy ca There are ow income subsidies and/or tax credits for famiies or individuas with incomes between 100% and 400% of the FPL that can hep you pay the cost of the premiums for insurance through the ACA Marketpace. The Marketpace wi aso screen your appication for eigibiity for CHIP or Medicaid. If you did not begin your appication for insurance through the ACA Marketpace by March 31, 2014, you wi need to wait unti the open enroment period for the ACA. The open enroment period wi begin each year on November 15th, and wi run through February 15th of the foowing year. For exampe, the open enroment period for 2015 wi be November 15, 2014, through February 15, HOW DO I GET MENTAL HEALTH OR SUBSTANCE ABUSE SERVICES? You can get these services by: Caing the to free ACCESS LINE at or TDD , Caing or visiting any VaueOptions network provider, or Asking your primary care physician. You are the most important part of the NorthSTAR program. We want to provide you the information you need. We have two departments to serve you-a Customer Service Department and a Cinica Department. They can hep you get the best possibe care. To tak to someone from Customer Service or the Cinica Department, ca the to free ACCESS LINE at or TDD We have -speaking empoyees avaiabe 24 hours a day, 7 days a week, and a service to interpret more than 100 foreign anguages. Our Customer Service Department is avaiabe Monday through Friday from 8 a.m. unti 5 p.m. to answer your questions about: If you or your famiy are eigibe to receive menta heath or substance abuse services How to get menta heath or substance abuse services How to find out about services you or your famiy members can receive if you are receiving STAR, CHIP, or other benefits, Information about having someone interpret for you in another anguage Information about educationa information or programs or about preventing iness or substance abuse, incuding how to receive tip sheets or brochures How to find information about community resources incuding sef-hep programs Information about how to give a compiment or make a compaint or fie a grievance or appea 3

5 VaueOptions NorthSTAR Member Information Our Cinica Department is avaiabe 24 hours a day, 7 days a week. The Cinica Department incudes icensed behaviora heath professionas (caed Care Managers) who can hep you: Find a provider who can provide the services you need and who is near by Obtain menta heath or substance abuse services Dea with a menta heath or substance abuse crisis WHAT IF I NEED EMERGENCY CARE? A menta heath or substance abuse emergency is when you fee ike hurting yoursef or someone ese, or if you beieve your ife or heath may be in danger. If you, a famiy member, or someone you know is having a menta heath or substance abuse emergency you shoud do at east one of these things: Ca your menta heath or substance abuse provider or Ca the to-free ACCESS LINE at or TDD or Ca the Mobie Crisis Team to free at Ca 911 Go to the nearest hospita emergency room WHAT IF I NEED TO BE ADMITTED TO A HOSPITAL? NorthSTAR members who have Medicaid or who have no insurance other than NorthSTAR must be screened at Green Oaks Hospita in Daas before admission to inpatient treatment at a hospita. NorthSTAR wi provide transportation from any other emergency room or hospita to Green Oaks for the screening. Members who have no insurance wi ony be admitted to Green Oaks Hospita. Members who have Medicaid who need to be hospitaized may choose Green Oaks, or any hospita in the NorthSTAR network to receive treatment after being screened at Green Oaks. NorthSTAR wi provide transportation for Medicaid members to the chosen network hospita. NorthSTAR members who have Medicare hospita benefits remaining may sti choose any hospita that accepts Medicare. Medicare eigibe members who have remaining hospita benefits do not have to be screened at Green Oaks prior to admission to a Medicare provider hospita. The ocation and phone number for Green Oaks Hospita is: Green Oaks Hospita (972) Codus Fieds Drive Daas, TX WHAT IF I AM AWAY FROM HOME AND NEED ROUTINE OR EMERGENCY CARE? The NorthSTAR service area incudes Coin, Daas, Eis, Hunt, Kaufman, Navarro, and Rockwa counties. When you receive services outside the NorthSTAR service area, this is caed out-of-area care. Ony emergency care for persons who have Medicaid and no other insurance is covered by NorthSTAR when you are out of the NorthSTAR service area. The Loca Menta Heath Authority (LMHA) for the area you are in may be abe to hep you with emergency services if you do not have Medicaid or other insurance such as Medicare or private insurance. You shoud ask the provider of your emergency services to contact the LMHA for that area. **(Note: some NorthSTAR providers may be ocated near you in neighboring non-northstar counties. Receiving care from these contracted NorthSTAR providers is not considered out-ofarea care.) If you have a menta heath or substance abuse emergency when you are outside of the service area, you can: Go straight to the hospita. Te the hospita your name and the VaueOptions ACCESS LINE phone number, The hospita wi ca us to te us you are there, or Ca the VaueOptions ACCESS LINE first. A VaueOptions Care Manager wi hep you get the care you need at the cosest hospita. If you beieve that you or someone with you is in immediate danger, ca 911. Give the VaueOptions ACCESS LINE number to the hospita if you are taken to a hospita. When your emergency care is competed, we wi work with the hospita to transfer you back to your provider in the NorthSTAR area. When you know you wi be traveing outside of the NorthSTAR service area, be sure that you take enough of your medications to ast unti you return. It is aso a good idea to take a ist that incudes your provider s name and phone number, the VaueOptions ACCESS LINE number, a ist of your medications and when you take them, and a phone number for a friend or reative who is your emergency contact. This information can be written on the VaueOptions NorthSTAR Program Information Card that you got in your packet of information when you enroed, or you can request one by caing the VaueOptions ACCESS LINE. HOW CAN I FIND A PROVIDER? You have the right to get the best possibe treatment. You aso have the right to choose your NorthSTAR provider and to change providers if you wish. Our menta heath or substance abuse providers have been heping peope for many years. They are ocated throughout the NorthSTAR service area. The NorthSTAR Provider Directory section of this handbook ists the providers who are contracted to provide behaviora heath services to individuas enroed in NorthSTAR. If you know a provider you woud ike to use and that provider is isted in the NorthSTAR Provider Directory section of this handbook, ca that provider to find out how to get services. If you do not know a provider you want to use, or if the provider you want to use is not a NorthSTAR provider, ca VaueOptions ACCESS LINE at or TDD We can hep you find a provider that you fee is right for you that is ocated cose to where you ive or work. Pease te us if you need a provider who speaks your native anguage, understands your cuture, or if you have any other specia needs, so the ACCESS LINE Care Manager wi be abe to hep you find the right provider. Be sure to te your provider about your specia needs when you ca to make an appointment. Remember, you need to receive treatment from a VaueOptions NorthSTAR provider. HOW DO I GET A REFERRAL TO ANOTHER PROVIDER? If you are aready in treatment and are having probems with your provider, or do not fee that you are getting the services you need, ca our ACCESS LINE for assistance before you make your next appointment. If you need different services from those your provider offers, you can aso ca the ACCESS LINE to find a provider who has those services. If you are not satisfied with your provider for any reason, ca our ACCESS LINE for hep. Our ACCESS LINE staff can hep you fie a compaint or grievance, or they can hep you find another provider. You wi be given a referra, which is the name, address, and teephone number of one or more menta heath or chemica dependency professionas who can hep you. WHAT IF I HAVE NO WAY TO GET TO MY PROVIDER? For transportation to your provider for routine care, if you are Medicaid-eigibe and you have no other form of transportation to your provider, you may ca the Medicaid Medica Transportation vendor for our area, LogistiCare, from 8 a.m. to 5 p.m. The to free number to ca to arrange your ride is: LogistiCare Medicaid Transportation Provider

6 VaueOptions NorthSTAR Member Information The number to ca to cance your ride or to check on your ride the day you need it is: LogistiCare Medicaid Transportation Ride Hep Pease ca for transportation as soon as you know about your appointment. You must ca at east 48 hours (2 days) before your appointment. When you ca, be sure to have: Your 9-digit Medicaid number Your address The name, address, and phone number of your provider The date and time of your appointment If you cance or change your appointment with your provider, you must ca the LogistiCare office and cance your ride. LogistiCare can refuse to give you a ride after the second time you fai to ca to cance a ride, or if you are not abe to give a good reason for not caing to cance the ride. A parent or guardian, or a person named by the parent or guardian, must ride with chidren under 14 years of age. To choose another person to accompany your chid, ca the tofree LogistiCare number and ask for the form to name another person to ride with your chid. This poicy is stricty enforced by LogistiCare. If you are not Medicaid-eigibe and you are unabe to get to your NorthSTAR provider, ca your provider for hep in getting to your appointment. You can aso ca the tofree VaueOptions ACCESS LINE at or TDD HOW DO I CANCEL OR CHANGE AN APPOINTMENT? If you cannot keep your appointment with a NorthSTAR provider, pease ca the provider at east 24 hours before your appointment. Caing your provider makes it possibe for someone ese to receive care they may need. If you cannot make a new appointment when you ca to cance, pease remember to ca as soon as possibe to make another appointment. WHAT ARE MEDICALLY NECESSARY SERVICES? Medicay necessary services are menta heath or substance abuse services that: Are reasonaby necessary for the diagnosis or treatment of a menta heath or substance abuse disorder or to improve, maintain, or prevent deterioration of functioning due to such a disorder Are in accordance with professionay accepted cinica guideines and standards of practice in behaviora heath care Are furnished in the most appropriate and east restrictive setting in which services can be deivered safey Are the most appropriate eve or amount of service that can be provided safey Services that coud not be omitted without negativey affecting the individuas menta and/or physica heath or the quaity of care given WHAT SERVICES OR BENEFITS DOES VALUEOPTIONS OFFER ME IN NORTHSTAR IF I AM MEDICAID-ELIGIBLE? If you are a Medicaid-eigibe enroee, you may receive the foowing services from VaueOptions NorthSTAR behaviora pan if they are medicay necessary and you meet the criteria for age and diagnosis, as indicated. If you have both a menta heath and a substance abuse diagnosis, you may receive both types of services. 1. MENTAL HEALTH SERVICES ADULT/CHILD/ADOLESCENT, MEDICAID-ELIGIBLE ENROLLEE Outpatient services, incuding assessment, individua and group therapy, psychoogica testing, medication management, and heath education. Inpatient services, incuding genera hospita and freestanding psychiatric hospitas Other services-crisis stabiization, subacute inpatient, in-home services, targeted/focused case management, 23-hour observation bed, emergency services, and services to interpret information in a foreign anguage, as needed. Medication is covered by your STAR pan if you are enroed in STAR, or by the State Medicaid vendor drug program if you are not enroed in STAR. If you are enroed in STARpus and have Medicare, your medications are covered by your Medicare Part D pan. 2. MENTAL HEALTH SERVICES CHILD/ADOLESCENT, MEDICAID ELIGIBLE ENROLLEE Medicaid-eigibe chidren and adoescents may receive a the services isted in section 1 above, as we as the foowing medicay necessary services: Rehabiitative Services through the Speciaty Provider Network (SPN) day treatment, partia hospitaization programs, community support services, service coordination/case management, respite, and eary intervention for ages 3 to MENTAL HEALTH SERVICES ADULTS WITH A SERIOUS MENTAL ILLNESS (SMI), MEDICAID-ELIGIBLE ENROLLEE Medicaid-eigibe aduts who have been diagnosed with a serious menta iness may receive a the services isted in section 1 above, as we as: Rehabiitative Services through the Speciaty Provider Network (SPN)-day treatment, partia hospitaization programs, community support services, service coordination/case management, supported housing, supported empoyment, and ACT Teams. 4. SUBSTANCE ABUSE/CHEMICAL DEPENDENCY ADULT/CHILD/ ADOLESCENT, MEDICAID- ELIGIBLE ENROLLEE Outpatient services, incuding assessment, individua and group therapy, intensive outpatient programs, partia hospitaization programs, medication management, outpatient detox, specia femae services with chid care, services to interpret information into another anguage, as needed, and heath education services. Inpatient services, incuding medicay managed residentia detox and residentia rehabiitation. Medication is covered by your STAR pan, or by your Medicare Part D pan if you have both Medicaid and Medicare. IF I AM NOT MEDICAID-ELIGIBLE, WHAT SERVICES DOES VALUEOPTIONS OFFER ME? If you are not Medicaid-eigibe and not enroed in one of the STAR physica heath pans, you may sti receive services from VaueOptions NorthSTAR behaviora heath pan if you meet the eigibiity criteria described on page 2 for non- Medicaid eigibe enroment. The services you are eigibe for are based on medica necessity, your age, or your diagnosis, as described in the ists beow. If you have both a menta iness and a substance abuse condition, you may receive services from both ists. 1.) MENTAL HEALTH ADULT/ CHILD/ADOLESCENT, NON- MEDICAID-ELIGIBLE AND NON- SMI/SED Persons who are financiay eigibe for NorthSTAR but do not have a target diagnosis, as defined by the state as Schizophrenia, Schizoaffective Disorder, Bipoar Disorder, or Major Depression are eigibe for Emergency services incuding crisis stabiization, 23 hour observation, and inpatient care when medica necessity criteria are met. 5

7 VaueOptions NorthSTAR Member Information 2.) MENTAL HEALTH ADULT WITH A SERIOUS MENTAL ILLNESS (SMI), NON-MEDICAID- ELIGIBLE NorthSTAR-enroed aduts who have been diagnosed with a serious menta iness that is a target diagnosis as defined by the state and who are not Medicaid-eigibe may receive, when medicay necessary, a the Menta Heath services isted in Section 1 above, as we as: Outpatient services, incuding assessment, medication management, psychiatric medications, individua and group therapy, and psychoogica testing Crisis stabiization, subacute inpatient, in-home services, targeted/focused case management, 23hour observation bed Rehabiitative Services through the Speciaty Provider Network (SPN)-day treatment, partia hospitaization programs, community support services, service coordination/case management, supported housing, supported empoyment, intensive crisis residentia services, persona care homes/assisted iving, adut foster care, and ACT Teams Transportation (when authorized) 3.) MENTAL HEALTH CHILD/ ADOLESCENT WITH A SERIOUS EMOTIONAL DISORDER (SED) NON-MEDICAID-ELIGIBLE NorthSTAR-enroed chidren and adoescents who have been diagnosed with a serious emotiona disorder who are not Medicaideigibe may receive, when medicay necessary, a the services isted in Sections 1 and 2 above, as we as: Rehabiitative Services through the Speciaty Provider Network (SPN)-day treatment, partia hospitaization programs, community support services, service coordination/case management, supported housing, supported empoyment, respite, intensive crisis residentia services, residentia treatment centers, and eary intervention for ages 3 to 5. A.) SUBSTANCE ABUSE ADULT/CHILD/ ADOLESCENT, NON-MEDICAID- ELIGIBLE Outpatient services, incuding assessment, individua and group therapy, intensive outpatient programs, partia hospitaization programs, medication management, outpatient detox, specia femae services (incuding primary care for pregnant women ony) with chid care, needed interpretive services, and heath education services B.) SUBSTANCE ABUSE CHILD/ ADOLESCENT, NON-MEDICAID- ELIGIBLE NorthSTAR-enroed chidren and adoescents who are not Medicaid-eigibe may receive, when medicay necessary, a substance abuse treatment services isted in Section 1, as we as: Inpatient services, incuding medicay managed residentia detox and residentia rehabiitatation SPECIAL POPULATIONS If you are a pregnant woman, a woman with dependent chidren, a parent of chidren in foster care, HIV-positive, or use needes to take drugs, you are eigibe to receive, as medicay indicated, a the outpatient substance abuse services isted in Section 1, as we as: Inpatient services, incuding medicay managed residentia detox and residentia rehabiitation CHEMICAL DEPENDENCY ADULT/CHILD/ADOLESCENT, NON- MEDICAID-ELIGIBLE If you are diagnosed with chemica dependency you are eigibe to receive, if medicay necessary, a of the substance abuse treatment services isted above. CAN I GET PRESCRIPTION DRUGS? Medicaid-eigibe, enroed in STAR If you are Medicaid-eigibe and enroed in the STAR program, your STAR pan wi pay for amost a of your prescriptions. This incudes the medicine your provider orders as part of your behaviora heath treatment as ong as it is on the ist of drugs provided under the pan. Pease ca your physica heath pan if you have questions about prescriptions. Moina AMERIGROUP Parkand Heath Pan Medicaid-eigibe, enroed in STAR- Pus Some NorthSTAR members may be enroed in the STAR-Pus pan, which serves the aged, bind, and disabed who receive Suppementa Security Income (SSI) benefits, and may aso receive Socia Security Disabiity Insurance payments. These members receive medications through their STAR-pus pan if they do not have Medicare, and through their Medicare Part D pan if they do have Medicare as we as Medicaid. There is no prescription imit. The companies that provide STAR-Pus programs in the NorthSTAR area are: Moina Heathcare of Texas Superior Heathpan Pus Medicare-Part D Recipient NorthSTAR members who have Medicare Part D wi receive their prescriptions through their Medicare Part D pans. If a member who has Medicare Part D but does not aso have Medicaid needs a prescription that is not incuded in any Medicare Part D Pan because the government excuded those types of drugs, such as benzodiazepines or barbiturates, NorthSTAR wi pay for those drugs when they are prescribed by a NorthSTAR doctor and are considered medicay necessary. NorthSTAR may aso hep with NorthSTAR prescribed medications if a member is in the doughnut hoe or gap in Medicare Part D coverage. Members who need excuded drugs or who are in the doughnut hoe, wi need to ca VaueOptions Customer Service at in order to find out how NorthSTAR can hep with medications. Non-Medicaid-eigibe If you are not Medicaid-eigibe and you are a person with a serious menta iness or a serious emotiona disorder, you may be eigibe for prescription drugs for your behaviora heath treatment under the NorthSTAR pan. For more information, pease check with your provider or ca the to free ACCESS LINE at or TDD HOW MUCH WILL I PAY FOR PRESCRIPTIONS? Persons who have Medicaid (but not Medicare) get their prescriptions through their STAR or STAR-pus pans. Medicaid members wi not have copays on medications. Persons who have both Medicaid and Medicare are caed dua eigibe. NorthSTAR members who are dua eigibe wi receive their prescriptions through their Medicare Part D pan. Because they are dua eigibe, they must enro in Medicare Part D or Medicare wi enro them in Part D. They wi have the owest cost Part D pans with no premium, no gap in coverage (caed the doughnut hoe), and ony very sma copays. It is a good idea for dua eigibe members to use the Medicare Part D pan finder each year during the open enroment period for Medicare to make sure the pan D they have is the best one for them. ARE THERE ANY BENEFIT LIMITS OR EXCLUDED SERVICES? The NorthSTAR pan ony provides menta heath and substance abuse reated services (behaviora heath services). It does not cover physica medica services except for some speciaized femae services for pregnant women who are not eigibe for other heathcare benefit pans such as Medicaid. The foowing behaviora heath services are excuded from 6

8 VaueOptions NorthSTAR Member Information the NorthSTAR benefits for Medicaid individuas, but may be covered by your physica heath pan: Screening for behaviora heath disorders during we adut checks Texas Heath Steps exams and other ambuatory heath exams Emergency medica transportation for behaviora heath emergencies Behaviora heath services provided by primary care physicians, other STAR physicians, or other appicabe Medicaid physicians within the scope of their icenses Behaviora heath services provided by federay quaified heath centers and rura heath cinics Ambuatory aboratory services Certain emergency room services Certain inpatient hospita services The STAR pans pay for prescription medications for STAR-enroed Medicaideigibe enroees in NorthSTAR. STAR-pus pans pay for medications for persons enroed in STAR-pus who do not have Medicare as we as Medicaid. Medicare Part D pans pay for medications for Star-pus enroees who have Medicare. For Non-Medicaid-eigibe aduts, new generation anti-psychotic medications may be imited, depending on the avaiabiity of designated funding. Famiy panning services are not covered services under NorthSTAR. If you are interested in famiy panning services, ask your primary care physician (PCP), famiy doctor, heath cinic, or oca county heath department for hep in finding these services. Your city or county information and referra service can aso te you which agencies in your community provide these services at ow or no cost. Medicaid members who are enroed in STAR can ca their STAR pans for hep in finding famiy panning services. WHAT IF I AM UNHAPPY WITH MY CARE OR YOUR SERVICE? VaueOptions cares about you and the quaity of services that you receive. We work hard to give you the best care. We aso understand that sometimes probems happen. If you are unhappy with any part of your menta heath or substance abuse treatment, or if you are denied care, you can contact the ACCESS LINE at or TDD A customer service representative can te you how to make a compaint or fie a grievance or appea. If you wish to find a new provider, a Cinica Care Manager can hep you find a provider that fits your needs. You have the right to ask questions or make a compaint about your menta heath or substance abuse care, provider, or VaueOptions without penaty. Medicaid recipients may request a Fair Hearing at any point in the compaint and appeas process. Information on how to ask for a Fair Hearing is on page 7. Non-Medicaid NorthSTAR members may request a review by an Independent Review Organization (IRO) at any point in the appea process if you are receiving inpatient services or are appeaing non-authorization of emergency services, or services that need immediate review. WHAT IS A COMPLAINT, AND HOW DO I MAKE ONE? A compaint is an easy way for you or your famiy member to resove issues or probems with your menta heath or substance abuse care before they become more serious. You can make a compaint to the VaueOptions customer service department through our ACCESS LINE or in writing. You can tak to a customer service representative who wi do everything possibe to sove your probem. To make a compaint, you may ca: VaueOptions Customer Service or TDD Maximus NorthSTAR Enroee Services NTBHA Consumer Ombudsman Texas Department of Insurance NorthSTAR Enroee and Provider Services at the Texas Department of State Heath Services (DSHS) Or, you can mai a etter of compaint to: VaueOptions, ATTN: Compaint and Grievance Coordinator 1199 South Betine, Suite 100 Coppe, TX Or to Texas Department of State Heath Services NorthSTAR Program PO Box /Mai Code 2012 Austin, TX If you make a written compaint to VaueOptions, our Quaity Management Department wi send you a etter within five working days or contact you to et you know we got your compaint. We wi send you a etter within 30 days after that to te you how we resoved the probem. If we can t sove your probem within 30 days, we wi send you a etter teing you why, and when you wi get an answer. If you are unhappy with our answer to your compaint, you may fie a grievance, which is a verba or written communication that tes us that you are not satisfied with the outcome of your compaint resoution. To fie a grievance, either ca our Customer Service department at for information on how to fie, or send your request for a grievance in writing to VaueOptions at the address given above. WHAT IS AN APPEAL, AND HOW DO I FILE ONE? An appea is a request that VaueOptions change a cinica decision, such as a change or denia of services. If you are unhappy with a VaueOptions decision about your behaviora heath treatment, you may fie an appea. A VaueOptions cinician or manager who was not invoved with the origina decision wi review the origina decision and decide whether or not to change that decision. To fie an appea, you can: Ca the ACCESS LINE at or TDD and ask the Customer Service representative to mai you an appea form. If you need hep with the appea process, VaueOptions has peer and famiy advocates to hep you. Compete an appea form or write a etter and send it to: VaueOptions, ATTN: Compaint and Grievance Coordinator 1199 S. Betine, Suite 100 Coppe, TX Ask your provider for an appea form The Compaint and Grievance Coordinator wi send you a etter within five working days after we receive your appea. If we need more information, we wi contact you to ask you for the information we need to work on your appea. Your hep is necessary to hep us resove your appea. A decision wi be made in response to your appea within 30 days from when we receive it. You may ask for an expedited appea if it invoves inpatient care or urgent or emergent treatment. A decision wi be made on an expedited appea within one day. Your provider wi be notified by phone of the decision on the appea. A etter describing the decision on your expedited appea wi be sent to you within three working days. HOW DO I GET A FAIR HEARING? Medicaid-eigibe NorthSTAR enroees who disagree with the resuts of the VaueOptions appea process may request a Fair Hearing. To request a fair hearing, NorthSTAR Medicaid eigibe enroees or someone acting on their behaf as a representative can ca or write the foowing: VaueOptions ACCESS ine at

9 VaueOptions NorthSTAR Member Information VaueOptions 1199 S. Betine, Ste 100 Coppe, TX Or contact the Department of State Heath Services (DSHS) Office of Consumer Rights at Or you may ca for DSHS NorthSTAR Enroee and Provider Reations for assistance in fiing for a Fair Hearing. Or write to: NorthSTAR Enroee and Provider Services Texas Department of State Heath Services NorthSTAR Program PO Box /Mai Code 2012 Austin, TX Non-Medicaid-eigibe NorthSTAR enroees who disagree with the resuts of the VaueOptions appea process may request a review of the appea decision by an Independent Review Organization (IRO). If you disagree with our decision to deny, deay, reduce, suspend, or stop services, a Medicaideigibe enroee may fie a request for a Fair Hearing, or a non-medicaid-eigibe enroee may request an IRO review, by caing the VaueOptions ACCESS LINE at or TDD The customer service representative or a peer or famiy advocate wi hep you compete the request form. CAN I BE DISENROLLED FROM NORTHSTAR? The State must approve any disenroment that is not requested by the enroee. However, VaueOptions may ask the State to disenro you from the program due to: Unruy behavior on the part of an enroee that is not caused by the enroee s menta iness or substance abuse disorder Loaning of your Medicaid enroee ID card to another person An enroee moving away from the NorthSTAR service area A change in financia status of a non- Medicaid-eigibe enroee so that the enroee no onger meets the income imits for NorthSTAR WHAT IF I MOVE? If you move within the NorthSTAR area, be sure to give your new address to your provider, and to ca VaueOptions ACCESS LINE at or TDD to report your new address. If you need a new provider because your new address is not near your current provider, a VaueOptions Cinica Care Manager can hep you find a new provider that is right for you and ocated near to your new address. 8 If you move outside of the NorthSTAR area, ca the VaueOptions ACCESS LINE at or TDD before you move to report that you are moving out of the area. We wi give you information about how to find the behaviora heath services you need in your new area. It is important that you keep getting care, especiay if you take medicine to hep you manage your iness. It is a good idea to see your current provider and get adequate medications before you move, so that you wi not run out of medication before you have time to make an appointment with a provider near your new address. WHAT IS FRAUD AND ABUSE? Heath care fraud and abuse is a wifu deception or ie, made by an enroee, famiy member, provider, or any other person, knowing that this coud resut in some unauthorized benefit to that person or another interested party. If you think that a provider, an enroee, or any other person is invoved with fraud and abuse invoving the NorthSTAR pan, report it immediatey to VaueOptions by caing our Customer Service Department on our ACCESS LINE at or TDD WHAT ARE MY RIGHTS? VaueOptions beieves that individuas who receive services in the NorthSTAR program are fu partners in their menta heath or substance abuse care. Certain rights are guaranteed to you whie you are receiving services under the NorthSTAR program. You shoud be aware of these rights. 1. You have the right to respect, dignity, privacy, confidentiaity, and non-discrimination.that incudes the right: a. To be treated fairy and with respect, and b. To know that your medica records and what you te your providers wi be kept private and confidentia, and not shared without your written permission. 2. You have the right to a reasonabe opportunity to choose a menta heath or substance abuse provider from the VaueOptions NorthSTAR network of providers, and to change that provider if you choose to do so. That incudes the right to be informed about how to choose and change your provider. 3. You have the right to ask questions and get answers about anything you don t understand. This incudes the right: a. To have your provider expain your behaviora heath care needs to you and tak to you about the different ways your behaviora heath care probems can be treated, and b. To be tod why care or services were denied and not given when you or your provider requested them. 4. You have the right to consent or refuse treatment, and to activey participate in decisions about your care. That incudes the right: a. To be treated in the east restrictive cinicay appropriate setting b. To give permission for your famiy members or guardians to be invoved in the panning of your treatment c. To work as part of a team with your provider in deciding what behaviora heath care is best for you, and d. To say yes or no to the care recommended by your provider. 5. You have the right to use each avaiabe compaint process through VaueOptions and through Medicaid and/or the State. This incudes the right: a. To make a compaint to VaueOptions or to the State about your behaviora heath care, your behaviora heath provider, or about VaueOptions. b. To get a timey answer to your compaint, and c. For Medicaid-eigibe-enroees to ask for and receive a Fair Hearing, or for Non- Medicaid-enroees to ask for a review by an Independent Review Organization (IRO). 6. You have the right to timey access to care that does not have any communication or physica access barriers. This means that you have the right to get in and out of a behaviora heath provider s office, with no barriers to access if you have a disabiity that imits your mobiity, in accordance with the Americans with Disabiities Act. This incudes the right: a. To have teephone access to a behaviora heath professiona 24 hours a day, 7 days a week to obtain any needed emergency or urgent care, b. To have someone interpret for you if you need information in another anguage, both when you ca VaueOptions or your provider, and when you go to see your provider. Interpreters incude peope who can speak in your native anguage, assist with a disabiity, or hep you understand information you need to make sure you get the care you need.

10 VaueOptions NorthSTAR Member Information c. To be given an expanation that you can understand about the VaueOptions NorthSTAR pan rues, incuding what services you can get and how to get them. WHAT ARE MY RESPONSIBILITIES IN MY RECOVERY? As a partner in your recovery, you have a responsibiity to take part in meeting the goas that you and your provider set. The foowing ist can hep you, your provider, and everyone ese invoved in your care make sure that you get the most out of your treatment. 1. You have the responsibiity to earn and understand the rights you have under the NorthSTAR program. That incudes the responsibiity: a. To ask questions if you don t understand your rights b. To ca VaueOptions ACCESS LINE at or TDD and inform a Cinica Care Manager when you change your provider c. To keep your schedued appointments with your provider d. To cance appointments at east 24 hours in advance, or as soon as you know you cannot keep them, so that your provider can use that time to give someone ese care. e. To use a NorthSTAR provider for a but emergency room care in an emergency or ife or heath threatening situation f. To understand when you shoud and shoud not go to the emergency room g. In a but emergency situations, to ca VaueOptions or the provider you wish to use to find out if that provider is a NorthSTAR provider. h. To abide by the NorthSTAR poicies and procedures, and, if you do not understand the poicies and procedures, to ca VaueOptions or your provider to have them expained to you. 2. You have the responsibiity to share information about your menta heath or substance abuse status with your provider, and to become fuy informed about the different types of treatment you can get for your disorder. This incudes the responsibiity to hep your behaviora heath provider get your medica records from past providers. 3. You have the responsibiity to activey participate in decisions reating to who your provider is, what services you want from that provider, and what type of care you get. This incudes the responsibiity to make persona choices and to take action to maintain your behaviora heath. It aso incudes the responsibiity to: a. Work as a team with your provider in deciding what care is best for you b. Understand how the things you do can affect your behaviora heath c. Do your best to stay heathy, and d. To treat behaviora heath providers and staff with respect DO YOU OFFER PREVENTION OR EDUCATION PROGRAMS? The best time to take care of a probem is before it gets so big that you need to see a doctor. In other words, prevention is the best medicine. Our prevention, education, and outreach programs can hep you find support groups and community programs in your area. We attend many community events and hod or sponsor workshops to provide information that can be hepfu to you or your famiy. We aso have tipsheets and other information that can hep you with everyday probems ike: Addiction Anger and Chid Discipine Deaing with Anger Good Parenting Heping Kids Like Themseves HIV and AIDS Hyperactive Chidren Preventing Reapse Understanding Stress VaueOptions beieves that heathy communities produce heathy famiies. We work with many community organizations to address issues that impact the menta heath of the peope who ive in the NorthSTAR area. If you woud ike information on a specia subject or about probems you may be facing, pease ca the ACCESS LINE at and ask to speak to our Prevention, Education, and Outreach Department. You can aso ask your provider for information about your menta heath or substance abuse, or about handing the probems that you and your famiy face in everyday ife. You can find hepfu information about your diagnosis, heath and weness tips, and how to cope with things that happen in ife on our VaueOptions NorthSTAR Achieve Soutions site by cicking on the ink to Achieve Soutions at WHAT ABOUT PROGRAMS FOR FAMILY MEMBERS? Famiies pay an important roe in a person s recovery. We encourage famiy members to become invoved in the treatment and recovery of their oved one. Famiy members can ca VaueOptions ACCESS LINE at or TDD for information on the NorthSTAR program, how to get services for their famiy member, or how to resove a compaint about a provider, services, or VaueOptions. If your famiy member cas, VaueOptions wi keep a information about your case confidentia, but we can answer genera questions about the NorthSTAR pan and services. We can hep you find specia programs for famiy members incuding: Educationa programs for famiy members to hep them earn about menta iness and substance abuse Support groups for famiy members Your provider can aso hep you find resources for education and support for your famiy. There are istings of groups and community resources on page 11 of this handbook. ARE THERE ANY SELF-HELP OR CONSUMER-RUN PROGRAMS? VaueOptions beieves that everyone who receives menta heath or substance abuse services shoud be abe to ive the fuest ife possibe. Sometimes, peope with a behaviora heath probem want to deveop their own programs to hep themseves and others who have simiar probems. These programs, caed Consumer-run Programs, are used with professiona menta heath or substance abuse programs. Together, professiona services and Consumer-run Programs can hep peope recover a meaningfu ife. VaueOptions sponsors Consumer-run Programs, sef-hep groups, and drop-in centers. We aso offer technica assistance to consumer groups who want to buid their own sef-hep groups. To get information about these programs, or to ocate the ones near you, ca VaueOptions ACCESS LINE at or TDD WHAT ARE ADVANCE DIRECTIVES? Advance Directives are ega papers you prepare whie you are heathy. Advance directives give instructions to those who might treat you in the future if you are unabe to make decisions about your care due to your iness. Advance Directives are a way for you to sti be a partner in your heath care, even if you are not abe to make decisions. 9

11 VaueOptions NorthSTAR Member Information Advance Directives say what types of care you do or do not want. There are two types of Advance Directives: Medica Advance Directives, which te your famiy and providers about your wishes in case you become disabed by a medica probem and are unabe to make decisions. An exampe woud be if you were unconscious. Psychiatric or Menta Heath Advance Directives, which te doctors and famiy members what your wishes are if you become disabed by a psychiatric iness. The State Legisature has deveoped forms for both types of Advance Directives. These forms are simpe to compete, and you are not required to have to have a awyer, even though Advance Directives are ega forms. For more information about Advance Directives and Living Wis, ca VaueOptions ACCESS LINE at or TDD and ask to speak to a member of the Prevention, Education, and Outreach Staff. It is a good idea to discuss what might go in an Advance Directive with your doctor or provider; however, your doctor or provider is not aowed to hep you compete an Advance Directive. If you have an Advance Directive, it is a good idea to te your Provider, and to give a copy to your provider. You or your provider shoud ca VaueOptions ACCESS LINE at or TDD and speak to a Cinica Care Manager so that the information about your Advance Directive can be put in your record. This way, in an emergency, your wishes for the type of treatment you want, or do not want, can be respected. It is aso a good idea to give a copy of your Advance Directive to a famiy member or other person who acts as your emergency contact person. A Living Wi is a specia type of Medica Advance Directive that tes your famiy members and doctors what you want them to do about medica procedures that woud proong your ife if you are unabe to te them yoursef. 10

12 VaueOptions NorthSTAR Member Information HOW CAN I FIND OTHER COMMUNITY RESOURCES? We have isted some exceent community resources beow. Our Customer Service Representatives or our Prevention, Education, and Outreach staff can give you additiona resources if you ca our ACCESS LINE at or TDD The North Texas Behaviora Heath Authority (NTBHA) can aso hep you with resources if you ca them at to free at , or go to their website The Menta Heath Association of Greater Daas and NAMI Daas, isted beow, can aso provide ists of support groups and other resources in the area. AIDS Arms, Inc / A-Anon Information Service...214/ Acohoics Anonymous, Daas...214/ or info@daasa-anon.org The ARC of Daas...214/ Battered Womens Hotine...214/ BRAIN (North TX Brain Injury Resource & Information Network, Inc.) (metro)...817/ Community Hepine (for information on a wide array of needs)...214/ 379-HELP or 214/ Depressive and Bipoar Support Aiance (metro)...817/ Deaf Action Aiance(TDD)...214/ Menta Heath Association of Greater Daas...214/ NAMI Daas...214/ NAMI Coin County...(214) 908-NAMI (6264) or info@namicco.org NAMI Southern Sector Daas...972/ Obsessive-Compusive Disorder Support Group...972/ Recovery, Inc...214/ Savation Army...214/ Texas Narcotics Anonymous...888/NAWORKS United Way of Greater Daas Hep Line...214/ United Way of Greater Daas Hispanic Hep Line...214/ WHAT ARE MY PRIVACY RIGHTS? VALUEOPTIONS NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY If you have any questions, pease contact VaueOptions at or TDD I. How we Safeguard Your Protected Heath Information. Your individua information about your past, present, or future heath, the heath care you receive, or the payment for the heath care is caed Protected Heath Information ( PHI ). We are required to protect PHI that we have received or created, and to give you this Notice about our privacy practices. We may receive PHI from sources other than you through a paper or eectronic inquiry to your group heath pan or its business associates, your other heath insurance companies, your providers, or other avaiabe databases. This Notice expains how, when and why we may use or share your PHI. In most cases, we must use or share ony the minimum necessary PHI to accompish a task. The aw has specia protections for some kinds of information, incuding substance abuse information. We are required to foow the privacy practices described in this Notice, but we may change our privacy practices and this Notice at any time. If we make changes, we wi put a new Notice on our Website at You may request a copy of the new Notice by caing the customer service number in your member materias or handbook. II. How We May Use Your Protected Heath Information and Share It With Others We use PHI and share it with others for a variety of reasons. Exampes of the types of persons who have access to your PHI are our customer service representatives, our care managers, our medica professionas, our caims administration staff, your group heath pan, if it compies with the aw, and pubic authorities that are permitted access under the aw. Sometimes we must have your written agreement to share PHI. Sometimes we are aowed by aw to use or share your PHI without your written agreement. Here are exampes of how we use and share PHI. For treatment: We may discose your PHI to caregivers who are invoved in providing your heath care or Empoyee Assistance Program (EAP) services. For exampe, your PHI may be shared with the heath professiona that is treating you. For payment: We may use and share your PHI to pay caims from the heath professionas who have provided services to you. We may aso use and share your PHI to obtain payment for our services. For exampe, we may reease portions of your PHI to a state Medicaid agency or to another insurance company that provides your coverage. We may aso use your PHI, aong with the PHI of many others, to set our premiums. For heath care operations: We may use and share your PHI to operate our heath pans, EAP programs, and other programs. For exampe, we may use your PHI in deciding whether you are eigibe for specific services, or share your PHI with other professionas invoved in your care. We may combine and anayze data from different sources so that your heath pans and treating professionas can receive information about the products and services you are receiving in order to better coordinate your care. Uness you provide us with different directions, we may send appointment reminders and other simiar information to your home. We may aso send you information about treatment aternatives and heath-reated benefits. We may aso use your PHI in studying the quaity of the heath care services provided, or share your PHI with our accountants or attorneys for audits or itigation. If we are providing heath benefits to you under an empoyer-sponsored group heath pan, we may discose your PHI to the sponsor of the pan. Individuas invoved in your care or payment for your care: We may reease PHI about you to a friend or famiy member who is invoved in your medica care. We may aso give information to someone who heps pay for your care. When required by aw: We wi share PHI about you when required by federa, state or oca aw. We may share PHI when a aw requires us to report information about suspected abuse, negect or domestic vioence, or reating to suspected crimina activity. We must aso share 11

13 VaueOptions NorthSTAR Member Information PHI with authorities that monitor our compiance with privacy requirements. For pubic heath activities: We may share PHI when we are required to coect information about disease or injury, or to report information to a pubic heath authority. For heath oversight activities: We may share PHI with an agency responsibe for monitoring the heath care system for activities authorized by aw. These oversight activities incude, for exampe, audits, investigations, inspections and icensing. Reating to decedents: We may share PHI reating to an individua s death with coroners, medica examiners or funera directors, and to organ procurement organizations reating to organ, eye, or tissue donations or transpants. For research purposes: In certain circumstances, and under supervision of a privacy board, we may share PHI in order to assist medica or psychiatric research. To prevent threats to heath or safety: In order to avoid a serious threat to heath or safety, we may share PHI with aw enforcement or other persons who might prevent or reduce the threat of harm. For specific government functions: We may share PHI of miitary personne and veterans in certain situations, with correctiona faciities in certain situations, with other government programs for eigibiity and enroment, and for nationa security reasons. Lawsuits and disputes: If you are invoved in a awsuit or dispute, we may discose PHI about you in response to a court or administrative order. We may aso discose PHI about you in response to a subpoena, discovery request or other awfu request by someone ese invoved in the dispute, but ony if efforts have been made to te you about the request (which may incude written notice to you) or to obtain an order protecting the information requested. Law enforcement: We may reease PHI if asked to do so by a aw enforcement officia: In response to a court order, subpoena, warrant, summons or simiar process; To identify or ocate a suspect, fugitive, materia witness, or missing person; About the victim of a crime if, under certain imited circumstances, we are unabe to obtain the per-son s agreement; About a death we beieve may be the resut of crimina conduct; About crimina conduct at a hospita; and In emergency circumstances to report a crime, the ocation of the crime or victims; or the identity, description or ocation of the person who committed the crime. By aw we must have your written permission (an authorization ) to use or give out your PHI for any purpose that is not set out in this Notice. You may take back ( revoke ) your written permission at any time, except if we or our subcontractors have aready acted based on your permission. IV. Your Rights Regarding Your Protected Heath Information. You have the foowing rights reating to your PHI. You may exercise these rights by contacting VaueOptions at To request restrictions on uses or sharing with others: You have the right to ask us to imit how we use or share your PHI. We wi consider your request, but we don t have to agree to it. If we do agree to restrictions, we wi put the agreement in writing and foow it, except in emergency situations. We cannot agree to imit the uses or sharing of information that are required by aw. To choose how we contact you: You have the right to ask that we communicate with you about medica matters in a certain way or at a certain ocation. For exampe, you can ask that we ony contact you at work or by mai. To make a request regarding how we communicate with you, you must make your request in writing as indicated in your member materias. We wi agree to your request as ong as it is reasonabe for us to do so. To inspect and copy your PHI: You have a right to see and copy your protected heath information if you put your request in writing as directed in your member materias. We wi respond to your request within the time required by aw. If we deny your request, we wi give you written reasons for the denia and expain your appea rights. In certain situations, we may deny access to some parts of your PHI and you cannot appea that decision. We wi not provide access to psychotherapy notes, information we coect for ega actions, or any ab test information protected by aw, and you can t appea those decisions. If you want copies of your PHI, a charge for copying may be required, depending on your circumstances. You have a right to choose to get a summary instead of a copy of the whoe record. To request changes or corrections of your PHI: If you beieve that there is a mistake or missing information in your PHI, you may request that we correct or add to the record. You must submit your request in writing as indicated in your member materias, aong with a reason that supports your request. We wi respond within the time required by aw. We may deny the request if we determine that the PHI: (i) is correct and compete; (ii) was not created by us and/or is not part of our records, or (iii) is a type of information that we cannot discose. If we deny your request for changes, we wi te you in writing the reasons for denia and expain your rights to have your request and our denia, together with any statement of disagreement made part of your PHI. If we approve the request for changes, we wi change the PHI, and te you and others that need to know, about the change. To find out what discosures have been made: You have the right to get a ist of the discosures we made of your PHI, incuding the date, the person receiving the PHI and the purpose of the discosure. This ist wi not incude discosures for treatment, payment or heath care operations, any reease of information we made to you or to those you authorized, your famiy, or any reease to nationa security or inteigence authorities. The ist wi not incude any discosures made before Apri 14, 2003 and may not incude discosures that aw enforcement or heath authorities asked us not to ist. To request this ist, you must send your request in writing as indicated in your member materias. We wi respond to your written request for a ist within a period required by aw. You can request a ist of discosures going back up to six years but no earier than Apri 14, There wi be no charge for one ist each year. There may be a charge for more than one ist per year. To receive this notice: You have a right to receive a paper copy of this Notice and/or an eectronic copy by emai upon request. V. How to Compain about our Privacy Practices: If you think we may have vioated your privacy rights, or you disagree with a decision we made about access to or changes to your PHI, you shoud foow the appea instructions we wi give you. You may fie a compaint at the number isted in your member materias. You aso may fie a compaint with the Office for Civi Rights, U.S. Department of Heath and Human Services, 1301 Young Street, Suite 1169, Daas, TX Voice Phone (214) FAX (214) TDD (214) We wi not discriminate against you in any way because you fie a compaint. 12

14 VaueOptions NorthSTAR Member Information WHAT IF I DON T UNDERSTAND THE INFORMATION IN THIS BOOK? On the next pages we te you what some of the words and phrases we use in this book mean. If you need hep understanding this handbook, or if you have any questions about what is in this book, pease: Ca our ACCESS LINE at or TDD for hep, or to speak to someone in your own anguage, or Ca or visit your provider for hep WHAT DOES THAT WORD MEAN? ACCESS LINE: The to-free number you can ca to get menta heath and/or substance abuse care, hep, or information about this pan. The number is or TDD Appea: If you fie a compaint and it is decided in a way that you are not happy with, you may appea the decision by making a written request that a professiona at the VaueOptions Service Center review the origina decision. This professiona wi then decide whether to change the origina decision. You can aso ask an independent reviewer to go over the decision. Assessment: The cinica process of ooking at a person s menta heath or substance abuse and medica history, his or her functioning, reationships, and deveopment to determine his or her need for treatment. Behaviora Heath Services: Services that hep peope think, fee, and act in heathy ways, sometimes caed menta heath, substance abuse or chemica dependency treatment services. These services can aso hep peope stop drinking and using drugs. Compaint: A verba or written statement expressing your unhappiness with a decision or service from VaueOptions or your provider. Confidentiaity: A aw that protects a person s persona and behaviora heath treatment information from becoming pubic. Peope who take care of the cient don t te other peope what they know about the cient uness the cient says that it is okay. Copay: A sma fee that some enroees pay for services they receive. Copays are based on eigibiity and consumer and famiy income. Crisis Stabiization: A short-term, intensive type of treatment offered to enroees in the event of a crisis. It invoves individua assessment, foow-up, and referra to ongerterm treatment if necessary. Eary Intervention: Speciaized services for chidren ages 3-5 incuding chid/famiy assessment, pay therapy, parent counseing, and parent educationa training. Eigibe Cient: A person who can get behaviora heath services if they meet specific financia and behaviora heath criteria estabished by TD-SHS. Emergency Behaviora Heath Condition: Any condition that, in the opinion of a prudent ay person possessing an average knowedge of medicine and heath, requires immediate medica attention without which an individua woud present a danger to themseves or others, or that renders individuas incapabe of controing, knowing, or understanding the consequences of their actions. Enroee: A person who is enroed in NorthSTAR. Famiy: To determine financia eigibiity for NorthSTAR by determining famiy income, famiy is defined as a spouse (whether or not that spouse is iving in the home) and chidren under age 18. The income of parents is not counted for persons over 18, even if that person ives with parents. Formuary: A ist of medications preapprovedby the Texas Department of State Heath Services that can be prescribed for eigibe peope receiving Medicaid and non- Medicaid heath care services. HIPPA: The Heath Insurance Portabiity and Accountabiity Act (HIPAA) is a federa aw. This federa aw and state egisation gives you important rights. The most important right in the aw is the privacy of your heath information. Managed Care: A system of providing care that heps you to find the right care from the right provider (a counseor, doctor or hospita) as soon as possibe. Medicaid: A program that pays for heath care for peope who might not otherwise be abe to receive heath care. Peope with disabiities, peope who are bind, and needy famiies with chidren may receive Medicaid so that their physica heath and menta heath needs can be met. Medication Management: A visit with a psychiatrist to decide if medication is an appropriate treatment, and on going visits to make sure the medication is heping the behaviora heath condition. 13

15 VaueOptions NorthSTAR Member Information New Generation Medication: New generation anti-psychotic medications, aso caed atypicas, such as Risperidone, that may be more effective and have fewer side effects for some patients. North Texas Behaviora Heath Authority (NTBHA): The oca behaviora heath authority for the NorthSTAR service area. NTBHA wi be responsibe for panning, poicy deveopment, coordination, and oversight of NorthSTAR menta heath and substance abuse services. You can ca them at NorthSTAR Program: Behaviora Heath State of Texas Access Reform Program covering pubicy funded menta heath, substance abuse, and chemica dependency treatment services for Coin, Daas, Eis, Hunt, Kaufman, Navarro, and Rockwa Counties. The Texas Department of State Heath Services manage NorthSTAR. Out of Area Care: The behaviora heath services you receive when you are out of the NorthSTAR service area. Peer or Famiy Advocate: A person who can hep famiies receive services, resove compaints, or do other things to ensure you and your famiy are receiving the best possibe care. Primary Care Physician (PCP): A physician or provider who has agreed with TDH or a STAR HMO to provide a medica home to Medicaid Enroees and who is responsibe for providing initia and primary care to patients, maintaining the continuity of patient care, and initiating referra for care. Prevention, Education & Outreach (PE&O): A recovery-focused program that teaches you to make heathy choices and dea with probems before they get out of contro. Provider: A counseor, doctor, menta heath treatment professiona, or treatment center that has agreed to provide behaviora heath services through VaueOptions. Recovery: The absence or reductions of symptoms of iness, usuay through treatment, so that a person with a menta iness and/or substance abuse probem can resume iving a meaningfu ife in the community. Rehabiitative Services: Services to hep consumers deveop the skis they need for recovery in order to function as independenty as possibe and to keep up a support network. Services incude improvement of communication and reationship skis, medication and symptom management, skis training reated to househod tasks, using transportation, managing money, using community services, and making choices for the use of eisure time. Residentia Treatment Center (RTC): A faciity such as a hospita or heath care organization that provides psychiatric, drug abuse, or acohoism services in a ess structured environment than that of an acute inpatient program. Respite: Services provided to famiy members of a person receiving services to hep aow the consumer to function as independenty as possibe. Services may incude shortterm residentia services outside of the home, providing a pace for the consumer to go during the day, or having respite staff come to the home. SPN: Speciaty Provider Network; a network of providers within VaueOptions NorthSTAR network. Each of these providers has a ot of experience working with severey mentay i individuas. SPN providers run cinics in the NorthSTAR area. Texas Heath Steps (THSTEPS): The name adopted by the State of Texas for the federa Eary, Periodic Screening, Diagnosis and Treatment (EPSDT) program. It incudes the state s Comprehensive Care Program extension to EPSDT. TDSHS: Texas Department of State Heath Services Therapeutic Foster Care: Speciaized iving arrangements for chidren or adoescents with serious emotiona disturbances who are unabe to receive needed services whie iving with their parents or primary caregivers. We understand menta heath and substance abuse probems, and we are here to hep you with any probems you may have. We want to partner with you, your famiy member(s) or others who provide you support, and your provider to hep you manage your iness so that you can achieve a meaningfu ife in your community. Expect Recovery! 14

16 VaueOptions NorthSTAR Pharmacy Network How to Read Our Provider Listings Exampe/Ejempo Como Leer Nuestra Lista de Proveedores Aphabetica isting of counties coin lista afabetica de Condados Provider s name and degree Smith,JohnA.,PhD Nombre y tituo escoar de proveedor Street address Street Ste.#A Domiciio City, state, zip code Town, State Ciudad, Estado, Zona Posta Office phone number (123) Numero de Teefono de a Oficina Age group provider treats CHILD ADULT Grupos de edades que e proveedor ayuda Foreign anguage(s) spoken Idioma(s) extranjeros habados Discipine (for practitioners) Discipina (para profesionaes) Psychiatrist MD Psiquiatra Licensed Master Socia Worker Trabajador(ra Socia con Maestria y Licenciatura - Advanced Cinica Practitioner LCSW ProfesionaAvanzadaCínica Psychoogist PhD Psicogo(ga) Licensed Professiona Counseors LPC Consejeros(ras) Profesionaes con Licenciatura Menta Heath Individua Provider Proveedor de Servicios Individuaes de Dependencia Química Hospitas and other faciities Hospitaes Outpatient Cinic Cínicas para Pacientes Externos Psychiatric Faciity Faciidad Psiquiátrica Chemica Dependency Faciity Faciidad de Dependencia Química Genera Hospita Hospita Genera Outpatient Services Servicios para Pacientes Externos Community Menta Heath Center Centro Comunitario de Saud Menta Accepting Current Patients Ony, s Accepting Referras 15

17 VaueOptions NorthSTAR Pharmacy Network NorthSTAR Pharmacies 3770 Bet Line Road Addison, TX (972) Sams Pharmacy 4150 Betine Road Addison, TX (972) Metrocare Pharmacy at Midway Midway Road, Ste. 200 Addison, TX (972) E Bethany Dr., Aen, TX (972) W McDermott Drive Aen, TX (214) North Greenvie Aen, TX (214) Exchange Parkway Aen, TX (214) W Exchange Pkwy Aen, TX (214) Eam Rd. Bach Springs, TX (972) Lake June Rd Bach Springs, TX (972) Centennia Bvd. Buckingham, TX (972) W Trinity Mis Rd Carroton, TX (800) E Trinity Mis Road Carroton, TX (972) East FM 1382 Cedar Hi, TX (972) Uptown Bvd. Cedar Hi, TX (469) Hwy 50 Commerce, TX (903) E Sandy Lake Rd Coppe, TX (972) West Hwy 31 Corsicana, TX (903) P & S Pharmacy 829 N Main St. Corsicana, TX (903) Forest Lane Daas, TX (214) Wynnewood Viage Daas, TX (214) Preston Rd Daas, TX (972) E Northwest Hwy Daas, TX (214) E Mockingbird Lane Daas, TX (214) Cedar Springs Daas, TX (214) Mape Ave Daas, TX (972) Capita Ave Daas, TX (972) Frankford Rd Daas, TX (972) Samue Bvd Daas, TX (214) North Centra Expressway Daas, TX (214) Gus Thomasson Road Daas, TX (214) Midway Road Daas, TX (972) North Cockre Hi Road Daas, TX (214) Montfort Drive Daas, TX (972) W Wheatand Road Daas, TX (972) Forest Ln. Daas, TX (972) Retai Rd Daas, TX (214) N Centra Expy Daas, TX (972) Greenvie Ave. Daas, TX (972) Webb Chape Rd Daas, TX (972) S Buckner Bvd Daas, TX (214) Short St. Daas, TX (972) Aceptando soamente pacientes actuaes, s Aceptar as referencias

18 VaueOptions NorthSTAR Pharmacy Network Wamart Pharmacy W Wheatand Rd Daas, TX (469) Sams Pharmacy Retai Rd Daas, TX (214) Sams Pharmacy McCree Road Daas, TX (214) Sams Pharmacy 2900 West Wheatand Road Daas, TX (972) Sams Pharmacy 9461 Webb Chape Rd Daas, TX (972) Sams Pharmacy 5555 S Buckner Bvd Daas, TX (214) Marsh Lane Daas, TX (972) Ravens Pharmacy 500 W Jefferson Bvd Daas, TX (214) Westmoreand OC DCMHMR 1350 N Westmoreand Rd Daas, TX (214) Daas Menta Heath Cinic 1380 Riverbend Dr., Ste. 340 Daas, TX (214) Lancaster OP DCMHMR 3330 S Lancaster Ave Daas, TX (214) Daas Menta Heath Cinic 4645 Samue Bvd., Ste. 107 Daas, TX (214) N Beckey, Ste. 500 Desoto, TX (972) West Bet Line Road Desoto, TX (972) Wamart Pharmacy W Parkervie Rd Desoto, TX (469) W Camp Wisdom Rd Duncanvie, TX (972) Ennis Pharmacy 800 E. Ennis Ave, Suite A Ennis, TX (972) East Ennis Ave Ennis, TX (972) Midway Road Farmers Branch, TX (972) Josey Ln Farmers Branch, TX (972) # Marketpace Bvd Forney, TX (972) East Highway 80 Forney, TX (972) Legacy Drive Frisco, TX (972) Custer Rd Frisco, TX (214) Preston Stonebrook Frisco, TX (972) Preston Rd Frisco, TX (469) Legacy Dr Frisco, TX (214) N Shioh Road Garand, TX (972) West I 30 Garand, TX (972) West Wanut Garand, TX (972) Broadway Bvd Garand, TX (972) West I 30 Garand, TX (972) N Garand Ave. Garand TX (972) Marketpace Dr Garand, TX (972) S Garand Ave Garand, TX (972) W Buckingham Rd Garand, TX (469) Sams Pharmacy 5150 North Garand Avenue Garand, TX (972) E. Pioneer Pkwy Grand Prairie, TX (972) S Carrier Parkway Grand Prairie, TX (972) Sams Pharmacy 2325 West Interstate 20 Grand Prairie, TX (972) W Interstate 20 Grand Prairie, TX (972) Metrocare Pharmacy 832 S Carrier Pkwy Grand Prairie, TX (214) Accepting Current Patients Ony, s Accepting Referras 17

19 VaueOptions NorthSTAR Provider Network Grand Prarie, TX (972) Interstate Highway 30 Greenvie, TX (903) Tota Care Pharmacy # Wesey St Greenvie, TX (903) N Macarthur Bvd Irving, TX (972) N Betine Rd Irving, TX (972) W Grauwyer Road Irving, TX (972) S Macarthur Irving, TX (972) Market Pace Bvd Irving, TX (214) West Airport Freeway Irving, TX (972) Sams Pharmacy 1213 Market Pace Bvd Irving, TX (972) Wamart Pharmacy Dae Evans Drive Itay, TX (972) Wamart Pharmacy Kings Fort Parkway Kaufman, TX (469) North Beckey Lancaster, TX (972) West Lucas Rd Lucas, TX (469) W University McKinney, TX (972) South Lake Forest Drive McKinney, TX (972) McKinney Ranch Parkway McKinney, TX (972) North Custer McKinney, TX (972) Redbud Bvd McKinney, TX (972) Sams Pharmacy 1670 West University Drive McKinney, TX (972) Apoo Pharmacy 4987 W University Dr., STE 120 McKinney, TX (972) Faithon P Lucas Bvd Mesquite, TX (469) N Gaoway Mesquite, TX (972) Gus Thomasson Road Mesquite, TX (972) North Town East Bvd Mesquite, TX (972) US Hwy 80 East Mesquite, TX (972) North Highway 67 Midothian, TX (972) W FM 544 Murphy, TX (972) Wamart Pharmacy N. Stacks Street Pamer, TX (479) N Daas Parkway Pano, TX (972) Custer Road Pano, TX (972) th St. Pano, TX (972) Coit Road Pano, TX (214) Independence Pwky Pano, TX (972) Ohio Drive Pano, TX (972) Coit Rd Pano, TX (972) Coit Road Pano, TX (972) Independence Parkway Pano, TX (972) Centra Expressway Pano, TX (972) Daas Parkway Pano, TX (972) Custer Rd Pano, TX (972) E Park Bvd Pano, TX (469) Aceptando soamente pacientes actuaes, s Aceptar as referencias

20 VaueOptions NorthSTAR Provider Network Preston Road Pano, TX (972) Sams Pharmacy 8621 Ohio Drive Pano, TX (469) Sams Pharmacy 301 Coit Road Pano, TX (972) Sams Pharmacy 1200 East Spring Creek Pkwy Pano, TX (972) The Pharmacy Pace 4031 W Pano Pkwy, Ste 211 Pano, TX (972) Lifepath Pharmacy 3920 Aama Dr. Pano, TX (469) Highway 34 South Quinan, TX (903) Ryan Dr. Red Oak, TX (972) N Coit Richardson, TX (972) East Buckingham Road Richardson, TX (972) North Coit Road Richardson, TX (972) Ridge Road Rockwa, TX (972) West Rusk Street Rockwa, TX (972) Interstate 30 Rockwa, TX (972) Lakeview Pkwy Rowett, TX (214) Wamart PHARMACY Lakeview Parkway Rowett, TX (479) Hwy 78 Sachse, TX (972) Wamart Pharmacy Woodbridge Parkway Sachse, TX (469) Wamart Pharmacy Murphy Rd Sachse, TX (469) North Highway 175 Seagovie, TX (972) West Moore Ave Terre, TX (972) Bass Rutedge Drug 201 W Moore Ave., Ste 1 Terre, TX (972) N Hwy 77 Waxahachie, TX (972) W FM 544 Wyie, TX (972) North Highway 78 Wyie, TX (972) Wamart Pharmacy Mccreary Rd Wyie, TX (972) Medication Station 700 Ed Ha Drive Kaufman, TX (972) Quaity Care Pharmacy 601 S Cay Street, Suite 108 Ennis, TX (972) Pano Care Pharmacy 2001 Coit Road, Suite 310 Pano, TX (469) Forney Pharmacy 414 Pinson Road Forney, TX (972) Accepting Current Patients Ony, s Accepting Referras 19