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Looking for Information About Your Plan and Benefits?
If you get benefits through Medicaid’s STAR, STAR+PLUS, or STAR Health Program, call your medical or dental plan first. If you don’t get the help you need there, you should do one of the following:
- Call Medicaid Managed Care Helpline at 1.866.566.8989 (toll-free).
- Online: Online Submission Form (only works in Internet Explorer)
- Mail: Texas Health and Human Services Commission
- Office of the Ombudsman, MC H-700
P.O. Box 13247
Austin, TX 78711-3247
- Fax: 1.888.780.8099 (Toll-Free)
Call our Member Services if you lose or misplace your Member ID Card and need a new one. Call toll-free at 1.888.760.2600.
1.877.847.8377 - http://www.txhealthsteps.com/cms/
We want to hear from you. You are invited to share your feedback about Community at our Member events. Team members are always on site to get your thoughts on how we can serve you better. Additionally, you may be asked during the year to participate in Member Advisory Focus Groups. These facilitated discussions help us learn what your thoughts and preferences are for a variety of items offered by our health plan.
What are co-payments? How much are they, and when do I have to pay for them?
Co-payments are the amount that a CHIP Member has to pay to get certain health care services. Co-payments for medical services or prescription drugs are paid to the health care Provider at the time of service. Your CHIP Member ID card lists the co-payments that apply. CHIP Members who are American Indian or Alaskan Native are exempt from all cost-sharing obligations. All CHIP Members are exempt from the co-pays on benefits for well-baby and well-child checkups, preventive services or pregnancy-related assistance. Show the ID card when you/your child goes to an office visit or the emergency room or to have a prescription filled.
Notice of Privacy Practices Effective April 14, 2003 Updated: September 23, 2013
Last Review Date: November 25, 2019
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 about this notice, please contact the Community Health Choice (Community) Privacy Officer.
This Notice of Privacy Practices is given to you as part of the Health Insurance Portability and Accountability Act (HIPAA). It says how we can use or share your protected health information (PHI) and sensitive personal information (SPI). It tells you who we can share it with and how we keep it safe. It tells you how to get a copy of or edit your information. You can allow or not allow us to share specific details unless needed by law.
Our responsibility to you regarding protected health information
“Protected health information” and “sensitive personal information” (PHI/SPI) is information that identifies a person or patient. This data can be your age, address, e-mail address, and medical facts. It can be about your past, present or future physical or mental health conditions. It also can be about sensitive health care services and other personal facts.
By law, Community must:
- Make sure that your PHI/SPI is kept private.
- Give you this notice of our legal duties and privacy practices. It describes the use and disclosure of your PHI/SPI.
Follow the terms of the notice in effect now.
- Tell you about any changes in the notice.
- Notify you that your health information (PHI/SPI) created or received by Community is subject to electronic disclosure.
- Give you an electronic copy of your record within 15 days after you ask in writing. We can also give this to you another way if you ask for it. There are some exceptions to this rule.
- With exceptions, not sell any PHI/SPI.
- Disclose any breach of unencrypted PHI/SPI we think an unauthorized person might have.
- Train employees about our privacy practices. Training is no later than 60 days after their first day and at least every two years after.
We have the right to change this notice. The effective date is on the bottom of each page. You can get a copy from our Web site: CommunityHealthChoice.org. You can also call our Privacy Officer at 713.295.2268 and ask for a copy to be mailed to you.
How Community can use or disclose your protected health information without your authorization
Here are some examples of allowed uses and disclosures of your PHI/SPI. These are not the only ones.
Treatment – Community will use and share your PHI/SPI to provide, coordinate or manage your health care and other services. We might share it with doctors or others who help with your care. In emergencies, we will use and share it to get you the care you need. We will only share what is needed.
Payment – We can use and share your PHI/SPI to get paid for the health care services that you received.
Health Care Operations – We can use or share your PHI/SPI in our daily activities. For example:
- To call you to remind you of your visit
- To conduct or arrange other health care activities
- To send you a newsletter
- To send news about products or services that might benefit you
- To give you information about treatment choices or other benefits
Business Associates – We can share your PHI/SPI with our Business Associates. They must also protect it. They must follow HIPAA privacy and security rules, HITECH rules, and Texas Privacy Laws. They can face fines and penalties. They have to report any breaches of unencrypted PHI/SPI.
Required by Law – By law, sometimes we must use or share your PHI/SPI. Here are some examples:
Public Health Authorities
- To prevent or control disease, injury or disability
- To report births and deaths
- To report child abuse or neglect
- To report problems with medicines or other products
- To notify authorities if we believe a patient has been the victim of abuse, neglect or domestic violence
Communicable Diseases – We can share your PHI/SPI to tell a person they might have been exposed to a disease. We can tell a person they might be at risk for getting or spreading a disease or condition.
Health Oversight Agencies and U.S. Food and Drug Administration – We will share your PHI/SPI when health oversight agencies ask for it.
Legal Proceedings – We will share your PHI/SPI for legal matters. We must receive a legal order or other lawful process.
Law Enforcement and Criminal Activity – We will share your PHI/SPI if we believe it helps solve a crime. We will share it to stop or reduce a serious threat. We can also share it to help law enforcement officers find or arrest a person.
Coroners, Funeral Directors, and Organ Donations – We share PHI/SPI with coroners, medical examiners, and funeral directors. We can also share it to help manage organ, eye or tissue donations.
Research – If Community agrees to be part of an approved research study, we will make sure that your PHI/SPI is kept private.
Military Activity and National Security – We can share PHI/SPI of Armed Forces personnel with the government.
Workers’ Compensation – We will share your PHI/SPI to follow workers’ compensation laws and similar programs.
Inmate – We can use or share your PHI/SPI if you are a correctional facility inmate and we created or received your PHI/SPI while providing your care.
Disclosures by the Health Plan – We will share your PHI/SPI to get proof that you are able to get health care. We will work with other health insurance plans and other government programs.
Parental Access – We follow Texas laws about treating minors. We follow the law about giving their PHI/SPI to parents, guardians or other person with legal responsibility for them.
For People Involved in Your Care or Payment for Your Care – We will share your PHI/SPI with your family or other people you want to know about your care. You can tell us who is allowed or not allowed to know about your care. You must fill out a form that will be part of your medical record.
Restrictions on Marketing – The HITECH Act does not let Community receive any money for marketing communications.
Other Laws that Protect Health Information – Other laws protect PHI/SPI about mental health, alcohol and drug abuse treatment, genetic testing and HIV/AIDS testing or treatment. You must agree in writing to share this kind of PHI/SPI.
Your privacy rights with respect to your health information
Right to Inspect and Copy Your Health Information – In most cases, you have the right to look at your PHI/SPI. You can get a printed copy of the record we have about you. It can also be given to you in electronic form. There might be a charge for copying and mailing.
Right to Amend Your Health Information – You can ask Community to change facts if you think they are wrong or not complete. You must do this in writing. We do not have to make the changes. If we deny your request, we will do so within 60 days.
Right to an Accounting of Disclosures – You can ask for a list of certain disclosures of your PHI/SPI. The list will not include PHI/SPI shared before April 14, 2003. You cannot ask for more than six years. The list can only go back three years for electronic PHI/SPI. There are other limits that apply to this list. You might have to pay for more than one list a year.
Right to Ask For Restrictions – You can ask us to not use or share part of your PHI/SPI for treatment, payment or health care operations. You must ask in writing. You must tell us (1) PHI/SPI you want restricted; (2) if you want to change our use and/or disclosure; (3) who it applies to (e.g., to your spouse); and (4) expiration date.
If we think it is not best for those involved, or cannot limit the records, we do not have to agree. If we agree, we will only share that PHI/SPI in an emergency. You can take this back in writing at any time.
If you pay in full for an item or service, you can ask a Provider to not share PHI/SPI with Community for payment or operations purposes. These are the main reasons we would need it. This does not apply if we need the PHI/SPI for treatment purposes.
Right to Receive Confidential Communications – You can tell us where and how to give you your PHI/SPI. You can ask us to only call at a certain number. You can also give us another address if you think sending mail to your usual address will put you in danger. You must be specific and put this in writing.
Right to Choose Someone to Act for You – If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure this person has this authority and can act for you before we take any action.
Right to a Copy of this Notice – You can ask for and get a copy of this notice from at any time, even if you have received this notice previously or agreed to receive this notice electronically.
Right to Withdraw an Authorization for Disclosure – If you have let us use or share your PHI/SPI, you can change your mind at any time. You must tell us in writing. In some cases, we might have already used or shared it.
Right to be Notified of Breach – You will be told if we find a breach of unsecured PHI/SPI. The breach could be from either Community or a business associate of Community.
Federal Privacy Laws
This notice of Privacy Practices is given to you as part of HIPAA. There are other privacy laws that also apply. Those include the Freedom of Information Act; Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act; the Health Information Technology for Economic and Clinical Health Act (HITECH) and the Texas Privacy Law, Health and Safety Code, Section 181.
You can file a complaint if you believe your privacy rights have been violated. You can call Community’s privacy officer at 713.295.2268 or 1.888.760.2600. You can also file a complaint with the Department of Health and Human Services, Office of Civil Rights. Please refer to the Office of Civil Rights contact information at the end of this notice. We urge you to tell us about any privacy concerns. You will not be retaliated against in any way for filing a complaint.
Authorization to use or disclose health information
Other than as stated above, we will not use or share your PHI/SPI without your written agreement. You can change your mind about letting us use or share your PHI/SPI at any time. You must tell us in writing.
The HITECH Act makes Community limit uses, disclosures, and requests of your PHI/SPI. We cannot ask for or share more than is needed.
This notice originally took effect April 14, 2003, and was updated September 23, 2013. This notice stays in effect until it is replaced by another notice.
If you have any questions or complaints:
Chief Compliance Officer
Community Health Choice, Inc.
2636 South Loop West, Suite 125
Houston, TX 77054
To report concerns anonymously please call toll-free: 1.877.888.0002
U.S. Department of Health and Human Services Office for Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, D.C. 20201
For more information, please see:
The following notice is only for STAR Members.
Alberto N. Settlement
This Notice Applies to all Community Health Choice Medicaid STAR Members under 21 years old: HHSC has settled a lawsuit that affects Private Duty Nursing, Home Health Skilled Nursing, Durable Medical Equipment and Supplies, and Personal Care Services for Medicaid beneficiaries under 21 years of age. A copy of the Settlement Agreement is at: www.hhsc.state.tx.us and www.advocacyinc.org. If you have any questions, call Advocacy, Inc. toll-free at 1.800.252.9108.
How do I find a Primary Care Provider or clinic?
Use our online Provider Search to find a Primary Care Provider or clinic. It is updated every weekday, excluding holidays. You also can search through our printed directories, which are updated quarterly.
What is a referral?
A referral is a consultation for evaluation and/or treatment of a patient requested by one doctor to another doctor. Community Health Choice will not pay the cost of non-emergency hospital care or medical equipment unless your Primary Care Provider gives you a referral.
These services do not need a referral from a Primary Care Provider.
CHIP and CHIP Perinatal
- Emergency care for CHIP and CHIP Perinate Newborn Members
- Emergency care for CHIP Perinatal Members: Emergency services and/or emergency medical care are covered services only if it is labor resulting in delivery of your baby. If your emergency care is not related to labor with the birth of your child, you will have to apply for Emergency Medicaid or pay for the services yourself.
- OB/GYN care
- Prenatal care: You may receive prenatal care without a referral. Your CHIP Perinatal Provider must request referral authorization for some tests and procedures and must notify us of pregnancy care visits.
- Behavioral (mental) health services or drug and alcohol treatment
- Emergency care
- OB/GYN care
- Texas Health Steps medical and dental checkups
- Family planning services
- Behavioral (mental) health services or drug and alcohol treatment
What are my prescription drug benefits?
You can receive medically necessary prescriptions ordered by your doctor or specialist. These prescriptions must be part of the Texas CHIP or Texas Medicaid Vendor Drug Formulary. Some prescriptions require pre-authorization. See what prescriptions are covered on the drug formulary.
Information is available in English and Spanish. Call us to get an interpreter. Information can also be made available in audio, large print, Braille or other languages if needed.
Call our Member Services toll-free at 1.888.760.2600 to ask for these special services or to answer any questions you may have about the Member Handbook. Call 8:00 a.m. – 6:00 p.m., Monday – Friday, excluding state-approved holidays. Access your Member account online 24 hours a day, seven days a week.
Community Members can get medical help from a healthcare professional 24 hours a day, seven days a week.
STAR/CHIP – Call our Nurse Help Line 24 hours a day, seven days a week toll-free at 1.888.332.2730 or TDD at 7-1-1.
Call the Nurse Help Line before going to the emergency room, unless it is an emergency. A nurse will answer your health care questions and help you get the care you need. Get help in English or Spanish. You can also ask for an interpreter.
Health Insurance Marketplace – Call Teladoc toll-free at 1.800.835.2362 or visit Teladoc.com.
Talk to a doctor to treat routine medical concerns or get a new prescription or a refill, 24/7 from anywhere by phone, web or mobile app.
Use Teladoc when your primary care doctor is not available, you are traveling or if you are thinking about visiting the emergency room or an urgent care center for routine medical concerns.
Providers: Call 713.295.2295, 8:00 a.m. - 5:00 p.m., Monday – Friday, for information on our managed care plan and the Members they serve; claims inquiries; contract clarification/interpretation; EFT/ERA request; provider education in-services; provider updates (address/phone/tax ID).
Marketplace Members: Call 713.295.6704 or toll-free 1.855.315.5386, Monday through Friday, 8:00 a.m. to 5:00 p.m., excluding state-approved holidays.
CHIP/STAR Members: For information on how to access all of your covered services, including pharmacy and dental information, call Member Services 713.295.2294 or toll-free at 1.888.760.2600. TDD: 7-1-1. Call 8:00 a.m. – 6:00 p.m., Monday – Friday, excluding state-approved holidays. In case of an emergency, call 9-1-1 or go to the nearest hospital. We speak English, Spanish or can get you an interpreter who speaks your language.
What are advance directives?
Advance directives are legal papers that allow you to say if you would accept or refuse medical treatment if you become too ill to speak for yourself. These papers can help your family decide what to do for you to relieve them of the stress of making the decision for you. It also helps the doctor care for you according to your wishes.
How do I get an advance directive?
Ask your doctor for the form(s) for advance directives. CHIP/STAR Members, call our Member Services toll-free at 1.888.760.2600 if you need more information.
How can I ask for a second opinion?
Please call our Member Services if you want a second opinion. You can get a second opinion from a network Provider or an out-of-network provider if a network Provider is not available. You may want to ask for a second opinion if:
1. You received a diagnosis or instructions from your Provider that you don’t feel are correct or complete
2. Your Provider says you need surgery
3. You have done what the doctor asked, but you are not getting better
When you go for your visit, tell the doctor you are there for a second opinion.