Texas STAR (Medicaid) Plan

Mother with child riding on her back

Texas STAR (Medicaid) Plan

Do you qualify for Texas STAR (Medicaid)?

Thinking about becoming a Community Health Choice Member? Here are some quick facts about the Medicaid Program and Community Health Choice to get you started.

Important: The state of Texas has automatically extended CHIP and STAR Medicaid benefits since the federal government issued a public health emergency (PHE) due to the COVID-19 epidemic.

Visit our public health emergency site for more information. 

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Apply for Texas STAR (Medicaid)

State of Texas Access Reform (STAR) Managed Care Program (Medicaid)

Community provides both Children’s Medicaid and Medicaid for Pregnant Women. These programs are at no cost to U.S. residents who cannot afford health insurance.

Children’s Medicaid – Children’s Medicaid covers a child up through the month of his or her 21st birthday. Income determines eligibility. That income level is different based on age and Medicaid program. Members must recertify every year.

Medicaid for Pregnant Women – Medicaid for Pregnant Women covers a childbearing woman of any age. Members must be at 185% or lower of the Federal Poverty Level (FPL). Members must recertify every year.

Medicaid Benefits and Coverage

Community Health Choice is a managed care organization that offers Texas Medicaid STAR coverage and provides services that are covered benefits of the Medicaid Program. Read the Benefits section of our Member handbook to see what is covered, what is not covered, and how to get these benefits.

Medicaid Service Area

Medicaid does not provide coverage if you are out of the country. Benefit coverage is limited to your service area. If you are outside of our service area, benefits are limited to emergency care.

Read about our service area coverage in our STAR Handbook.

For a list of covered services listed in our Member handbook, click here.

For a list of exclusions listed in our Member handbook, click here.

Provider Network

After a person chooses a managed care organization, like Community Health Choice, to provide their health care, they then choose a Primary Care Provider to give them all their primary care services. This includes coordinating referrals for all medically necessary specialty services.

Want to see if your Provider, specialist or hospital is in our network? Search our Find a Doctor directory.

Prescription Drug Services

Community follows the Texas Vendor Drug Formulary for Medicaid and CHIP. Updates to the formulary are managed by the Texas Vendor Drug Program.

Here is how to search:

  1. Visit the formulary at https://www.txvendordrug.com/formulary/formulary-search.
  2. Enter the name of your drug.

This search will tell you:

  • If the drug is on the formulary
  • if the drug requires a prior authorization

Drugs are listed as “preferred” and “non-preferred.” If you need a “non-preferred” drug, your doctor will need to submit a special request to get the “non-preferred” drug by calling Member Services toll-free at 1.888.760.2600.

Utilization Management

Some benefits and services must be reviewed and approved by our Utilization Management Department. Here are some things you should know about utilization management services.

  • Preservice review – Some services require prior authorization before you receive the service. This is to make sure you only receive medically necessary services. See our Prior Authorization Guide for more information.
  • Urgent concurrent review – This is a request for services made while you are in the process of receiving care. This typically happens while you are receiving inpatient care in a hospital or are receiving ongoing outpatient care. The submission of urgent concurrent review requests will be handled by your Provider.
  • Post-service review – Sometimes requests have to be reviewed after services have been provided. The submission of post-service requests would be handled by your Provider.
  • Filing an appeal – If your service is denied, you can appeal. Read the Appeals section of Member Handbook for more information.

Private Health Information

Our 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). We review this notice annually and update if needed.

“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 healthcare services and other personal facts.

It tells you who we can share it with and how we keep it safe. This includes protection of your oral, written and electronic information across the organization. It tells you how to get a copy of or edit your information. It ensures that any oral, written, and electronic information you share with us is confidential and secure.

You can allow or not allow us to share specific details unless needed by law. You have the right to approve or withdraw the use of your information.

Read our full Privacy Notice section in our Member Handbook.

Texas Healthy Women Program

Lost your Medicaid benefits? The Texas Healthy Women Program provides family planning exams, related health assessments, and birth control to women ages 18 to 44 whose family income is at or below the program’s income limits (185 percent of the federal income level). of poverty).

You must apply to find out if you can receive services through this program. Visit this site for more information.

What is Autism?

Autism Spectrum Disorder (ASD) is a developmental disorder that affects communication and behavior. It is characterized by restricted, repetitive patterns of behavior, interests, or activities and deficits in social communication and social interaction, with onset of symptoms occurring in early childhood.

Who is eligible for Autism benefits?

Effective February 1, 2022, Autism Services, to include Applied Behavior Analysis (ABA) evaluation and treatment, became a benefit of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP) for Texas Medicaid recipients who are 20 years of age and younger and who meet the criteria outlined in the Autism Services benefit description. This benefit is not available for CHIP recipients.

Does this service require prior authorization?

Yes, prior authorization is required for evaluation and treatment. A great place to start is your child’s Primary Care Provider (PCP). They may recommend a Provider that meets your child’s needs. A signed referral must be submitted to the ABA Provider to accompany their Authorization request.

Who can evaluate my child?

Your child can be evaluated by any of the following health care providers.
  • A developmental pediatrician
  • A neurologist
  • A psychiatrist
  • A licensed psychologist
  • An interdisciplinary team composed of a physician, physician assistant or nurse practitioner in consultation with one or more providers who are qualified child specialists who have expertise in autism limited to:
    • Any provider listed above
    • Licensed clinical social worker
    • Licensed professional counselor
    • Licensed psychological associate
    • Licensed specialist in school psychology
    • Occupational therapist (OT)
    • Speech-language pathologist (SLP)
To find a provider, visit https://providersearch.communityhealthchoice.org or call Member Services at 713.295.2294, or toll free at 1.888.760.2600.

Non-Emergency Transportation - Access2Care

Access2Care provides transportation to non-emergency health care appointments for STAR (Medicaid) Members who have no other transportation options. These trips include transportation to the doctor, dentist, hospital, pharmacy, and any other place where you receive Medicaid services. These trips DO NOT include ambulance trips. More information.

General Information
Local: 713.295.2222
Toll-Free: 1.877.635.6736

Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 6:00 p.m

Member Services
Local: 713.295.2294 | Toll-Free: 1.888.760.2600
Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 6:00 p.m.

Provider Services Hotline
Call 713.295.2295, 8:00 a.m. - 5:00 p.m., Monday – Friday

Additional Contact Numbers

State of Texas Access Reform (STAR) Managed Care Program (Medicaid)

Community provides both Children’s Medicaid and Medicaid for Pregnant Women. These programs are at no cost to U.S. residents who cannot afford health insurance.

Children’s Medicaid – Children’s Medicaid covers a child up through the month of his or her 21st birthday. Income determines eligibility. That income level is different based on age and Medicaid program. Members must recertify every year.

Medicaid for Pregnant Women – Medicaid for Pregnant Women covers a childbearing woman of any age. Members must be at 185% or lower of the Federal Poverty Level (FPL). Members must recertify every year.

Medicaid Benefits and Coverage

Community Health Choice is a managed care organization that offers Texas Medicaid STAR coverage and provides services that are covered benefits of the Medicaid Program. Read the Benefits section of our Member handbook to see what is covered, what is not covered, and how to get these benefits.

Medicaid Service Area

Medicaid does not provide coverage if you are out of the country. Benefit coverage is limited to your service area. If you are outside of our service area, benefits are limited to emergency care.

Read about our service area coverage in our STAR Handbook.

For a list of covered services listed in our Member handbook, click here.

For a list of exclusions listed in our Member handbook, click here.

Provider Network

After a person chooses a managed care organization, like Community Health Choice, to provide their health care, they then choose a Primary Care Provider to give them all their primary care services. This includes coordinating referrals for all medically necessary specialty services.

Want to see if your Provider, specialist or hospital is in our network? Search our Find a Doctor directory.

Prescription Drug Services

Community follows the state Vendor Drug Formulary for Medicaid and CHIP. You can review the list at https://www.txvendordrug.com/formulary/formulary-search

This list will tell you:

  • If the drug is on the formulary
  • if the drug requires a prior authorization

If the drug you need is non-preferred, you will need to request an exception by contacting Member Services toll-free at 1.888.760.2600.

Utilization Management

Some benefits and services must be reviewed and approved by our Utilization Management Department. Here are some things you should know about utilization management services.

  • Preservice review – Some services require prior authorization before you receive the service.  This is to make sure you only receive medically necessary services. See our Prior Authorization Guide for more information. (Link)
  • Urgent concurrent review – If your situation is urgent, we can review your situation quickly to avoid delays in care.
  • Post-service review – Sometimes requests have to be reviewed after services have been provided.

Filing an appeal – If your service is denied, you can appeal. Read the Appeals section of Member Handbook for more information.

Private 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 healthcare services and other personal facts.

Read the Privacy Notice section in our Member Handbook for more information.

Texas Healthy Women Program

Lost your Medicaid benefits? The Texas Healthy Women Program provides family planning exams, related health assessments, and birth control to women ages 18 to 44 whose family income is at or below the program’s income limits (185 percent of the federal income level). of poverty).

You must apply to find out if you can receive services through this program. Visit this site for more information.

What is Autism?

Autism Spectrum Disorder (ASD) is a developmental disorder that affects communication and behavior. It is characterized by restricted, repetitive patterns of behavior, interests, or activities and deficits in social communication and social interaction, with onset of symptoms occurring in early childhood.

Who is eligible for Autism benefits?

Effective February 1, 2022, Autism Services, to include Applied Behavior Analysis (ABA) evaluation and treatment, became a benefit of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP) for Texas Medicaid recipients who are 20 years of age and younger and who meet the criteria outlined in the Autism Services benefit description. This benefit is not available for CHIP recipients.

Does this service require prior authorization?

Yes, prior authorization is required for evaluation and treatment. A great place to start is your child’s Primary Care Provider (PCP). They may recommend a Provider that meets your child’s needs. A signed referral must be submitted to the ABA Provider to accompany their Authorization request.

Who can evaluate my child?

Your child can be evaluated by any of the following health care providers.

  • A developmental pediatrician
  • A neurologist
  • A psychiatrist
  • A licensed psychologist
  • An interdisciplinary team composed of a physician, physician assistant or nurse practitioner in consultation with one or more providers who are qualified child specialists who have expertise in autism limited to:
    • Any provider listed above
    • Licensed clinical social worker
    • Licensed professional counselor
    • Licensed psychological associate
    • Licensed specialist in school psychology
    • Occupational therapist (OT):
    • Speech-language pathologist (SLP)

To find a provider, visit our provider search page or call Member Services at 713.295.2294, or toll free at 1.888.760.2600.

Non-Emergency Transportation - Access2Care

Access2Care provides transportation to non-emergency health care appointments for STAR (Medicaid) Members who have no other transportation options. These trips include transportation to the doctor, dentist, hospital, pharmacy, and any other place where you receive Medicaid services. These trips DO NOT include ambulance trips. More information.

Why Choose Community?

As a local nonprofit health plan, Community Health Choice gives you plenty of reasons to join our Community. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, Community is always working life forward for you and your family.

“I always tell people to choose Community Health Choice. I tell them it’s the best health insurance they will ever be with.”
– Chandolyn
Member of Community Health Choice