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. This is covered under the Benefits section of our Member handbook.

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.

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.

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. (Bookmark to covered benefits section).

Medicaid Service Area

Medicaid coverage is limited to your service area. Read the Benefits section of our Member handbook to see how you get coverage when you are out of town or the country. (Bookmark to these questions in the handbook).

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. (Bookmark)

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