Is Superior Health Plan Medicaid

Support For Superior Members Affected By Fire In Palo Pinto County

If you are a member of Superior HealthPlan and have been impacted by the fire in Palo Pinto County, there are services available to help you.

All Superior members who have been impacted by the fire in Palo Pinto County and need to replace necessary medical equipment, services, or supplies should seek replacement through any available supplier. If you cannot find a supplier, call Member Services to find one for you. Your supplies will be replaced even if you are temporarily outside of the county in which you live.

Superior Healthplan Star+plus Medicare

How Are Mcos Held Accountable For The Healthcare They Provide To Members

Financial data for Superior and all other MCOs are available on the Texas Health and Human Services website. Managed care organizations that participate in Texas Medicaid programs have to abide by thorough financial accounting and audit standards set by HHS and the Department of Insurance. These include:

• Financial reports accounting for all MCO expenses are submitted to HHS quarterly. These are audited each year by external accountants hired by HHS. These are done to make sure all MCOs consistently comply with accounting standards and regulations.
• Financial audits every 3 years from the Texas Department of Insurance.
• Audits from the State Auditors Office and Office of Inspector General for areas of financial impact.
• Contractual limits to profit that Medicaid MCOs are allowed to make.
• No limit on the amount of dollars an MCO can lose if medical costs increase during a financial period.
• Contract guidelines for what MCOs can count in their expenses. This means anything that is not defined by these rules is not paid for by HHS.

Annual financial audits by an external accounting firm. Conducted to provide confirmation of financial records accuracy and compliance with all standards and regulations to Superiors Board of Directors.

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Welcome Texas Medicaid Providers

WARNING: THIS IS A TEXAS HEALTH AND HUMAN SERVICES INFORMATION RESOURCES SYSTEM THAT CONTAINS STATE AND/OR U.S. GOVERNMENT INFORMATION. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW.———————–AMA/ADA End User License AgreementLICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION

CPT only copyright 2021 American Medical Association. ALL rights reserved. CPT is a registered trademark of American Medical Association.

You, your employees and agents are authorized to use CPT only as contained in materials on the Texas Medicaid & Healthcare Partnership website solely for your own personal use in directly participating in healthcare programs administered by THHS. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

U.S. Government Rights

Disclaimer of Warranties and Liabilities

Accessing Care: Medicaid And Chip Members

To choose a doctor or Primary Care Provider , call Superior Member Services. They can give you the name, address and phone number of a doctor or specialist. They can also help you get a provider’s:

• Professional qualifications

More information on how to choose a PCP can be found in your member handbook.

To find out which nursing facilities are in Superior’s network, you can call us at 1-877-277-9772 or search our Find a Provider online tool.

If you are a STAR Kids or STAR+PLUS member and are dual eligible, Medicare pays your doctor. That means you do not need to choose a PCP in STAR Kids or STAR+PLUS. You can keep seeing the Medicare doctor you have been seeing for your health care.

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How Many Providers And Specialists Are In The Superior Network

Superior has the largest provider network of all MCOs. Below is information about the providers that care for our members each day:

• Superior has more than 90,000 providers across all 254 Texas counties. This includes more than 500 hospitals.
• In a 2020 survey conducted by Superior, 89% of providers rated Superior favorably compared to other health plans.
• More than 87% of providers said they would recommend Superior to their peers. Provider satisfaction with the health plan is also 5 points higher than Medicaid benchmarks.

Ambetter From Superior Healthplan

The Health Insurance Marketplace is an online shopping mall of healthcare plans. Ambetter from Superior HealthPlan offers affordable healthcare coverage for individuals and families. Depending on your family size and income, you may even qualify for help to pay your monthly premium.

Learn how we transform the health of the community, one person at a time, by visiting our Members First webpage now.

Centene Corporation is a leading healthcare enterprise committed to helping people live healthier lives. The Company takes a local approach with local brands and local teams to provide fully integrated, high-quality, and cost-effective services to government-sponsored and commercial healthcare programs, focusing on under-insured and uninsured individuals. Centene offers affordable and high-quality products to nearly 1 in 15 individuals across the nation, including Medicaid and Medicare members as well as individuals and families served by the Health Insurance Marketplace, the TRICARE program, and individuals in correctional facilities. The Company also provides a variety of specialty services focused on treating the whole person. Centene focuses on long-term growth and value creation as well as the development of its people, systems, and capabilities so that it can better serve its members, providers, local communities, and government partners.

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How Has Superior Performed As The Only Provider Of Healthcare For Children In Foster Care

Superior was awarded the first STAR Health contract with a start date of April 1, 2008. This was based on participation in a competitive bid process. Superior has been the only provider since. The company earned the contract again in 2015 based on rigorous standards in a competitive process. According to Medicaid/CHIP in Perspective, 11th Edition , STAR Health is designed to better coordinate the health care of children in foster care and kinship care through one statewide MCO.

Superior has demonstrated continued high performance in customer satisfaction and quality requirements for children and youth in STAR Health. Superior also drives innovation and improvements across many facets of the STAR Health program:

Timeframe For Prior Authorization Decision

In most cases, your provider should submit a prior authorization request five business days before the desired start date of the service.

The timeframes required to provide a decision in response to a prior authorization request is listed below, for different types of prior authorization requests:

Physical Health Services, Supplies, Equipment, Behavioral Health Services, Clinician Administered Drugs

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Star Health Foster Care Plan

We Do More for STAR Health Members in Texas.Discover Superior HealthPlan.

Superior HealthPlan proudly offers STAR Health, a Medicaid managed care program serving children and youth in foster care. Superior is the only health program to include STAR Health coverage for children and youth in foster care in all 254 counties in Texas.

When children are housed within the foster care system, they are often not eligible for a traditional Medicaid plan. This is where STAR Health comes in.

Superior works very closely with the Texas Department of Family and Protective Services to make sure children in foster care in the state of Texas get the medical services they need. These STAR Health services may include:

• Primary and specialty physician care services.
• Prescription drugs and medical supplies.
• Medical checkups, including Texas Health Steps.
• Behavioral health services.
• Family planning services.
• Dental services.

Superior has also established Foster Care Centers of Excellence across Texas. These clinics provide many of the services listed above to STAR Health members.

Superior Healthplan Texas Medicaid & Chip Benefits & Services

We are here to ensure you have everything you need to know about your Texas Medicaid Plan and CHIP benefits, services, co-pays and more.

Superior HealthPlan provides benefits and services for Medicaid, CHIP, and health insurance in Texas. In this section, you can learn about the Texas Medicaid benefits, pharmacy services and value- added services Superior HealthPlan offers.

Need help understanding these Texas Medicaid benefits and services? Please contact Superior Member Services.

You can also view more information about Superior HealthPlan and health insurance in Texas in our Member Handbook.

All services must be medically necessary in order to be covered by Medicaid in Texas. Your Primary Care Provider will work with you to make sure you get the services you need. These services must be given by your Primary Care Provider or by another provider that your Primary Care Provider refers you to.

Some services may:

• Need a doctors order.
• Need prior approval.

*Some Medicaid members may not have all the benefits listed.

Your Texas Medicaid plan from Superior will determine your coverage and eligibility for specific treatments, medications, and services. Please contact Superior HealthPlan with any questions you may have regarding your eligibility.

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Special Services For Star Medicaid Pregnant Members

• Start Smart® For Your Baby Program. Diaper bag, diapers and educational materials for pregnant members who complete the Notification of Pregnancy form and attend Superiors baby shower.
• Up to $150 My Health Pays® rewards each year for completing prenatal and postpartum visits. Visit My Health Pays ® for more rewards information.
• Extra dental benefits. This includes up to $250 for pregnant women ages 21 and older.
• In-home OB assistance from non-clinical community caregivers for pregnant members in Obstetrician Care Management.
• Home visits for members who are pregnant.
• Telephonic outreach, education and support services offered to reduce the health risks associated with smoking during pregnancy through Superiors Puff-Free Pregnancy program.
• Extra help getting a ride.

Value-added Services are extra health care services offered by Superior. Services may vary by area. These services are valid through 8/31/23.

*Restrictions and limitations may apply.

Who Can Be In Star+plus

To get services through STAR+PLUS you must: be approved for Medicaid, be one or more of the following:

• Age 21 or older, getting Supplemental Security Income benefits, and able to get Medicaid due to low income.
• Not getting SSI and able to get STAR+PLUS Home and Community-Based Services.
• Age 21 or older, getting Medicaid through what are called “Social Security Exclusion programs” and meet program rules for income and asset levels.
• Age 21 or over residing in a nursing home and receiving Medicaid while in the nursing home.
• In the Medicaid for Breast and Cervical Cancer program.

The following people can’t be in the STAR+PLUS program:

• People over 21 who get Medicaid 1915 waiver services or who live in community homes for people with Intellectual Developmental Disabilities , and get Medicare.
• People who are not able to get full Medicaid benefits, such as Frail Elderly program members, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, Qualified Disabled Working Individuals and illegal immigrants.
• People who aren’t able to get Medicaid.
• Children in state foster care.
• Age 20 or younger and not in the Medicaid for Breast and Cervical Cancer program.

Important notes for those covered by Medicare:

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You Are Not Eligible To Participate If You Are:

• Under the age of 21
• Signed up for both Medicare and Texas Medicaid and have other insurance
• Living in an Intermediate Care Facility for Individuals with Intellectual Disabilities and related conditions and
• An individual with developmental disabilities who gets services through one of these waivers:
• Community Living Assistance and Support Services
• Deaf Blind with Multiple Disabilities Program
• Home and Community-based Services
• Texas Home Living Program

Contact the state enrollment broker at 1-877-782-6440, from 8 a.m. to 6 p.m. Monday through Friday. TTY users should call 711.

For more information, call Member Services at 1-866-896-1844. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned the next business day. TTY users call 711.

There Are Many Advantages In Joining This Type Of Plan Including:

• Getting all of your covered Medicare and Medicaid services from Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan . You wont pay extra to join our health plan.
• Having both an individual Service Coordinator and service coordination team who will work with you, and with your care providers, to come up with a Plan of Care specifically designed to meet your health needs. Your service coordinator will be responsible for coordinating the services you need such as informing your doctors about the medicines you take and ensuring that your test results are shared with you.

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Medicaid Prior Authorization Procedures And Requirements

Standard Prior Authorization Request – Incomplete or Insufficient Documentation

• Medicaid prior authorization requests must contain all Essential Information
• Essential Information is prescribed in HHSCs UMCM, Chapter 3.22, II. A., and includes all elements below.
• Member name, Medicaid ID number and date of birth
• Requesting and rendering/servicing provider name, National Provider Identifier , and Tax Identification Number
• Service requested – Current Procedural Terminology , Healthcare Common Procedure
• Service requested start and end date
• Quantity of service units requested

Contact Us Online Form

The Contact Us form will send your message to Superior HealthPlan as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Superior through email, you accept the risks associated thereof. Superior does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information , please send us a message through the Secure Member Portal or Provider Portal, or you can call us at the Member Services number on the back of your Superior ID card to speak directly to a customer service representative.

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Prior Authorization Of Health

Superior members have access to all Medicaid and CHIP covered benefits that are medically necessary health-care services. Some of these services need to be reviewed before the service is provided to make sure the service is appropriate and medically necessary. This review is called prior authorization, and is made by doctors, nurses and other health-care professionals. If a prior authorization request cannot be approved based on medical necessity, you will receive a letter with the reason why the prior authorization request was not approved. This is called an adverse determination . You can ask Superior to review the prior authorization request again. This is called an appeal of the adverse determination.

A list of the Medicaid and CHIP covered services that require prior authorization may be found by visiting:

Health-care providers are responsible for submitting prior authorization requests. These requests can be submitted by phone, fax or online, using Superiors Secure Provider Portal. Your provider can also get more information by visiting Superiors Medicaid and CHIP Prior Authorization Requirements webpage.

Review the information below to learn more about which services may need prior authorization approval before the service is provided. If you have any questions, please call Member Services :

• CHIP: 1-800-783-5386
• STAR+PLUS: 1-877-277-9772

Are Medicaid Members Satisfied With The Care They Get From Superior

Superior HealthPlan and the State of Texas measure member satisfaction in many ways. As shown below, Superior consistently earns high marks in member satisfaction:

• Since 2015, Superior HealthPlan has received a score of 3.5 or higher on a 5.0 scale on the National Committee for Quality Assurance Medicaid Health Insurance Plan Ratings. This includes a score of 3.5 for 2021.
• According to a 2020 survey, 91% of members said they were satisfied with how quickly they received care. Nearly 90% of customers were happy with the health plan overall.
• 86% of Medicaid recipients say they are satisfied with the care they receive. This is according to a June 2018 survey from the Texas Association of Health Plans.

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Chip Prior Authorization Procedures And Requirements

Demographic and Clinical Information

• To ensure that the medical necessity review of a prior authorization request can be timely processed for determination, the following information must be included with each prior authorization request:
• Member information and
• Provider information (Rendering provider name, NPI, TIN and
• Physician signature/Physician order and
• Specification and description of service, supply, equipment, or CAD procedural/service code and description and
• Pertinent diagnosis/conditions that relate to the need for the service and
• Objective clinical information necessary to support medical necessity for the requested service and
• Start and end date of service and
• Frequency and duration

Incomplete Prior Authorization Requests

• If a prior authorization request does not include the demographic and/or clinical information necessary to complete the medical necessity review of the request, two phone call attempts are completed to obtain the missing documentation/information.
• If the required information is not received as required in the request, the prior authorization request is forwarded to a Medical Director for determination, based on the clinical information available.