Medicaid managed care assistance in Texas: Success Stories

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	Success Stories

If you need any of the following information in alternative formats or languages please contact us at 1-866-566-8989.

Help with Out-of-Network Access

A mother was trying to enroll her 3 year old daughter in her local Headstart program, however she was unable to do so because the child needed both a dental and medical checkup prior to being enrolled. The family had recently moved and when the Mother called her child's health plan the request for authorization was denied because the plan representative stated the situation was not "an emergency" and therefore they would not approve an out-of-network authorization.

STARLink contacted the health plan and obtained authorization for the checkups and assisted the doctor's office in getting the necessary pre-authorization numbers to facilitate the billing process. The child received her checkups and was able to enroll in the Headstart program without any further delays.

Problems Accessing Urgent Care

A two year old child with a bad rash was not able to get seen by the assigned PCP because the provider only does well child checkups. Even though the provider had requested that the health plan remove them from their PCP list they were continuing to assign patients to them. The mother called the plan to change the PCP but was told that the change wouldn't be effective until the first of the following month. The plan instructed the mother to contact the assigned PCP (who the child had never seen) to request a referral to the clinic she had chosen as the new PCP.

STARLink attempted to contact both doctor's offices to find out if they would be willing to accept and provide the necessary referral. Both phones at the doctors' offices rang busy for several hours. STARLink contacted the child's health plan and requested an internal referral. The following day (two days after the mother originally contacted the plan) the plan had still not authorized the referral and the mother ended up taking her child to the minor emergency center due to the child's persistent rash and her inability to get authorization to see a PCP. Finally three days after her request the health plan authorized referrals to the new PCP for the remainder of the month so the child could be seen at any time without having to obtain any more referrals.

Getting Administrative Errors Fixed so People can Access Care

A woman with a high risk pregnancy enrolled with her STAR health plan through the expedited process but when she called her health plan she was informed that they didn't have her information in their system and would be unable to assist her. Her OBGYN was unable to refer her to a specialist because the health plan wouldn't acknowledge her as their member.

STARLink confirmed that the member's enrollment information was accurate and available in the Department of Human Services', NHIC's and the Enrollment Broker's computer systems. Since the health plan was the only entity without the information STARLink contacted the Enrollment Broker and the health plan and requested they share the necessary data so the member could begin receiving care immediately. The health plan immediately assigned an OB Case Manager and began coordinating the necessary care for the member.

A Social Worker turned in a child's Medicaid recertification paperwork however DHS said they never received it and as a result the child's Medicaid coverage was terminated. The child has Grand-Mal seizures and only had one more days supply of her medicine. The mother was told she would need to physically go to her local DHS office and redo the application (the DHS office was 35 miles away).

STARLink contacted the Department of Human Services office and spoke with a Supervisor regarding the situation and clarified the new Children's Medicaid application and renewal procedures. The supervisor spoke with the mother over the phone, the mother faxed a renewal form and the child's Medicaid case was reinstated immediately. As a result the mother was able to refill the prescription and her daughter did not miss any doses.

A mother called because she wanted to disenroll her son from the STAR program because he has numerous health problems and she felt it would be easier for him to access care and providers on traditional Medicaid. The child's original Medicaid case was processed through the Department of Human Services and as a result he was mandatory for the STAR program. The mother stated that her child was certified for Supplemental Security Income (SSI) and with that type of Medicaid her child would be able to disenroll from the STAR program.

STARLink researched the child's Medicaid case in the state system and confirmed that the child was certified for SSI through the Social Security Administration. STARLink contacted the Department of Human Services and requested they close his DHS Medicaid case so that the Social Security Medicaid case would be showing in the system. The child's case information was updated and the mother was able to process her child's disenrollment to be effective the following month. In the meantime STARLink also assisted the mother in accessing care for her son through his health plan for the remainder of the month.

The mother of a newborn with special health care needs called in because she was unable to schedule a sonogram for her baby due to numerous errors in the baby's Medicaid case. The provider's office was unwilling to overlook so many errors on one case and referred the mother to the DHS office to get the information corrected.

STARLink contacted the Department of Human Services with the mother and explained the situation to them. They were suspicious of, and reluctant to make so many changes to one case. After an explanation by the mother they did agree to make the changes. The mother was able to immediately pick up a temporary Medicaid ID form complete with all the necessary corrections and she was able to schedule the sonogram after presenting the temporary ID form to the doctor.

Intervening with the State on behalf of consumers

A 3 month old child in private foster care was unable to obtain a special immunization shot that she needed due to being born prematurely. The child was enrolled in the STAR program but the pediatrician was not a provider for any of the STAR health plans. Children in private foster care are assigned a type of Medicaid that makes them mandatory for the STAR program even though they face some of the same challenges as state foster children who are excluded from the STAR program.

STARLink contacted the Health and Human Services Commission and requested that the child be removed from the STAR program immediately. Within 4 days the child was disenrolled from the STAR program and the pediatrician's office was able to order and administer the required shot on the day the original appointment was scheduled.

Ensuring Continuity of Care while Administrative Errors get Fixed

A mother had requested her 16 year old daughter be enrolled in a specific health plan but when she attempted to schedule her daughter's regularly recurring psychiatric appointment the office told her she was enrolled with a different health plan and that they did not accept that particular plan.

STARLink contacted the Behavioral Health Organization (BHO) that the daughter was mistakenly enrolled with and explained the situation to them. The BHO contacted the provider's office, worked out a payment plan and immediately authorized out-of-network referrals for the remainder of the month so the daughter could continue seeing her regular psychiatrist. STARLink also contacted the Enrollment Broker with the mother to ensure the daughter was enrolled with the correct health plan as soon as possible. The daughter was able to continue receiving her behavioral health services without any interruption and the mother was put into contact with the BHO as she was concerned that her daughter might need emergency hospitalization and she did not know which hospitals were part of their network.

Delay of Medically Necessary Treatment

A 9 year old child had been referred to a specialist for surgery but the child's PCP had not sent the medical records. The mother had been waiting for the records to be transferred for two and a half months when she contacted STARLink.

STARLink confirmed that the specialist had requested the records over two months ago. STARLink then contacted the PCP's office and followed up with them on a daily basis for 4 days until they finally provided copies of the correct medical records to the specialist. Subsequently the child was able to schedule a consultation with the specialist and begin scheduling the surgery.