Trad Med Handbook

7/27/2019 Trad Med Handbook

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Free Help Line

1-800-335-8957

Your Health

2012 EditionCare Guide

Vea al dorso

la version

en espaol.


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- Your address.

- Your expenses.

- People living in the home.

- Amount o money you get(income).

- Things you own (resourcesor assets).

- Insurance (including healthinsurance premiums).

- Land and buildings you own(property).

Ifyouneed

help

withthisgu

ide,

callthefree

MedicaidHelp

Line

at1-800-335-8957.

Remember

Pick one doctor or clinic or your health care.

Get prescriptions only rom your main doctor or

specialists that your doctor reers you to.

Try to use one drug store at one location to get al l o your medicine.

Do not get the same type o medicine rom dierent doctors.

Use the emergency room or an urgent care clinic only when you need

treatment right away.

Take your Medicaid ID to doctor visits and to the drug store.

Do not let anyone else use your Medicaid ID.

I you have a doctor visit and you cant make it, call the doctors ofce to

cancel. Then set up a new visit.

Tell us about changes to your case within 10 days o the change. When youhave a change, call 2-1-1 or 1-877-541-7905. Tell us about changes in things

such as:


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This guide tells you how to

use your Medicaid benefts.

Welcome.

This guide is

rom the Texas Healtand Human Services

Commission (HHSC).HHSC is the state agency

that runs Texas Medicaid. C1-800-335-8957 to ask or copy o this guide in audiolarge print, Braille, or othe

languages.


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Where to Get Help

Get Help on the Phone

Medicaid Help Line1-800-335-8957

Monday to Friday, 7 a.m. to 7 p.m.

Call this number to:

Find a Medicaid doctor.

Learn more about Medicaid services.

Texas Health Steps

1-877-847-8377


Call this number to nd a Texas Health Stepsdoctor, dentist, or other provider. Texas HealthSteps is or children, teens, and young adults age20 and younger.

Rides to the Doctor, Dentist, or Drug

Store

1-877-633-8747


Call this number i you need a ride or gas money

to get to visits with your Medicaid providers.

Relay Texas - For People with

a Hearing or Speech Disability

7-1-1 or 1-800-735-2989

Any time, day or night

Call any HHSC oce or program by using therelay service o your choice. The state o Texasofers Relay Texas at 7-1-1.

Alloft

he

phonen

umbers

inthis

bookar

e

freeto

call.

www.YourTexasBenefts.com

View your Medicaid services and healthhistory.

Check your benets case.

Finding Help in Texas2-1-1

Dialing 2-1-1 is a ree, easy way to nd outabout services you can get in your area orthrough state programs. Staf can talk to youMonday to Friday, 8 a.m. to 8 p.m. CentralTime.

Call 2-1-1 to:

Report changes to your case. (Youshould do this within 10 days o thechange.)

Check your Medicaid benets.

Check that we received items you sentus.

When you dial 2-1-1, pick a language andthen press 2. I you cant connect to 2-1-1,call 1-877-541-7905. You also can visit the2-1-1 Texas website at www.211texas.org tond services in your area.

Complaints about Medicaid Services1-877-787-8999

Monday to Friday, 8 a.m. to 5:30 p.m.

Call this number ater you call the oce orprogram you have a complaint about.

www.hhsc.state.tx.us

Learn about other benet programs.

Report Medicaid abuse or raud.

Get Help on the Web


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Services or People Age 65 and Older

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Content

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2 | Need a ride to the doctor, dentist, or drug store? Call 1-877-633-8747

Services or EveryoneWhat Medicaid CoversMedicaid pays or many health-care services. Here are some examples:

Doctor and clinic visits.

Hospital visits.

Emergency care.

Medicine.

Glasses.

Dentist visits.

Family planning.

Pregnancy and childbirth care.

Mental health care.

Care in a nursing home or other place o care.

Care in your home.

Speech therapy (helps you learn how to speak again or speak better).

Occupational therapy (helps you learn how to do everyday activities

like getting around your home, getting in a car, and getting dressed). Physical therapy (helps you learn how to move around better or

become stronger).

To nd out about other services, call the Medicaid Help Line at

1-800-335-8957.


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Medicaid Help Line 1-800-335-8957 | 3

Using the Your Texas BeneftsMedicaid Card

What is the Your Texas Benefts Medicaid card?

Its your Medicaid ID card. It's plastic and it has your Medicaid ID

number and other acts you need to get Medicaid services.

How oten will I get a new card?

You will get a new Your Texas Benets Medicaid card when you are

rst approved or Medicaid.

You will get a new card i yours is lost or stolen and you ask or a

new one.

You will get a new card i the type o Medicaid you get changes.

When do I use the Your Texas Benefts Medicaid card?

Carry the card with youjust like your drivers license or a credit card.

Take it with you every time you:

Visit your Medicaid doctor or dentist.

Get medicine at the drug store.

Go to the hospital.

They will use the acts on your card to make sure youre covered by

Medicaid.

YourTexasBenefts.comBy using this site, you can:

Check your Medicaid case.

View your Medicaid health history.

Update your address and phone number.

Get Texas Health Steps reminders.

Apply or other benets such as SNAP ood benets.

Get answers to common questions.

What i I lose my card?

I you lose your card or have problems using

it, call 1-855-827-3748. I you dont have your

card, you can still go to your doctor, dentist, or

drug store. They will need to make a call or go

online to see i you get Medicaid.


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Finding a Medicaid Doctor

What i I dont have a doctor or my doctor doesnt take

Medicaid?

Call the Medicaid Help Line at 1-800-335-8957.

Go to www.hhsc.state.tx.us. Click on Questions about your benets.

Then click on Find a Doctor.

How will I know when to use the emergency room or an urgent

care clinic?

The rst time you visit your Medicaid doctor, ask what health problems

you should call him or her about. Also, ask i your doctors oce is open

in the evenings or on the weekends. This will help you avoid going to the

emergency room when its better to go to the doctors oce. Most health

problems do not need a trip to the emergency room.

I you need treatment right away and you cant visit with your doctor,

you can go to an urgent care clinic. These clinics usually have night and

weekend hours. You dont need to call the clinic beore going. You must go

to a clinic that takes Medicaid. To nd one near you, call 1-800-335-8957.

Getting Medicine and Supplies

How do I get my medicine?

Medicaid pays or most medicine that your doctor says you need. Yourdoctor will write a prescription so you can take it to the drug store.

Children age 20 and younger do not have a limit on medicines.

Most adults (age 21 and older) have a limit o 3 medicines each month.

Medicine that helps you quit smoking doesnt count toward the limit o

3 medicines.

How do I fnd a drug store that takes Medicaid? Visit www.hhsc.state.tx.us. Click on Questions about your benets?

Then click on Find a Drug Store.

Call 2-1-1 or the Medicaid Help Line at 1-800-335-8957.

What i my medicine needs pre-approval?

Some medicine needs to be pre-approved beore you can pick it up rom

the drug store. The drug store will need to get this pre-approval rom your

doctor. I they cant reach your doctor right away, they should give you a 3

day supply until your doctor approves the medicine.

Where do I get my

medicine?

Find a drug store thattakes Medicaid.

Use this same drugstore every time.


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What i I need help getting medical supplies or equipment?

Call the Medicaid Help Line or2-1-1 to nd a drug store that can help

you get supplies or equipment. Supplies and equipment can include:

Spacers or inhalers to treat asthma.

Diabetic supplies.

Crutches.

Getting a Ride to the Doctor,Dentist, or Drug Store

What i I need a ride?

Children with Medicaid and their parent can get ree rides or gas

money to help get to and rom Medicaid-covered visits. Adults with

Medicaid can get ree rides, too. You can get gas money or rides to:

Pick up medicines covered by Medicaid at a drug store. Go to a Medicaid doctor or dentist.

How do I set up a ride?

Set up a ride or the day and time o your doctor visit. I you need

to go to a drug store, nd out when your medicine will be ready.

Call 1-877-633-8747 Monday to Friday, 8 a.m. to 5 p.m. Central

Time.

Call at least 2 weekdays (Monday to Friday) beore you need a

ride. I it will be a long ride, or the doctor is in another county, call

at least 5 weekdays ahead. I you need a ride sooner than that, call1-877-633-8747.

Have your Medicaid ID or Social Security number ready when you

call.

What kind o ride can I get?

You can get rides by bus, van, car, or plane.

I you have a car but no money or gas, Medicaid might be able to

send you gas money or your trip.

Someone you know (amily, neighbor, or riend) can give you a ride

and get paid back by the mile.

To learn more:

Call 1-877-633-8747.

Visit www.hhsc.state.tx.us. Click on Questions about your

benets? Then click on How to Get a Ride to the Doctor,

Dentist, or Drug Store.

Important

Theres a diferent number to

call or rides i you live in th

Dallas / Fort Worth or

Houston / Beaumont areas.

Dallas / Fort Worth Call

1-855-687-3255 to set up a

ride i you live one o these

counties: Collin, Dallas,

Denton, Ellis, Hood, Hunt,

Johnson, Kauman, Navarro,

Parker, Rockwall, Tarrant, or

Wise.

Houston / Beaumont Call

1-855-687-4786 to set up a

ride i you live in one o the

ollowing counties: Austin,

Brazoria, Chambers, FortBend, Galveston, Hardin,

Harris, Jasper, Jeferson, Libe

Matagorda, Montgomery,

Newton, Orange, Polk, San

Jacinto, Tyler, Walker, Waller,

Wharton.


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Help or Mental Health,Drug, or Alcohol Problems

What kind o help can I get?

A visit to nd out what type o help you need.

Tests.

Counseling.

Medicine.

Hospital care.

Drug and alcohol treatment.

How do I get help or mental health, drug, or alcohol problems?

Ask your doctor to help you nd a provider who ts your needs. A provider can

be a doctor, therapist, hospital, community mental health center, or drug abuse

treatment acility.

Reporting Accidents

What i I have an accident?

I Medicaid paid or medical care that you got or an accident or injury,

you must call 1-800-846-7307 and give:

Your name.

Medicaid ID number.

Date o the accident or injury.

Also, give the name, address, and phone number o your lawyer or insurance

company i:

You have a lawyer working or you.

There is an insurance company involved.

You led a claim or this accident or injury.

You also must tell Medicaid staf about any lawsuits you or your amily le or

being injured. Include the name and address o your lawyer or the insurance

company working on your lawsuit.

It is important to ollow all o these rules to keep your Medicaid benets.

You also can mail your inormation to: TMHP/TORT

PO Box 202948

Austin, TX 78720-2948

ImportantI you live in Collin,

Dallas, Ellis, Hunt,

Kauman, Navarro, or

Rockwall County, and

need help with mental

health problems, call:

NorthStar at

1-888-800-6799

Or

The North Texas

Behavioral Health

Authority at

1-877-653-6363.


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Other Health Insurance

I I have other insurance, can I still get Medicaid services?

You can still see a Medicaid doctor i you have other insurance and

Medicaid. I a doctor takes you as a Medicaid patient, the doctor must le

claims with your other insurance.

You must tell Medicaid staf about any other health insurance you have.

This includes insurance or medicine. Call 1-800-846-7307 i:

You lose your other insurance.

You get new insurance.

You have questions about other insurance.

Will Medicaid help me pay or other insurance?

The Medicaid Health Insurance Premium Payment (HIPP) program can

pay or other health insurance i:

Someone in your amily gets Medicaid. It could be you, your spouse, or

your child, and

Someone in your amily can get health insurance at work.

People in the HIPP program can:

Get coverage rom another health insurance plan.

Get coverage or amily memberseven those who dont get Medicaid.

Go to any doctor who takes the other insurance.

To learn more: Call 1-800-440-0493.

Visit www.GetHIPPTexas.org.

How do I keep getting Medicaid?

Most people must sign up every 6 months to keep getting Medicaid. We will send you a

orm in the mail to renew Medicaid benets. Fill out the orm and mail it back. I you have

questions, call 2-1-1 or your HHSC benets oce.


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8

Medicaid Buy-In Programs

What are the Medicaid Buy-In programs?

Medicaid Buy-In programs ofer health-care services to people who make

too much money to be approved or other types o Medicaid. Buy-inprograms allow some people to get Medicaid by paying a monthly ee.

Services can include community-based services and supports.

To be in the Medicaid Buy-In program or people with disabilities who

work, a person must:

- Have a physical, intellectual, developmental, or mental disability.

- Work.

- Live in Texas.

- Not live in a state institution or nursing home all the time.

To learn more, visit www.hhsc.state.tx.us. Click on How to get help.Then click on People 65 and Older and People with Disabilities.

To be in the Medicaid Buy-In or Children program, a child must:

- Be age 18 or younger.

- Not be married.

- Meet the same rules or a disability that are used to get

Supplemental Security Income (SSI). The child doesnt have to get

SSI.

- Live in Texas.

To learn more

Go to www.hhsc.state.tx.us. Click

on How to get help. Then clickon Children.


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Services or ChildrenMedical and Dental Carewith Texas Health StepsTexas Health Steps is the Medicaid health program or people age 20

and younger. Texas Health Steps services include:

Medical checkups and treatment.

Dental checkups and treatment starting at 6 months old.

A case manager to help you nd and get other services.

Texas Health Steps will help you:

Find a doctor, dentist, or case manager.

Set up doctor and dentist checkups.

Learn about services or your child.

Get a ree ride or gas money to get to checkups or the drug store.

Medical and dental checkups will:

Help nd problems beore they get worse and are harder to treat.

Make sure your child is growing like other children their age.Children need these checkups even when they are healthy.

How is your baby?

Children grow and learn

more in their rst 3 years

than any other time in their

lives. Is your baby having

diculty learning to sit up,

walk, or talk? I yes, talk to

your childs doctor or:

Call 1-800-628-5115.

Visit www.dars.state.tx.us

Click on EarlyChildhood Intervention

Services.


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When is the right time or a Texas Health Steps checkup?

Texas Health Steps will send you a letter when your child is due or a

medical or dental checkup. Even i your child is not due or a checkup,

Medicaid will pay or health services i your child is sick or in pain.

Medicaid also will pay to treat other health problems ound during a Texas

Health Steps checkup.

To learn more: Call 1-877-847-8377 or2-1-1.

Visit www.dshs.state.tx.us/thsteps.

Help or Children with Disabilitiesor Delays in Growing or LearningChildren age 2 and younger who have disabilities or delays in growing

or learning can get special help. You can get a checkup to see i

your childs growth and learning are on target. We can visit your

childs home or child care center. To learn more, watch the videos at

www.dars.state.tx.us/ecis/videos.


Visit www.dars.state.tx.us. Click on

Early Childhood Intervention Services.

Extra Help or Children withSpecial Health NeedsAsk to get a case manager to help you i:

Your child has a health issue, disease, or disability (such as asthma,

diabetes, or mental health problems).

Your child is at risk or certain health problems (due to things such as

your amilys health history or growing or eating issues).

A case manager can help you:

Work with doctors and get medical services.

Deal with amily, school, housing, and other concerns.

Get medical equipment and supplies.

Work with other agencies.


Visit www.dshs.state.tx.us.

You can use this checklist

to make sure your child gets

checkups at certain ages:

3-5 days old

2 weeks old

2 months old

4 months old

6 months old

9 months old

12 months old

15 months old

18 months old

2 years old

2 1/2 years old

Children 3 years and older

need Texas Health Steps

checkups once a year.


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Services or WomenWomens Health ProgramThis program is or women who are age 18 to 44 and not pregnant. Women

in this program can get limited Medicaid services or health issues such as:

A history o pregnancies with problems.

Diabetes.

High blood pressure.

Heart disease beore pregnancy.

Vaginal bleeding.

Drug abuse or mental health issues.

A amily planning exam every year, which might include:

- Pap smear.

-Screening or breast and cervical cancers, diabetes, sexually transmitteddiseases, and high blood pressure.

- Family planning counseling and education, including natural amily

planning and abstinence.

- Birth control (except emergency birth control).


Visit www.hhsc.state.tx.us. Click on How to get help.

Then click on Women. Scroll down to Womens

Health Program.

Breast and Cervical Cancer ProgramMedicaid covers medical care or women age 18 to 64 who have:

Breast cancer.

Cervical cancer.

Some breast or cervical pre-cancer conditions.

Women in this program get ull Medicaid services while getting treatment.

To learn more: Call 2-1-1.

Visit www.hhsc.state.tx.us. Click on How to Get

Help. Then click on Women. Scroll down toMedicaid or Breast and Cervical Cancer.


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Extra Help or Pregnant WomenMedicaid ofers help with getting medical services and other needs or

women with high-risk pregnancies. The people who give this help are

called case managers.

Ask or a case manager or help i you are pregnant and have health issuessuch as:

A history o pregnancies with problems.

Diabetes.

High blood pressure.

Heart disease beore pregnancy.

Vaginal bleeding.

Drug abuse or mental health issues.


Visit www.dshs.state.tx.us/caseman.

Stop Smoking Help orPregnant WomenStarting January 1, 2012, pregnant women age

10 to 55 can get help rom their doctor to stop

smoking. Women can get up to 8 counseling

sessions per pregnancy. The sessions can take place

during the pregnancy and 6 weeks ater the birth o

the baby. To learn more, ask your doctor.


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Services or PeopleAge 65 and Older andPeople with DisabilitiesLong-Term ServicesI you have a long-lasting illness or disability, you might be able to get help

with daily health-care and living needs. This help can be at home or in an

adult day care center, nursing home, or assisted living acility.

A case manager can help you get the services you need. Long-term

services include:

- Help dressing, bathing, and using the bathroom.

- Help xing meals, grocery shopping, and using money.

- Help with light housework.

- Nursing care in the home.

- Hospice services (care or people in severe pain due to diseases such

as cancer).- Care in a nursing home or other place o care.

To learn more:

Call 2-1-1 or Consumer Rights and Services at 1-800-458-9858.

Visit www.dads.state.tx.us. Click on Help or Texans.


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Medicaid RulesMedicaid Program RulesI you get Medicaid, you must ollow these rules:

Pick one doctor or clinic to see when you need care.

Be sure your main doctor and any specialists you see are the only doctors that give you prescriptions. Pick one drug store to use all the time.

Do not get the same type o medicine rom diferent doctors.

Do not use the emergency room i you dont have an emergency.

I you dont ollow these rules, you might be put in the Medicaid Limited Program. This program might

limit which doctor and drug store you can use. You also might be put in this program i you commit raud

or abuse services.

We will let you know i you are going to be put in the Limited Program. People in this program stil l get

Medicaid benets. To learn more, call 1-800-436-6184. Pick option 8.

Report Medicaid Waste, Abuse, or FraudLet us know i you think a doctor, pharmacist at a drug store, other health-care provider, or a person getting

Medicaid is doing something wrong. Doing something wrong could be waste, abuse, or raud, which is

against the law. For example, tell us i you think someone is:

Getting paid or Medicaid services that werent given or necessary.

Getting Medicaid services that are not approved.

Not telling the truth about a medical condition to get medical treatment.

Letting someone else use a Medicaid ID.

Using someone elses Medicaid ID. Not telling the truth about the amount o money or resources he or she has.

To report waste, abuse, or raud, you can do one o the ollowing:

Call 1-800-436-6184.

Visit oig.hhsc.state.tx.us. Click on Click Here to Report Waste, Abuse, and Fraud. Fill out the

online orm.

Mail a letter to report a doctor, pharmacist, or other provider to:

Ofce o Inspector General

Medicaid Provider Integrity / Mail Code 1361

PO Box 85200 Austin, TX 78708-9920

Mail a letter to report a person who gets Medicaid to:

Ofce o Inspector General

General Investigations / Mail Code 1368

PO Box 13247 Austin, TX 78711


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Your RightsYour Rights While Getting Medicaid

You have the right to:

Be treated airly and with respect by doctors and medical staf.

Be treated airly, regardless o race, color, national origin, sex, age, disability, religion, or political belies.

Pick your doctor as long as he or she is accepting people with Medicaid.

Have a reasonable amount o time to pick your doctor.

Change to another doctor in a air and easy manner.

Get another doctors opinion about your treatment.

Get help in talking with your doctor i you speak a diferent language or use sign language.

Get emergency care rom the emergency room closest to you.

Get a letter that tells you why you cant get a Medicaid service you asked or.

Use the Medicaid complaint and appeal process.

Get a ast response to your complaint.

Get a Medicaid Fair Hearing i you couldnt get a Medicaid service.

Your Right to PrivacyEvery time you get a health-care service, your doctor writes down what happened and puts it in your le. This le is

kept private. Your doctor can only give out your le i you agree.

Your Right to Your Health FilesYour Right to Share Your Health RecordsMedicaid doctors and other approved providers can use a secure online network to share your Medicaid health

records. When doctors can see your Medicaid health records online, they can help you aster. Sharing your records

online is more secure than mailing or axing your records.

You have the right to let us know i you dont want us to share your Medicaid health records. I you dont want your

Medicaid doctors to see your health records on our secure online network, call 1-877-518-0899. You also can visit

www.tmhp.com. Then click on Clients / English.

Your Right to Get a Copy o Your Case Files and Health RecordsYou have the right to get copies o your case les and health records. You might have to pay or the copies. You also

can ask or changes to your les or records i you know something is wrong.

You can ask or copies o your health records. I you change your doctor, you can ask that your records be sent to you

new doctor. I your doctor, or other Medicaid provider, doesnt give you or your new doctor a copy o your health

records within 3 work days, you can call 2-1-1 or1-800-335-8957.

Your Right to be Treated FairlyContact the HHSC Civil Rights Oce right away i anything like the ollowing happens to you when using Medicaid:

Someone treated you unairly because o race, color, national origin, sex, age, disability, religion, or political

belies.

You could not get services because o race, color, national origin, sex, age, disability, religion, political belies

or language needs.


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You were the victim o unwanted sexual advances.

Someone threatened you with words or actions.

You can contact the HHSC Civil Rights Oce by:

Mail or

in Person Civil Rights Ofce

Health and Human Services Commission

701 West 51st St., MC W206 Austin, TX 78751

Phone 1-888-388-6332. People in the Austin area can call 1-512-438-4313

Fax 1-512-438-5885 or 1-512-438-4754 (not toll-ree outside the Austin

area)

E-mail [email protected]

To learn more, visit www.hhs.state.tx.us. Click on Civil Rights.

Your Right to a Fair HearingA air hearing is a chance or you to tell us the reasons you think you should have a Medicaid service you asked or bu

did not get. You can ask or a hearing within 90 days o the date o the letter that said you could not get the service.You can ask or a air hearing by calling 1-800-727-5436. Pick option 5. I you would like to make your request in

writing, send it to the ollowing address:

Texas Medicaid & Healthcare Partnership (TMHP)

Attention: Medical Aairs Support, MC A13

PO Box 204270 Austin, TX 78720-4270

Ater we get your phone call or letter, a hearing ocer will send you a letter. The letter will tell you the date and time

o the hearing. It also will tell you what you need to know to get ready or the hearing. The hearing can take place by

phone or in person.

During the HearingYou can explain why you asked or the service that you didnt get. You can speak or yoursel. Or you can ask

someone else to speak or you. This could be a riend, amily member, or lawyer. The hearing ocer will listen

to what you have to say. The hearing ocer also will listen to the reasons why you were told you couldnt get the

service. You can ask questions about these reasons. The hearing ocer might ask you some questions. A nal decision

will be made within 90 days rom the date you asked or the hearing.

Your Right to File a ComplaintI you have a complaint about Medicaid services, call the department, oce, or program you have a complaint about.

I you dont get the help you need there, contact the HHSC Oce o the Ombudsman by:

Mail HHSC Ofce o the Ombudsman

PO Box 13247, Mail Code H-700

Austin, TX 78711

Phone

Fax

1-877-787-8999

1-888-780-8099

E-mail http://txheart.dhs.state.tx.us/heartwebextr/hhscOmd

Documents

Trad Med Handbook