STAR Health Member Handbook

Welcome to STAR Health

At STAR Health we are committed to providing affordable, highquality health coverage for individuals, families, and small businesses throughout the United States. This handbook is your guide to understanding the benefits, responsibilities, and resources that come with your membership. Use it as a quick reference when you have questions about coverage, claims, or member services.

How to Use This Handbook

• Quick reference: Look up specific topics using the navigation headings.
• Glossary: Definitions of common insurance terms are provided at the end of the document.
• Contact information: All essential phone numbers, email addresses, and online portals are included.

Membership Basics

Eligibility

STAR Health coverage is available to:

• Individuals and families residing in the United States
• Employees of small and mediumsize businesses
• Members of participating affiliates and partner organizations

Enrollment Periods

There are two main enrollment opportunities:

• Open Enrollment: Occurs annually from November1 through January15. During this window you can join, change, or cancel coverage.
• Special Enrollment: Triggered by qualifying life events such as marriage, birth, loss of other coverage, or relocation.

Plan Types

STAR Health offers a range of plans to suit different needs:

• HMO (Health Maintenance Organization): Requires primary care physician (PCP) referrals for specialists.
• PPO (Preferred Provider Organization): Provides greater flexibility in choosing providers, both innetwork and outofnetwork.
• HDHP (HighDeductible Health Plan) with HSA: Paired with a Health Savings Account for taxadvantaged savings.

Key Benefits

Preventive Care

All plans cover a comprehensive set of preventive services at no cost to you when you use an innetwork provider. This includes annual physicals, vaccinations, cancer screenings, and wellness visits.

Medical Services

Covered services include:

• Doctor visits (primary and specialty)
• Hospital stays, surgery, and emergency care
• Maternity and newborn care
• Mental health counseling and substanceuse treatment
• Prescription drugs (formulary tiers vary by plan)

Additional Resources

• Telehealth: 24/7 virtual visits with boardcertified clinicians.
• Wellness Programs: Discounts on gym memberships, smokingcessation programs, and nutrition coaching.
• Member Discounts: Savings on vision, dental, and hearing services.

How to Get Care

Finding a Provider

Use the online Provider Search Tool to locate doctors, hospitals, and pharmacies that participate in your plan.

Making an Appointment

1. Confirm the provider is innetwork.
2. Call the providers office and mention your STAR Health coverage.
3. Bring your member ID card and a photo ID to the visit.

Using Telehealth

Log in to the STAR Health portal or download the mobile app, select Telehealth, and follow the prompts. No copay is required for most preventive televisits.

Emergency Situations

Call 911 or go to the nearest emergency department if you need immediate care. Emergency services are covered regardless of network status, but you may be billed for any nonemergency services received after stabilizing the patient.

Financial Responsibilities

Premiums

Premiums are due on the first of each month. You can pay via automated bank draft, credit card, or online portal.

CostSharing

Each plan includes a combination of:

• Deductible the amount you pay before insurance begins covering services.
• Copayment a fixed amount per visit (e.g., $20 for a PCP visit).
• Coinsurance a percentage of the allowed charge after the deductible is met.
• OutofPocket Maximum the most youll pay in a calendar year; after reaching it, the plan pays 100% of covered services.

Prescription Drug Costs

Drugs are placed in tiers. Tier1 (generics) have the lowest copay, while Tier3 (brandname) may require a higher copay or coinsurance. Some specialty medications have separate costsharing rules.

Claims and Billing

Submitting a Claim

Innetwork providers submit claims electronically on your behalf. If you receive a bill from an outofnetwork provider, you can submit a claim using the online claims portal or by mailing the claim form to:

Understanding Your Explanation of Benefits (EOB)

An EOB is a statement that explains what the plan paid, what you owe, and why. Review it carefully; if you spot an error, contact Member Services within 60days.

Appeals Process

1. Request a copy of the insurers internal appeal decision.
2. If unsatisfied, submit an external appeal to the states Department of Insurance.
3. Include all supporting documents (medical records, letters from providers).

Member Services

• Phone: 1800555STAR (7827) 24hour assistance
• Live Chat: Available on the website during business hours
• Email: memberservice@starhealth.com
• Mobile App: Download from the App Store or Google Play for ID cards, claims tracking, and telehealth.

Member Rights and Responsibilities

Rights

• Receive clear, understandable information about benefits and costs.
• Access your health records and claims information.
• Appeal denied services or claims.
• Be treated with respect and without discrimination.

Responsibilities

• Pay premiums on time.
• Provide accurate personal and health information.
• Use innetwork providers when required.
• Notify STAR Health of any changes in address, marital status, or dependent information.

Glossary of Common Terms

Deductible

The amount you must pay for covered services before your insurance starts to pay.

Copayment (Copay)

A fixed dollar amount you pay for a specific service, usually at the time of care.

Coinsurance

Your share of the cost of a covered service, expressed as a percentage of the allowed amount.

InNetwork

Providers who have contracted with STAR Health to accept negotiated rates.

OutofNetwork

Providers who have not contracted with STAR Health; services are usually covered at a lower rate.

Primary Care Physician (PCP)

The doctor who coordinates your overall health care and provides referrals for specialists.

Formulary

List of prescription drugs covered by your plan, organized into tiers.

Health Savings Account (HSA)

A taxadvantaged account used with a highdeductible health plan to save for qualified medical expenses.

Explanation of Benefits (EOB)

A statement from the insurer showing what was covered, the amount paid, and what you may owe.