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Member HandbookAmerigroup Florida, Inc.

Florida Medicaid/MediKids Program

Real

Solutions

1-800-600-4441 n www.myamerigroup.com/fl

FL-M

HB-0

026-

13 0

9.13

www.myamerigroup.com

FL-MHB-0026-13 Update Contact Form

Dear Member: If your name, address, county or phone number has changed, please fill out the Amerigroup Address Change Form below and return it in the enclosed postage paid envelope. You must also report these changes to the Department of Children and Family Services by calling them toll free 1-866-762-2237, Monday through Friday from 8:00 a.m. to 5:30 p.m. Eastern time. These are a number of ways to tell DCF about these changes: 1. Go online to download the DCF Change Report Form at www.dcf.state.fl.us/DCFForms/

Search/OpenDCFForm.aspx?FormId=243

2. Mail the DCF Change Report Form to your local DCF office; your local office can be found

online at www.myflfamilies.com/contact-us

3. Fax the DCF Change Report Form toll free to 1-866-886-4342

4. Create an online account at https://myaccessaccount.dcf.state.fl.us/Login.aspx; update

contact information online at www.myflfamilies.com

Amerigroup Address Change Form

Name:

Street Address:

City: State:

ZIP code: County (Required):

Phone Number:

Signature:

Date:

www.myamerigroup.com

Dear Member: Welcome to Amerigroup Community Care. We are happy you chose us to arrange for quality health care benefits for your family. This member handbook tells you how Amerigroup works and how to keep your family healthy. It also explains how to get health care when you need it. You will get your Amerigroup ID card and more information from us in a few days. Your ID card tells you when your Amerigroup membership starts. The name of your family doctor is on the card, too. Please check your ID card right away. If the name of your doctor or any other information is not right, please call us at 1-800-600-4441. We will send you a new ID card with the correct information. You can call 1-800-600-4441 and talk to a Member Services representative about your benefits or visit our website at www.myamerigroup.com/FL. You can also talk to a nurse on our 24-hour Nurse HelpLine if you need advice. We are here to help you get quality health care coverage. Thank you again for choosing us as your family’s health plan. Thanks again for choosing Amerigroup. Sincerely,

Rosy Cozad Chief Executive Officer Amerigroup Community Care

Amerigroup is a company of all kinds of people. We welcome all into our health plans. We do not base membership on health status. If you have questions or concerns, please call 1-800-600-4441 and ask for extension 34925. Or visit www.myamerigroup.com.

Amerigroup Community Care Member Handbook

4200 W. Cypress St., Suite 900 ● Tampa, FL 33607-4173 1-800-600-4441

www.myamerigroup.com/FL Welcome to Amerigroup Community Care! This member handbook will tell you how to get medical care, home support and community services as an Amerigroup member.

WELCOME TO AMERIGROUP COMMUNITY CARE! ............................................................................. 1

Information About Your Health Plan ..................................................................................................................... 1 New Member Tips ................................................................................................................................................. 1 Your Amerigroup Member Handbook .................................................................................................................. 1 How to Get Help .................................................................................................................................................... 1

Amerigroup Member Services Department ..................................................................................................... 1 Amerigroup 24-Hour Nurse HelpLine .............................................................................................................. 2 Important Phone Numbers .............................................................................................................................. 2 Medicaid Area Offices and Phone Numbers Only............................................................................................ 2

Your Identification Cards ....................................................................................................................................... 3

YOUR DOCTORS — LIMITATIONS AND GENERAL RESTRICTIONS ON PROVIDER ACCESS ...................... 3

Choosing a Primary Care Provider ......................................................................................................................... 3 Second Opinion ..................................................................................................................................................... 4 If You Had a Different Doctor Before You Joined Amerigroup ............................................................................. 4 If Your Primary Care Provider’s Office Moves, Closes or Leaves the Amerigroup Network ................................. 4 How to Change Your Primary Care Provider ......................................................................................................... 4 If Your Primary Care Provider Asks for You to Be Changed to a New Primary Care Provider .............................. 5 If You Want to Go to a Doctor Who is Not Your Primary Care Provider ............................................................... 5 Choosing an OB/GYN ............................................................................................................................................. 5 Specialists .............................................................................................................................................................. 5

GOING TO THE DOCTOR .................................................................................................................... 6

Your First Doctor’s Appointment .......................................................................................................................... 6 How to Make an Appointment .............................................................................................................................. 6 Wait Times for Appointments ............................................................................................................................... 6 What to Bring When You Go for Your Appointment............................................................................................. 6 How to Cancel a Doctor Visit ................................................................................................................................. 7 How to Get to a Doctor Appointment or to the Hospital ..................................................................................... 7 Disability Access to Amerigroup Network Doctors and Hospitals ........................................................................ 7 What Does Medically Necessary Mean? ............................................................................................................... 7

WHAT IS COVERED BY AMERIGROUP? ............................................................................................... 8

Authorization Requirements ................................................................................................................................. 8 Inpatient Hospital Stay (including Behavioral Health Care) .................................................................................. 8 Outpatient Services ............................................................................................................................................... 8 Emergency Medical Services and Care .................................................................................................................. 8 Doctor Services ...................................................................................................................................................... 9

Table of Contents

Family Planning Services ....................................................................................................................................... 9 Maternity Care ...................................................................................................................................................... 9 Prescription Benefit ............................................................................................................................................... 9

What Are Psychotropic Drugs? ...................................................................................................................... 10 Psychotropic Drugs That Now Require Consent ............................................................................................ 10 What Over-The-Counter Medicines Are Covered? ........................................................................................ 10 Common Over-The-Counter Medicines ......................................................................................................... 11

Behavioral Health Care Services .......................................................................................................................... 11 What is an Emergency Behavioral Health Condition? ................................................................................... 12 Behavioral Health Limitations and Exclusions ............................................................................................... 12

Vision Services ..................................................................................................................................................... 12 Hearing Services .................................................................................................................................................. 13 Dental Services .................................................................................................................................................... 13 Lab and X-ray Services ......................................................................................................................................... 13 Home Health Care ............................................................................................................................................... 13 Transplant Services ............................................................................................................................................. 13

EXTRA AMERIGROUP BENEFITS ....................................................................................................... 14

WHAT SERVICES ARE COVERED BY FEE-FOR-SERVICE MEDICAID? ..................................................... 14

WHAT SERVICES ARE EXCLUDED (NOT PAID FOR) BY AMERIGROUP? ............................................... 15

DIFFERENT TYPES OF HEALTH CARE ................................................................................................. 15

Routine, Urgent and Emergency Care: What Is the Difference? ........................................................................ 15 Routine Care................................................................................................................................................... 15 Urgent Care .................................................................................................................................................... 15 Emergency Care ............................................................................................................................................. 16

What is an Emergency Medical Condition? ........................................................................................................ 16 What is an Emergency Behavioral Health Condition? ........................................................................................ 16 What is Poststabilization? ................................................................................................................................... 16 How to Get Health Care When Your Doctor’s Office is Closed ........................................................................... 17 How to Get Health Care When You Are Out of Town ......................................................................................... 17 How to Get Care When You Cannot Leave Your Home ...................................................................................... 17 Out-of-Network Care ........................................................................................................................................... 17

WELLNESS CARE FOR CHILDREN AND ADULTS .................................................................................. 18

Well Care for Children, the Child Health Check-Up Program .............................................................................. 18 Why Well-Child Visits Are Important For Children ........................................................................................ 18 When Should Your Child Get Well-Child Visits? ............................................................................................. 18 Blood Lead Testing ......................................................................................................................................... 18 Vision Screening ............................................................................................................................................. 19 Hearing Screening .......................................................................................................................................... 19 Dental Screening ............................................................................................................................................ 19 Immunizations (Shots) ................................................................................................................................... 19

WELLNESS CARE FOR ADULTS .......................................................................................................... 23

Wellness Visits Schedule For Adults .................................................................................................................... 23 When You Miss One of Your Wellness Visits ...................................................................................................... 23

SPECIAL CARE FOR PREGNANT MEMBERS ........................................................................................ 23

When You Become Pregnant .............................................................................................................................. 23 When You Have a New Baby ............................................................................................................................... 25

DISEASE MANAGEMENT .................................................................................................................. 26

SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING ................................................................... 27

Health Information .............................................................................................................................................. 27 Health Education Classes .................................................................................................................................... 27 Community Events .............................................................................................................................................. 27 Domestic Violence Resources ............................................................................................................................. 27 Bullying Resources............................................................................................................................................... 28 Smoking Cessation .............................................................................................................................................. 29 Minors ................................................................................................................................................................. 30

STATEMENT OF ADVANCE DIRECTIVE OR LIVING WILLS ................................................................... 31

A Living Will ......................................................................................................................................................... 31 A Durable Power of Attorney for Health Care .................................................................................................... 31 Is a Living Will Better Than a Durable Power of Attorney for Health Care? ....................................................... 31

GRIEVANCES AND APPEALS ............................................................................................................. 32

Complaints and Grievances ................................................................................................................................. 32 Medical Appeals .................................................................................................................................................. 34

OTHER INFORMATION .................................................................................................................... 38

Quality Improvement and Member Satisfaction ................................................................................................ 38 Interpretation Services ........................................................................................................................................ 38

ENROLLMENT .................................................................................................................................. 38

If You Move ......................................................................................................................................................... 38 Open Enrollment ................................................................................................................................................. 38 Enrollment Lock-In .............................................................................................................................................. 38 Recertify Your Medicaid Benefits on Time .......................................................................................................... 39 Reinstatement ..................................................................................................................................................... 39 Disenrolling from Amerigroup............................................................................................................................. 39 Reasons Why You Can Be Disenrolled from Amerigroup .................................................................................... 40 If You Get a Bill .................................................................................................................................................... 40 Changes in Your Amerigroup Coverage .............................................................................................................. 40 How to Tell Amerigroup About Changes You Think We Should Make ............................................................... 41 How Amerigroup Pays Providers ......................................................................................................................... 41

SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES ............................... 41

Your Rights .......................................................................................................................................................... 41 Your Responsibilities ........................................................................................................................................... 42

HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID PROGRAM ..................................... 43

NOTICE OF PRIVACY PRACTICES ....................................................................................................... 46

1 FL-MHB-0026-13 FL Medicaid MHB 10.13 ENG

WELCOME TO AMERIGROUP COMMUNITY CARE!

Information About Your Health Plan Welcome to Amerigroup Florida, Inc., doing business as Amerigroup Community Care. Amerigroup is a Health Maintenance Organization (HMO) committed to helping you get the right care close to home. As a member of Amerigroup, you and your Primary Care Physician (PCP) will work together to help keep you healthy and care for your health problems. Amerigroup helps you get quality health care. This member handbook is for all Amerigroup members who are eligible for Medicaid and MediKids. It will help you understand your health plan.

New Member Tips As a new member: 1. Review your Amerigroup ID card. Make sure the names, birth dates, sex and doctor’s information is correct. 2. Read all member information. 3. Call your doctor. Make an appointment for a physical exam for you or your child within the first 90 days of

joining Amerigroup. 4. Keep your member handbook in a safe place.

Your Amerigroup Member Handbook This handbook will help you understand your Amerigroup health plan. If you have questions, or need help understanding or reading it, call Member Services. Amerigroup also has the member handbook in:

A large print version

An audio version

A Braille version The other side of this handbook is in Spanish.

How to Get Help

Amerigroup Member Services Department If you have any questions about your Amerigroup health plan, you can call our Member Services department at 1-800-600-4441. You can call us Monday through Friday 8:00 a.m. to 7:00 p.m. Eastern time except for holidays. If you call after 7:00 p.m., you can leave a voice mail message. A Member Services representative will call you back the next business day. Member Services can help you with:

This member handbook

Member ID cards

Health care benefits

Choosing or changing your doctor

What services are offered at Amerigroup network hospitals

Where to find urgent care centers

Going to the emergency room

Doctor appointments

Finding an Amerigroup network pharmacy

Grievances and appeals

Health education

Call Member Services:

If you wish to request a copy of the Amerigroup Notice of Privacy Practices. This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

When you move. We will need to know your new address and phone number. You should also call the Medicaid Options Hotline at 1-888-367-6554 to let them know your new address.


For members who do not speak English, we can help in many different languages and dialects. This service is also available for visits with your doctor at no cost to you. Please let us know if you need an interpreter at least 24 hours before your appointment. Call Member Services for more information. For members who are deaf or hard of hearing, call the toll-free AT&T Relay Service at 1-800-855-2880. Amerigroup will set up and pay for you to have a person who knows sign language help you during your doctor visits. Please let us know if you need an interpreter at least 24 hours before your appointment.

Amerigroup 24-Hour Nurse HelpLine You can call our 24-hour Nurse HelpLine at 1-800-600-4441 if you need advice on:

How soon you need care when you are sick

What kind of health care you need

What to do to take care of yourself until you see the doctor

How you can get the care you need We want you to be happy with your services through the Amerigroup network of doctors and hospitals. Please call Member Services if you have any problems with your care.

Important Phone Numbers

Services Needed Phone Number

If you have an emergency 911

Enrollment or disenrollment information Medicaid Options Hotline at 1-888-367-6554

The Department of Children and Families (DCF) Automated ACCESS Information and Customer Call Center

1-866-762-2237

The Beneficiary Assistance Program 1-850-412-4502

Statewide Consumer Call Center 1-888-419-3456

Behavioral health care 1-800-600-4441

Eye care — CompBenefits 1-800-491-9222

Hearing care — HearUSA 1-800-698-6767

Disease management 1-888-830-4300, ask to speak with a disease management care manager

Medicaid Area Offices and Phone Numbers Only Counties Served Phone Number

Citrus, Hernando, Lake, Marion, Sumter 1-877-724-2358

Pasco, Pinellas 1-800-299-4844

Hardee, Highlands, Hillsborough, Manatee, Polk 1-800-226-2316

Orange, Osceola, Seminole, Brevard 1-877-254-1055

Charlotte, Collier, DeSoto, Glades, Hendry, Sarasota 1-800-226-6735

Indian River, Martin, Okeechobee, St. Lucie 1-800-226-5082

Broward 1-866-875-9131

Dade, Monroe 1-800-953-0555

Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia 1-800-273-5880

If you need a ride to a covered medical or dental appointment, please see the section How to Get to a Doctor’s Appointment or to the Hospital for the phone number for your county.


Your Identification Cards Each Medicaid-eligible member has a plastic gold card as ID from the Department of Children and Families (DCF) office. To learn more about the gold card, please get in touch with your area’s DCF office. You will also get an Amerigroup ID card. If you do not have your ID card yet, you will get it soon. Please carry your Amerigroup ID card and your gold card with you at all times. The card tells doctors and hospitals:

You are a member of Amerigroup

Who your Amerigroup Primary Care Provider (PCP) is

Amerigroup will pay for the medically needed benefits listed in the section Amerigroup Covered Services

Your Amerigroup ID card has the name and phone number of your PCP on it. The date you became a member is also shown. Your ID card lists many of the important phone numbers you need to know:

Our Member Services department

Our Nurse HelpLine

Eye care If your Amerigroup ID card is lost or stolen, call Member Services at 1-800-600-4441. We will send you a new one.

YOUR DOCTORS — LIMITATIONS AND GENERAL RESTRICTIONS ON PROVIDER ACCESS

Choosing a Primary Care Provider All Amerigroup members must have a family doctor, also called a Primary Care Provider (PCP). Your PCP must be in the Amerigroup network. Your PCP will give you a medical home, which means he or she will:

Get to know you and your health history

Help you get quality care

Give you all of the basic health services you need

Send you to other doctors or hospitals when you need special care When you enrolled in Amerigroup, you should have picked a PCP. If you did not, we chose one for you. We chose one who should be close by you. This PCP’s name and phone number are on your Amerigroup ID card.


If we chose your PCP, you can choose a new one. Just look in the provider directory you got with your Amerigroup enrollment package. Or we can also help you choose a new PCP. Call Member Services for help. If you need a new provider directory, contact Member Services or go online at www.myamerigroup.com/FL. If you are already seeing a doctor, you can look in the provider directory. You can find out if that doctor is in our network. If so, you can tell us you want to keep that doctor as your PCP. PCPs can be any of the following, as long as they are in the Amerigroup network:

General practitioners

Family practitioners

Internists

Pediatricians

Obstetrician/Gynecologists (OB/GYNs) (for women when they are pregnant)

Advanced registered nurse practitioners Family members do not have to choose the same PCP. They can also choose a different PCP based on each member’s needs.

Second Opinion Amerigroup members have the right to ask for a second opinion for any covered health care services. You can get a second opinion from a network provider. You can also ask a non-network provider (if a network provider is not available). Ask your PCP to ask for your second opinion. You can choose a provider from the physician directory. Your PCP may be able to help you get an appointment sooner. There is no cost to you. Your PCP will also send copies of all related records to the doctor who will provide the second opinion.

If You Had a Different Doctor Before You Joined Amerigroup You may have been seeing a doctor who is not in our network when you joined Amerigroup. You may be able to keep seeing this doctor while you pick a new doctor. Call Member Services to find out more. We will make a plan with you and your doctor, so we all know when you need to start seeing your new PCP.

If Your Primary Care Provider’s Office Moves, Closes or Leaves the Amerigroup Network Your PCP’s office may move, close or leave the Amerigroup network. If this happens, we will call or send you a letter to tell you. In some cases, you may be able to keep seeing this PCP for care for up to six months if you are in a course of treatment. Call Member Services for more information. We will make a plan with you and your PCP, so we all know when you need to start seeing your new PCP. We can also help you choose a new PCP. Call Member Services for help. Once you have picked a new PCP, we will send you a new ID card within 10 working days.

How to Change Your Primary Care Provider If you need to change your PCP, you may choose another PCP from our network. You can change your PCP at any time. Look in the Amerigroup provider directory that came with your enrollment package. You can also find the provider directory online at www.myamerigroup.com/FL.


We can also help you choose a doctor. Call Member Services at 1-800-600-4441. We can change your PCP on the same day you ask for the change. The change will be made immediately. You can also change your PCP online at www.myamerigroup.com/FL. Call the doctor office if you want to make an appointment. If you need help, call Member Services. We will help you make the appointment.

If Your Primary Care Provider Asks for You to Be Changed to a New Primary Care Provider Your PCP may ask for you to be changed to another PCP. Your doctor may do this if:

Your PCP does not have the right experience to treat you

The assignment to your PCP was made in error (like an adult assigned to a child’s doctor)

You fail to keep your appointments

You do not follow his or her medical advice over and over again

Your doctor agrees that a change is best for you

If You Want to Go to a Doctor Who is Not Your Primary Care Provider If you want to go to a doctor who is not your PCP, talk to your PCP first. In most cases, your PCP needs to refer you first. This is done when your PCP cannot give you the care you need. Please read the section Specialists to find out more. If you go to a doctor that your PCP has not referred you to, the care you receive may not be covered by Amerigroup.

Choosing an OB/GYN Female members can see an Amerigroup network obstetrician and/or gynecologist (OB/GYN) for OB/GYN health needs. These services include:

Well-woman visits

Prenatal care

Family planning

Referral to a special doctor within the network

Care for any female medical condition You do not need a referral from your PCP to see your OB/GYN. If you do not want to go to an OB/GYN, your PCP may be able to treat you for your OB/GYN health needs. Ask your PCP if he or she can give you OB/GYN care. If not, you will need to see an OB/GYN. You will find a list of network OB/GYNs in the Amerigroup provider directory that came with your enrollment package. You can also find the provider directory online at www.myamerigroup.com/FL. While you are pregnant, your OB/GYN can become your PCP. The nurses on our 24-hour Nurse HelpLine can help you decide if you should see your PCP or an OB/GYN. If you need help picking an OB/GYN, call Member Services.

Specialists Your PCP can take care of most of your health care needs, but you may also need care from other kinds of doctors. Amerigroup offers services from many different kinds of doctors who provide other medically needed care. These doctors are called specialists. They have training in a special area of medicine. Specialists include:

Allergists (allergy doctors)

Dermatologists (skin doctors)

Cardiologists (heart doctors)

Podiatrists (foot doctors)


Your PCP will refer you to a specialist in the network if your PCP cannot give you the care you need. Your PCP will give you a referral form to take to the specialist. The referral form tells you and the specialist what kind of health care you need. Be sure to take the referral form with you when you go to the specialist. Members identified by Amerigroup to have special health care needs do not need a referral to see a specialist. This is done through a standing referral or an approved number of visits. Members with special health care needs are adults and children who face daily physical, mental or environmental challenges. These challenges risk the member’s ability to fully function in society. If you believe you have special health care needs, please call Member Services.

GOING TO THE DOCTOR Amerigroup members are able to choose any Primary Care Provider (PCP) in the Amerigroup network of providers. When a specialist is needed, your PCP will work with you to find a provider to help meet your medical needs.

Your First Doctor’s Appointment You can call your doctor to set up your first appointment. You should see your PCP for a wellness visit (a general checkup) within 90 days of enrolling in Amerigroup. By finding out more about your health now, your PCP can take better care of you if you get sick. We can also help you set up your first appointment. Call Member Services if you want our help. If you have already been seeing the doctor who is now your Amerigroup network doctor, call the doctor to see if it is time for you to get a checkup. If it is, make an appointment to see the doctor as soon as possible.

How to Make an Appointment It is easy to make an appointment with your PCP. Call the doctor’s office. The phone number is on your Amerigroup ID card. If you need help, call Member Services. We will help you set up a visit. When you call, let us know what you need (for example, a checkup or a follow-up visit). Also, tell the PCP’s office if you do not feel well. This will let the doctor’s office know how soon you need to be seen.

Wait Times for Appointments We want you to be able to get care at any time. When your PCP’s office is closed, an answering service will take your call. Your doctor should call you back within 30 minutes. Once you talk to your doctor and set up an appointment, you will be able to see the doctor as follows:

Urgent care Within one day

Routine sick patient care Within one week

Wellness visit Within one month

What to Bring When You Go for Your Appointment When you go to the doctor visit, bring:

Your Amerigroup ID card

Your plastic gold card

Any medicines you take now

A list of questions for your doctor


If the visit is for your child, bring your child’s:

ID card

Shot records

Any medicine he or she takes now

How to Cancel a Doctor Visit If you set up a visit with your PCP and then can’t go, call the PCP’s office. Tell the office to cancel the visit. You can set up a new visit when you call. Try to call at least 24 hours before the visit. This will let someone else see the doctor during that time. If you want us to cancel the visit for you, call Member Services. If you do not call to cancel your doctor visits, your doctor may ask for you to be changed to a new doctor.

How to Get to a Doctor Appointment or to the Hospital You can get a ride to and from your medical appointments. All you have to do is call the number for your county below. Please call three to five days in advance.

If you have an emergency and need transportation, call 911 for an ambulance. Be sure to tell the hospital staff you are an Amerigroup member. Get in touch with your PCP as soon as you can so your doctor can arrange your treatment and help you get the needed hospital care.

Disability Access to Amerigroup Network Doctors and Hospitals Amerigroup network doctors and hospitals should help members with disabilities get the care they need. Members who use wheelchairs, walkers or other aids may need help getting into an office. If you need a ramp or other help, make sure your doctor’s office knows this before you go there. This way, they will be ready for your visit. If you want help talking to your doctor about your special needs, call Member Services.

What Does Medically Necessary Mean? Your PCP will help you get the services you need that are medically necessary as defined below. Medically necessary health services are: a) Necessary to protect life, to prevent significant illness or disability, or to lessen severe pain b) Consistent with the symptoms or diagnosis of the illness or injury under treatment c) Consistent with generally accepted professional medical standard (i.e., not experimental or investigational) d) Furnished at the most appropriate level that can be provided safely and effectively to the member e) Not mainly for the ease of the member, the member’s caregiver or the doctor

County Phone Number Brevard, Broward, Manatee and Sarasota Counties 1-866-867-0729

Dade County 1-866-726-1457

Hernando County 352-799-5177

Hillsborough County 813-253-3618

Lake County 352-326-2278

Orange, Osceola and Seminole Counties 407-423-8747

Pasco County 727-834-3200

Pinellas County 727-545-2100

Polk County 863-534-5500

Volusia County 1-866-289-1520


WHAT IS COVERED BY AMERIGROUP? The following list shows the health care services and benefits Amerigroup will cover when you need them. Your Primary Care Provider (PCP) will give you the care you need or refer you to a doctor who can give you the care you need. For a few special benefits, members have to be a certain age or have a certain kind of health problem.

Authorization Requirements Some health care services and benefits need prior authorization from Amerigroup. Your PCP will work with Amerigroup to get approval. If you have questions or want to know more about your benefits, call Member Services. All inpatient admissions need authorization (approval) from Amerigroup. The following services may not need prior authorization:

Emergency services

Preventive care services Well-visits Immunizations (shots)

Inpatient Hospital Stay (including Behavioral Health Care) Inpatient hospital stay is the care you get when you are in a hospital. This includes all items and services you need to get the right care during your stay.

Room and board

Nursing care

Medical supplies

Diagnostic and therapeutic services Adults age 21 and older are covered for no more than 45 days. Children under age 21 are covered for 365 days. Amerigroup covers no more than 45 days. Medicaid covers the other 320 days. Inpatient behavioral health care services are included. These services include up to 28 inpatient hospital days for pregnant members in an inpatient hospital substance abuse treatment program.

Outpatient Services Outpatient services include all medically needed diagnostic services, therapeutic care and services provided in an outpatient hospital setting. Outpatient services must be ordered by your Amerigroup network doctor. Outpatient behavioral health services are included.

Emergency Medical Services and Care Emergency medical services mean all emergency care available 24 hours a day, 7 days a week. This includes emergency care at a facility that is not part of the network, until the member can be safely moved to a network facility. Emergency service and care include a medical screening, exam and review by a doctor or, when allowed by law, by proper personnel managed by a doctor. The purpose of this service is to find out if there is an emergency medical condition. If there is, the doctor decides the care, treatment or surgery needed to ease or end the condition within the service means of a hospital. See the section Emergency Care for the definition of an emergency medical condition. Emergency behavioral health care services are offered 24 hours a day, 7 days a week.


Doctor Services Doctor services include all services and procedures you get from an Amerigroup network doctor when medically needed for preventive, diagnostic, therapeutic or palliative (pain relief) care, or to treat a certain illness or disease. These services also include immunizations (shots). Doctor services do not include:

Nonclinically proven procedures

Cosmetic surgery

Abortions, unless the life of the mother is or would be in danger, or if the woman is a victim of rape or incest

Family Planning Services Family planning services let you plan family size or think about when you want to have children. These services include:

Information and referral for learning and counseling

Diagnostic procedures

Contraceptive drugs and supplies

Sterilization and follow-up care You may use these services if you wish. You can choose the method and the family planning service. Norplant is covered. You do not need prior approval to get family planning services if you get these services from a provider who participates in Medicaid. Want to go to a pregnancy prevention program? Amerigroup has a listing of the different types available. Call Member Services for a complete list. Here are a few to visit:

Florida Abstinence Education program at www.greattowait.com

Local school districts

Local health departments

Florida Department of Health — Teen Outreach program

Maternity Care Maternity services include nursing review and counseling, nutrition review, prenatal care, OB delivery and follow-up care. See the section Special Care for Pregnant Members for more information.

Prescription Benefit You will get covered prescription drugs at no cost when written by a licensed prescriber. Plus, you can choose from several community pharmacies and major drugstore chains. You can look in the provider directory that came with your enrollment package for a list of network pharmacies.

There is no copayment for prescription drugs. Starting September 2011, certain medication(s) your child may use are now under a new Florida state law. Medicaid will not pay for psychotropic medication prescribed for a child under 13 years old in the Medicaid program unless express and informed consent of the child’s parent or legal guardian is given. Your child’s doctor must have a record of consent in your child’s records. In addition, the doctor will need to give the pharmacy an authorization form with the prescription.

The consent forms are online at acha.myflorida.com/Medicaid/Prescribed_Drug/med_resource.


What Are Psychotropic Drugs?

Psychotherapeutic drugs are antipsychotics, antidepressants, antianxiety medications and mood stabilizers. Anticonvulsants and ADHD medications (stimulants and nonstimulants) are not included at this time. If your child uses one or more of the generic medications listed below, informed consent is needed.

Psychotropic Drugs That Now Require Consent

Alprazolam Amitriptyline Amobarbital Amoxapine Aripiprazole Armodafinil Asenapine Bupropion Buspirone Butabarbital Carbamazepine Chloralhydrate Chlordiazepoxide Chlorpromazine Citalopram Clomipramine Clorazepate Clozapine Desipramine Desvenlafaxine

Dexmedetomidine Doxepin Droperidol Duloxetine Escitalopram Estazolam Eszopiclone Fluoxetine Fluphenazine Flurazepam Fluvoxamine Haloperidol Iloperidone Imipramine Isocarboxazid Lithium Loxapine Lurasidone Maprotiline Meprobamate

Midazolam Mirtazapine Modafinil Molindone Nefazodone Nortriptyline Olanzapine Oxazepam Paliperidone Paroxetine Pentobarbital Perphenazine Phenelzine Pimozide Protriptyline Quazepam Quetiapine Ramelteon Risperidone Secobarbital

Selegiline Sertraline Sodium Oxybate Temazepam Thioridazine Thiothixene Tranylcypromine Trazodone Triazolam Trifluoperazine Trimipramine Venlafaxine Vilazodone Zaleplon Ziprasidone Zolpidem

Amerigroup works with your doctor to get you and your family the best medical care possible. If you have questions about your child’s prescription drug program, please contact Member Services toll free at 1-800-600-4441, Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. If you are deaf or hard of hearing, please call 1-800-855-2880.

What Over-The-Counter Medicines Are Covered? In addition to the over-the-counter products covered on our formulary, you also have an over-the-counter drug benefit. Your household can get up to $10 worth of certain over-the-counter products per month at any Amerigroup network pharmacy that takes part in this benefit. Just pick the product and show the pharmacist your Amerigroup ID card. The pharmacist will let you know when your household has reached the $10 limit for the month. Some of the types of over-the-counter drugs you can get include:

Vitamins and minerals

Pain relievers

First aid supplies

Cough, cold and allergy medicine


OTC items can be picked up at any network pharmacy. This list below is not a complete list. It gives examples of some common brand names of OTC drugs. Not all members will be able to get cough and cold medications.

Common Over-The-Counter Medicines Analgesics (pain relief) Advil Aleve Bayer Aspirin EC Bengay Ecotrin Max Strength Tylenol Antacids Maalox Mylicon Tums Zantac Antidiarrheals Imodium Pepto-Bismol Antihistamines (allergy) Benadryl Claritin Chlortrimeston Nasal spray

Cough/Cold/Decongestants (age limits apply) Afrin Nasal Spray Cough drops Robitussin Vicks VapoRub Herbal treatments Coenzymes Gingko Biloba Glucosamine/Chondrotin Laxatives Colace Dulcolax Fiberlax Glycerin suppositories

(child) Laxative enemas Laxative suppositories Medical Supplies/Other Bandages Condoms Digital thermometers Nicotine patches/gum Peroxide Pill splitters Pregnancy tests

Mouth/Throat Oragel Throat lozenges Ophthalmic Collyrium eye wash Visine Other topicals Benzoyl peroxide Calamine Clearasil Cortisone Compound W Diaper rash ointment Hydrocortisone Lac-Hydrin Lice/scabies treatments Neosporin OxyClean Sunscreen Tinactin Vaseline

Rectal Preparation H Vaginal Conceptrol Gyne-Lotrimin Monistat Vagistat Vitamins/Minerals Pediatric vitamins

(Flintstones, One-a-Day Kids)

Prenatal vitamins (Complete Prenatal, GNP Daily Prenatal, Mission Prenatal, Stuart Prenatal)

Vitamins: A, B, B-Complex, C, D, E, K and Zinc

Behavioral Health Care Services Sometimes the stress of handling the many responsibilities of a home and family can lead to depression, anxiety, marriage and family problems, parenting problems, and alcohol and drug abuse. If you or family members are having these kinds of problems, you can get help. You can call Amerigroup Member Services for help. You can also get the name of a doctor who will see you if you need one. We will set up all outpatient behavioral health care services and inpatient hospital stays. You DO NOT need a referral from your PCP to get behavioral health services. A behavioral health care provider is a licensed doctor, nurse, psychologist or social worker who is trained and skilled to provide behavioral health care. If you need to change your behavioral health care case manager or behavioral health care doctor, please call Member Services. You can get these nonemergent services within the service area by calling Member Services. Member Services will help arrange for the following care:

Planning and review

Evaluation and testing services


Counseling services

Therapy and treatment services provided by a psychiatrist

Therapy and treatment services provided by a behavioral health care provider

Rehabilitation services

Children’s behavioral health care services

Day-treatment services Amerigroup is not responsible for nonemergency behavioral health care services you get from an out-of-network provider, unless we approve coverage of such services. Amerigroup behavioral health emergency coverage is available 24 hours a day, 7 days a week. You can use any hospital or other location for emergency care.

What is an Emergency Behavioral Health Condition? An emergency behavioral health condition meets the standards listed above. Examples of an emergency behavioral health condition include:

Likely danger to self and others

So much harm that the person is not able to handle daily life

Harm that will likely cause death or serious injury

Behavioral Health Limitations and Exclusions Adults can get:

Up to 45 inpatient treatment days a year

Substance abuse treatment covered by Medicaid

Prior authorization (approval) or referral by a PCP is not required You can expect to get help for behavioral health services and referrals as follows:

Urgent care Within one day

Routine sick-patient care Within one week

Well-visits Within one month

Vision Services Amerigroup members do not need a referral from their PCPs for medically needed eye care benefits. Vision services include:

Medically needed eye exams

One pair of eyeglasses per year if medically needed

Up to two additional pairs of eyeglasses per year if medically needed

Eyeglass repairs and adjustments

Contact lenses if medically needed Please call CompBenefits toll free at 1-800-491-9222 for help finding a network eye doctor (optometrist) in your area. As an extra vision benefit, Amerigroup does not limit eye exams and eyeglasses if medically needed.


Hearing Services Amerigroup covers the following hearing services:

Hearing evaluation and diagnostic testing

One standard hearing aid per ear every three years (includes fitting and dispensing). Members can get up to $500 for the upgrade from a standard medically needed (behind the ear) hearing aid to a digital canal hearing aid

Hearing aid repairs

Cochlear implant (limit of one) and cochlear implant repairs You can look in the provider directory that came with your enrollment package for a list of network hearing providers. Please call HEARx toll free at 1-800-698-6767 for help finding a HEARx center near you.

Dental Services Dental services are not covered by Amerigroup. You may contact your local Medicaid area office for any dental problems.

Lab and X-ray Services These services include medically needed lab and radiology services ordered by an Amerigroup network doctor. These services are also part of emergency care.

Home Health Care Home health care coverage includes medically needed:

Short-term or part-time nursing services by a registered nurse or licensed practical nurse

Personal care services by a home health aide

Medical items Medical items are limited to approved supplies, appliances and durable medical gear fit for use in the home. All services, supplies and gear must be ordered by an Amerigroup network doctor in a written plan. Some services may require prior authorization.

Transplant Services Transplant services include evaluations for a transplant and care before and after a transplant is performed. The types of medically necessary transplants covered are:

Bone marrow

Cornea

Kidney

Heart

Lung

Liver

Pancreas

Intestinal/multivisceral


EXTRA AMERIGROUP BENEFITS Amerigroup covers extra benefits eligible members cannot get from fee-for-service Medicaid or MediKids. These extra benefits are called value-added services. Amerigroup offers the following:

Additional vision benefit — Members can get unlimited eye exams and eyeglasses, if medically needed. See the section Vision Services under Amerigroup Covered Services for more information

Enhanced hearing aid benefit — Members can get up to $500 for the upgrade from a standard medically needed (behind the ear) hearing aid to a digital canal hearing aid; see the section Hearing Services under Amerigroup Covered Services for more information

Respite care services — If medically needed, members can get an initial home health visit by a registered nurse and eight follow-up visits (each lasting four hours) by an aid; this extra benefit includes a maximum of 16 hours in a given month and 32 hours per year; see the section Home Health Care under Amerigroup Covered Services for more information

Added programs like disease management and health education that Amerigroup provides for the benefit of its members — See the sections Disease Management and Special Amerigroup Services for Healthy Living for more information

We give you these benefits to help keep you healthy and to thank you for choosing Amerigroup as your health care plan.

WHAT SERVICES ARE COVERED BY FEE-FOR-SERVICE MEDICAID? Some services are covered by fee-for-service Medicaid instead of Amerigroup Community Care. If you think you need these services, please call Member Services. We can help to refer you to the right provider.

Nonemergency transportation (see the section How to Get to a Doctor’s Appointment, Hospice Care or to the Hospital for more information)

Dental care

Specialized therapeutic foster care

Therapeutic group care services

Behavioral health overlay services

Certain community substance abuse services

Residential care

Sub-acute Inpatient Psychiatric Program (SIPP) services

Clubhouse services

Comprehensive behavioral assessment

Florida Assertive Community Treatment services (FACT)

Hospice care

Long-term care institutional services in:

− A nursing facility

− An institution for persons with developmental disabilities

− Specialized therapeutic foster care

− Children’s residential treatment services

− State hospital services


WHAT SERVICES ARE EXCLUDED (NOT PAID FOR) BY AMERIGROUP? Elective abortions

Experimental or investigational drugs, procedures, or equipment

Substance abuse treatment (except for pregnant women)

Procedures not medically needed

Procedures that are cosmetic

Residential care

Statewide inpatient psychiatric program

Clubhouse services

DIFFERENT TYPES OF HEALTH CARE

Routine, Urgent and Emergency Care: What Is the Difference?

Routine Care In most cases when you need medical care, you call your Primary Care Provider (PCP) to make an appointment. Then you go to see the PCP. This will cover most minor illnesses and injuries, as well as regular checkups. This type of care is known as routine care. Your PCP is someone you see when you are not feeling well, but that is only part of your PCP’s job. Your PCP also takes care of you before you get sick. This is called wellness care. See the section in this handbook Wellness Care for Children and Adults. You should be able to see your PCP within one week for routine care.

Urgent Care The second type of care is urgent care. There are some injuries and illnesses that are not emergencies but can turn into an emergency if they are not treated within 24 hours. Some examples are:

High fever

Animal bites

Fractures

Severe pain

Infectious or respiratory illnesses

Flu For urgent care, you should call your PCP. Your PCP will tell you what to do. Your PCP may tell you to go to his or her office right away. You may be told to go to some other office to get immediate care. You should follow your PCP’s instructions. In some cases, your PCP may tell you to go to the urgent care center or the emergency room at a hospital for care. See the next section about emergency care for more information. You can also call our 24-hour Nurse HelpLine at 1-800-600-4441 for advice about urgent care. You should be able to see your PCP within one day for an urgent care appointment. If you need care right away and your need is not an emergency, Amerigroup has many urgent care centers in our network. Often urgent care centers have shorter wait times so you can get home more quickly.


Emergency Care After routine and urgent care, the third type of care is emergency care. If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away. If you want advice, call your PCP or our 24-hour Nurse HelpLine at 1-800-600-4441. The most important thing is to get medical care as soon as possible. You should be able to see your PCP immediately for emergency care. When you go to the hospital, you will get a medical screening. After the medical screening, you will need to show your Amerigroup ID card and your gold card. Ask the hospital to call Amerigroup. The process for providers to follow is on your ID card.

What is an Emergency Medical Condition? An emergency medical condition is when not seeing a doctor for care right away could cause death or very bad harm to your body. The problem is so bad that you can tell the problem may result in death or may cause bad damage to any organ or part of the body (or, in the case of a pregnant woman, the health of the woman or her unborn child).

In the case of a pregnant woman, an emergency medical condition is when:

There is not enough time to safely move her to a new hospital before delivery

A transfer may be a threat to the health and safety of the patient or her unborn child

There is proof of prolonged uterine contractions or rupture of the membranes

Here are some examples of problems that are most likely emergencies:

Trouble breathing

Chest pains

Loss of consciousness

Very bad bleeding that does not stop

Very bad burns

Shakes called convulsions or seizures

What is an Emergency Behavioral Health Condition? An emergency behavioral health condition meets the standard described above. Examples of an emergency behavioral health condition include:

Likely danger to self and others

So much harm that the person is not able to carry out actions of daily life

Harm that will likely cause death or serious harm to the body

What is Poststabilization? Poststabilization services are covered services you receive after emergency medical care. You get these services to help keep your condition stable. Medical emergencies and poststabilization care that have to do with your emergency do not need prior approval by Amerigroup. You should call your PCP as soon as you can after you visit the emergency room. If you cannot call, have someone else call for you. Your PCP will give or arrange any follow-up care you need.


How to Get Health Care When Your Doctor’s Office is Closed Except in the case of an emergency (see previous section) or when you need care that does not need a referral, you should always call your PCP first before you get medical care. If you call your PCP’s office when it is closed, leave a message with your name and a phone number. If it is not an emergency, someone should call you back soon to tell you what to do. You may also call our 24-hour Nurse HelpLine at 1-800-600-4441 for help. If you need services right away that are not an emergency, you can go to one of many Amerigroup urgent care centers. If you think you need emergency services (see previous section), call 911 or go to the nearest emergency room right away.

How to Get Health Care When You Are Out of Town If you need emergency services when you are out of town or outside of Florida,* go to the nearest hospital emergency room or call 911. You must get in touch with your PCP as soon as you can about your out-of-area emergency care. This will allow your PCP to set up follow-up care. If you are placed in the hospital, have the hospital call Amerigroup. This call should be made within 24 hours of admission or as soon as possible to confirm coverage. Any nonemergency care you get outside the service area is not covered unless you get prior approval from Amerigroup. If you need urgent care when you are out of town, call your PCP. If your PCP’s office is closed, leave a phone number where you can be reached. Your PCP or someone else should call you back soon. Follow the doctor’s instructions. You may be told to get care where you are if you need it very quickly. You can also call our 24-hour Nurse HelpLine for help. If you need routine care like a checkup or a prescription refill when you are out of town, call your PCP or our 24-hour Nurse HelpLine. *If you are outside of the United States and get health care services, they will not be covered by Amerigroup or fee-for-service Medicaid.

How to Get Care When You Cannot Leave Your Home Amerigroup will find a way to help take care of you. Call Member Services right away if you cannot leave your home. We will put you in touch with a case manager who will help you get the medical care you need.

Out-of-Network Care Amerigroup wants to make sure you get the care you need. Sometimes, Amerigroup doesn’t have a network provider who can give you covered services. If that happens, we’ll pay for the services out-of-network if medically needed. Amerigroup must approve this care before you get the services.

Amerigroup will pay for the care we approve. You may have to pay for care we don’t approve. We only approve care that is medically needed.


WELLNESS CARE FOR CHILDREN AND ADULTS

All Amerigroup members need to have regular wellness visits with their Primary Care Provider (PCP). During a wellness visit, your PCP will check your overall health. Many health problems can be treated and controlled if found early. Your PCP can also answer your medical questions and help you stay healthy. When you become an Amerigroup member, call your PCP and make your first appointment within 90 days.

Well Care for Children, the Child Health Check-Up Program

Why Well-Child Visits Are Important For Children Babies need to see their PCP seven times by the time they are 12 months old and more times if they get sick. If your child has special needs or an illness like asthma or diabetes, one of our care coordinators can help your child get checkups, tests and shots. Your child can get well-child visits from his or her PCP or any Amerigroup network provider. Your child does not need a referral for these visits. At these Health Check-Up visits, your child’s PCP will:

Make sure your baby is growing well

Help you care for your baby

Talk to you about what to feed your baby and how to help your baby go to sleep

Do vision, hearing and dental screenings

Do laboratory tests (including blood lead testing for children ages 12 and 24 months)

Give your baby shots that will help protect him or her from illnesses

Tell you about health education and help with preventive care

See if your baby has any problems that may need more health care

Referral and follow-up, as needed

When Should Your Child Get Well-Child Visits? The first well-child visit will happen in the hospital right after the baby is born. For the six visits after that, you must take your baby to his or her PCP’s office. You must set up a well-child visit with the baby’s PCP when the baby is:

1 month old

2 months old

4 months old

6 months old

9 months old

12 months old

15 months old

18 months old

24 months old

Each year from ages 2–18

Be sure to make these appointments. Take your child to his or her PCP when scheduled. Amerigroup will send out reminders and call you to help remind you about well-child visits.

Blood Lead Testing Your child’s PCP will test your child for lead poisoning. Your child will be tested at:

12 months

24 months

Between 24 and 72 months if the child has not been tested before For the blood test, your child’s doctor will take a blood sample by pricking the child’s finger or taking blood from the vein. This test will tell if your child has harmful lead in his or her blood.


Vision Screening Your child’s PCP should check your child’s vision at every well-child visit. Please see the section Vision Services under the heading Amerigroup Covered Services for more information.

Hearing Screening Your child’s PCP should check your child’s hearing at every well-child visit.

Dental Screening Your child should have his or her teeth and gums checked by his or her PCP as a part of the regular well-child visits. At age 3, your child should begin seeing a dentist every six months. Fluoride treatments are covered by Amerigroup if provided by your child’s doctor or a dentist.

Immunizations (Shots) It is important for your child to get his or her immunizations on time. Take your child to the doctor when his or her PCP says a shot is needed. Use the chart below to help keep track of the shots your child needs.





WELLNESS CARE FOR ADULTS Preventive screenings can help you find problems early. Earlier findings may mean you have more treatment choices. Staying healthy means seeing your PCP for regular checkups. Use the chart below to make sure you are up-to-date with your yearly wellness exams.

Wellness Visits Schedule For Adults

Who Needs It? Type of Exam How Often?

Adults: Age 18 and over Wellness visit Every year

Men: Age 35–65 Women: Age 45–65

Cholesterol screening Every 5 years (more often, if elevated)

Women: Age 16–24 Chlamydia screening Every year and at PCP’s recommendation

Women: Age 21–64 Cervical cancer screening (Pap)

Every 1–3 years

Women: Age 40 and over Mammogram (Breast X-ray) Every 1–2 years

Adults: Age 50 and over Colorectal cancer screening

Fecal blood occult test

Every year

Adults: Age 65 and over Eye exam (Glaucoma screening)

Every year

When You Miss One of Your Wellness Visits If you or your child does not get a wellness care visit on time, make an appointment with the PCP as soon as you can. If you need help setting up the appointment, call Member Services. If your child has not visited his or her PCP on time, Amerigroup will send you a postcard reminding you to make your child’s well-child appointment.

SPECIAL CARE FOR PREGNANT MEMBERS Taking Care of Baby and Me® is the Amerigroup program for all pregnant members. It is very important to see your Primary Care Provider (PCP) or OB/GYN for care when you are pregnant. This kind of care is called prenatal care. It can help you have a healthy baby. Prenatal care is always important even if you have already had a baby. With our program, members receive health information and a baby gift for getting prenatal care. When you use our Taking Care of Baby and Me program, you will get a care manager. The care manager can work with you to help you get the prenatal care and services you need during your pregnancy and until your six-week postpartum checkup. Your care manager may call you to see how you are doing with your pregnancy. He or she can help you if you have any questions. Your care manager can also help you find prenatal resources in your community to help you when you are pregnant. To find out more about the Taking Care of Baby and Me program, call Member Services.

When You Become Pregnant If you think you are pregnant, call your PCP or OB/GYN doctor right away. You do not need a referral from your PCP to see an OB/GYN doctor. Your OB/GYN should see you within two weeks. We can help you find an OB/GYN in the Amerigroup network, if needed. Call Member Services and your Department of Children and Families (DCF) case worker when you find out you are pregnant. This will help your baby get Amerigroup health care benefits when he or she is born. You will need to choose a PCP for your baby in your last trimester of pregnancy. The third trimester begins in week 28 through the end of your pregnancy. If you don’t choose a PCP for your baby during this time, we’ll choose one for you.


When you are pregnant, Amerigroup will send you a pregnancy education package. It will include:

A letter welcoming you to the Taking Care of Baby and Me program

A self-care book

A Taking Care of Baby and Me reward program brochure

A Nurse HelpLine Ameritips fact sheet

A Healthy Start Hot Tip fact sheet The book gives you information about your pregnancy. You can also use the book to write down things that happen during your pregnancy. The Taking Care of Baby and Me brochure tells you how to get your gift for getting prenatal care. While you are pregnant, you need to take good care of your health. Amerigroup encourages you to contact these two free programs: 1. Healthy Start — a program for pregnant women and families with babies less than 1 year old. Healthy Start

offers classes on:

How to have a healthy pregnancy

Eating well while you are pregnant

How to stop smoking

Breastfeeding

How to care for your baby

Family planning

Childbirth

Parenting Healthy Start offers home visits. To learn more, call 1-800-541-BABY.

2. Women, Infants and Children (WIC) — a program for pregnant women, infants and children under 5 years

old. WIC offers:

Health foods at no cost

Nutrition education and counseling

Breastfeeding support

Referrals for health care and immunizations To learn more about WIC, call 1-800-642-3556.

When should you go to your PCP or OB/GYN?

Stages of Your Pregnancy When to Go to Your Doctor

Less than 13 weeks pregnant (or sooner if you think you are pregnant)

Get your first prenatal visit as soon as possible

14–28 weeks pregnant Every 4 weeks

29–36 weeks pregnant Every 2 weeks

37–40 weeks pregnant Every week

After you deliver your baby Get your postpartum checkup between 21–56 days after you had your baby, even if you see your doctor before three weeks have passed

Your PCP or OB/GYN may want you to visit more than this based on your health needs.


When You Have a New Baby When you deliver your baby, you and your baby may stay in the hospital at least:

48 hours after a vaginal delivery

96 hours after a Caesarean section (C-section) You may stay in the hospital less time if your PCP or OB/GYN and the baby’s doctor see that you and your baby are doing well. If you and your baby leave the hospital early, your PCP or OB/GYN may ask you to have an office or in-home nurse visit within 48 hours. You must call Member Services as soon as you can to let your care manager know you had your baby. We will need to get information about your baby, too. You may have already picked a PCP for your baby before he or she was born. If not, we can help you pick a PCP for him or her. You must also call your DCF case worker when you have your baby. If you do not wish for the baby to become a member, you must call the Medicaid Options Hotline at 1-888-367-6554 to make another managed care choice for your baby. After you have your baby, Amerigroup will send you the Taking Care of Baby and Me postpartum education package. It will include:

A letter welcoming you to the postpartum part of the Taking Care of Baby and Me program

A baby care book

A Taking Care of Baby and Me reward program brochure about going to your postpartum visit

A brochure about postpartum depression

A Nurse HelpLine Ameritips fact sheet

A Healthy Start Hot Tip fact sheet

You can use the baby-care book to write down things that happen during your baby’s first year. This book will give you information about your baby’s growth. After your baby is born, you will need to see your OB/GYN or PCP for a postpartum visit between 21–56 days after your baby is born. Your baby should be seen 1–2 weeks after birth or sooner.


DISEASE MANAGEMENT Amerigroup has a Disease Management Centralized Care Unit (DMCCU) program. A team of licensed nurses and social workers, called DMCCU care managers, educate you about your condition and help you learn how to manage your care. Your Primary Care Provider (PCP) and our team of DMCCU care managers will assist you with your health care needs.

DMCCU care managers provide support over the phone, for members with:

Diabetes

HIV/AIDS

Behavioral health conditions – Bipolar disorder – Major depressive disorder – Schizophrenia

Heart conditions – Coronary artery disease – Congestive heart failure – Hypertension

Lung conditions – Asthma – Chronic obstructive pulmonary disease

DMCCU care managers work with you to create health goals and help you develop a plan to reach them. As a member in the program, you will benefit from having a care manager who:

Listens to you and takes the time to understand your needs

Helps you make a care plan to reach your health care goals

Gives you the tools, support and community resources that can help you improve your quality of life

Provides health information to help you make better choices

Helps you coordinate care with your providers

As an Amerigroup member enrolled in the DMCCU, you have certain rights and responsibilities.

You have the right to:

Have information about Amerigroup. This includes programs, services and our staff’s education and work experience. It also includes contracts we have with other businesses.

Refuse to take part in or disenroll from programs and services we offer.

Know which staff members help with your health care services and who to ask for a change.

Have Amerigroup help you make choices with your doctors about your health care.

Know about all DMCCU-related treatments. These include anything stated in the clinical guidelines, whether covered by Amerigroup. You have the right to discuss all options with your doctors.

Have personal and medical information kept private under HIPAA; know who has access to your information; know what Amerigroup does to keep it private and privacy.

Be treated with courtesy and respect by Amerigroup staff.

File a complaint with Amerigroup and be told how to make a complaint; this includes knowing about Amerigroup standards of timely response to complaints and resolving issues of quality.

Get information that you can understand.

Have Amerigroup act as an advocate for you, if needed.

You have the responsibility to:

Listen and know the importance of accepting or rejecting health care advice.

Provide Amerigroup with information needed to carry out our services.

Tell Amerigroup and your doctors if you decide to disenroll from the DMCCU program.

If you have one of these conditions or would like to know more about our DMCCU, please call 1-888-830-4300, Monday through Friday from 8:30 a.m. to 5:30 p.m. Eastern time. If you are deaf or hard of hearing, please call the AT&T Relay Service toll free at 1-800-855-2880. Ask to speak with a DMCCU care manager. You can also visit our website at www.myamerigroup.com/FL.


SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING

Health Information Learning more about health and healthy living can help you stay healthy. One way to get health information is to ask your PCP. Another way is to call us. Our Nurse HelpLine is available 24 hours a day, 7 days a week to answer your questions. They can tell you if you need to see the doctor. They can also tell you how you can help take care of some health problems you may have.

Health Education Classes Amerigroup works to keep you healthy with its health education programs. We can also help you find classes near your home. You can call Member Services to find out where and when these classes are held. Some of the classes include:

Amerigroup services and how to get them

Childbirth

Children’s programs

Infant care

Parenting

Pregnancy

Protecting yourself from violence

Quitting cigarette smoking

Substance abuse programs

Other classes about health topics

Some of the larger medical offices (like clinics) in our network show health videos that talk about immunizations (shots), prenatal care and other important health topics. We hope you will learn more about staying healthy by watching these videos.

Community Events Amerigroup sponsors and participates in community events and health fairs where you can get health information and have a good time. You can learn about topics like healthy living and fitness. People from Amerigroup will be there to answer your questions. Call Member Services to find out when and where these events will be.

Domestic Violence Resources Domestic violence is abuse. Abuse is unhealthy. Abuse is unsafe. It is never OK for someone to hit you. It is never OK for someone to make you afraid. Domestic violence causes harm and hurt on purpose. Domestic violence in the home can affect your children, and it can affect you. If you feel you may be a victim of abuse, call or talk to your doctor. Your doctor can talk to you about domestic violence. He or she can help you understand you have done nothing wrong and do not deserve abuse. Safety tips for your protection:

If you are hurt, call your PCP. Call 911 or go to the nearest hospital if you need emergency care. Please see the section Emergency Care for more information.

Have a plan on how you can get to a safe place (like a women’s shelter or a friend’s or relative’s home).

Pack a small bag and give it to a friend to keep for you until you need it. If you have questions or need help, please call our Nurse HelpLine at 1-800-600-4441 or call the National Domestic Violence hotline number at 1-800-799-7233 (TTY 1-800-787-3224).


Bullying Resources Bullying has become a serious problem and can happen anywhere: face-to-face, text messages or on the web. It is not limited to age, gender or school level. It is not a phase, and it is not a joke. Bullying can cause lasting harm. Amerigroup wants you to know the warning signs that could indicate that someone is involved in bullying, either by bullying others or by being bullied. These warning signs may show other issues or problems as well. To learn more about bullying visit www.stopbullying.gov. These may be signs of someone being bullied if he or she:

Comes home with damaged or missing clothing or items

Loses things like books, electronics, clothing or jewelry

Has unexplained injuries

Complains often of headaches, stomachaches or feeling sick

Has trouble sleeping or has frequent bad dreams

Has changes in eating habits

Hurts themselves

Is very hungry after school from not eating lunch

Runs away from home

Loses interest in visiting or talking with friends

Is afraid of going to school or other activities with peers

Loses interest in school work or begins to do poorly

Appears sad, moody, angry, anxious or depressed when he or she comes home

Talks about suicide

Feels helpless

Often feels like he or she is not good enough

Suddenly has fewer friends

Avoids certain places

Acts differently than usual

These may be signs of someone bullying others: Becomes violent with others Gets into physical or verbal fights with others Gets sent to the principal’s office or detention a lot Has extra money or new belongings that cannot be explained Is quick to blame others Will not accept responsibility for his or her actions Has friends who bully others Needs to win or be best at everything


If you suspect you or your child is being bullied:

Action Response

Someone is in immediate risk of harm because of bullying Call 911

Your child is feeling suicidal because of bullying Call the suicide prevention hotline toll free at 1-800-273-TALK (8255)

Your child’s teacher is not keeping your child safe from being bullied

Contact local school leaders (principal or superintendent)

Your school is not keeping your child safe from being bullied Contact the State School Department

Your child is sick, stressed, not sleeping or is having other problems because of bullying

Contact your counselor or other health professional

Your child is bullied because of his or her race, ethnicity or disability, and local help is not helping to solve the problem

Contact the U.S. Department of Education’s Office on Civil Rights

Smoking Cessation The smoking cessation program is designed to help you find the way to quit smoking and stay smoke free. Amerigroup offers a variety of resources and services free of charge with may options, including:

Community classes — A listing of classes taught in the community

Phone counseling — Trained health coaches work with you to find a program designed just for you that looks at how you act and how you live

Prescription benefits

Additional resources and tools – Phone counseling for stopping tobacco use

o The Florida Quitline: a toll-free, phone-based tobacco use cessation service. Any person living in Florida who wants to try to quit smoking can use the quitline. The following services are available: Counseling sessions Self-help materials Counseling and materials in English and Spanish Translation service for other languages Pharmacotherapy assistance TDD service for deaf and hard of hearing

– Online Resources o www.smokefree.gov o www.quitnet.com o www.quitsmokingsupport.com

– Printed Resources Member o You Can Quit Smoking Flier o Ameritip “Tobacco Use — Breaking the Habit” o Ameritip “Tobacco Use — Reasons To Quit”


Minors For most Amerigroup members under age 18, the Amerigroup network doctors and hospitals cannot give them care without a parent’s or legal guardian’s consent. This does not apply if emergency care is needed. Parents or legal guardians also have the right to know what is in their child’s medical records. Members under age 18 can ask their doctor not to tell their parents about their medical records, but the parents can still ask the doctor to see the medical records. These rules do not apply to emancipated minors. Members under age 18 may be emancipated minors if they:

Are married

Are pregnant or

Have a child Emancipated minors may make their own decisions about their medical care and the medical care of their children. Parents no longer have the right to see the medical records of emancipated minors.


STATEMENT OF ADVANCE DIRECTIVE OR LIVING WILLS This section tells you about Florida law on advance directives or living wills. Under Florida Law (see note below), every adult age 18 and older has the right to make certain decisions about his or her medical treatment. The law allows for the respect of your rights and personal wishes, even if you are too sick to make choices yourself. You have the right, under certain cases, to choose whether to accept or reject medical treatment, including whether to keep getting medical treatment and other procedures that would keep you alive by artificial means. You have the right to participate in decisions regarding your health care, including the right to refuse treatment. You may spell out these rights in a living will. Your living will has your personal orders about treatment to keep you alive in the case of serious illness that could cause death. You may also choose another person, or surrogate, who may decide for you if you become mentally or physically unable to do so. This surrogate may act on your behalf for the life-threatening or non-life-threatening illness. Any limits to the power of the surrogate to decide for you should be clearly expressed. You have the right to file a complaint if you think any of the laws about advance directives or living wills are not being followed. To file a complaint, call the Consumer Hotline toll free at 1-888-419-3456. The Living Will and Designation of Health Care Surrogate forms are in this handbook.

A Living Will A living will is a statement that lets your doctor and family know your wishes if there were no hope for you to recover, and you cannot make your own choices. An example of this would be whether to keep using a breathing machine to stay alive if you were in a permanent coma after a car accident.

A Durable Power of Attorney for Health Care A Durable Power of Attorney for Health Care is a statement in which you choose a person to make medical judgments for you if you cannot make those choices for yourself. That person should be someone you trust to make health choices like the ones you would make if you were able. Usually, that person would be a relative or close friend.

Is a Living Will Better Than a Durable Power of Attorney for Health Care? A living will and a durable power of attorney for health care are not the same and are used for different things. For these reasons, they both are good. These statements are to help your family and your doctor make choices about your health care at a time when you are not able to. You may use one or both of these forms of advance directives to provide the course for your medical care. You may combine them into one statement that appoints a person to make medical choices for you but also tells that person of your wishes if there is no hope for reasonable survival. You can change your mind or cancel your statements at any time. Changes should be written, signed and dated. You can also change your mind by telling someone (an oral statement). Give your PCP a copy of the new living will or durable power of attorney for health care to keep with your medical records. The only time an advance directive can be used is when you are mentally disabled and cannot make health care choices. Once you are able to make choices again, the advance directive is not in effect. It will be on standby should you ever become disabled again and cannot make choices for yourself.


Note: The legal basis for this right can be found in the Florida Statutes: Life-Prolonging Procedure Act, Chapter 765; Health Care Surrogate Act, Chapter 745; Durable Power of Attorney Section 709.08; and Court Appointed Guardianship, Chapter 744; and in the Florida Supreme Court, decision on the constitutional right of privacy, Guardianship of Estelle Browning, 1990. If you have any questions about the legal requirements or issues with these forms, you should talk to a licensed attorney in the state of Florida. Amerigroup cannot provide you with any legal advice.

GRIEVANCES AND APPEALS You have the right to tell us if you are not happy with your care or the coverage of your health care needs. These are called grievances and appeals. A grievance is when you are unhappy about something besides your benefits. A grievance could be about a doctor’s behavior or about information you should have received, but didn’t. An appeal is when you feel you should be getting a service covered and you are not, or that service has been discontinued or stopped. If you have any questions or concerns with your care or coverage, please call Member Services.

Complaints and Grievances I Have a Concern I Would Like to Report Amerigroup has a process to solve complaints and grievances. If you have a concern that is easy to solve and can be resolved within 24 hours, Member Services will help you. If your concern cannot be handled within 24 hours and needs to be looked at by our grievance coordinator, your concern will be noted and turned over to the grievance coordinator. How do I let Amerigroup know about my concern? A complaint or grievance must be given orally or in writing within one year of the occurrence.

To file a complaint or grievance you can: 1. Call Member Services at 1-800-600-4441. If you are deaf or hard of hearing, call the toll-free AT&T Relay Service at

1-800-855-2880.

2. Write us a letter regarding your concern. Mail it to:

Grievance Coordinator Amerigroup Community Care 4200 W. Cypress St., Suite 900 Tampa, FL 33607-4173

You can have someone else help you with the grievance process. This person can be:

A family member

A friend

Your doctor

A lawyer Write this person’s name on the grievance form. If you need help filing the complaint, Amerigroup can help. Call Member Services at 1-800-600-4441. If you are deaf or hard of hearing, call the toll-free AT&T Relay Service at 1-800-855-2880.


If you would like to speak with the grievance coordinator to give more information, tell Member Services when you file the complaint or put it in your letter. Once Amerigroup gets your grievance (oral or written), we will send you a letter within five working days telling you the date we got your grievance. What happens next? The grievance coordinator will review your concern. If more information is needed or you have asked to talk to the coordinator, the coordinator will call you. If you have more information to give us, you can bring it to us in person or mail it to:

Grievance Coordinator Amerigroup Community Care 4200 W. Cypress St., Suite 900 Tampa, FL 33607-4173 Medical concerns are looked at by medical staff. Amerigroup will tell you the decision of your grievance within 30 calendar days from the date we got your grievance. What can I do if I’m unhappy with the decision? You have the right to file a state fair hearing, you must do so no later than 90 days from the date you got notice that coverage of a service has been denied, stopped, reduced or delayed. The Office of Fair Hearing is not part of Amerigroup. They look at grievances of Medicaid members who live in Florida. If you contact the Office of Fair Hearing, we will give them information about your case, including the information you have given us. To ask for a state fair hearing write:

Office of Public Assistance Appeals Hearings 1317 Winewood Blvd., Building 5, Room 203 Tallahassee, FL 32399-0700 1-850-488-1429 Note: You cannot ask for a Medicaid fair hearing if you have MediKids. Note: You can seek a Medicaid fair hearing without finishing the Amerigroup Grievance and Appeals process. You have the right to ask to receive benefits while the hearing is pending by calling Member Services toll free at 1-800-600-4441. If you are deaf or hard of hearing, please call the AT&T Relay Service toll free at 1-800-855-2880.


Medical Appeals There may be times when Amerigroup says it will not pay, in whole or in part, for care that your doctor recommended. If we do this, you (or your doctor on your behalf and with your written consent) can appeal the decision. A medical appeal is when you ask Amerigroup to look again at the care your doctor asked for, and we said we will not pay for. You must file for an appeal within 30 days from the date on the letter that says we will not pay for a service. Amerigroup will not hold it against you or your doctor for helping you file an appeal or for filing an appeal for you. Amerigroup said it will not pay for care I need. What can I do about this? You or your representative can file an appeal. An appeal is when you ask Amerigroup to look again at the service we said we would not pay for. You can ask for an expedited appeal if you or your doctor thinks you need the services for an emergency or life-threatening illness. If coverage of the service you asked for has been denied, limited, reduced, suspended or terminated, you must ask for an appeal within 30 days of the date on the letter that said you would not pay for the service. You can have someone else help you with the appeal process. This person can be a family member, a friend, your doctor or a lawyer. Write this person’s name on the appeal form and fill out a Request to Designate a Personal Representative form. You can ask us to send you more information to help you understand why we would not pay for the service you requested. I want to ask for an appeal. How do I do it? An appeal may be filed verbally or in writing within 30 calendar days of when you get the notice of action. Except when expedited resolution is required, an oral notice must be followed by a written notice within 10 calendar days of the oral notice. The date of the oral notice will be the date we receive the notice. There are two ways to file an appeal: 1. Write us and ask to appeal. 2. Call Member Services at 1-800-600-4441 and ask to appeal. If you are deaf or hard of hearing, please call the

AT&T Relay Service toll free at 1-800-855-2880. What else do I need to know? If you call us, we will send you an appeal form. If you want someone else to help you with the appeal process, let us know, and we will send you a form for that. Fill out the form. Mail it back to us. You must mail it back to us within 10 days of your call. We need the appeal in writing to continue. We can help you fill out the form when we talk on the phone. When we get your letter or appeal form, we will send you a letter within five business days. This will tell you we got your appeal. You may talk to the doctor who looks at your case to get more information. We can arrange for you to meet with or talk to this person. Or you can mail it to us. You may ask for a free copy of the guidelines, records or other information used to make this decision. We will tell you what the decision is within 30 calendar days of getting your appeal request.


If we reduce coverage for a service you are receiving and you want to continue to get the service during your appeal, you can call us to ask for it. You must call within 10 days of the date of the letter mailed to you that tells you we will not pay for the service. If you have more information to give us, you can bring it in person or mail it to the address below. Also, you can look at your medical records and information on this decision before and during the appeal process. The time frame for an appeal may be extended up to 14 calendar days if:

You ask for an extension

Amerigroup finds additional information is needed, and the delay is in your interest If the time frame is extended other than at your request, Amerigroup will notify you in writing within five business days of when the decision is made. If you have a special need, we will give you additional help to file your appeal, please call Member Services at 1-800-600-4441, Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. If you are deaf or hard of hearing, please call the AT&T Relay Service at 1-800-855-2880. Where do I mail my letter? Mail all medical information and medical necessity appeals to: Medical Appeals Amerigroup Community Care P.O. Box 62429 Virginia Beach, VA 23466-2429 What can I do if Amerigroup still will not pay? You (or your doctor or legal representative on your behalf with your written consent) have a right to ask for a state fair hearing. You do not need to file an appeal before you request a fair hearing. If you would like to request a fair hearing, you must do so no later than 90 days from the date of this letter. The Office of Fair Hearing is not part of Amerigroup. They look at appeals of Medicaid members who live in Florida. If you contact the Office of Fair Hearing, we will give them information about your case, including the information you have given us. You have the right to ask to receive benefits while the hearing is pending by calling Member Services toll free at 1-800-600-4441. If you are deaf or hard of hearing, please call the AT&T Relay Service toll free at 1-800-855-2880. Note: You cannot ask for a Medicaid fair hearing if you have MediKids. How do I contact the state for a state fair hearing? You can contact the Office of Fair Hearing at any time during the Amerigroup appeals process at: The Office of Public Assistance Appeals Hearings 1317 Winewood Blvd., Building 5, Room 203 Tallahassee, FL 32399-0700


How do I ask for an external appeal review? After receiving a final determination from Amerigroup, you can call or write the Beneficiary Assistance Program (BAP):

Beneficiary Assistance Program 2727 Mahan Drive, Building 1, M.S. 26 Tallahassee, FL 32308 1-888-419-3456 or 1-850-412-4502

Before filing with the BAP, you must finish the Amerigroup appeals process.

You must ask for the appeal to the BAP within one year after receipt of the final decision letter from Amerigroup.

The BAP will not handle an appeal that has already been to a Medicaid fair hearing.

The BAP will finish its review and make a decision. What can I do if I think I need an urgent or expedited appeal? You can ask for an urgent or expedited appeal if you think the time frame for a standard appeal process could seriously jeopardize your life or health or ability to attain, maintain or regain maximum function.

You can also ask for an expedited appeal by calling Member Services toll free at 1-800-600-4441, Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. If you are deaf or hard of hearing, please call the AT&T Relay Service toll free at 1-800-855-2880.

We must respond to you within three business days (72 hours) after we receive the appeal request, whether the appeal was made verbally or in writing.

If the request for an expedited appeal is denied, the appeal will be transferred to the time frame for standard resolution, and you will be notified within three business days (72 hours).

If you have any questions or need help, please call Member Services toll free at 1-800-600-4441, Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. If you are deaf or hard of hearing, please call the AT&T Relay Service toll free at 1-800-855-2880. Payment Appeals If you receive a service from a provider and Amerigroup does not pay for that service, you may receive a notice from Amerigroup called an Explanation Of Benefits (EOB). This is not a bill.

The EOB will tell you the date you received the service, the type of service and the reason we cannot pay for the service. The provider, health care place or person who gave you this service will get a notice called an Explanation Of Payment (EOP).

If you receive an EOB, you do not need to call or do anything at that time, unless you or your provider wants to appeal the decision. An appeal is when you ask Amerigroup to look again at the service we said we would not pay for. You must ask for an appeal within 30 days of receiving the EOB. To appeal, you or your doctor can call Member Services at 1-800-600-4441 or mail your request and medical information for the service to:

Payment Appeals Amerigroup Community Care P.O. Box 61599 Virginia Beach, VA 23466-1599


If you call us, we will send you a letter to let you know we got your request for an appeal. We will include an appeal form for you to fill out and mail back to us. We can accept your appeal by phone, but you must follow up in writing within 15 days of calling us.

You have the right to ask for a fair hearing during the Amerigroup appeal process. You can request a fair hearing by sending a letter to:

The Office of Public Assistance Appeals Hearings Department of Children and Families 1317 Winewood Blvd., Building 5, Room 203 Tallahassee, FL 32399-0700

You must ask for a fair hearing within 90 days from the date you get the letter from Amerigroup that tells you the result of your payment appeal. If you have any questions about your rights to appeal or request a fair hearing, call Member Services.

How to keep your benefits while going through the grievance or Medicaid fair hearing process? To keep your benefits, this must happen: • Your appeal must be about ending, stopping or reducing treatment that had been previously approved. • Your authorization (approval) time must not have expired. • Your services must have been ordered by an authorized provider. • You must file your appeal within 10 calendar days of the date of the notice of action, if filing verbally. • You must file in writing via the U.S. mail within 14 calendar days or prior to the intended effective date of

our proposed action. • You must ask for an extension of benefits.

If we continue your benefits during the hearing process, the benefits will continue until one of the following happens: • Ten calendar days pass from a verbal request or 15 calendar days pass from a written (mailed) request from

the date of the plan’s adverse decision; and you have not asked for a Medicaid fair hearing with continuation of benefits until a Medicaid fair hearing decision is decided

• A Medicaid fair hearing decision is made that is not in your favor • The authorization expires (ends) or the authorized service limits are met • You withdraw (remove) your appeal Services will continue upon appeal of a denied authorization; if you lose the hearing, you may have to pay for all costs that happen during the review; Amerigroup may ask you for the cost of the services given to you during this process. What happens if the Medicaid fair hearing decides I am right? Amerigroup will approve and pay for services as quickly as possible. We will pay for services that were in question. We’ll do this: • According to state policy and rules • If the services were given while the hearing was going on • If the final decision reverses (changes) our decision


OTHER INFORMATION

Quality Improvement and Member Satisfaction We’re always looking for ways to improve care and service for our members. Each year we choose certain things to review: • We check to see how we are doing in different areas of service. • We may check to see how our providers are doing. • We want to know if you are happy with the care and service you get. Want to know about our quality ratings? Call Member Services. You can ask about how happy our members are with Amerigroup. You can also provide comments or suggestions about: • How we are doing • How we can improve our services

Interpretation Services Call Member Services if you need help in a language other than English or in an alternate format. This includes: • All foreign languages • Braille • TTY services if you are deaf or hard of hearing These services are available free of charge.

ENROLLMENT

If You Move Report your new address as soon as possible to the Medicaid Options Hotline and the Amerigroup Member Services department at 1-800-600-4441. If you move out of our service area, you will be disenrolled. To choose another health plan, you can call the Medicaid Options Hotline at 1-888-367-6554.Please use the Address Change form in your welcome packet.

Open Enrollment If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your enrollment year telling you that you can change plans if you want to. This is called open enrollment. You do not have to change plans. If you choose to change plans during open enrollment, you will begin in the new plan at the end of your current enrollment year. Whether you pick a new plan or stay in the same plan, you will be locked into that plan for the next 12 months. Every year you can change health plans during your 60-day open enrollment period.

Enrollment Lock-In Enrollment If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Amerigroup or the state enrolls you in a health plan, you will have 90 days from the date of your first enrollment to try the plan. During the first 90 days you can change health plans for any reason. After the 90 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next nine months. This is called lock-in.


Recertify Your Medicaid Benefits on Time Keep the right care. Do not lose your health care benefits! You could lose your Medicaid benefits even if you still qualify. For example, you could lose your benefits if you move or fail to recertify on time.

If you lose your Medicaid benefits, Amerigroup cannot arrange for your health care coverage until you become eligible for Medicaid again. If you become eligible for Medicaid again within six months or less, your membership in Amerigroup will start again. If possible, you will be given the same Primary Care Provider (PCP) you had when you were in Amerigroup before.

The good news is that recertifying has been made easier. Now you can do it online. Go to www.myflorida.com/ accessflorida, or visit a Department of Children and Families ACCESS location near you. You can call the Automated ACCESS Information and Customer Call Center at 1-866-762-2237, 24 hours a day, 7 days a week.

We want you to keep getting your health care benefits from us if you still qualify. Your health is very important to us.

Reinstatement If you lose your Medicaid eligibility and get it back within 60 days, you will be reassigned to Amerigroup. We’ll send you a letter within 10 days after you become a member again. You’ll be assigned to your original PCP, or you can pick a different one.

Disenrolling from Amerigroup If you are a mandatory enrollee and you want to change plans after the initial 90-day period ends or after your open enrollment period ends, you must have a state-approved good cause reason to change plans. The following are state-approved cause reasons to change health plans:

You move out of the county, or your address is incorrect and you don’t live in a county where Amerigroup is authorized to provide services.

Your provider is no longer with the Amerigroup.

You are excluded from enrollment.

A substantiated marketing or community outreach violation has occurred.

You are prevented from participating in the development of your treatment plan.

You have an active relationship with a provider who is not on the Amerigroup panel but is on the panel of another health plan.

You are in the wrong health plan as determined by AHCA.

Amerigroup no longer participates in the county.

The state has imposed intermediate sanctions upon Amerigroup — this is explained in 42 CFR 438.702(a)(3) in the Code of Federal Regulations.

You need related services to be performed concurrently, but not all related services are available within the Amerigroup network; or your PCP has determined that receiving the services separately would subject you to unnecessary risk.

Amerigroup does not, because of moral or religious objections, cover the service you seek.

You missed open enrollment due to a temporary loss of eligibility for 60 days.

Other reasons per 42 CFR 438.56(d)(2), including, but not limited to:

− Poor quality of care

− Lack of access to services covered under the contract

− Inordinate or inappropriate changes of PCPs

− Service access impairments due to significant changes in the geographic location of services

− Lack of access to providers experienced in dealing with your health care needs

− Fraudulent enrollment

Voluntary enrollees may disenroll from the plan at anytime


Some Medicaid recipients can change health plans whenever they choose, for any reason. For example, people who are eligible for both Medicaid and Medicare benefits and children who receive SSI benefits can change plans at any time for any reason. To find out if you can change plans, call the Medicaid Options Hotline at 1-888-367-6554.

Reasons Why You Can Be Disenrolled from Amerigroup There are several reasons you could be disenrolled from Amerigroup without asking to be disenrolled. Some of these are listed below. If you have done something that may lead to disenrollment, we will contact you. We will ask you to tell us what happened. You could be disenrolled from Amerigroup if you:

Let someone else use your ID card

Take part in disruptive or abusive behavior

Continue to fail to follow a proposed plan of medical care

Lose Medicaid eligibility

Move out of the approved service area

Get services through the Medicaid AIDS waiver (Project AIDS Care) program, the assisted living waiver program, a prescribed pediatric extended care center or Children’s Medical Services

Have other creditable health care coverage If you have any questions about your enrollment, call Member Services.

If You Get a Bill Always show your Amerigroup ID card and your gold card when you see a doctor, go to the hospital or go for tests. Even if your doctor told you to go, you must show your Amerigroup ID card to make sure you are not sent a bill for services covered by Amerigroup.

If you do get a bill, send it to us with a letter saying you have been sent a bill. Send the letter to the address below:

Claims Amerigroup Community Care P.O. Box 61010 Virginia Beach, VA 23466-1010

You can also call Member Services for help.

Changes in Your Amerigroup Coverage Sometimes Amerigroup may have to make changes in the way it works, its covered services or its network doctors and hospitals. We will mail you a letter when we make changes in the services that are covered. Your PCP’s office may move, close or leave our network. If this happens, we will call or send you a letter to tell you about this.

We can also help you pick a new doctor. You can call Member Services if you have any questions. Member Services can also send you a current list of our network doctors.


How to Tell Amerigroup About Changes You Think We Should Make We want to know what you like and do not like about Amerigroup. Your ideas will help us make Amerigroup better. Please call Member Services to tell us your ideas. You can also send a letter to:

Amerigroup Community Care P.O. Box 62509 Virginia Beach, VA 23466-2509

Amerigroup has a group of members who meet quarterly to give us their ideas. These meetings are called Member Advisory Meetings. This is a chance for you to find out more about us, ask questions and give us suggestions for improvement. If you would like to be part of this group, call Member Services.

We also send surveys to some members. The surveys ask questions about how you like Amerigroup. If we send you a survey, please fill it out and send it back. Our staff may also call to ask how you like Amerigroup. Please tell them what you think. Your ideas can help us make Amerigroup better.

How Amerigroup Pays Providers Different providers in our network have agreed to be paid in different ways by us. This is known as a Physician Incentive Plan. Your provider may be paid each time he or she treats you (fee-for-service). Or your provider may be paid a set fee each month for each member whether or not the member actually gets services (capitation).

These kinds of pay may include ways to earn more money. This kind of pay is based on different things like member satisfaction, quality of care, accessibility and availability.

You can contact Amerigroup to get any other information you want, including the structure and operation of Amerigroup and how we pay providers (the amount of these payments are private). Please call Member Services or write us at:

Amerigroup Community Care P.O. Box 62509 Virginia Beach, VA 23466-2509

SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES The Patient's Bill of Rights and Responsibilities was created to promote the interests and well being of patients and to promote better communication between the patient and the health care provider. Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider’s or health care facility’s right to expect certain behavior on the part of patients. See Section 381.026, Florida Statutes.

Your Rights As a patient, you have the right to: Be treated with respect and with due consideration for your dignity and privacy. A prompt and reasonable response to questions and requests. Know who is providing medical services and who is responsible for your care. Know what member

support services are available, including whether an interpreter is available if you don’t speak English. Know what rules and regulations apply to your conduct.


Receive information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand. Members are given the opportunity to be involved in decisions involving their health care, except when such participation is contraindicated (not recommended) for medical reasons.

Participate in decisions regarding your health care, including the right to refuse treatment. Be given health care services in line with federal and state regulations. Be given, upon request, full information and necessary advice of available financial help for your care. Know as a member eligible for Medicare, upon request and before treatment, whether your health care

provider or health care facility accepts the Medicare assignment rate. Receive, upon request, before treatment, a reasonable estimate of charges for medical care. Receive a copy of a reasonably clear and easy-to-understand itemized bill and, upon request, to have

the charges explained. Impartial access to medical treatment or accommodations, no matter of race, national origin, religion,

physical handicap or source of payment. Treatment for any emergency medical condition that will get worse from not getting the proper

treatment. Know if medical treatment is for experimental research and to give your consent or refusal to be

involved in that research. File grievances regarding any violation of your rights, as states in Florida law, through the grievance

procedure to the health care provider or health care facility which served you and to the appropriate state licensing agency.

Be free from any form of restraint (control) or seclusion used as coercion (force), discipline, convenience or retaliation (revenge).

Participate in decisions about your health care, including the right to refuse treatment. Ask for and get a copy of your medical records and ask that they be updated or corrected.

Also, the state must make sure you are able to use your rights and those rights do not adversely (negatively) affect the way Amerigroup and its providers or the state agency treat you.

Your Responsibilities As a patient, you have the responsibility to: Provide your health care provider, to the best of your knowledge, accurate (correct) and complete

information about present complaints, past illnesses, hospitalizations, medications (including over-the-counter products), dietary supplements, any allergies or sensitivities, and other matters relating to your health.

Report unexpected changes in your condition to your health care provider. Report to your health care provider whether you understand a planned action and what is expected of

you. Follow the treatment plan recommended by the health care provider. Keep appointments and, when you are not able to for any reason, tell the health care provider or health

care facility. Understand your actions if you refuse treatment or don’t follow the health care provider’s instructions. Inform your provider about any living will, medical power of attorney or other directive that could

change your care. Making sure the financial obligations (needs) of your health care are met as quickly as possible. Follow health care facility rules and regulations about member care and conduct. Behave in a way that is respectful of all health care providers and staff, as well as of other members.


HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID PROGRAM If you know someone who is misusing (through fraud, abuse and/or overpayment) the Medicaid program, you can report him or her. To report doctors, clinics, hospitals, nursing homes or Medicaid enrollees, write or call Amerigroup at:

Corporate Investigations Department Amerigroup Community Care 4425 Corporation Lane Virginia Beach, VA 23462 1-800-600-4441 Suspicions of fraud and abuse can be emailed directly to the Amerigroup Corporate Investigations Department at [email protected]. Online: Suspicions of fraud and abuse can also be sent to the Corporate Investigations Department through the Amerigroup website at www.myamerigroup.com. There are fraud and abuse links on the website to report details about a possible issue. This information is sent directly to the email address above which is checked every business day. The Bureau of Medicaid Program Integrity (BMPI) at the Agency for Health Care Administration audits and investigates providers suspected of overbilling or defrauding Florida’s Medicaid program. The BMPI recovers overpayments, issues fines and refers cases of suspected fraud for criminal investigation.

To report suspected fraud and/or abuse in Florida Medicaid: 1. Call the Consumer Complaint Hotline toll free at 1-888-419-3456 or complete a Medicaid Fraud and Abuse

Complaint form, online at https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx. 2. If you report suspected fraud and your report results in a fine, penalty, or forfeiture of property from a

doctor or other health care provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program. Call toll free 1-866-966-7226 or 850-414-3990. The reward may be up to 25 percent of the amount recovered or a maximum of $500,000 per case (Florida Statutes Chapter 409.9203).

You can talk to the Attorney General’s Office about keeping your name confidential (private) and protected. We hope this book has answered most of your questions about Amerigroup. For more information, you can call our Member Services department. This program is sponsored by the Agency for Health Care Administration and operated by Amerigroup Florida, Inc.




NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This Notice is in effect April 14, 2003. What Is this Notice? This Notice tells you:

How Amerigroup handles your Protected Health Information (PHI)

How Amerigroup uses and gives out your PHI

Your rights about your PHI

The responsibilities Amerigroup has to protecting your PHI This Notice follows what is known as the HIPAA Privacy Regulations. These rules were given out by the federal government. The federal government expects Amerigroup to follow the terms of the regulations and of this Notice. This Notice is also available on our website at www.myamerigroupcorp.com. NOTE: You may also get a Notice of Privacy Practices from the state and other organizations. What Is Protected Health Information? The HIPAA Privacy Regulations define Protected Health Information (PHI) as:

Information that identifies you or can be used to identify you

Information that either comes from you or has been created or received by a health care provider, a health plan, your employer or a health care clearinghouse

Information that has to do with your physical or mental health or condition, providing health care to you or paying for providing health care to you

In this Notice, Protected Health Information will be written as PHI. What Are the Amerigroup Responsibilities to You about Your Protected Health Information? PHI is personal for both you and your family. We have rules to help keep PHI private. These rules follow state and Federal laws. Amerigroup must:

Protect the privacy of the PHI that we have or keep about you

Provide you with this Notice about how we get and keep PHI about you

Follow the terms of this Notice

Follow state privacy laws that do not conflict with or are stricter than the HIPAA Privacy Regulations We will not use or give out your PHI without your consent, except as described in this Notice.


How Do We Use Your Protected Health Information? The sections that follow tell some of the ways we can use and share PHI without your written authorization. FOR PAYMENT — We may use PHI about you so that the treatment services you get may be looked at for payment. For example, a bill that your provider sends us may be paid using information that identifies you, your diagnosis, the procedures or tests, and supplies that were used. FOR HEALTH CARE OPERATIONS — We may use PHI about you for health care operations. For example, we may use the information in your record to review the care and results in your case and other cases like it. This information will then be used to improve the quality and success of the health care you get. Another example of this is using information to help enroll you for health care coverage. We may use PHI about you to help provide coverage for medical treatment or services. For example, information we get from a provider (nurse, doctor or other member of a health care team) will be logged and used to help decide the coverage for the treatment you need. We may also use or share your PHI to:

Send you information about one of our disease or case management programs

Send reminder cards that let you know that it is time to make an appointment or get services like EPSDT or Child Health Check-Up services

Answer a customer service request from you

Make decisions about claims requests and appeals for services you received

Look into any fraud or abuse cases and make sure required rules are followed Other Uses of Protected Health Information Business Associates — We may contract with business associates that will provide services to Amerigroup using your PHI. Services our business associates may provide include:

Dental services for members

A copy service that makes copies of your record

Computer software vendors They will use your PHI to do the job we have asked them to do. The business associate must sign a contract to agree to protect the privacy of your PHI. People Involved With Your Care Or With Payment For Your Care — We may make your PHI known to a family member, other relative, close friend or other personal representative that you choose. This will be based on how involved the person is in your care or payment that relates to your care. We may share information with parents or guardians, if allowed by law. Law Enforcement — We may share PHI if law enforcement officials ask us to. We will share PHI about you as required by law or in response to subpoenas, discovery requests, and other court or legal orders. Other Covered Entities — We may use or share your PHI to help health care providers that relate to:

Health care treatment

Health care payment

Health care operations Public Health Activities — We may use or share your PHI:


For public health activities allowed or required by law (for example, we may use or share information to help prevent or control disease, injury or disability)

With a public health authority allowed to get reports of child abuse, neglect or domestic violence Health Oversight Activities — We may share your PHI with a health oversight agency for activities approved by law, such as:

Audits

Investigations

Inspections

Licensure or disciplinary actions

Civil, administrative, or criminal proceedings or actions Oversight agencies include:

Government agencies that look after the health care system

Benefit programs including Medicaid, SCHIP or Healthy Kids

Other government regulation programs Research — We may share your PHI with researchers when an institutional review board or privacy board has followed the HIPAA rules. Coroners, Medical Examiners, Funeral Directors and Organ Donation — We may share your PHI:

To identify a deceased person

To determine a cause of death

To do other coroner or medical examiner duties allowed by law

With funeral directors, as allowed by law.

With organizations that handle organ, eye, or tissue donation and transplants To Prevent a Serious Threat to Health or Safety — We may share your PHI if we feel it is needed to prevent or reduce a serious and likely threat to the health or safety of a person or the public. Military Activity and National Security — Under certain conditions, we may share your PHI if you are, or were, in the Armed Forces. This may happen for activities believed necessary by appropriate military command authorities. Disclosures to the Secretary of the U.S. Department of Health and Human Services — We must share your PHI with the Secretary of the U.S. Department of Health and Human Services. This happens when the secretary looks into or decides if we are following HIPAA Privacy Regulations. What Are Your Rights Regarding Your PHI? We want you to know your rights about your PHI and your Amerigroup family members’ PHI. Right to Get the Amerigroup Notice of Privacy Practices We must send each Amerigroup head of case or head of household this Notice in the New Member Welcome package. We have the right to change this Notice. Once the change happens, it will apply to PHI that we have at the time we make the change and to the PHI we had before we made the change. A new Notice that includes the changes and the dates they are in effect will:

Be mailed to you at the address we have for you


Be available on our website at www.myamerigroup.com/FL

Be available at any time by calling Member Services toll-free at 1-800-600-4441. If you are deaf or hard of hearing impaired and want to talk to Member Services, call the toll-free AT&T Relay Service at 1-800-855-2880.

Right to Request a Personal Representative You have the right to request a personal representative to act on your behalf. Amerigroup will:

Treat that person as if that person were you

Allow your personal representative full access to all of your Amerigroup records (unless you say otherwise)

If you would like someone to act as your personal representative, call Member Services. We will send you a form to be filled out. Send it back to the Amerigroup Member Privacy Unit. The address and phone number are at the end of this Notice. Right to Access You have the right to look at and get a copy of your enrollment, claims, payment and case management information on file with Amerigroup. This file of information is called a designated record set. We will provide the first copy to you in any 12-month period without charge. If you would like a copy of your PHI, you must send a written request to the Amerigroup Member Privacy Unit. The address is at the end of this Notice. We will answer your written request in 30 calendar days. We may ask for an extra 30 calendar days to process your request, if needed. We will let you know if we need the extra time. We do not keep complete copies of your medical records. If you would like a copy of your medical record,

contact your doctor or other provider. Follow the provider’s instructions. Your provider may charge a fee for the cost of copying and/or mailing the record

We have the right to keep you from having or seeing all or part of your PHI for certain reasons: If the release of the information could cause harm to you or other persons If the information was gathered or created for research or as part of a civil or criminal proceeding. We

will tell you the reason in writing. We will also give you information about how you can file an appeal if you do not agree with us

Right to Amend You have the right to ask and get a copy of your medical records and to ask that they be changed or corrected. To ask for a change, send your request to the Amerigroup Member Privacy Unit. We can send you a form to complete. You can also call Member Services to request a form. The address and phone number are at the end of this Notice.

State the reason why you are asking for a change

If the change you ask for is in your medical record, get in touch with the doctor who wrote the record. The doctor will tell you what you need to do to have the medical record changed

We will answer your request within 30 days of when we receive it. We may ask for an extra 30 days to process your request, if needed. We will let you know if we need the extra time. We may deny the request for change. We will send you a written reason for the denial if:

The information was not created or entered by Amerigroup

The information is not kept by Amerigroup

You are not allowed by law to see and copy that information

The information is already correct and complete


Right to an Accounting of Certain Disclosures of Your Protected Health Information You have the right to get a list of certain disclosures of your PHI. This is a list of times we shared your information when it was not part of payment and health care operations. Most disclosures of your PHI by our business associates or us will be for payment or health care operations. To ask for a list of disclosures, please send a request in writing to the Amerigroup Member Privacy Unit. We can send you a form to complete. For a copy of the form, contact Member Services. The address and phone number are at the end of this Notice. Your request must:

Give a time-period that you want to know about

Not be longer than six years

Not include dates before April 14, 2003 Right to Request Restrictions You have the right to ask that your PHI not be used or shared. You do not have the right to ask for limits when we share your PHI if we are asked to do so by:

Law enforcement officials

Court officials

State and Federal agencies in keeping with the law We have the right to deny a request for restriction of your PHI. To ask for a limit on the use of your PHI, send a written request to the Amerigroup Member Privacy Unit. We can send you a form to fill out. You can contact Member Services for a copy of the form. The address and phone number are at the end of this Notice. The request should include:

The information you want to limit and why you want to restrict access

If you want to limit when the information is used, when the information is given out or both

The person or persons that you want the limits to apply to We will look at your request and decide if we will allow or deny the request within 30 days. If we deny the request, we will send you a letter and tell you why. Right to Cancel a Privacy Authorization for the Use or Disclosure of Protected Health Information We must have your written permission to use or give out your PHI for:

Any reason other than payment and health care operations

Other uses and disclosures listed under Other Uses of Protected Health Information We will send you a form if we need your permission. We will also explain the use for that information. You can cancel your authorization at any time by following the instructions below:

Send your request in writing to the Amerigroup Member Privacy Unit

We can send you a form to complete

You can contact Member Services for a copy of the form The address and phone number are at the end of this Notice. This cancellation will only apply to requests to use and share PHI asked for after we get the form.


Right to Request Confidential Communications You have the right to ask that we contact you about your PHI in a certain way. For example, you may ask that we send mail to an address that is different from your home address. If you want to change how we communicate with you, write to the Amerigroup Community Care Member Privacy Unit. We can send you a form to complete. For a copy of the form, contact Member Services. The address and phone number are at the end of this Notice. Your request should state how and where you want us to contact you. What Should You Do If You Have a Complaint About the Way That Your Protected Health Information is Handled by Amerigroup or Our Business Associates? You may file a complaint with Amerigroup or with the Secretary of Health and Human Services. To file a complaint with Amerigroup or to ask for a decision about your PHI, send a written request to the Amerigroup Member Privacy Unit or call Member Services. The address and phone number are at the end of this Notice. To file a complaint with the Secretary of Health and Human Services, send your written request to:

Office for Civil Rights U.S. Department of Health and Human Services Atlanta Federal Center 61 Forsyth St. SW, Suite 3B70 Atlanta, GA 30303 You will not lose your Amerigroup membership or health care benefits if you file a complaint. Even if you file a complaint, you will still get health care coverage from Amerigroup as long as you are a member. Where Should You Call or Send Requests or Questions about Your Protected Health Information? You may call Member Services toll free at 1-800-600-4441. If you are deaf or hard of hearing, call the AT&T Relay Service toll free at 1-800-855-2880. You can also send questions or requests like the ones listed in this Notice, to the address below:

Member Privacy Unit Amerigroup Community Care 4425 Corporation Lane Virginia Beach, VA 23462 Send your request to this address so that we can process it timely. Requests sent to persons, offices or addresses other than the address listed above might be delayed. If you are deaf or hard of hearing, please call the toll-free AT&T Relay Service at 1-800-855-2880.

Documents

Real - Amerigroup · You will get your Amerigroup ID card and more information from us in a few days. ... Amerigroup 24-Hour Nurse HelpLine ... For members who do not speak English,