Member Handbook. Amerigroup Florida, Inc. Florida Healthy Kids Program FL-MHB B 10.

Transcription

1 Member Handbook Amerigroup Florida, Inc. Florida Healthy Kids Program FL-MHB B

2 Dear Parent/Guardian: Welcome to Amerigroup. Thank you for choosing us to help you get quality health care benefits for your family. Your child s member handbook tells you how Amerigroup works and how to: Help keep your child healthy. Get health care, too. You should have your child s Amerigroup ID card by now. If not, you ll get it soon. The ID card lists: When your child s Amerigroup membership starts. Your child s provider. Check the ID card right away. If your child s doctor or any other information is not right, please call us at (TTY 711). We will send you a new ID card with the correct information. AMERIGROUP BENEFITS Here are some important Amerigroup benefits: No copay for well-child visits with a primary care provider $5 copay for office visits Free immunizations (shots) $10 a month to buy certain personal care items and over-the-counter (OTC) medicines $100 for hypoallergenic bedding (if medically needed) $5 copay for medicines (per monthly supply) Six months of free fitness and healthy behavior coaching for kids ages 7 to 13 years A free mouth guard for children who play contact sports Amerigroup On Call: A 24-hour nurse helpline to answer your medical questions day or night Do you have questions about your child s benefits? Please call Member Services at (TTY 711). You can also visit our website at Do you have medical questions and want to talk to a nurse? Call Amerigroup On Call at hours a day, 7 days a week, 365 days a year. Our nurses can answer your health questions and help you find the help your child needs. Sincerely, Rosy Cozad Chief Executive Officer Amerigroup We can translate this into another language at no cost. Call Member Services toll free at (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time. Podemos traducirle esta información a otro idioma sin costo. Llame a la línea gratuita de Servicios al Miembro al (TTY 711) de lunes a viernes de 8 a.m. a 7 p.m. hora del Este.

3 AMERITIPS: HEALTH TIPS THAT MAKE HEALTH HAPPEN YOU NEED TO GO TO YOUR DOCTOR NOW! WHEN IS IT TIME FOR A WELL-CARE VISIT? All Amerigroup members need regular well-care visits. Your primary care provider (PCP) can also see if you have any problems. Children need more well-care visits than adults. Well-care visits are part of Florida s Child Health Check-Up program. Your child should have a well-child exam (physical) every year. WHAT IF YOUR DAUGHTER BECOMES PREGNANT? If you think your daughter is pregnant, call her PCP or OB/GYN right away. This can help her have a healthy baby. If you have any questions or need help making an appointment with the PCP or OB/GYN, contact Member Services. Please call (TTY 711). Alert! Keep the right care. Do not lose your child s health care benefits. Renew your child s eligibility for Florida Healthy Kids program benefits on time.

4 AMERIGROUP Florida Healthy Kids Member Handbook 4200 W. Cypress St., Suite 900 Tampa, FL TTY Table of Contents WELCOME TO THE AMERIGROUP HEALTHY KIDS PROGRAM... 1 INFORMATION ABOUT YOUR CHILD S NEW HEALTH PLAN... 1 Important New Member Information... 1 Member Handbook... 1 Provider Directory... 1 Identification Card... 2 Eligibility... 2 HOW TO GET HELP... 3 Amerigroup Member Services... 3 Online and Automated Self-service Features... 4 Mobile Identification Card Application... 4 Amerigroup On Call A 24-hour Nurse Helpline... 4 Other Important Phone Numbers... 5 YOUR CHILD S DOCTORS... 5 Choosing a Primary Care Provider... 5 If Your Child Had a Different Provider Before Joining Amerigroup... 6 If Your Child s Primary Care Provider s Office Moves, Closes or Leaves the Amerigroup Network. 6 How to Change Your Child s Primary Care Provider... 6 If Your Child s Primary Care Provider Asks for Your Child to Be Changed to a New Primary Care Provider... 7 If You Want Your Child to Go to a Provider Who Is Not the Primary Care Provider... 7 Choosing an OB/GYN... 7 Specialists... 8 GOING TO THE DOCTOR... 8 Your Child s First Doctor Visit... 8 How to Make an Appointment... 9 Wait Times for Appointments... 9 What to Bring When Your Child Goes to a Provider Visit... 9 How to Cancel a Visit... 9 YOUR CHILD S AMERIGROUP BENEFITS What Is Covered by Amerigroup? Payment for Services Monthly Premiums Renewal... 11

5 AMERIGROUP AND HEALTHY KIDS BENEFITS Extra Amerigroup Benefits Utilization Management Services That Don t Need Prior Authorization Dental Services Getting a Prescription Filled DIFFERENT TYPES OF HEALTH CARE Routine, Urgent and Emergency Care: What is the Difference? Routine Care Urgent Care Emergency Care What Is an Emergency Medical Condition? What Is an Emergency Behavioral Health Condition? What Is Post-stabilization? WELLNESS CARE Vision Screening Hearing Screening Dental Screening Immunizations SPECIAL CARE FOR PREGNANT MEMBERS When Your Child Becomes Pregnant When Should Your Child Go to Her PCP or OB/GYN? When Your Child Has a New Baby DISEASE MANAGEMENT CASE MANAGEMENT SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING Health Information Amerigroup On Call Health Education Classes Bullying Resources Smoking Cessation Community Events GRIEVANCES AND APPEALS Medical Appeals Payment Appeals Continuation of Benefits OTHER INFORMATION If You Move Reasons Why You Can be Disenrolled from Amerigroup and Healthy Kids If You Get a Bill Changes in Your Child s Amerigroup Coverage New Technology How to Tell Amerigroup About Changes You Think We Should Make How Amerigroup Pays Providers... 36

6 SUMMARY OF THE FLORIDA PATIENT S BILL OF RIGHTS AND RESPONSIBILITIES You and Your Child s Rights You and Your Child s Responsibilities HOW TO REPORT SOMEONE WHO IS MISUSING THE HEALTHY KIDS PROGRAM IMPORTANT TERMS HIPAA NOTICE OF PRIVACY PRACTICES... 41

7 WELCOME TO THE AMERIGROUP HEALTHY KIDS PROGRAM INFORMATION ABOUT YOUR CHILD S NEW HEALTH PLAN Welcome to Amerigroup Florida, Inc., doing business as Amerigroup. We are committed to helping your child get quality care close to home. The Healthy Kids program is offered through the Florida Healthy Kids Corporation. Healthy Kids has contracted with Amerigroup to provide services in your county. Through this program, parents can get health care for their children who are eligible for coverage. The Florida Healthy Kids Corporation is a nonprofit organization created in 1990 by the state of Florida. It provides affordable health care coverage for children from ages 5 to 18. Your child s primary care provider (PCP) will work together with you to keep your child healthy and care for his or her health problems. This member handbook will help you understand your child s health plan. Important New Member Information There are three important items every new member needs: 1. Member handbook 2. Provider directory 3. Identification (ID) card Member Handbook To make it easy for busy FHK members, our member handbook is online and in print. You can view the member handbook online at Go to Florida Healthy Kids. To get a printed member handbook? Call Member Services at (TTY 711). This handbook will help you understand your child s health plan. If you have questions or need help with this member handbook, 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. Provider Directory Is your child s provider part of Amerigroup? Our provider directory is online and in print. You can see this directory at Go to Florida Healthy Kids. Or use the interactive search online at Find A Doctor. To get a printed provider directory, call Member Services at (TTY 711). 1

8 Identification Card Your child s Amerigroup ID card will be mailed. The ID card has: Primary care provider information: Name Address Office and after-hours phone number The date you became an Amerigroup member Your child s date of birth Your subscriber (Amerigroup) identification number Other important numbers you need to know: Amerigroup Member Services Amerigroup On Call The number to find a network vision care provider The number to report Medicaid Fraud and Abuse What to do if you have an emergency If your child s Amerigroup ID card is lost or stolen, call us right away at (TTY 711). We will send you a new one. Eligibility Your child is eligible for the Healthy Kids program if he or she is: 5 to18 years old Uninsured Not eligible for Medicaid or the Children s Medical Services Network Meet eligibility income levels You may apply for Healthy Kids coverage at any time. If your child has lost Healthy Kids coverage, please call KIDS (5437) (TTY ) Monday through Friday from 7:30 a.m. to 7:30 p.m. They can answer any questions you have about your child s eligibility or benefits with Healthy Kids. 2

9 HOW TO GET HELP Amerigroup Member Services You can call Member Services at (TTY 711) Monday through Friday 8 a.m. to 7 p.m. Eastern time except for holidays. Member Services can help you with: Understanding your member handbook Making office visits Understanding your member ID card Understanding your health care Using your health care benefits Understanding wellness care Getting to know your child s doctor: Using healthy living benefits Names Finding transportation Specialties Getting health education Addresses Filing grievances and appeals Office and after-hours phone numbers Understanding your rights and responsibilities You can also call us: If you want to get a copy of the Amerigroup Notice of Privacy Practices (NOPP). It is also located in this handbook. The NOPP describes: How medical information about your child may be used and disclosed. How you can get access to this information. If you move. We ll need to know your new address and phone number. You should also call Healthy Kids at KIDS (5437) (TTY ) Monday through Friday from 7:30 a.m. to 7:30 p.m. Eastern time. If you want to get the member handbook in a different language. For members who don t speak English, we can: Help in many languages and dialects. Translate for you at provider visits at no cost to you. For members who are deaf or hard of hearing: Call TTY 711. We ll set up and pay for someone who knows sign language to help you during your office visits. Please let us know at least 24 hours before your appointment, if you need an interpreter. Call Member Services to learn more. 3

10 Online and Automated Self-service Features These services are online at or on our automated phone line 24 hours a day, 7 days a week. You can: Choose or find a PCP in the Amerigroup network Ask to change your PCP Request an ID card Update your address or phone number Request a member handbook or provider directory Mobile Identification Card Application You can now access your child s Amerigroup member Identification (ID) card from anywhere. Just download the Amerigroup Mobile app to your iphone, ipad or Android tablet or smartphone. With Amerigroup Mobile, you can show, or fax your child s member ID card to your doctor, pharmacy or hospital. It s fast. It s free. And best of all, it s safe. You just need your child s ZIP code and Amerigroup ID number, which is the subscriber number shown on your ID card, to use these services. To download the app, go to the Apple itunes Store or the Android Market or visit our website at Amerigroup On Call A 24-hour Nurse Helpline When your child is sick, call Amerigroup On Call at (TTY 711). A registered nurse can help you: Find a doctor after hours or on weekends. Get to an urgent care center or a walk-in clinic. Schedule an appointment with your doctor or a network doctor. Speak directly with a doctor about your health needs. We want you to be happy with all the services you get from our network of providers and hospitals. If you have any problems, please call us. We want to: Help you with your care Help you correct any problems you may have with your care We want you to be happy with all the services your child gets from the Amerigroup network of doctors and hospitals. Please call Member Services if you have any problems with your child s care. 4

11 Other Important Phone Numbers Service Needed Who to Call Phone Number If you have an Local emergency services 911 emergency Enrollment or disenrollment Healthy Kids Customer Service KIDS (5437) (TTY ) information Behavioral health care Amerigroup Member Services (TTY 711) Dental care Healthy Kids Customer Service KIDS (5437) Disease Amerigroup Member Services management (TTY 711) (ask to speak with a disease management care manager) Vision care eyequest (TTY ) YOUR CHILD S DOCTORS Choosing a Primary Care Provider All Amerigroup members must have a family doctor. This doctor is known as a primary care provider (PCP). Your child s PCP must be in the Amerigroup network. Your child s PCP will: Get to know your child and his or her health history Help your child get quality care Give your child all the basic health services he or she needs Send your child to other doctors or hospitals when your child needs special care When your child enrolled in Amerigroup, you should have picked a PCP for your child. If you did not, we picked one for your child. We chose one whose office is close by you. This PCP s name and phone number are on your child s Amerigroup ID card. If we chose a PCP for your child, you can pick a new one. Just look in the provider directory online at Click on Find A Doctor. Or we can also help you choose a PCP. Call Member Services for help. If your child is already seeing a PCP, you can look in the provider directory to see if that PCP 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: Family practitioners Pediatricians Obstetrician/Gynecologists (OB/GYNs) for women if they are pregnant Advanced registered nurse practitioners Physician assistants 5

12 You may choose the same PCP for all of your children. You can also choose a different PCP for each child based on each child s needs. Second Opinion Amerigroup members in the Healthy Kids program have the right to ask for a second opinion about the use of any covered health care services. Your child can get a second opinion from a network provider. Your child can also ask a non-network provider if a network provider is not available. If approved, this will not cost any more than if the service came from an in-network provider. Ask your child s PCP to ask us for your child to get a second opinion. Once approved, your child s PCP will tell you the date and time of the appointment. Your child s PCP will also send all medical records to the doctor who will give the second opinion. Your child s PCP will let you and Amerigroup know the results of the second opinion. If Your Child Had a Different Provider Before Joining Amerigroup Your child may have been seeing a provider not in our network before he or she joined Amerigroup and the Healthy Kids program. Your child may be able to keep seeing this provider for care while you pick a new provider. Call Member Services to find out more about this. We will make a plan with you and your child s provider, so we all know when your child needs to start seeing his or her new provider. If Your Child s Primary Care Provider s Office Moves, Closes or Leaves the Amerigroup Network Your child s PCP office may move, close or leave the Amerigroup network. If this happens, we will call or send you a letter to tell you. Sometimes, your child may be able to keep seeing his or her PCP for care for up to six months if he or she is in a course of treatment. Call Member Services to find out more about this. Amerigroup will make a plan with you and your child s PCP, so we all know when your child needs to start seeing the new Amerigroup network PCP. We can also help you pick a new PCP for your child. 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 Child s Primary Care Provider If you need to change your PCP, you may pick another PCP from our network. Look in the Amerigroup provider directory. You can view the provider directory online at < Click on Find A Doctor. Or call Member Services to ask for a printed version. We can also help you pick a doctor. Call Member Services at (TTY 711). We can change your PCP on the same day you ask for the change. The change will begin right away. Call your provider if you want to make an appointment. If you need help, call Member Services. We can help you make the appointment. 6

13 If Your Child s Primary Care Provider Asks for Your Child to Be Changed to a New Primary Care Provider Your child s PCP may ask for your child to be changed to another PCP. Your child s provider may do this if: Your child s PCP does not have the right experience to treat your child. The PCP your child was assigned to was by mistake (like a child assigned to an adult s provider). Your child doesn t go to his or her appointments. Your child doesn t follow the provider s medical advice many times. Your child s provider agrees this change is best for your child. If You Want Your Child to Go to a Provider Who Is Not the Primary Care Provider If you want your child to go to a provider who is not your child s PCP, please talk to your child s PCP first. Usually, the PCP needs to give your child a referral. This is done when your child s PCP can t give your child the care he or she needs. Please read the section Specialists to find out more. If your child goes to a provider that the PCP has not referred him or her to, the care your child gets may not be paid for 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 Care for any female medical condition Family planning Referral to a special doctor within the network Your daughter does not need a referral from her PCP to see her OB/GYN. If she doesn t want to go to an OB/GYN, her PCP may be able to treat her OB/GYN health needs. Ask your daughter s PCP if he or she can give your daughter OB/GYN care. If not, your daughter will need to see an OB/GYN. You will find a list of network OB/GYNs in the Amerigroup provider directory. The provider directory is also online at < Click on Find A Doctor. While your daughter is pregnant, her OB/GYN can be her PCP. To speak with a registered nurse, call Amerigroup On Call at If you need help picking an OB/GYN, you can: Refer to the online Amerigroup provider directory at < Click on Find A Doctor Call Member Services at (TTY 711). 7

14 Specialists Your child s PCP can take care of most of your child s health care needs. But your child may also need care from other kinds of doctors. Amerigroup offers services from many kinds of doctors. These doctors provide other medically needed care. They are called specialists because they have training in a special area of medicine. Examples of specialists are: Allergists (allergy doctors) Dermatologists (skin doctors) Cardiologists (heart doctors) Podiatrists (foot doctors) Your child s PCP will refer your child to a specialist in the network if your child s PCP cannot give your child the care he or she needs. In most cases, your child will need to have a referral from his or her PCP to see another doctor. Your child s PCP will give your child a referral form so he or she can see a specialist. The referral form tells you and the specialist what kind of health care your child needs. Be sure to take the referral form with you when you take your child to the specialist. Members identified by Amerigroup to have special health care needs don t 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 children who face daily physical, mental or environmental challenges. These challenges risk the member s ability to fully function in society. If you believe your child has special health care needs, please call Member Services. Sometimes, we can t get your child a needed and covered service from a doctor in our network. If that happens, with approval, we ll pay for this services from an out-of-network doctor. Amerigroup will do this for as long as we can t get this service from our network of doctors. Your child s PCP will ask Amerigroup to approve this change. You will not pay any more than if you were getting the service from us. GOING TO THE DOCTOR Your Child s First Doctor Visit You can call your child s provider to set up his or her first visit. Your child should see his or her primary care provider (PCP) for a well-child visit (a general checkup) within 90 days of enrolling in Amerigroup. By finding out more about your child s health now, your child s PCP can take better care of your child if he or she gets sick. We can also help you set up your child s first appointment. Call Member Services if you want our help. If your child has already been seeing the provider who is now your Amerigroup network provider, call that office. You need to see if it s time for your child to get a checkup. Is it time for a checkup? Make an appointment for your child to see the provider as soon as you can. 8

15 How to Make an Appointment It s easy to make an appointment with your child s PCP. Just call the office. The phone number is on your child s Amerigroup ID card. If you need help, call Member Services. We will help you make the appointment. When you call to make an appointment, let the person you talk to know what your child needs (for example, a checkup or a follow-up visit). Also, tell the office if your child is not feeling well. This will let them know how soon your child needs to be seen. Wait Times for Appointments We want your child to be able to get care at any time. When the office is closed, an answering service will take your call. Your child s provider should call you back within 30 minutes. Once you talk to your child s provider and set up an appointment, your child should be able to see the provider quickly. See the chart below: Urgent Care Routine Sick Patient Care Wellness Visit Within one day Within one week Within one month What to Bring When Your Child Goes to a Provider Visit When you go to the provider visit, bring: Your child s Amerigroup ID card Any medicines your child is taking Your child s shot records A list of questions you might want to ask your child s doctor How to Cancel a Visit If you make an appointment and then can t go, call the PCP s office. Tell the office to cancel the visit. Make a new appointment when you call. Try to call at least 24 hours before the visit. This will let someone else see the provider during that time. If you want us to cancel the appointment, call Member Services. If you don t call to cancel the visit, your child s provider may ask for your child to go to another provider. How to Get Your Child to an Office Visit or to the Hospital If your child has an emergency and needs transportation, call 911 for an ambulance. Be sure to tell the hospital you re an Amerigroup member. Call your child s PCP as soon as you can. The PCP can arrange treatment and help your child get needed hospital care. Disability Access to Amerigroup Network Doctors and Hospitals The Amerigroup network of doctors and hospitals help members with disabilities get needed care. Members who use wheelchairs, walkers or other aids may need help getting into an office. If your child needs help, make sure your child s doctor knows this before you go. This way, they will be ready for your child s visit. If you want help talking to your child s doctor about your child s special needs, call Member Services. What Does Medically Necessary Mean? Your child s PCP will help your child get the services he or she needs that are medically necessary. 9

16 Medically necessary health services are health services which are: Needed to treat your child s injury or illness, or to prevent an injury or illness for example, if your child has a fever, is complaining of pain or has an injury that needs more than home treatment A treatment that most people would expect your child to get from a doctor, such as shots, or medical care for a possible broken bone or ear infection A treatment or service that most doctors in your area would give to your child for example, to give stitches for a cut or medicine to treat a high temperature Given in the most correct place for your child s health and safety for example: You might need to take your child to the doctor for a small cut that is not bleeding a lot, but you shouldn t take him or her to the emergency room for that same cut. You might take your child to urgent care if your child has an illness or injury that can t wait until the next morning. You would bring your child to the emergency room if your child is injured badly or is so sick that you fear for his or her life if he or she is not treated right away. YOUR CHILD S AMERIGROUP BENEFITS When you enroll your child in the Healthy Kids program and Amerigroup, he or she becomes a member of a Health Maintenance Organization (HMO). An HMO is a health plan that pays for most types of medical care without large out-of-pocket costs for you. Amerigroup pays for treatment when your child is sick or injured. We also pay for services that can help your child stay healthy. This includes annual checkups and immunizations (shots). What Is Covered by Amerigroup? Payment for Services Amerigroup is easy to use. We re not like traditional health care plans, where you must file claim forms and wait for your payment. When your child gets covered services, you pay a small copay, if needed. Amerigroup pays for the rest without any paperwork. It s very important for you to pay any copays for nonemergency or nonurgent services so that your child is not denied (refused) care. Monthly Premiums In addition to small copays for certain services, a monthly premium (payment) is also needed to keep your child s coverage. Premium payments are due 30 days in advance to Healthy Kids. You will get a coupon book to help remind you to make your payments. You can pay your premium online or by phone with Healthy Kids. If a payment is not received in time, your child s coverage will be cancelled. To start your child s coverage after it s cancelled, you must call Healthy Kids at KIDS (5437) (TTY ). If your child s coverage has been cancelled because you didn t pay, you must wait 30 days to start coverage again. Services will not be paid for by Amerigroup during this time. Monthly premiums can be paid by mail or phone or over the Internet. Checks by phone and payments by debit or credit card are also OK. 10

17 Mail monthly premiums to: Florida Healthy Kids Corporation P.O. Box Tampa, FL Overnight payments aren t accepted at this address. Call KIDS (5437) (TTY ) to pay by phone. Payments by phone can be made 24 hours a day, 7 days a week. Payments can also be made online at A small fee will be charged for payments made over the phone and online. Renewal Every family must renew Healthy Kids coverage once a year. You will get a letter from Florida Healthy Kids about two months before your child s renewal date. It will have a form with most of your current information already filled in. You may also review your information online at It s very important for you to return this renewal letter. If you have any questions, please contact Florida Healthy Kids. The toll-free number for the Customer Service department is (TTY ) Monday through Friday from 7:30 a.m. to 7:30 p.m. AMERIGROUP AND HEALTHY KIDS BENEFITS This is a list of the health care services that the Healthy Kids program and Amerigroup will cover when your child needs them. Your child s primary care provider (PCP) will give your child the care he or she needs or refer him or her to a provider who can. For some special benefits, members have to be a certain age or have a certain kind of health problem. Sometimes, your child s doctor may need to get prior authorization (approval) from Amerigroup before your child can get a benefit. Your child s doctor will work with Amerigroup to get approval. If you have a question or are not sure whether we offer a certain benefit, call Member Services. COVERED SERVICES COVERAGE LIMITS COPAYS Well-child care, including preventive care visits, immunizations (shots), and routine hearing and vision screenings Primary care provider (PCP) office visits Specialist office visits Diagnostic testing (laboratory, X-rays) Prescription drugs (generic drugs, unless brand name is medically necessary) Hearing and vision screenings and immunizations must be provided by your child s PCP Must use an Amerigroup network provider Must use an Amerigroup network provider Must be referred by your child s PCP Must use an Amerigroup network provider Must meet medical necessity Must use Amerigroup network pharmacy Must be prescribed by your child s PCP or an Amerigroup-approved specialist or doctor No copay No copay $5 per visit No copay $5 per prescription (up to a 31-day supply) 11

18 COVERED SERVICES COVERAGE LIMITS COPAYS Inpatient hospital stays Stays must be approved by Amerigroup No copay (semiprivate room) Limited to 15 days per year for rehabilitation and physical therapy stays Chiropractic services Limited to one visit per day for up to 24 visits per $5 per visit calendar year Podiatric services Limited to one visit per day for up to two visits $5 per visit Maternity services and newborn care, including prenatal and postpartum care, and the initial inpatient care of the newborn Family planning services Emergency services, including visits to an emergency room (see Emergency Care Emergency transportation services Vision services Your child s PCP will test his or her eyesight; if the tests show problems, your child will be referred to a specialist Behavioral health services, including inpatient and outpatient care for evaluation, diagnosis and treatment per month for certain foot disorders Coverage for the newborn limited to three days or until transferred Limited to one visit per year and one supply visit every 90 days Must use an Amerigroup network hospital or provider for emergency care, unless the time to reach a network provider would risk permanent damage to your child s health Must be for an emergency (see Emergency Care). If you have an emergency, call 911 or go to the nearest hospital emergency room right away. If you want advice, call your PCP or Amerigroup On Call at Your child will get a new pair of eyeglasses: After a failed vision screening Every two years or when head size or prescription changes Limited to Medicaid frames and certain kinds of lenses Limits are similar to those of physical illnesses: Duration of services Number of visits Number of days for hospitalization or residential services Some services may need precertification before you can get them. Please have your doctor call Member Services at No copay $5 per visit $10 per visit (no copay if admitted or if visit approved by your child s PCP) $10 per trip $5 per visit with specialist $10 for corrective lenses No inpatient copay $5 per outpatient visit 12

19 COVERED SERVICES COVERAGE LIMITS COPAYS Substance abuse services, including inpatient and outpatient care for drug and alcohol abuse (such as counseling and help with placement) Limits are similar to those of physical illnesses: Duration of services Number of visits Number of days for hospitalization or residential services No inpatient copay $5 per outpatient visit Outpatient services include evaluation, diagnosis and treatment Nursing facility services, including regular nursing services, rehabilitation services, semiprivate room Therapy services, including physical, occupational, respiratory and speech therapies for short-term rehabilitation where your child s condition will significantly improve Home health services, including prescribed home visits by registered and licensed practical nurses to provide skilled nursing services on a part-time, short-term basis Hospice services, including reasonable and necessary services to manage a terminal illness Some services may need precertification before you can get them. Please have your doctor call Member Services at Must be approved by Amerigroup and provided by a network facility Limited to 100 days per year (rehabilitation and physical therapy stays are limited to 15 days per year) Excludes private duty nurses, television, custodial care, specialized treatment centers and independent kidney disease treatment centers Must be provided by an Amerigroup network provider or upon approved referral Limited to 24 sessions in a 60-day period per incident (begins with first visit) Must be approved by Amerigroup Limited to skilled nursing services Excludes meals, housekeeping and personal comfort items Private duty nursing is covered, if medically necessary If you want your child to get hospice care, services which do not treat the terminal condition will not be covered No copay $5 per visit $5 per visit $5 per visit 13

20 COVERED SERVICES COVERAGE LIMITS COPAYS Durable Medical Equipment (DME) and prosthetic devices if prescribed by your child s Amerigroup doctor as medically necessary Must be approved by Amerigroup and provided by an Amerigroup supplier Covered prosthetics include artificial eyes and limbs, braces Hearing aids covered only when medically No copay Organ transplant services, including care before, during and after the transplant, and treatment of complications after the transplant necessary Must be deemed necessary and appropriate within guidelines of the Organ Transplant Advisory Council or the Bone Marrow Transplant Advisory Council No copay Extra Amerigroup Benefits To better meet all your needs, Amerigroup offers extra benefits called value-added services. These extra benefits include: $10 a month to buy certain personal care items and over-the-counter (OTC) medicines $100 for hypoallergenic bedding (if medically needed) Six months of free fitness and healthy behavior coaching for kids ages 7 to 13 years A free mouth guard for children who play contact sports Amerigroup On Call: A 24-hour nurse helpline to answer your medical questions day or night. Call toll free at (TTY 711) We give you these benefits to help keep your family healthy. Making Decisions on Care and Services Sometimes, we need to make decisions about how we pay for care and services. This is called Utilization Management (UM). Our UM process is based on the standards of the National Committee for Quality Assurance (NCQA). All UM decisions are based on medical needs and current benefits only. We do this for the best possible health results for our members. We don t tell or ask providers to not use these services. We don t create issues to getting health care. Providers don t get rewards for limiting or denying care. Utilization Management Some services and benefits need prior authorization (approval). This means your provider must ask Amerigroup to approve the services first. Amerigroup has a utilization review team that looks at approval requests. You or your doctor can ask for a review if Amerigroup says it won t pay for the care. Amerigroup will let you and your doctor know after we get the request. 14

21 Services That Don t Need Prior Authorization Some services don t need prior authorization (approval) from Amerigroup or your child s PCP. These services include: Outpatient behavioral health care services Emergency behavioral health care services Outpatient substance abuse and rehabilitation treatments Emergency room visits Well-child care Family planning services PCP office visits Chiropractic care services If you have questions about these covered services or how to access care, call Member Services. Dental Services If you get dental benefits, they are provided through a different company. Please contact Healthy Kids Customer Service at KIDS (5437) (TTY ) to find out about your child s dental plan. Getting a Prescription Filled You ll get covered prescription drugs when written by a licensed prescriber. You can pick from several local pharmacies (drugstores) and major drugstore chains to get the drugs. Look in the provider directory for a list of network drugstores. There is a $5 copay for prescription drugs. Your $5 copay covers up to a 31-day supply of a formulary medication. The formulary is a list of drugs we pay for. Certain drugs may require approval before they are covered as a benefit. When this happens, it is called a prior authorization (approval). An Amerigroup network pharmacist may need to get information from your doctor to make sure the medicine is the best one for you. Amerigroup will talk with your doctor about prior treatments to help make these decisions. The pharmacist will use a generic (instead of brand-name) drug if one is available. A brand-name drug is only covered if a generic drug is not available or when your physician says a brand name is medically necessary. Along with the over-the-counter (OTC) items covered on our formulary, your child also has an OTC drug benefit. Your household can get up to $10 worth of certain OTC items per month. You must get the item at an Amerigroup network drugstore that takes part in this benefit. Choose the item. Show the pharmacist your Amerigroup ID card. The pharmacist will let you know when your household has reached the $10 limit for the month. 15

22 Some types of OTC items you can get are: Vitamins and minerals Pain relievers First aid supplies Cough, cold and allergy medicine DIFFERENT TYPES OF HEALTH CARE Routine, Urgent and Emergency Care: What is the Difference? Routine Care In most cases when your child needs medical care, you call your child s doctor to make an appointment. Your child will go to see the doctor. This will be good for most minor illnesses, injuries and regular checkups. This care is called routine care. Your child s primary care provider is someone your child sees when he or she is not feeling well. But that is only part of the PCP s job. Your child s PCP also takes care of your child before he or she gets sick. This is called wellness care. See the Wellness Services in this handbook. Your child should be able to see his or her PCP within one week for routine care. Urgent Care The second type of care is urgent care. There are some injuries and illnesses that aren t emergencies. But they can turn into an emergency if not treated within 24 hours. Some examples are: High fever Animal bites Fractures Severe pain Infectious or respiratory illnesses Flu For urgent care, call your child s PCP. Your child s PCP will tell you what to do. Your child s PCP may tell you to come to the office right away. You may be told to go to another office for your child to get care right away. You need to follow what your child s PCP says. Sometimes, your child s PCP may tell you to go to the emergency room at a hospital. See the next section about emergency care to find out more. You can also call Amerigroup On Call, our 24-hour nurse helpline, at (TTY 711) for questions about urgent care. Your child should be able to see his or her PCP within one day for an urgent care appointment. Emergency Care The third type of care is emergency care. If your child has an emergency, you should call 911. Or take your child to the nearest hospital emergency room right away. If you want advice, call your child s PCP. You can also call Amerigroup On Call at (TTY 711). 16

23 The most important part is to get medical care as soon as you can. Your child should be able to see a physician right away for emergency care. When your child goes to the hospital, he or she will get a medical screening. After the screening, you will need to show your child s Amerigroup ID card. Ask the hospital to call Amerigroup. The steps for providers to follow are 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 child s body. The problem is so bad that a person with an average knowledge of health and medicine can tell the problem may cause death. Or it may cause harm to any organ or part of the body. Or in the case of a pregnant child, it may cause harm to the health of the child or her unborn baby. In the case of a pregnant child, an emergency medical condition is when: There is not enough time to safely move her to a new hospital before delivery. A transfer may threaten the health and safety of the patient or her unborn baby. There is proof of prolonged uterine contractions or rupture of the membranes Here are 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 above. Examples of an emergency behavioral health condition include: Likely danger to self and/or others So much functional harm that the person is not able to carry out actions of daily life Functional harm that will likely cause death or serious harm to the body What Is Post-stabilization? Post-stabilization services are covered services your child gets after emergency medical care. Your child gets these services to help keep his or her condition stable. Medical emergencies and post-stabilization care that are because of your child s emergency don t need prior approval by Amerigroup. Call your child s PCP as soon as you can after the emergency room visit. If you can t call, have someone else call for you. Your child s PCP will give or arrange any follow-up care your child needs. 17

24 How to Get Health Care When Your Child s PCP s Office Is Closed Except in the case of an emergency (see previous section) or when your child needs care that does t need a referral, always call your child s PCP first before your child gets medical care. If you call your child s PCP s office when it s closed, leave a message with your name and a phone number where you can be reached. If it s not an emergency, someone should call you back soon to tell you what to do. You can also call Amerigroup On Call 24 hours a day, seven days a week for help. If you think your child needs emergency services (see previous section), call 911. Or go to the nearest emergency room right away. How to Get Health Care When Your Child Is Out of Town If your child needs emergency services when out of town or outside of Florida,* go to the nearest hospital emergency room. Or call 911. You must get in touch with your child s PCP as soon as you can. You need to tell the PCP about your child s out-of-area emergency care. This will help your child s PCP to set up follow-up care. If your child is 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 your child gets outside the service area is not covered unless your child gets prior approval from Amerigroup. Follow the doctor s orders. You may be told to get care for your child where he or she is if he or she needs it very quickly. You can also call Amerigroup On Call 24 hours a day, seven days a week for help. If your child needs routine care like a checkup or a prescription refill when he or she is out of town, call the PCP. If your child s PCP directs you to get care while you are out of town, then Amerigroup will pay for the care. *If your child is outside of the United States and gets health care services, he or she will not be covered by Amerigroup. How to Get Care When Your Child Can t Leave Your Home Amerigroup will find a way to help take care of your child. Call Member Services right away if your child can t leave your home. We will put you in touch with a case manager who will help your child get the medical care he or she needs. WELLNESS CARE Your child needs to have routine wellness visits with his or her primary care provider (PCP). During a wellness visit, your child s PCP will check his or her overall health. Many health problems can be treated and handled, if found early. Your child s PCP can also answer your medical questions and help your child stay healthy. When your child becomes an Amerigroup member, call your child s PCP. You need to make his or her first appointment within 90 days. You must set up a well-child visit with the doctor once per year from age two through the month your child turns 19. Be sure to make these appointments. Take your child to his or her PCP when scheduled. 18

25 Vision Screening Your child s PCP should check your child s vision at every well-child visit. Please see the section Vision Services under 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 the PCP as a part of the routine well-child visits. Please see Dental Services under Amerigroup Covered Services to learn more. Immunizations It is important for your child to get immunizations (shots) on time. Take your child to the provider when the PCP says a shot is needed. Use the chart that follows to help keep track of the shots your child needs. 19

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28 When Your Child Misses a Wellness Visit If your child does not get a wellness care visit on time, make an appointment with his or her PCP as soon as you can. If you need help to set up the appointment, call Member Services. If your child has not visited the PCP on time, Amerigroup will send you a postcard to remind you. SPECIAL CARE FOR PREGNANT MEMBERS Taking Care of Baby and Me is the Amerigroup program for pregnant members. It s very important to see your child s primary care provider (PCP) or OB/GYN for care when your child is pregnant. This kind of care is called prenatal care. It can help your child have a healthy baby. Prenatal care is always important even if your child has already had a baby. With our program, members receive health information and baby gifts for getting prenatal care and postpartum care. Our program also helps pregnant members with complex health care needs. Nurse case managers work closely with these members to help teach them about these needs. They give emotional support. They help members follow their provider s care plan. Our nurses also work with providers. They help with other services members may need. The goal is to promote better health for members and the birth of healthy babies. When Your Child Becomes Pregnant If you think your child is pregnant, call her PCP or OB/GYN provider right away. You don t need a referral from her PCP to see an OB/GYN. Her OB/GYN should see her within 14 days. We can help you find an OB/GYN in the Amerigroup network. You must also call Amerigroup Member Services when you find out your child is pregnant. If she is a new Amerigroup member who is pregnant and has been seen by a non-amerigroup provider for at least one complete prenatal checkup before she joined Amerigroup, then she may be able to keep seeing that provider throughout her pregnancy. She may also keep seeing the provider through the delivery and up to two months after her baby is born. When your child is pregnant, Amerigroup will send her a pregnancy education package. It will include a: Letter welcoming her to the Taking Care of Baby and Me program Self-care book Taking Care of Baby and Me reward program brochure Amerigroup On Call (nurse helpline) Ameritips fact sheet The self-care book gives her information about her pregnancy. She can also use the book to write down things that happen during her pregnancy. The Taking Care of Baby and Me brochure tells your child how to get her gift for getting prenatal care. 22

29 When Should Your Child Go to Her PCP or OB/GYN? Stages of Her Pregnancy When to Go to Her Doctor Less than 13 weeks pregnant (or sooner if she Get her first prenatal visit as soon as possible thinks she is pregnant) weeks pregnant Every 4 weeks weeks pregnant Every 2 weeks weeks pregnant Every week After she delivers her baby Get her postpartum checkup between days after she has her baby, even if she sees her doctor before three weeks have passed Your child s PCP or OB/GYN may want her to visit more than this based on her health needs. While your child is pregnant, she needs to take good care of her health. She may be able to get healthy food from the Women, Infants, and Children program (WIC). Call Member Services to get the phone number for the WIC program close to you. When Your Child Has a New Baby When your child delivers her baby, she and her baby may stay in the hospital at least: Two days (not including the day of delivery) after a vaginal delivery Four days (not including the day of delivery) after a cesarean section (C-section) She may stay in the hospital less time if her PCP or OB/GYN and the baby s provider see that she and her baby are doing well. She and her baby should stay in the hospital until her provider says they can leave. They can leave the hospital before the provider releases them. But it is best not to do this. If she and her baby leave the hospital early, the provider may ask her to have an office or in-home nurse visit within 48 hours. After your child has her baby, you must call Amerigroup Member Services as soon as you can. You need to call us to let us know she had her baby. When your child has had her baby, Amerigroup will send her the Taking Care of Baby and Me postpartum education package. It will include a: Letter welcoming you to the postpartum part of Taking Care of Baby and Me program Babycare book Taking Care of Baby and Me reward program brochure about going to your postpartum visit Brochure about postpartum depression Amerigroup On Call (nurse helpline) Ameritips fact sheet She can use the baby-care book to write down things that happen during her baby s first year. This book will give her information about her baby s growth. 23