Member Handbook. Real. Solutions. Amerigroup Florida, Inc. Florida Long-Term Care Nursing Home Diversion Program

Transcription

1 Real Solutions B-TXMHB FL-MHB Member Handbook Amerigroup Florida, Inc. Florida Long-Term Care Nursing Home Diversion Program n

2 Dear Member: Thank you for choosing Amerigroup Community Care as your health care plan. We want to let you know of some updates to your member handbook. This insert tells you about these updates. Please keep this insert with your handbook so you have the most up-to-date information. The Covered Services and Limitations section has been updated to include the following information: Plan of Care The plan of care includes goals and services necessary to address your health and social service needs. Your case manager will work with you to choose those personal goals. Covered services must be authorized by Amerigroup. Your case manager will give you a copy of your plan of care. Summary of the Florida Long-Term Care Nursing Home Diversion Program Patient s Bill of Rights and Responsibilities section has been updated to include the following information: Your Rights As a patient, you have the right to Get home- and community-based services in a home-like setting and take part in your community no matter what your living arrangements If you have any questions about your benefits, please call the Case Management team at You can talk to a case manager Monday through Friday from 8:30 a.m. to 5:00 p.m. Eastern time. Thank you again for choosing us as your health plan. Sincerely, Rosy Cozad Chief Executive Officer Amerigroup Community Care FL-MHB FL-ENG-02/13

3 Dear Member: Welcome to Amerigroup Community Care. We are happy that you picked us to arrange for your quality health care benefits. The member handbook tells you how Amerigroup works and how to help keep you healthy. It tells you how to get health care when it is needed, too. You will get your Amerigroup ID card and more information from us in a few days. Your ID card will tell you when your Amerigroup membership starts. Please check your ID card right away. If any information is not right, please call us. We will send you a new ID card with the correct information. If you have any questions about your benefits, please call the Case Management team at You can talk to a case manager Monday through Friday from 8:30 a.m. to 5:00 p.m. Eastern time. Thank you again for picking us as your health plan. 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 and ask for extension Or visit

4 Amerigroup Community Care Member Handbook Florida Long-Term Care Nursing Home Diversion Program Case Management 4200 W. Cypress Street, Suite 900 Tampa, FL Welcome to Amerigroup Community Care! This member handbook explains how to obtain medical care, home support and community services as an Amerigroup member. Table of Contents WELCOME TO AMERIGROUP COMMUNITY CARE!... 1 Information About Your Health Plan... 1 Eligibility... 1 Enrollment... 2 Reinstatement... 2 Medicare Coverage... 2 Oral and Written Translations/Interpretive Services... 3 Getting an Interpreter for Those Who Are Deaf or Hard of Hearing... 3 AMERIGROUP PLAN BENEFITS... 3 Covered Services and Limitations... 3 Home and Community Services... 4 Medical Services... 7 GETTING STARTED Your Identification Card Case Management Staff Primary Care Provider Services HOW TO OBTAIN CARE Your Doctor Appointments Medical Services Second Opinions Hospital Care Mental Health Care... 12

5 Emergency Care Nonemergency Care Outside the Service Area Use of Participating Providers Provider Directory Status Change DISENROLLMENT Voluntary Disenrollment Loss of Medicaid Eligibility Termination of Benefits MEMBER SATISFACTION How to Report Someone Who Is Misusing the Medicaid Program Concerns, Suggestions and Complaints Grievance Process Appeals Expedited Appeals Medicaid Fair Hearing Continuation of Benefits OTHER INFORMATION Abuse and Neglect Confidentiality of Records Additional Information Statement of Advance Directive or Living Wills SUMMARY OF THE FLORIDA PATIENT S BILL OF RIGHTS AND RESPONSIBILITIES Your Rights Your Responsibilities NOTICE OF PRIVACY PRACTICES... 25

6 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 that coordinates comprehensive health care coverage and long-term care coverage to voluntarily enrolled members. We are committed to helping you get the right care close to home. Our goal is to help you live in your home and community by offering a wide range of medical coverage, home care coverage and community services. A case manager will discuss your specific needs with you and coordinate services. The concept is to closely coordinate your medical and home support needs with participation from you, your Primary Care Provider (PCP) and your case manager. Your PCP will supervise your care by treating you when you become ill, ordering necessary lab tests and X-rays, and arranging for necessary hospital admissions and emergency care. The case manager will coordinate your medical and long-term care services by assessing your medical and home care needs and arranging services. This handbook explains how to obtain medical care, home support and community services as an Amerigroup member and provides other information about your membership. If you have any questions, please contact: Case Management Amerigroup Community Care 621 NW 53rd St., Suite 175 Boca Raton, FL Eligibility You are eligible to become a member of Amerigroup if you: Are 65 years of age or older Are already enrolled in Medicare Live in the Amerigroup service area Meet the clinical eligibility requirements; for example, you need help with daily living activities like bathing, dressing, eating or walking, or you have a chronic condition requiring nursing services Meet Medicaid financial eligibility requirements or are Medicaid pending (waiting to find out if you are financially eligible for Medicaid)* FL-MHB FL-ENG-01.13

7 Are determined by the Comprehensive Assessment and Review for Long-Term Care Services program (CARES) to be a person who, on the effective date of enrollment, can be safely served with home- and community-based services *You can choose to join Amerigroup while you wait to find out if you are financially eligible for Medicaid. If you are not found to be financially eligible for Medicaid, you will be disenrolled from Amerigroup and have to pay for the services you received as an Amerigroup Medicaid-pending member. Enrollment When you are determined to be eligible and choose to enroll in the Long-Term Care Nursing Home Diversion Program, CARES will enroll you into the program. CARES will then forward your request for enrollment to Amerigroup. Upon enrollment, an Amerigroup case manager will meet with you in person within five business days if you live in a community setting or seven business days if you live in a facility to explain the program and services. Reinstatement If you are no longer a member of the Long-Term Care Nursing Home Diversion Program and wish to participate, Amerigroup can assist with reinstatement for those eligible for the program. For help, contact your case manager. If you lose your membership and become reinstated within two months, you will be automatically re-enrolled with Amerigroup. Your benefits will remain the same. Medicare Coverage Amerigroup is not a Medicare program;however, to be a member of this program, you must also have Medicare coverage and receive Medicare services either through the Medicare fee-for-service program or through membership in a Medicare Health Maintenance Organization (HMO). In either case, you will receive Medicare services from one of these programs, as your Medicare coverage continues separately from membership in Amerigroup. For example, if you are in the Medicare fee-for-service program, you will receive Medicare-covered services from providers, hospitals and other providers who participate in the Medicare program. Amerigroup will reimburse these providers for the Medicare deductible and coinsurance according to Medicaid guidelines or according to a contracted amount. 2

8 If you are a member of a Medicare HMO, you will receive Medicare services according to the guidelines of that program. Medicare beneficiaries receive prescription drug coverage under the Medicare Prescription Drug Benefit (Part D). Please call your case manager at if you have any questions about reimbursement of your Medicare services. Oral and Written Translations/Interpretive Services We are able to help in many different languages and dialects. Please call the Case Management team if you need interpreter services. All member materials are available in English and Spanish. Materials are also available in Braille and audio format upon request. There is no charge for translated materials. Call the Case Management team to request translations of member materials. Getting an Interpreter for Those Who Are Deaf or Hard of Hearing If you have any questions about your Amerigroup benefits, please call the toll-free AT&T Relay Service number at We can also set up and pay for you to have a person who knows sign language to help you during your doctor visits. Please let us know if you need an interpreter at least 24 hours before your appointment. Or you can tell your provider you need an interpreter before you go to your appointment. The provider can arrange to have one for you when you get there at no cost to you. AMERIGROUP PLAN BENEFITS Covered Services and Limitations In order to receive coverage by Amerigroup, you must follow the proper procedure to ensure authorization for payment of services. Covered services are composed of two types of services: Home and community services Medical services Home and community services are provided in accordance with an individualized plan of care. The Amerigroup Case Management team develops the plan of care based on an assessment, other available information, and in consultation with you, your family or caregiver. The plan of care is guided by delivering services in the least restrictive, appropriate and cost-effective setting. The plan of care includes goals and services necessary to address your health and social service needs. Covered services must be authorized by Amerigroup. Your case manager will give you a copy of your plan of care. 3

9 To be a member of this program, along with other qualifications, you must be covered by the Medicare program. You will continue to receive Medicare-covered services from the Medicare program. The plan will pay for Medicare deductibles and coinsurance according to Medicaid guidelines or a contracted amount. Many of the services are covered through the Medicare program, which is separate from Amerigroup. Medicare coverage is used prior to services being covered by Amerigroup. A member is entitled to receive covered medical services, which are determined to be medically necessary and authorized by Amerigroup. Services are limited to covered services as specified in the contract with the Department of Elder Affairs (DOEA). The following is a summary of Amerigroup benefits and limitations on covered services. Amerigroup reimburses for services that are determined medically necessary in accordance with the member s plan of care, do not duplicate another provider s service and are: Individualized, specific, consistent with impairments, symptoms or confirmed diagnosis of the illness or injury under treatment and not in excess of the member s needs Not experimental or investigational Reflective of the level of services that can be safely furnished and for which no equally effective and more conservative or less costly treatment is available Furnished in a manner not primarily intended for the convenience of the member, member s caregiver or the provider The fact that a provider has prescribed, recommended or approved medical or allied care, goods or services does not in itself make such care, goods or services medically necessary or a covered service. Home and Community Services Coverage of the following services is provided by Amerigroup when essential to the health and welfare of the member instead of the member s family or caregiver. Personal Care Aids Assistance in the home with bathing, dressing, eating, personal hygiene and other activities Assistance with chores such as light cleaning, bed making and meal preparation (does not include the cost of the meal) 4

10 Homemaker General household activities such as meal preparation and routine household care provided by a trained homemaker Chores Assistance with heavy household chores such as washing floors and windows, and moving heavy items of furniture to provide safe entry and exit Transportation Services to Medical Appointments Individual escorts for a member who needs special assistance getting to and from service providers Language interpretation for people who have hearing or speech impairments or who speak a language different from that of the provider Escort services do not include transportation Respite Care Services Respite personal care or supervision provided to a member on a short-term basis due to the absence or need for relief of persons normally providing the care Respite care does not substitute for the care usually provided by a registered nurse, a licensed practical nurse or a therapist Services must be provided in the home/place of residence, licensed hospital, nursing facility or assisted living facility Adult Day Health Center Social and health activities in an organized day program at a center Meals are included when member is at the center during meal time Case Management Help the member to obtain medical, social and educational services Develop personal care plan Coordinate, integrate and continually monitor services Visit the member s home to discuss needs Help arranging rides Help keeping financial eligibility Consumable Medical Supplies Disposable diapers, gloves and other consumable medical supplies Amerigroup also covers an extra over-the-counter benefit; you can get $30 per month for certain over-the-counter items such as certain vitamins and minerals, pain relievers, first aid, cough/cold medicine, allergy medicine, laxatives, and antacids Please contact your case manager for assistance in using this benefit. 5

11 Home-delivered Meals Home-delivered meals for members who have difficulty shopping for or preparing food without assistance Nutritional supplements for members who have a medical need Personal Emergency Response Systems (PERS) Electronic device that enables a member at high risk of institutionalization to secure help in an emergency Limited to members who live alone or who are alone for significant parts of the day and who would otherwise require extensive supervision Nutritional Assessment/Risk Reduction Services Assessment and guidance to caregivers and members with respect to nutrition Adult Companion Services Nonmedical care, supervision and socialization Help or supervision of tasks such as meal preparation, laundry and shopping Home Adaptation Services Physical adaptations to the member s home required by his or her plan of care, which are necessary to help ensure health, welfare and safety, or which enable the member to function with greater independence in the home and without which the member would require institutionalization Family Training Services Training and counseling services for the member s family Instruction about treatment regimens and use of equipment included in the plan of care Financial Assessment/Risk Reduction Assessment and guidance to the caregiver and member regarding financial activities Assisted Living Services Services such as personal care, assistance in the home, medication oversight and social programs to assist the member in an assisted living facility The member is responsible for paying the assisted living facility room and board amount; based on the member s income, the member may also be required to pay an additional amount for assisted living services, as determined by the Florida Department of Children and Families The member or member s family may need to pay the assisted living facility an additional amount if the facility s cost exceeds the member s designated amount and the plan s payment amount 6

12 Nursing Home Nursing home services are available for members who require them under medically necessary standards The plan covers this service to the extent it is not covered by Medicare The Florida Department of Children and Families assesses a patient responsibility amount for financial contribution by the member When a member is placed in a nursing facility, home- and community-based longterm care waiver services are no longer available, except for case management Respiratory Therapy Treatment of breathing or lung functions Evaluation and treatment related to lung dysfunction Medical Services Claims for covered medical services are covered by Amerigroup to the extent that they are not covered by Medicare or other insurance and not reimbursed by Medicaid pursuant to Medicaid s Medicare cost-sharing policies. These include: Physicians Visits Immunizations Chronic disease follow-up Inpatient Hospital Inpatient services, including ancillary services Limitation: Inpatient coverage is for a maximum of 45 days per year for the period beginning July 1 and ending June 30 Outpatient Hospital/Emergency Medical Services Outpatient preventive, diagnostic, therapeutic or palliative care at a licensed hospital Emergency room services Poststabilization care services inside or outside of the Amerigroup service area if one of the following is true: The services were preapproved by Amerigroup The services are the result of an emergency and are considered medically necessary after an emergency medical condition has been stabilized. These are not emergency services, but are nonemergency services that Amerigroup would not cover except in these circumstances 7

13 Diagnostic Procedures Laboratory and X-rays Hospice Services End-of-life services offered to members who choose hospice Home Health Nurse Home health nurse visits by a registered nurse or licensed practical nurse Monitor health status, wound care and other services as ordered by a doctor Occupational, Physical and Speech Therapy Services Occupational therapy: Treatment to restore, improve or maintain impaired functions aimed at increasing or maintaining the member s ability to perform tasks required for independent functioning in the home setting when determined through a multidisciplinary assessment Physical therapy: Treatment to restore, improve or maintain impaired functions when determined through a multidisciplinary assessment to improve a member s ability to live safely in the home setting Speech therapy: Evaluation and treatment of problems related to an oral motor dysfunction when determined through a multidisciplinary assessment to improve a member s capability to live safely in the home setting Medical Equipment and Supplies Wheelchairs, beds, walkers and other equipment Bandages, colostomy and catheter supplies Mental Health Psychiatric services Community mental health services Prescription Drugs Medically necessary and appropriate drugs prescribed by a provider and dispensed by a licensed participating pharmacy for the prevention, mitigation, control and cure of disease; not covered by Medicare Part D and covered by Medicaid Prescriptions will be dispensed with a generic drug when one is available Prescriptions must be filled at participating pharmacies Your prescribed drug services are covered under the Medicare Modernization Act, also known as the Medicare Prescription Drug Benefit (Part D), because you also have Medicare benefits; Amerigroup will not cover drugs that are covered by your Medicare Prescription Drug Benefit Certain drugs may not be included in your Medicare Part D benefit. Amerigroup may cover some of the drugs not included in Part D under this program 8

14 Dental Services Medically necessary emergency dental care (emergency oral exam, X-rays, extractions, incisions and drainage of abscess) One set of full or partial dentures per lifetime Amerigroup also covers extra dental care benefits; before you go to the dentist, please call the dental phone number on your Amerigroup ID card to be sure you are eligible for these extra benefits: Nonemergency diagnostic exams Full series of X-rays (one set every two years) Teeth cleaning (one every six months) Instruction about proper oral hygiene Nonemergency simple extractions (four per year) Nonemergency surgical extractions (two per year) Discount of 25 percent off usual fees for other services To find a dentist that participates with Amerigroup, please call the dental phone number on your Amerigroup ID card. When you call, you can also find a dentist that is close to you. Hearing Services Hearing evaluation and diagnostic testing One standard hearing aid per ear every three years (includes fitting and dispensing) Hearing aid repair services Cochlear implant (limit of one) Cochlear implant repairs Vision Services Medically needed eye exams Eyeglass repairs and adjustments One pair of eyeglasses per year if medically needed Up to two additional pairs of eyeglasses per year if medically needed Contact lenses if medically needed To find an optometrist that participates with Amerigroup, please call the vision phone number on your Amerigroup ID card. When you call, you can also find an optometrist that is close to you. 9

15 GETTING STARTED Your Identification Card Each member will receive a plastic gold card as identification (ID) from the Medicaid office. This card can be used to obtain transportation services covered under the state Medicaid Program; this card is not used for services covered by Amerigroup. For further information about the gold card, please contact your area s Medicaid office. As an Amerigroup member, you will also receive an ID card. Carry this ID card, along with your gold card and Medicare ID at all times. Case Management Staff Our Case Management department is dedicated to helping you. Your case manager will discuss the services you need with you, your caregiver and your Primary Care Provider (PCP). A plan of care will be developed by your case manager based on your health needs, home situation and support available from your family and friends. As your needs change, your case manager will review information with you and make adjustments in your plan of care. Case management staff can arrange many services for you, such as: Personal care aides and homemakers Coordination with hospitals and home health agencies Medical supplies and equipment Assisted living facilities and nursing home placement Transportation You can call your case manager at This number is also listed on your Amerigroup ID card. Please contact your case manager if you are admitted to a hospital, move, enroll in a hospice or change PCPs, or your needs change, so that your case manager can coordinate your care effectively. Your case manager can also help you make sure that you continue to be eligible for the Long-Term Care Nursing Home Diversion Program. 10

16 Primary Care Provider Services Your Primary Care Provider (PCP) will take care of most of your medical needs and will coordinate other necessary medical services. He or she will treat you if you become ill, will order X-rays or lab tests, will make referrals for consultations and will arrange for hospitalization. From time to time, your PCP and case manager may discuss your need for various services to ensure that you receive assistance. In the event of an urgent situation or sudden illness or if you need care after regular office hours, please call your PCP. If there is an emergency, dial 911. Your PCP, specialists, other medical care providers and case manager work together to provide you with services. HOW TO OBTAIN CARE Your Doctor Appointments To make a medical appointment or to change an appointment, please call your doctor directly. Call your case manager if you need help scheduling appointments or arranging transportation. Medical Services When you need the care of a doctor or medical specialist or need other services covered by the Medicare program, you do not have to contact your case manager; however, you are encouraged to do so. Your case manager can determine if the service will be provided through your Medicare or Amerigroup coverage. If you are a member of a Medicare participating Health Maintenance Organization, you must follow the guidelines of that program. Before receiving a service not covered by Medicare, please make sure your case manager authorized the service. If Amerigroup covered services are not authorized by Amerigroup, you will be responsible for payment. Only preauthorized services are covered and will be paid according to the benefits of your plan. Examples of services for which you must contact your case manager to verify coverage are home health aide, personal emergency response system, chore, home adaptation, assisted living facility, adult day care and nursing home services. 11

17 Second Opinions All members may get a second medical opinion. Similar to other medical expenses covered by the Medicare program, you do not have to contact your case manager, although you are encouraged to do so. Your case manager can determine if the service will be provided through your Medicare or Amerigroup coverage. If you are a member of a Medicare participating Health Maintenance Organization, you must follow the guidelines of that program. Hospital Care If hospital care is required within the service area, your doctor will arrange for hospital admission. Please call your case manager if you receive hospital or rehabilitation services. Mental Health Care Medicare covers inpatient and outpatient mental health care. Contact your case manager if you want assistance to arrange mental health services. Emergency Care In the event of a medical emergency, you should go to the nearest hospital emergency room right away, dial 911 or its local equivalent. Present your Medicare ID and Amerigroup ID if possible. You do not need your ID cards or prior authorization in order to get emergency care. Notify your doctor and case manager as soon as possible so that follow-up care and other services may be coordinated or authorized. Nonemergency Care Outside the Service Area In case of nonemergency medical services that happen while you are outside of the service area, you must contact your case manager prior to receiving these services. Please remember that any nonemergency care outside the service area will not be covered by Amerigroup, unless prior authorization is given by your case manager. Members will be responsible for payment of all unauthorized services. Home- and community-based services are not covered outside the service area. Use of Participating Providers Amerigroup is not liable for payment of services obtained from providers that are not authorized by Amerigroup except for emergency and urgently needed services. 12

18 Provider Directory A list of contracted providers is found in the Amerigroup provider directory. Your case manager is available to help you choose providers and to arrange services. If you are receiving services through your Medicare fee-for-service coverage, you do not need to use the Amerigroup provider directory for Medicare-covered services. If you are a member of a participating Medicare health maintenance organization, please follow the guidelines provided by that plan for Medicare-covered services. The provider directory is helpful for services that are not covered by Medicare, but are covered by Amerigroup. For example, if you are prescribed a drug not covered by Medicare but covered by Medicaid, the pharmacy section of the directory lists the pharmacies you may use. It is important to note that for most services, you need to call your case manager and not the provider to get authorization for services. For example, if you need home health or adult day care services, you would call your case manager to review your needs and to authorize services. Usually you do not need authorization from your case manager for Medicaid-covered pharmacy items or over-the-counter voucher items, but you do need to use participating providers. Status Change Contact your case manager if you: Change your address or telephone number Obtain other health care coverage, which includes government programs Are admitted to a hospital or nursing home Enroll in a hospice DISENROLLMENT Voluntary Disenrollment You may submit a request to disenroll from Amerigroup at any time, for any reason. Disenrollment is not immediate. We must submit your request to disenroll to the state. The state s monthly deadline for submissions is the 15th of the month. If your request is submitted on or before the 15th of the month, disenrollment will be effective on the first day of the following month. If your request is submitted after the 15th of the month, disenrollment will be effective on the first day of the month after the following month. 13

19 For example, if your request is submitted on or before June 15th, disenrollment will be effective July 1. If your request is submitted after June 15th, disenrollment will be effective August 1. Call our Case Management team at to obtain a disenrollment form and for assistance in resolving any problems. A disenrollment form will be sent to you upon request for disenrollment Submit the disenrollment request in writing to the attention of our Case Management team: Case Management Amerigroup Community Care 621 NW 53rd St., Suite 175 Boca Raton, FL Loss of Medicaid Eligibility Anyone may lose their Medicaid eligibility for a variety of reasons, such as moving or missing a scheduled recertification. If you lose Medicaid eligibility, Amerigroup cannot cover your health services until eligibility is regained. Financial eligibility is determined by the state. Clinical eligibility is determined by Comprehensive Assessment and Review for Long-Term Care Services (CARES). Your case manager can help you make sure that you continue to be eligible for the Long-Term Care Nursing Home Diversion Program. Termination of Benefits Grounds for termination by Amerigroup include: Permitting unauthorized member ID card use Disruptive or abusive behavior and approved by the Department of Elder Affairs (DOEA) Noncooperation such as failing to follow recommended plan of care, and approved by the DOEA Being admitted into another Medicaid waiver project, MediPass, prison or correctional facility Moving out of the authorized service area 14

20 MEMBER SATISFACTION How to Report Someone Who Is Misusing the Medicaid Program You can report someone who is misusing the Medicaid program through fraud, abuse or overpayment. To report doctors, clinics, hospitals, nursing homes or Medicaid enrollees, write or call Amerigroup Community Care at: Corporate Investigations Department Amerigroup Community Care 4425 Corporation Lane Virginia Beach, VA You can suspicions of fraud and abuse to the Amerigroup Corporate Investigations department. The address is You can also report fraud and abuse online. You can do this through the Amerigroup website. The website address is There are fraud and abuse links on the website; click these links to report a possible issue. Information you give is sent directly to the Amerigroup Corporate Investigations department at the address above. It is checked every business day. Concerns, Suggestions and Complaints There are times when you may have questions about your coverage or may wish to suggest ways to improve services. We will work to take care of your questions and complaints in a timely manner. Most questions can be solved by calling the Case Management team at or Member Services toll free at To file a complaint about a health care facility, report Medicaid fraud, get information about the Agency for Health Care Administration or request a publication, call the statewide Consumer Call Center toll free at Grievance Process You have the right to file a grievance. The request must be made within one year of the event that started your grievance. If you wish to file a formal grievance, you can call us or send us a letter. Your letter should include your name, address, member number, signature and the date. Let us know about your problem and the action you wish to be taken. 15

21 Contact Amerigroup at: Grievance Coordinator Amerigroup Community Care 4200 W. Cypress St., Suite 1000 Tampa, FL If you need help, the Case Management team will help you prepare and submit this concern. The grievance coordinator will look into your problem and send you a written decision within 90 days of when we get your request. You can reach the grievance coordinator by calling the Case Management team toll free at , Monday through Friday from 8:30 a.m. and 5:00 p.m. Eastern time. If you are not pleased with the outcome of your grievance, you have the right to ask for a review of this decision by the Agency for Health Care Administration. You must ask for this review within 90 days after you get the decision from Amerigroup. The address to request the fair hearing is: Department of Children and Families Office of Public Assistance Appeals Hearings 1317 Winewood Blvd., Building 5, Room 203 Tallahassee, FL To request the hearing verbally, call the Department of Children and Families at You may also call the Agency for Health Care Administration at or toll free at See the Medicaid Fair Hearing section to learn more. Note: If you ask for a fair hearing, the Agency for Health Care Administration will not review your request. 16

22 Appeals There may be times when your provider asks for a service that is not covered by Amerigroup. 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 or the letter that tells you that coverage of the service has been denied, stopped, reduced or delayed. To appeal, you or your provider can call the Case Management team or mail your request and medical information for the service to: Medical Appeals Amerigroup Community Care P.O. Box Virginia Beach, VA Amerigroup can accept your appeal by phone, but you must follow up in writing within 10 days of calling us. You can also request to meet or present information in person. Call Member Services to find out how to arrange a meeting. We will resolve your appeal within 45 days from the date we received your appeal. If you are still not pleased with the decision Amerigroup makes, you can ask for a second review by committee within 10 days from the date on the letter that says we still will not pay for the service. 17

23 You can write us at the above address or call Member Services to ask for this review. When we get your letter, we will send you a letter within five days to tell you we got the appeal. The committee will meet to review your appeal and normally will have an answer for you in 15 days unless more information is needed. If they need more time, we will let you know that 14 more days will be needed to decide your appeal. You or your representative (with a signed power of attorney or authorization of representation) may attend this meeting and present any extra information that may help us with your case. If you are not pleased with the decision Amerigroup makes on your appeal, you have the right to ask for a review of this decision by the Agency for Health Care Administration. You must ask for this review within 90 days after you get our decision. If services were discontinued and you want services continued, you must request a fair hearing within 10 days from the date of the letter. The address to file your appeal is: Department of Children and Families Office of Public Assistance Appeals Hearings 1317 Winewood Blvd. Building 5, Room 203 Tallahassee, FL To request the hearing verbally, call the Department of Children and Families at Expedited Appeals When coverage of a service that is urgent (for example, admission to a hospital or skilled nursing facility, or referral to a specialist) has been denied, reduced or ended, you may ask for an expedited appeal. You may also ask for an expedited appeal if you feel the time frame of the formal appeal process would greatly risk your ability to regain the greatest level of function. If we approve your request for an expedited appeal, we must respond to your appeal in writing within three business days. We may also need to extend our resolution time frame by up to 14 days if we feel that there is a need for more information and it is in your best interest that we have this information. We will let you know in writing the reason for the delay. If we do not approve your request for an expedited appeal, we will also let you know in writing within two days. We will then resolve your appeal within 45 days, the standard appeal time frame. 18

24 Medicaid Fair Hearing You (or your provider on your behalf and with your written consent) also have the right to ask for a Medicaid fair hearing during the grievance or appeal process. You can request a fair hearing by sending a letter to: Department of Children and Families Office of Public Assistance Appeals Hearings 1317 Winewood Blvd., Building 5, Room 203 Tallahassee, FL To request the hearing verbally, call the Department of Children and Families at You must ask for a fair hearing within 90 days from the date you receive the Explanation Of Benefits (EOB) or the letter that tells you that coverage of the service has been denied, stopped, reduced or delayed. If you did not receive any letter or an EOB from Amerigroup or a letter explaining why we will not pay for care, you have 365 days to contact the Office of Fair Hearing. If you have any questions about your request for a fair hearing, call the Case Management team. Note: If you ask for a fair hearing, the Subscriber Assistance Program will not review your request. Continuation of Benefits You may ask Amerigroup to continue to cover your benefits during an appeal or fair hearing. Upon your request, Amerigroup must continue to cover your benefits during the appeal process if: The appeal is filed within 10 days of the date on the Explanation Of Benefits (EOB) or the intended date the EOB takes effect The appeal involves the termination, suspension or reduction of a previously approved course of treatment The services were ordered by an Amerigroup network provider The approval period is still in effect 19

25 We must continue coverage of your benefits until: Ten business days from the date of our first decision if you have not requested a fair hearing A fair hearing decision is reached and is not in your favor Authorization expires or your service limits are met You withdraw the appeal You may have to pay for the cost of any continued benefit. OTHER INFORMATION Abuse and Neglect Elder abuse and neglect may be reported to the statewide Elder Abuse Hotline at ABUSE ( ). Confidentiality of Records Member records will be regarded as confidential information. Providers involved in the member s care will have access to the member information for the purpose of providing care. If requested, Amerigroup must disclose member records to the Department of Elder Affairs and the Agency for Health Care Administration. Additional Information Your case manager is available to answer questions and to assist you. You may also obtain additional information about the Amerigroup authorization and referral process for services, the process used to determine whether services are medically necessary, quality assurance program, member satisfaction, credentialing process, prescription drug benefits program, and confidentiality and disclosure of medical records. Statement of Advance Directive or Living Wills The following is provided to inform you about Florida law regarding advance directives or living wills. Under Florida law (see note below), every adult has the right to make certain decisions concerning his or her medical treatment. The law allows for your rights and personal wishes to be respected even if you are too sick to make decisions yourself. You have the right, under certain conditions, to decide whether to accept or reject medical treatment, including whether to continue medical treatment and other procedures that would prolong life artificially. 20

26 These rights may be spelled out by you in a living will containing your personal directions about life-prolonging treatment in the case of special, serious medical conditions. You may also designate another person, or surrogate, who may make decisions for you if you become mentally or physically unable to do so. This surrogate may function on your behalf for a brief time, lasting no longer than for the duration of the lifethreatening or nonlife-threatening illness. Any limits to the power of the surrogate in making decisions for you should be clearly expressed. If you have complaints about noncompliance with your advance directive, please call the Florida Department of Elder Affairs at (TTY ). For more information about advance directive rules in Florida, these websites may help: Please be aware that Internet sites, and the information and materials at these sites, are not provided by or controlled by Amerigroup. Amerigroup is providing these links only as a convenience to you, and your access to these external sites is done at your own risk. A Living Will A living will is a statement that lets you tell your Primary Care Provider (PCP) and family your wishes if there is no hope for your recovery and you become unable to make your own decisions. An example of this would be whether to continue the use of a breathing machine to keep you alive if you were in a permanent coma following an automobile accident. A Durable Power of Attorney for Health Care A durable power of attorney for health care is a statement in which you appoint a person to make medical judgments for you if you become unable to make those decisions for yourself. That person should be someone you trust to make health decisions 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? They are different and are used for different things, so they both are good. These documents are designed to help your family and your PCP make decisions concerning your health care at a time when you are unable to. 21

27 You may use one or both of these forms of advance directives to provide direction for your medical care. You may combine them into a single statement that appoints a person to make medical decisions for you and tells that person of your wishes if there is no hope for your recovery. You can change your mind or cancel your statements at any time. Changes should be written, signed and dated. You can also make your changes by telling someone (an oral statement). The only time an advance directive can be used is when you are mentally disabled or cannot make health care decisions. Once you are able to resume decision making, the advance directive is not in effect, although it will remain on standby should you ever again become disabled and cannot make decisions 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 ; and Court Appointed Guardianship, Chapter 744; and in the Florida Supreme Court decision on the constitutional right of privacy, Guardianship of Estelle Browning, Amerigroup cannot provide legal advice. If you have questions regarding this, please consult a legal advisor. 22

28 SUMMARY OF THE FLORIDA PATIENT S BILL OF RIGHTS AND RESPONSIBILITIES 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. You may request a copy of the full text of this law from your health care provider or health care facility. Your Rights As a patient, you have the right to: Be treated with courtesy and respect, with appreciation of your individual dignity, and protection of your need for 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 patient support services are available, including whether an interpreter is available if you do not speak English Know what rules and regulations apply to your conduct Be given, by your health care provider, information concerning diagnosis, planned course of treatment, alternatives, risks and prognosis Refuse any treatment, except as otherwise provided by law Be given, upon request, full information and necessary counseling on the availability of known financial resources for your care Know upon request and in advance of treatment whether the health care provider or health care facility accepts the Medicare assignment rate Receive, upon request and prior to treatment, a reasonable estimate of charges for medical care Receive a copy of a reasonable, clear and understandable itemized bill and, upon request, to have the charges explained Access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap or source of payment Know if medical treatment is for purposes of experimental research and to give your consent or refusal to participate in such experimental research Confidential handling of medical records and, except when required by law, you are given the opportunity to approve or refuse their release Express grievances regarding any violation of your rights as stated in Florida law through the grievance procedure of the health care provider or health care facility that served you and to the appropriate state-licensing agency Request and receive a copy of your care plan and to have it corrected 23

29 Receive, upon request, a detailed description of the following: The Amerigroup authorization and referral process for covered services The Amerigroup process used to determine whether services are medically necessary The Amerigroup quality assurance program The Amerigroup credentialing process Amerigroup policies and procedures for the prescription drug benefits program Amerigroup policies and procedures for your medical records Amerigroup aggregate enrollee satisfaction data Deciding to use your rights will not change the way Amerigroup, our providers or the state cares for you. Your Responsibilities As a patient, you have the responsibility to: Provide your health care provider, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters related to your health Report unexpected changes in your condition to your health care provider Report to your health care provider whether you understand a recommended or considered course of action and what is expected of you Follow the treatment plan recommended by your health care provider Keep appointments and, when you are unable to do so for any reason, notify the health care provider or the health care facility Answer for your actions if you refuse treatment or do not follow the health care provider s instructions Assure that the financial obligations of your health care are fulfilled as promptly as possible Follow health care facility rules and regulations affecting patient care and conduct We hope this book has answered most of your questions about Amerigroup. For more information, you can call Amerigroup at

30 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, 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 Amerigroup responsibilities in protecting your PHI This Notice follows the HIPAA Privacy Regulations. These regulations were given out by the federal government. The federal government requires companies such as Amerigroup to follow the terms of the regulations and of this Notice. This Notice is also available on the Amerigroup website at 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. 25