Real. Member Handbook. Solutions. Amerigroup Florida, Inc. Florida Healthy Kids Program FL-MHB

Transcription

1 Real Solutions B-TXMHB FL-MHB Member Handbook Amerigroup Florida, Inc. Florida Healthy Kids Program n

2 Dear Parent/Guardian: Welcome to Amerigroup Community Care. We re happy your child is now an Amerigroup member, and we re ready to help arrange for his or her health care benefits. Your child s member handbook will explain how Amerigroup works and how to: Help keep your child healthy Get health care when it is needed You should have your child s Amerigroup ID card by now. If not, you ll be getting it soon. The ID card lists: When your child s Amerigroup membership starts Your child s doctor Check the ID card right away. If your child s doctor or any other information is not right, please call us at (TTY ). We will send you a new ID card with the correct information. AMERIGROUP BENEFITS Here are some important Amerigroup benefits: No copays for Primary Care Provider (PCP) office visits Amerigroup On Call: Access to a 24-hour Nurse HelpLine and physician consultations to answer your medical questions day or night Allergy bedding: Up to $100 toward the purchase of hypoallergenic bedding for members with a diagnosis of asthma or severe allergies Do you have questions about your child s benefits? Please call Member Services at (TTY ). You can also visit our website at Do you have medical questions and want to talk to a nurse? Call Amerigroup On Call at Amerigroup On Call is here for you and your child 24 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. Thanks again for choosing Amerigroup. Sincerely, Rosy Cozad Chief Executive Officer Amerigroup Community Care

3 AMERITIPS: HEALTH TIPS THAT MAKE HEALTH HAPPEN YOU NEED TO GO TO YOUR DOCTOR NOW! WHEN IS IT TIME FOR A WELLNESS VISIT? Your child needs to have regular wellness visits. This way, your child s Primary Care Provider (PCP) can see if there is a problem before it gets worse. When your child becomes an Amerigroup member, call his or her PCP. Make the first PCP appointment before the end of 90 days. 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 Alert! Keep the right care. Do not lose your child s health care benefits. Renew your child s eligibility for Healthy Kids program benefits on time. See Page 7 for more details. 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 Florida Healthy Kids Member Handbook 4200 W. Cypress St, Suite 900 Tampa, FL TTY Welcome to Amerigroup Community Care! Your child will get most health care services through Amerigroup. This member handbook will tell you how to use Amerigroup to get the health care your child needs. Table of Contents WELCOME TO THE AMERIGROUP COMMUNITY CARE HEALTHY KIDS PROGRAM... 6 INFORMATION ABOUT YOUR CHILD S NEW HEALTH PLAN... 6 New Member Tips... 6 Your Child s Amerigroup Member Handbook... 6 Your Child s Identification Card... 7 Amerigroup Mobile Smartphone Application... 7 Eligibility... 7 HOW TO GET HELP... 8 Amerigroup Member Services Department... 8 Online and Automated Self-service Features... 8 Mobile Identification Card Application... 9 Amerigroup On Call... 9 Amerigroup 24-Hour Nurse HelpLine... 9 Other Important Phone Numbers... 9 YOUR CHILD S DOCTORS Choosing a Primary Care Provider Second Opinion If Your Child Had a Different Doctor Before Joining Amerigroup If Your Child s Primary Care Provider s Office Moves, Closes or Leaves the Amerigroup Network How to Change Your Child s Primary Care Provider If Your Child s Primary Care Provider Asks for Your Child to Be Changed to a New Primary Care Provider If You Want Your Child to Go to a Doctor Who Is Not the Primary Care Provider Choosing an OB/GYN Specialists GOING TO THE DOCTOR Your Child s First Doctor Appointment How to Make an Appointment Wait Times for Appointments What to Bring When Your Child Goes to a Doctor Visit How to Cancel a Doctor Visit How to Get Your Child to a Doctor s Visit or to the Hospital... 14

5 Disability Access to Amerigroup Network Doctors and Hospitals What Does Medically Necessary Mean? Your Child s Amerigroup Benefits WHAT IS COVERED BY AMERIGROUP? Payment for Services Monthly Premiums Renewal Amerigroup and Healthy Kids Benefits Extra Amerigroup Benefits Prior Approval of Certain Medical Procedures Services That Do Not Need Prior Approval 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 Poststabilization? How to Get Health Care When Your Child s PCP s Office Is Closed How to Get Health Care When Your Child Is Out of Town How to Get Care When Your Child Cannot Leave Your Home WELLNESS CARE Vision Screening Hearing Screening Dental Screening Immunizations (Shots) When Your Child Misses a Wellness Visit 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 SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING Health Information Amerigroup On Call Nurse HelpLine Health Education Classes Bullying Resources Smoking Cessation Community Events Minors... 32

6 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 How to Tell Amerigroup About Changes You Think We Should Make How Amerigroup Pays Providers 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 NOTICE OF PRIVACY PRACTICES... 43

7 WELCOME TO THE AMERIGROUP COMMUNITY CARE HEALTHY KIDS PROGRAM INFORMATION ABOUT YOUR CHILD S NEW HEALTH PLAN Welcome to Amerigroup Florida, Inc., doing business as Amerigroup Community Care. We are committed to helping you get the right 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 that was created in 1990 by the state of Florida. It provides affordable health care coverage for children from ages You and your child s Primary Care Provider (PCP) will work together to help keep your child healthy and care for his or her health problems. Amerigroup helps your child get quality health care. This member handbook will help you understand your child s health plan. New Member Tips As a new member: 1. Review your Amerigroup ID card. Make sure the name, birth date, sex and doctor s information is correct 2. Read all member information 3. Call your doctor. Make an appointment for a physical exam for your child within the first 90 days of joining Amerigroup 4. Keep your member handbook in a safe place Your Child s Amerigroup Member Handbook 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. 6

8 Your Child s Identification Card Your child s Amerigroup 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/Nurse HelpLine - The number to find a network vision care provider - The number to report Medicaid Fraud and Abuse What you need to do if you have an emergency If your child s Amerigroup ID card is lost or stolen, call us right away at (TTY ). We will send you a new one. Amerigroup Mobile Smartphone Application You can now access your child s Amerigroup member 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 Eligibility Your child is eligible for the Healthy Kids program if he or she is: 5 18 years old Uninsured Not eligible for Medicaid or the Children s Medical Services Network You may apply for Healthy Kids coverage at any time. If your child has lost Healthy Kids coverage, please call KIDS (5437). You can see if your child is eligible for reenrollment in the program. Customer service representatives are available Monday through Friday from 7:30 a.m. to 7:30 p.m. They can answer any questions that you may have about your child s eligibility or benefits with Healthy Kids. 7

9 HOW TO GET HELP Amerigroup Member Services Department You can call Member Services at , Monday through Friday 8:00 a.m. to 7:00 p.m. Eastern time except for holidays. If you call after 7:00 p.m., you can leave a voice mail message. Member Services will call you back the next working day. He or she can help answer your questions about: Understanding your member handbook Making doctor 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. This notice describes: How medical information about your child may be used and disclosed How you can get access to this information If you move; we will need to know your new address and phone number. You should also call Healthy Kids at KIDS (5437) to let them know your new address If you want to get the member handbook in a different language For members who do not speak English: We can help in many languages and dialects We can translate for you at doctor visits at no cost to you For members who are deaf or hard of hearing: Call the toll-free AT&T Relay Service at We will set up and pay for you to have a person who knows sign language help you during your doctor visits Please let us know at least 24 hours before your appointment, if you need an interpreter. Call Member Services to learn more. Online and Automated Self-service Features These services are online at or with our automated phone line 24 hours a day, 7 days a week. You can: Choose or find a PCP in the Amerigroup network Change your PCP Request an ID card Update your address or phone number Request a member handbook or provider directory 8

10 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 When your child is sick, call Amerigroup On Call at 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 You can also call Amerigroup On Call if you need help making doctor visits for an urgent medical issue. Amerigroup On Call is here for you 24 hours a day, 7 days a week, 365 days a year. 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 Amerigroup 24-Hour Nurse HelpLine Do you have questions about your child s health? Do you need to know what kind of doctor your child should see? Call the Nurse HelpLine at Our 24-hour Nurse HelpLine can help you speak with a nurse 24 hours a day, 7 days a week, 365 days a year. If you are deaf or hard of hearing, please call the AT&T Relay Service at 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. Other Important Phone Numbers Service Needed Phone Number If you have an emergency 911 Enrollment or disenrollment information Healthy Kids Customer Service at KIDS (5437) Behavioral health care Dental care Healthy Kids Customer Service at KIDS (5437) Disease management (ask to speak with a disease management care manager) 9

11 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 give your child a medical home, which means he or she 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 that came with your child s enrollment package. 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 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. Ask your child s PCP to submit a request for your child to get a second opinion. Once approved, your child s PCP will let you know the date and time of the appointment. Your child s PCP will also send copies of all related records to the doctor who will provide the second opinion. Your child s PCP will let you and Amerigroup know the outcome of the second opinion. 10

12 If Your Child Had a Different Doctor Before Joining Amerigroup Your child may have been seeing a doctor who is not in our network before he or she joined Amerigroup and the Healthy Kids program. Your child may be able to keep seeing this doctor for care while you pick a new doctor for him or her. Call Member Services to find out more about this. We will make a plan with you and your child s doctor, so we all know when your child needs to start seeing his or her new PCP. If Your Child s Primary Care Provider s Office Moves, Closes or Leaves the Amerigroup Network Your child s PCP s office may move, close or leave the Amerigroup network. If this happens, we will call or send you a letter to tell you. In some cases, 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 his or her 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 choose another PCP from our network. Look in the Amerigroup provider directory that came with your enrollment package. You can also find the provider directory online at We can also help you pick a doctor. Call Member Services at We can change your PCP on the same day you ask for the change. The change will go into effect right away. Call the doctor s office if you want to make an appointment. If you need help, call Member Services. We will help you make the appointment. 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 doctor may do this if: Your child s PCP does not have the right experience to treat your child The assignment to your child s doctor was made in error (like a child assigned to an adult s doctor) Your child fails to keep his or her appointments Your child does not follow his or her medical advice over and over again Your child s doctor agrees that a change is best for your child If You Want Your Child to Go to a Doctor Who Is Not the Primary Care Provider If you want your child to go to a doctor who is not your child s PCP, please talk to your child s PCP first. In most cases, the PCP needs to give your child a referral. This is done when your child s PCP cannot give your child the care he or she needs. Please read the section Specialists to find out more. If your child goes to a doctor that the PCP has not referred him or her to, the care your child receives may not be covered by Amerigroup. 11

13 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 does not 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 that came with your child s enrollment package. You can also find the provider directory online at While your daughter is pregnant, her OB/GYN can become 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 Call Member Services 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 do not need a referral to see a specialist. This is done through a standing referral or an approved number of visits. Members with special health care needs are 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. 12

14 GOING TO THE DOCTOR Your Child s First Doctor Appointment You can call your child s doctor to set up his or her first appointment. Your child should see his or her Primary Care Provider (PCP) for a wellness 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 doctor who is now your Amerigroup network doctor, call the doctor. You need to see if it is time for your child to get a checkup. If so, make an appointment for your child to see the doctor as soon as you can. How to Make an Appointment It is easy to make an appointment with your child s PCP. Just call the doctor s 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 doctor s office if your child is not feeling well. This will let the doctor s office 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 your child s PCP s office is closed, an answering service will take your call. Your child s doctor should call you back within 30 minutes. Once you talk to your child s doctor and set up an appointment, your child should be able to see the doctor as follows: 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 Doctor Visit When you go with your child to the doctor 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 Doctor Visit If you make an appointment to visit with your child s PCP and then can t go, call the PCP office. Tell the office to cancel the visit. You can make a new appointment for a visit when you call. Try to call at least 24 hours before the visit. This will let someone else see the doctor during that time. If you want us to cancel the appointment for your child, call Member Services. If you do not call to cancel your child s doctor visits, your child s doctor may ask for your child to be changed to another doctor. 13

15 How to Get Your Child to a Doctor s Visit or to the Hospital If you have an emergency and need transportation, call 911 for an ambulance. Be sure to tell the hospital staff you are an Amerigroup member. Get in touch with your child s PCP as soon as you can. This way, his or her doctor can arrange treatment and help your child get the needed hospital care. Disability Access to Amerigroup Network Doctors and Hospitals Amerigroup network doctors and hospitals will help members with disabilities get the care they need. Members who use wheelchairs, walkers or other aids may need help getting into an office. If your child needs help, make sure your child s doctor knows this before you take your child there. 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 as defined below: Medically necessary health services mean 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 a lot 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 appropriate 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 should not 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 cannot 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 will become a member of a Health Maintenance Organization (HMO). An HMO is a plan that covers most types of medical care without large out-of-pocket costs for you. Amerigroup covers treatment when your child is sick or injured. We also cover services that can help your child stay healthy. This includes annual checkups and immunizations (shots). 14

16 WHAT IS COVERED BY AMERIGROUP? Payment for Services Amerigroup is easy to use. It is not like traditional health care plans, where you must file claim forms and wait for the plan to send payment. When your child gets covered services, you just pay a small copay, if one is needed. Amerigroup covers the rest without any paperwork. It is very important for you to pay any copays for nonemergency or nonurgent services so that you are not denied care. Monthly Premiums In addition to small copays for certain services, a monthly premium 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). If your child s coverage has been cancelled because you did not pay, you must wait 30 days to start coverage again. Services will not be covered 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 accepted. Mail monthly premiums to: Florida Healthy Kids Corporation P.O. Box Tampa, FL Overnight payments are not accepted at this address. You can pay by phone by calling KIDS (5437). 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 Internet. Renewal Every family must renew their child s 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 include a form with most of your current information already filled in. It is very important for you to respond to this renewal letter. If you have any questions, please contact Florida Healthy Kids. The toll-free number for the Customer Service department is You can call Monday through Friday from 7:30 a.m. to 7:30 p.m. for help. Amerigroup and Healthy Kids Benefits Below 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 doctor who can. 15

17 For a few special benefits, members have to be a certain age or have a certain kind of health problem. In some cases, your child s doctor may need to get prior authorization from Amerigroup before your child can receive 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, you can call Member Services for help. COVERED SERVICES COVERAGE LIMITS COPAYS Well-child care, including Hearing and vision screenings and immunizations No copay preventive care visits, immunizations (shots), and routine hearing and vision screenings must be provided by your child s PCP Primary Care Provider (PCP) No copay office visits Specialist office visits Diagnostic testing (laboratory, X-rays) Prescription drugs (generic drugs, unless brand name is medically necessary) Inpatient hospital stays (semiprivate room) Chiropractic services Podiatric services 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 the section Emergency Care on Page 20) Emergency transportation services Vision services Your child s PCP will test his or her eyesight; if the tests Must use an Amerigroup network provider and be referred by your child s PCP Must use Amerigroup network pharmacy Must be prescribed by your child s PCP or an Amerigroup-approved specialist or doctor Stays must be approved by Amerigroup Limited to 15 days per year for rehabilitation and physical therapy stays Limited to one visit per day for up to 24 visits per calendar year Limited to one visit per day for up to two visits 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 in response to an emergency (see the section Emergency Care on Page 20). 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 $5 per visit No copay $5 per prescription (up to a 31-day supply) No copay $5 per visit $5 per visit 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 16

18 COVERED SERVICES COVERAGE LIMITS COPAYS show problems, your child prescription changes $10 for corrective will be referred to a specialist Limited to Medicaid frames and certain kinds of lenses Behavioral health services, including inpatient and outpatient care for evaluation, diagnosis and treatment Substance abuse services, including inpatient and outpatient care for drug and alcohol abuse (such as counseling and help with placement) 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 lenses Limits, such as duration of services, number of visits or number of days for hospitalization or residential services, are similar to those for physical illnesses. Some services may need precertification before you can get them. Please have your doctor call Member Services at Limits, such as duration of services, number of visits or number of days for hospitalization or residential services, are similar to those for physical illnesses. 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 inpatient copay $5 per outpatient visit No inpatient copay $5 per outpatient visit No copay $5 per visit $5 per visit $5 per visit 17

19 COVERED SERVICES COVERAGE LIMITS COPAYS terminal illness 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: No copays for Primary Care Provider (PCP) office visits Amerigroup On Call: Access to a 24-hour Nurse HelpLine and physician consultations to answer your medical questions day or night Hypoallergenic bedding Offers members diagnosed with asthma a one-time $100 benefit towards the purchase of any hypoallergenic bedding Healthy Families program: Six months of fitness and healthy behavior coaching for kids ages 7 13 Free mouthguards for members involved in contact sports We give you these benefits to help keep you healthy. Prior Approval of Certain Medical Procedures Amerigroup believes it is important that your child gets quality care. We want to be sure your child gets the care he or she needs. One of the ways we do this is by working closely with doctors and hospitals. Your child s PCP must get either verbal or written approval from Amerigroup before certain hospital stays, medical procedures and outpatient surgical procedures. Services That Do Not Need Prior Approval Some services do not need prior approval from Amerigroup or your child s PCP. These services include: Behavioral health care services Substance abuse and rehabilitation treatment Emergency room visits Well-child care Family planning services PCP office visits Chiropractic care services 18

20 If you have questions about these covered services or how to access care, call Member Services. Dental Services If you receive dental benefits, they are provided through a different plan. Please contact Healthy Kids Customer Service at KIDS (5437) to find out about your child s dental plan. Getting a Prescription Filled You will get covered prescription drugs when written by a licensed prescriber. Plus, you can choose from several local pharmacies and major drug store chains. You can look in the Provider Directory that came with your enrollment package for a list of network pharmacies. 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 covered medicines. Certain medicines may require approval before they are covered as a benefit. When this happens, it is called a prior authorization. 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) medicine if one is available. Brand-name medicines are only covered if a generic medicine is not available or when your physician says a brand name is medically necessary. Along with the over-the-counter products covered on our formulary, your child also has an over-thecounter drug benefit. Your household can get up to $10 worth of certain over-the-counter products per month at any Amerigroup network pharmacy that takes part in this benefit. Just choose the product and show the pharmacist your Amerigroup ID card. The pharmacist will let you know when your household has reached the $10 limit for the month. Some of the types of over-the-counter drugs you can get include: Vitamins and minerals Pain relievers First aid supplies Cough, cold and allergy medicine 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. Then your child goes to see the doctor. This will cover most minor illnesses and injuries, as well as normal checkups. This type of care is known as 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 his or her 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 19

21 the Wellness Services section 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 are not emergencies. But they can turn into an emergency if they are not treated within 24 hours. Some examples are: High fever Animal bites Fractures Severe pain Infectious or respiratory illnesses Flu For urgent care, you should call your child s PCP. Your child s PCP will tell you what to do. Your child s PCP may tell you to come to his or her office right away. You may be told to go to some other office for your child to get care right away. You should follow what your child s PCP says. In some cases, your child s PCP may tell you to go to the emergency room at a hospital for care. See the next section about emergency care to find out more. You can also call our 24-hour Nurse HelpLine at for advice about urgent care. Your child should be able to see his or her PCP within one day for an urgent care appointment. Emergency Care After routine and urgent 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 our 24-hour Nurse HelpLine at The most important thing 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 present your child s Amerigroup ID card. Ask the hospital to call Amerigroup. The process for providers to follow is on your ID card. What Is an Emergency Medical Condition? An emergency medical condition is when not seeing a doctor for care right away could result in 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 result in 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 pose a threat to the health and safety of the patient or her unborn baby There is proof of prolonged uterine contractions or rupture of the membranes 20

22 Here are some examples of problems that are most likely emergencies: Trouble breathing Chest pains Loss of consciousness Very bad bleeding that does not stop Very bad burns Shakes called convulsions or seizures What Is an Emergency Behavioral Health Condition? An emergency behavioral health condition meets the standard listed above. Examples of an emergency behavioral health condition include: Likely danger to self and 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 Poststabilization? Poststabilization services are covered services your child receives after emergency medical care. Your child gets these services to help keep his or her condition stable. Medical emergencies and poststabilization care that have to do with your child s emergency do not need prior approval by Amerigroup. You should call your child s PCP as soon as you can after your child visits the emergency room. If you cannot call, have someone else call for you. Your child s PCP will give or arrange any follow-up care your child needs. 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 not need a referral, you should always call your child s PCP first before your child gets medical care. If you call your child s PCP s office when it is closed, leave a message with your name and a phone number where you can be reached. If it is not an emergency, someone should call you back soon to tell you what to do. You may also call our Nurse HelpLine 24 hours a day, 7 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 he or she is 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 allow 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. 21

23 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 our 24-hour Nurse HelpLine 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. Or call our 24-hour Nurse HelpLine. 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 State and gets health care services, he or she will not be covered by Amerigroup. How to Get Care When Your Child Cannot Leave Your Home Amerigroup will find a way to help take care of your child. Call Member Services right away if your child cannot 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. During a wellness visit, your child s PCP will check his or her overall health. Many health problems can be treated and controlled 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. Vision Screening Your child s PCP should check your child s vision at every well-child visit. Please see the section Vision Services under the heading Amerigroup Covered Services for more information. Hearing Screening Your child s PCP should check your child s hearing at every well-child visit. Dental Screening Your child should have his or her teeth and gums checked by the PCP as a part of the routine well-child visits. Please see Dental Services under Amerigroup Covered Services to learn more. Immunizations (Shots) It is important for your child to get immunizations on time. Take your child to the doctor when the PCP says a shot is needed. Use the chart that follows to help keep track of the shots your child needs. 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 setting 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. 22

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27 SPECIAL CARE FOR PREGNANT MEMBERS Taking Care of Baby and Me is the Amerigroup program for all pregnant members. It s very important to see your child s Primary Care Provider 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 do not 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 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. 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. 26