Real. Member Handbook. Solutions. Amerigroup New Jersey, Inc n

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1 Real Solutions Member Handbook Amerigroup New Jersey, Inc. NJ-MHB The emergency room isn t always the answer. Did you know the average emergency room wait time is over 4 hours? Need nonemergency medical help? Call your Primary Care Provider (PCP) at the number on your Amerigroup Community Care ID card. Can t reach your PCP? Call our 24-hour Nurse HelpLine at (TTY ). What if I have an emergency? Go to the emergency room right away. Not sure? Call your PCP or our Nurse HelpLine n

2 Dear Member: Welcome to Amerigroup Community Care. We are happy you chose Amerigroup to arrange for health care services for you or your family as part of New Jersey Medicaid/NJ FamilyCare. The member handbook explains how Amerigroup works and how to help keep your family healthy. It tells you how to receive health care or emergency care when you need it and gives you information about going to your Primary Care Provider (PCP). Your PCP is the family doctor or provider that you will go to for most of your health care needs. Your handbook also tells you how to select a dentist and explains your extra Amerigroup benefits. You may have already received your Amerigroup ID card and additional information from us. Your ID card will tell you when your Amerigroup membership starts and the name of your PCP. Please check your ID card right away. If you have not received an ID card from us within one week of receiving this packet, or if the name of your PCP or any other information on the card is not correct and needs to be changed, please call us at (TTY ). We will send you a new ID card with the correct information right away. We want to hear from you. Call (TTY ). You can talk to a nurse on our 24-hour Nurse HelpLine or you can talk to a Member Services representative about your benefits, Monday through Friday, 8:00 a.m. to 6:00 p.m. You can also search for network providers and learn more about your benefits online at We are here to help you and your family receive the right care in your own community. Thank you again for choosing us as your family s health plan. Sincerely, John Koehn Chief Executive Officer Amerigroup Community Care

3 歡 迎 光 臨 AMERIGROUP COMMUNITY CARE ( 關 懷 保 健 )! 如 有 任 何 疑 問, 需 要 任 何 援 助 或 欲 了 解 可 享 用 的 服 務 : 請 撥 (TTY ) 與 24 小 時 護 士 熱 線 與 護 士 交 談 週 一 至 週 五 的 上 午 8:00 至 下 午 6:00, 與 會 員 服 務 部 代 表 討 論 您 的 福 利 事 項 如 欲 使 用 您 的 母 語 交 談, 可 要 求 翻 譯 服 務 在 您 就 診 時, 我 們 也 可 為 您 提 供 免 費 的 翻 譯 服 務 如 您 需 要 翻 譯 服 務, 請 在 預 約 至 少 24 小 時 前 知 會 我 們 此 外, 我 們 會 設 法 幫 助 您 聯 絡 與 您 使 用 同 一 語 言 的 醫 師 我 們 在 社 區 內 為 您 和 您 的 家 人 提 供 滿 意 的 醫 療 保 健 服 務 我 們 會 在 本 年 度 向 您 寄 發 單 張 和 簡 訊, 以 知 會 您 各 種 醫 療 主 題 您 將 能 瞭 解 我 們 所 提 供 服 務 的 相 關 資 訊, 以 幫 助 您 獲 取 優 質 的 醫 療 保 健 服 務 我 們 每 年 都 會 向 您 寄 發 會 員 簡 報, 內 含 會 員 滿 意 度 調 查 結 果 有 關 品 質 改 進 計 劃 的 資 訊 以 及 我 們 的 改 善 計 劃 欲 查 看 會 員 簡 報, 請 造 訪 我 們 的 網 站 如 欲 瞭 解 有 關 品 質 改 進 計 劃 的 更 多 資 訊, 請 撥 (TTY ) 即 可 BEM-VINDO A AMERIGROUP COMMUNITY CARE! Se tiver alguma pergunta, precisar de ajuda ou quiser saber quais serviços estão disponíveis, você pode: Ligar para (TTY ) Falar com uma enfermeira na nossa Nurse HelpLine de 24 horas Falar com um representante de Serviços para Membros sobre seus benefícios, de segunda a sexta, de 8:00 às 18:00 hs. Se quiser falar com alguma pessoa no seu idioma, peça um intérprete. Também podemos fornecer a você um intérprete para sua consulta médica sem nenhum custo. Se precisar de um intérprete, avise-nos pelo menos 24 horas antes da sua consulta. Além disso, tentaremos ajudá-lo a encontrar um médico que fale o seu idioma. Estamos para ajudar a você e à sua família para que recebam o cuidado adequado na sua comunidade. Estaremos enviando a você boletins e folhetos informativos durante o ano para mantê-lo informado sobre vários temas de saúde. Você encontrará informações sobre as coisas que fazemos para ajudá-lo a ter acesso ao cuidado e serviço de qualidade. Todos os anos enviaremos um Boletim para Membros com os resultados da nossa pesquisa de satisfação do membro e informações sobre o nosso programa de melhoramento da qualidade, juntamente com alguns dos planos que temos para fazer melhoras. Para ver o Boletim para Membros, visite o nosso website em ou se quiser mais informações sobre o nosso programa de melhoramento da qualidade, ligue para (TTY ).

4 !, : (TTY ) 24- आपक प र प त ह न व ल,, 8:00 6:00 / 24, औ प औ, औ (TTY ) औ, औ BYENVENI NAN AMERIGROUP KI BAY SWEN KOMINOTÈ! Oka w ta genyen nenpòt kesyon, oswa w bezwen yon koudmen pou jwenn ki sèvis ki disponib, w kapab: Rele (TTY moun ki soud ak bèbè ) Pale ak yon enfimyè ki nan Nurse Helpline (telefòn Enfimyè) ki la 24 trè sou 24 Pale ak yon ajan Member Services (Sèvis pou moun ki se manm) konsènan benefis ou yo, dilendi jiska vandredi, de 8 tè dimaten rive 6 zè nan lapremidi. Si w ta renmen pale ak yon moun ki pale lang pa w, mande yon entèprèt. Nou kapab bay yon entèprèt gratis pou pran randevou ak doktè ou a. Tanpri fè nou konnen si w ap bezwen yon entèprèt omwen 24 trèdtan alavans anvan randevou ou a. Anplis sila, nou pral chèche ede ou jwenn yon doktè ki pale lang pa w. Nou la pou ede w ak fanmi ou resevwa swen ki kòrèk nan kominote ou a. Nou prale voye ou bilten ak bilten-nouvèl pandan ane pou fè ou konnen latriye sijè sou lasante. W ap jwenn enfòmasyon sou bagay nou fè yo pou ede ou trouve bon kalite swen ak sèvis. Chak ane n ap voye ba ou yon bilten pou manm. Bilten sila ap genyen rezilta sondaj satisfaksyon manm nou yo ansanm ak enfòmasyon sou pwogram nou genyen pou rann bon kalite vini pi bon. Bilten sila prale bay kèk nan plan nou genyen yo pou pou fè amelyorasyon sila yo. Si ou vle wè bilten manm nan, vizite sit entènèt nou an nan oswa si w ta renmen plis enfòmasyon sou pwogram kalite amelyorasyon nou an, tanpri souple rele (TTY ).

5 مرحب ا بكم في مؤسسة أمريجروب للرعاية المجتمعية! 0 إذا كانت لديكم أية أسئلة أو كنتم في حاجة للمساعدة أو أردتم التعرف على الخدمات المتاحة يمكنكم: االتصال برقم )أو إرسال برقية على رقم ( التحدث إلى إحدى الممرضات على خط المساعدات التمريضية على مدار 04 ساعة التحدث إلى أحد مندوبي خدمات األعضاء لالستفسار عن المزايا التي يمكنكم التمتع بها من االثنين إلى الجمعة أسبوعي ا من صباح ا وحتى 0 مساء. إذا كنت تريد التحدث إلى أحد ما بلغتك يمكنك طلب مترجم فوري. كما يمكن توفير مترجم فوري مجان ا ليصطحبك إلى الموعد المحدد للكشف عند الطبيب. وفي حالة الرغبة في اصطحاب مترجم ي رجى إخطارنا قبل الموعد ب 04 ساعة على األقل. كما يمكننا أن نعينك في البحث عن طبيب يتحدث لغتك. كما أننا على أتم االستعداد لمساعدتك أنت وعائلتك في تلقي الرعاية الصحية المثلى في مجتمعك وسنداوم على إرسال مطبوعات ورسائل إخبارية على مدار العام إلبقائكم على اطالع على مختلف األمور المتعلقة بالرعاية الصحية وستجدون في هذه المطبوعات معلومات حول الخدمات التي نقدمها لكي تحصلوا على أفضل رعاية وخدمة صحية. كما سنرسل لكم سنوي ا النشرة المخصصة لألعضاء التي تتضمن نتائج االستطالع الخاص بمدى رضا عمالئنا إضافة إلى المعلومات المتعلقة ببرنامج تطوير جودة الخدمات التي نقدمها هذا فضال عن بعض الخطط التي ننوي تطبيقها في إطار عمليات تحسين الخدمات. لالطالع على النشرة الخاصة باألعضاء يمكنكم زيارة موقعنا اإللكتروني /NJwww.myamerigroup.com أو في حالة الرغبة في الحصول على المزيد من المعلومات حول برنامج تطوير جودة الخدمات ي رجى االتصال برقم )أو إرسال برقية على رقم (. AMERIGROUP COMMUNITY CARE를 소개합니다! 질문이 있거나 도움이 필요하거나 이용 가능한 서비스를 알아보려는 경우 다음과 같이 문의할 수 있습니다 (TTY )로 전화 문의 24시간 너스 헬프라인의 간호사에게 문의 월요일부터 금요일까지 오전 8:00부터 오후 6:00 사이에 회원 서비스 담당자에게 혜택 문의 영어가 아닌 모국어로 말하고 싶으면 통역자를 요청하십시오. 진료 예약에도 추가 비용 없이 통역자를 이용할 수 있습니다. 통역자가 필요한 경우 최소 예약 24 시간 전에 알려 주십시오. 또한 Amerigroup은 모국어를 사용하는 의사를 찾을 수 있도록 도와 드립니다. Amerigroup은 여러분과 여러분의 가족이 지역 사회에서 올바른 관리를 받을 수 있도록 지원합니다. 연중 소식지와 뉴스레터를 통해 건강과 관련된 다양한 주제에 대한 정보를 제공해 드립니다. 이러한 소식지/뉴스레터를 통해 양질의 건강 관리 및 서비스를 제공하기 위해 Amerigroup이 어떤 노력을 하고 있는지도 확인할 수 있습니다. 매년 Amerigroup은 회원들의 만족도 조사 결과, 개선을 위해 노력 중인 일부 보험에 대한 품질 개선 프로그램 정보 등이 담긴 회원 소식지를 보내 드립니다. 회원 소식지를 보려면 웹 사이트 을 방문하시면 됩니다. 품질 개선 프로그램에 대한 자세한 내용을 알고 싶으면 (TTY )로 문의해 주십시오.

6 AMERIGROUP COMMUNITY CARE મ આપન સ વ ગત છ! જ આપન ક ઈ પ રશ ન હ ય, મદદન જર ર હ ય અથવ કઈ કઈ સ વ ઓ ઉપલબ ધ છ ત જ ણવ મ ગત હ ત, આપ : પર ક લ કર શક (TTY ) અમ ર 24-hour Nurse HelpLine (ન સ હ લ પલ ઇન) પર ન સ સ થ વ ત કર. આપન ફ યદ ઓ વવષ અમ ર સભ ય સહ ય પ રવતવનવધ સ થ વ ત કર, સ મવ રથ શ ક રવ ર સવ ર 0:66 વ ગ ય થ સ જ 0:66 વ ગ ય સ ધ. જ તમ ક ઈન સ થ તમ ર ભ ષ મ વ ત કરવ ઇચ છત હ ત, અથસ સમજ વન ર વ યક તત વવષ પ છ. અમ વધ ર ન ક ઈ જ ખર સ વગર આપન આપન ડ તટર સ થ ન મ લ ક ત મ ટ પણ અથસ સમજ વન ર વ યક તતન સહ ય પ ર પ ડ એ છ. જ આપન અથસ સમજ વન ર વ યક તતન જર ર હ ય ત આપન અપ ઈન ટમ ન ટન 04 કલ ક પહ લ અમન જ ણ કરવ વવન ત. વધ મ, અમ આપન આપન જ ભ ષ મ વ ત કરત ડ તટર મળ ત વ પ રય સ કર શ. અમ અહ ય આપન અન આપન પરરવ રન આપન ક મ ય વનટ મ ય ગ ય સ રવ ર મળ ત મ ટ ય ગ ય મદદ કરવ મ ટ છ એ. આર ગ યન લગત વવવવધ મ દ દ ઓ વવષ આપન મ રહતગ ર ર ખવ મ ટ અમ વષસ દરવમય ન આપન બ લ રટન સ અન ન ય ઝ લ ટ સ મ કલ શ. ત મ આપન સ ર સ ભ ળ અન સ વવધ અપ વવ મ ટ અમ શ પ રય ન કર એ છ એ ત વવષ મ રહત મળશ. દર વષ, અમ આપન અમ ર સભ ય સ ત ષ ટટ સવ ન પરરણ મ ત મજ અમ ર ગ ણવત ત સ ધ રણ ક યસક રમન સ થ સ થ એ સ ધ ર ઓ કરવ મ ટ ન અમ ર ક ટલ ક ય જન ઓ સરહતન સભ ય પવ ક મ કલ શ. આ સભ ય પવ ક જ વ મ ટ, અમ ર વ બસ ઈટ અથવ જ આપ ગ ણવત ત સ ધ રણ ક યસક રમ વવષ વધ મ રહત મ ળવવ ઇચ છત હ ત ક પ કર પર ક લ કર (TTY ).

7 AMERITIPS: HEALTH TIPS THAT MAKE HEALTH HAPPEN YOU NEED TO GO TO YOUR DOCTOR NOW! WHEN IS IT TIME FOR A WELLNESS VISIT? All Amerigroup Community Care members need to have regular wellness visits. This way, your Primary Care Provider (PCP) can determine if you have a health problem that requires medical treatment or follow-up. When you become an Amerigroup member, call your PCP and make the first appointment for you and your child before the end of 90 calendar days after you enroll. WELLNESS CARE FOR CHILDREN Children need more wellness visits than adults. Your child should get wellness visits at the ages listed below. Newborn 9 months Under 6 weeks 12 months 2 months 15 months 4 months 18 months 6 months 24 months After age 2, your children should keep going to your PCP every year through age 20 for well-child visits. WHAT IF I BECOME PREGNANT? If you think you are pregnant, call your PCP or OB-GYN doctor right away. This can help you have a healthy baby and stay healthy yourself. If you have any questions or need help making an appointment with your PCP or OB-GYN, please call Amerigroup Member Services at (TTY ). IMPORTANT! Keep your health care coverage. Do not lose your health care benefits. Renew your eligibility for New Jersey Medicaid/NJ FamilyCare benefits on time. See page 56 for more details. Amerigroup is a culturally diverse company. We welcome all eligible individuals into our health care programs, regardless of health status. If you wish to submit a concern or complaint to the Amerigroup Beneficiary Rights Ombudsman, please call (TTY ).

8 AMERIGROUP COMMUNITY CARE MEMBER HANDBOOK 101 Wood Avenue South, 8th Floor Iselin, NJ TTY Welcome to Amerigroup Community Care! You will get most of your health care services covered through Amerigroup. This member handbook will tell you how to use Amerigroup to get the health care you need. Table of Contents FREQUENTLY ASKED QUESTIONS... 1 WELCOME TO AMERIGROUP COMMUNITY CARE... 2 INFORMATION ABOUT YOUR NEW HEALTH PLAN... 2 HOW TO GET HELP... 3 AUTOMATED SELF-SERVICE FEATURES... 3 MEMBER SERVICES DEPARTMENT HOUR NURSE HELPLINE... 4 IMPORTANT PHONE NUMBERS... 4 QUE HAGO SI NO HABLO INGLES? (WHAT IF I DO NOT SPEAK ENGLISH?)... 4 YOUR AMERIGROUP MEMBER HANDBOOK... 5 YOUR AMERIGROUP IDENTIFICATION CARD... 6 ENROLLMENT IN AMERIGROUP... 6 INFORMATION ABOUT NJ FAMILYCARE... 7 GOING TO THE DOCTOR... 7 CHOOSING YOUR FAMILY DOCTOR... 7 HOW TO GET A LIST OF AMERIGROUP PROVIDERS... 8 AMERIGROUP PROVIDERS NEED TO KNOW YOUR HEALTH HISTORY AFTER YOU ENROLL... 8 SECOND OPINIONS... 8 CHANGING FAMILY DOCTORS... 8 IF YOUR FAMILY DOCTOR ASKS YOU TO CHANGE TO A NEW FAMILY DOCTOR... 9 GETTING TO YOUR DOCTOR TRANSPORTATION SERVICES... 9 CANCELING AN APPOINTMENT... 9 AFTER-HOURS CARE SPECIALISTS IF YOU WANT TO SEE A DOCTOR WHO IS NOT IN THE AMERIGROUP NETWORK CHOOSING A DENTIST DISABILITY ACCESS TO AMERIGROUP NETWORK DOCTORS AND HOSPITALS PREMIUMS FOR NJ FAMILYCARE D MEMBERS AND COPAYMENTS FOR NJ FAMILYCARE C AND D MEMBERS.. 12 PREMIUMS FOR NJ FAMILYCARE D MEMBERS COPAYMENTS FOR NJ FAMILYCARE C AND D MEMBERS... 12

9 MEMBERS AGE 55 AND OVER AMERIGROUP COVERED SERVICES FOR NEW JERSEY MEDICAID/NJ FAMILYCARE MEMBERS EXTRA AMERIGROUP BENEFITS FOR NEW JERSEY MEDICAID/NJ FAMILYCARE MEMBERS SERVICES PROVIDED UNDER MEDICAID FEE-FOR-SERVICE FOR NEW JERSEY MEDICAID/NJ FAMILYCARE MEMBERS SERVICES THAT DO NOT NEED REFERRALS SERVICES NOT COVERED BY AMERIGROUP OR FEE-FOR-SERVICE FOR NEW JERSEY MEDICAID/ NJ FAMILYCARE MEMBERS DIFFERENT TYPES OF HEALTH CARE ROUTINE CARE URGENT CARE EMERGENCY CARE EMERGENCY DENTAL CARE IF YOU NEED TO GO TO THE HOSPITAL OUT-OF-TOWN CARE NEW TYPES OF CARE WELLNESS VISITS: EARLY PERIODIC, SCREENING AND DIAGNOSTIC TREATMENT SERVICES WHY WELLNESS CARE IS IMPORTANT FOR CHILDREN MISSING WELLNESS VISITS SPECIAL KINDS OF HEALTH CARE SPECIAL CARE FOR PREGNANT MEMBERS SPECIAL SERVICES FOR PREGNANT AND NURSING WOMEN WIC LOCAL AGENCIES AND SERVICE AREAS MEDICINES IF YOU ARE UNABLE TO LEAVE YOUR HOME SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING HEALTH INFORMATION HEALTH EDUCATION CLASSES CARE MANAGEMENT SERVICES/SERVICES FOR ENROLLEES WITH SPECIAL NEEDS DISEASE MANAGEMENT CENTRALIZED CARE UNIT MINORS MAKING A LIVING WILL COMPLAINTS, GRIEVANCES AND MEDICAL APPEALS IF YOU HAVE A COMPLAINT FILING A GRIEVANCE LEVEL 1 GRIEVANCE LEVEL 2 GRIEVANCE... 51

10 MEDICAID FAIR HEARING IF AMERIGROUP WILL NOT PAY FOR OR AUTHORIZE A SERVICE HOW TO FILE A MEDICAL APPEAL STAGE 1 APPEAL STAGE 2 APPEAL INDEPENDENT HEALTH CARE APPEALS PROGRAM IF YOUR DOCTOR FILES A CLAIM APPEAL MEDICAID FAIR HEARING FOR APPEALS MEMBER EXPLANATION OF BENEFITS OTHER INFORMATION IF YOU MOVE RENEW YOUR ELIGIBILITY FOR YOUR MEDICAID, SSI OR NJ FAMILYCARE BENEFITS ON TIME LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES HOW TO DISENROLL FROM AMERIGROUP FOR AFDC/TANF OR ABD AND RELATED GROUPS FOR NJ FAMILYCARE MEMBERS REASONS YOU CAN BE DISENROLLED FROM AMERIGROUP FOR AFDC/TANF OR ABD AND RELATED GROUPS FOR NJ FAMILYCARE MEMBERS YOU ASKED TO BE ENROLLED IN AMERIGROUP AND DID NOT GET ENROLLED IF YOU HAVE OTHER HEALTH INSURANCE WHAT YOU SHOULD DO IF YOU GET A BILL FOR A SERVICE CHANGES IN YOUR AMERIGROUP COVERAGE HOW TO TELL AMERIGROUP ABOUT CHANGES YOU THINK SHOULD BE MADE HOW AMERIGROUP PAYS PROVIDERS YOUR RIGHTS AND RESPONSIBILITIES HOW TO REPORT SOMEONE WHO IS MISUSING THE NEW JERSEY MEDICAID/NJ FAMILYCARE PROGRAM HIPAA NOTICE OF PRIVACY PRACTICES... 67

11 FREQUENTLY ASKED QUESTIONS As an Amerigroup Community Care member, we want you to be able to easily find information that best helps you use your Amerigroup benefits and services. We speak to thousands of members every day, and we often hear the same questions from them. So that you also get the benefit of those frequently asked questions, we have put together the most commonly asked questions (and our answers) for you: Q: Do I have dental benefits? Who is my dentist? A: Your dental coverage will be shown on your ID card. We contract with Healthplex for your dental benefits. Please call Healthplex toll free at (TTY ) and request a list of dentists in your area. Q: Do I have vision benefits? Who is my eye doctor? A: Your vision coverage will be shown on your ID card. We contract with Block Vision for your vision benefits. Please call Block Vision at (TTY ) and request a list of providers in your area. Q: What do I do if I need a ride to my doctor s appointment? A: Rides to your providers are nonemergency transportation. This is covered by the state if you are eligible. Eligible members should call LogistiCare Medical Transportation at (TTY ). Transportation appointments must be scheduled at least three days in advance. Please have the following information when calling to schedule your transportation: Name of the doctor or medical provider Address Telephone Time of appointment Type of transportation needed (e.g., regular car, wheelchair-accessible van) Q: How do I change my PCP? A: Please call our Member Services department at (TTY ), Monday Friday, 8 a.m. 6 p.m. They will help you choose a new doctor. You will receive a new member ID card with the updated information. If you need to visit the doctor before you receive the new card, let Member Services know, and they will help you. Q: How do I give Amerigroup my new address and phone number? A: You will need to contact the state directly toll free at (TTY ). Q: How do I find out if Amerigroup covers my medications? What do I do if they are not covered? A: The pharmacist you go to will inform you if a medication is covered or not. If a medication is not covered, it might be because it needs prior authorization. This means that the provider who prescribed the medicine will have to contact Amerigroup first to request it for you. You or your pharmacist can call your provider to ask for a prior authorization or change the medicine to a similar one that is covered. 1

12 Q: What is an Amerigroup care manager, and what do they do for me? A: Care managers are nurses and social workers who assist members with the coordination of medical services, provide information about additional supportive services, and provide education about medical conditions and preventive measures. Care managers can assist with locating specialists, scheduling appointments, and ensuring that members receive medical equipment and other supportive services at home or in the community. Q: What can I do for help after my provider s office is closed? A: Your provider will have an on-call service. Call your provider s office to speak with someone from their on-call service. You can also call our 24-hour Nurse HelpLine at (TTY ). Q: How do I get another member handbook? A: Please call our Member Services department at (TTY ). Q: How do I get an Amerigroup member ID card? A: All members get a member ID card from us when they first enroll. If you need a new one, you can call Member Services at (TTY ). Q: How do I use the free glucometer program through Amerigroup? A: Your doctor can call NIPRO at and request the True Test glucometer and starter supply kit. Q: What are the common phone numbers I should have on hand? Amerigroup Member Services: (TTY ) Healthplex (dental): (TTY ) Block Vision: (TTY ) New Jersey Medicaid/NJ FamilyCare: (TTY ) Q: What should I do if I get a bill from my provider s office? A: If you receive a bill from your doctor, please call Member Services at (TTY ), Monday Friday, 8 a.m. 6 p.m. A representative can let you know what to do. WELCOME TO AMERIGROUP COMMUNITY CARE Information About Your New Health Plan Welcome to Amerigroup New Jersey, Inc., doing business as Amerigroup Community Care. Amerigroup is a New Jersey Health Maintenance Organization (HMO) committed to helping you get the care you need when you need it. In Amerigroup, you and your family doctor work together to help keep you healthy and care for your health problems. Amerigroup gives you many ways to get quality health care. Our members include the following groups: Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families (TANF) Foster Care Children receiving title IV-E foster care payments or with title IV-E adoption assistance agreements AFDC/TANF-Related, New Jersey Care Special Medicaid Program for Pregnant Women and Children, including restricted alien pregnant women SSI-Aged, Blind, Disabled 1619(b) Disabled individuals whose earnings are too high to receive SSI cash 2

13 Breast and Cervical Cancer - Uninsured low-income women under the age of 65 who have been screened at a NJ cancer education and early detection site and needs treatment; no Medicaid income or resource limit New Jersey Care Special Medicaid programs for Aged, Blind, and Disabled New Jersey Care Special Medicaid Programs for Poverty level pregnant women; poverty level infants; poverty level children age 1-5; poverty level infants and children receiving inpatient services who lose eligibility because of age must be covered through an inpatient stay Special Home and Community Based Services Group: Individuals who would be eligible in an institution and receiving services through MLTSS Chafee Kids Individuals under 18 who would be mandatorily categorically eligible except for income and resources Pregnant women who would be categorically eligible except for income and resources 1902(a)(10)(C)(ii)(II) Pregnant women who lose eligibility receive 60 days coverage for pregnancy-related and postpartum services 1902(a)(10)(C) 1905(e)(5) Division of Developmental Disabilities Clients including the Division of Developmental Disabilities Community Care Waiver (CCW) (acute care services only) (CCW services are covered by FFS) Medicaid only or SSI-related Aged, Blind, and Disabled Uninsured parents/caretakers and childless adults with income up to and including 133% FPL Children who are covered under NJ FamilyCare, including restricted alien children Children in DCP&P/DCF custody residing in resource families or residential treatment centers with a county of residence as 0-21, and individuals under the New Jersey Chafee Plan Breast and Cervical Cancer Program enrollees Individuals in the Provider Lock-in or Hospice programs Indians who are members of federally recognized tribes continue to be voluntary How to Get Help Amerigroup is here to help you. We want you to be happy with the care you get. If you have any questions, need help or want to find out what services are available, you can call (TTY ) Monday Friday, 8 a.m. 6 p.m. When you call, you can access our automated self-service features, speak with a Member Services representative or get in touch with a nurse on our 24-hour Nurse HelpLine. We can also help you if you need help in another language. If you have questions regarding an authorization or request for services, you can call Member Services at (TTY ). Automated Self-Service Features You can take advantage of these services with our automated line 24 hours a day, 7 days a week. You can: Choose or find a Primary Care Provider (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 3

14 Member Services Department You can also contact Member Services to speak with a representative. Call (TTY ),Monday through Friday, 8:00 a.m. to 6:00 p.m. Member Services can help answer questions about: This member handbook Member ID cards Getting services Doctor appointments Transportation Special needs Choosing your family doctor Choosing a dentist Changing family doctors Out-of-town care/out-of-state care Urgent care Finding an Amerigroup network pharmacy Healthy living Health education classes Authorization for out-of-network or out-of-state providers, if needed Please also contact Member Services if: You wish to request a copy of the Amerigroup Notice of Privacy Practices, which describes how medical information about you may be used and disclosed and how you can get access to this information You move; we will need to know your new address and telephone number You may also need to give your new address to other agencies. NJ FamilyCare members should call the state s Health Benefits Coordinator at (TTY ). If you are an AFDC/TANF member with Medicaid, call the County Welfare Agency in your county (see pages for a list of telephone numbers). SSI (Supplemental Security Income) members should call the Social Security Administration at hour Nurse HelpLine You can speak with a nurse on our 24-hour Nurse HelpLine anytime. Call (TTY Our nurses can help you know: How soon you need to get care when you are sick What kind of health care you need What you can do to take care of yourself until you see your doctor How you can get the care you need Important Phone Numbers For dental care, call Healthplex at For vision care, call Block Vision at (TTY ) New Jersey Medicaid/NJ FamilyCare, call (TTY ) Que Hago Si No Hablo Ingles? (What If I Do Not Speak English?) Si no habla inglés, llame a Servicios para Miembros al (TTY ) de lunes a viernes, de 8:00 a.m. a 6:00 p.m. Nuestro personal de Servicios para Miembros habla diferentes idiomas. 4

15 Nuestro departamento tratara de encontrarle un médico que hable su idioma o le ayudara á comunicarse con su doctor. Es muy importante que usted hable con su médico y entienda lo que le dice. For members who do not speak English, we can help in many different languages and dialects. This service is also available for visits with your doctor at no cost to you. Please let us know if you need an interpreter at least 24 hours before your appointment. We will also try to help you find a doctor who speaks your language. Call Member Services at (TTY ) for more information. For members who are deaf or hard of hearing, call the AT&T Relay Service toll free at Amerigroup will set up and pay for you to have a person who knows sign language help you during your medical visits. Please let us know if you need an interpreter at least 24 hours before your appointment. Your Amerigroup Member Handbook This member handbook tells you about your Amerigroup health plan and benefits. If you have questions about the handbook or your benefits, call Member Services toll free at (TTY ). You may write to us at: Amerigroup Community Care 101 Wood Ave. South, 8th Floor Iselin, NJ We can help you in many languages. If you are deaf or hard of hearing, call the AT&T Relay Service toll free at You can also get this handbook in large print, on audio tape or in Braille from Member Services if you need it. The other side of this handbook is in Spanish. 5

16 Your Amerigroup Identification Card If you do not have your Amerigroup ID card yet, you will get it soon. Please carry it with you at all times. Show it to any doctor, dentist or hospital you visit. The card shows you are a member of Amerigroup. You do not have to show your ID card before you get emergency care. Your ID card has the name and telephone number of your family doctor on it. Your effective enrollment date, or the date you became an Amerigroup member, is also shown. The ID card tells your doctor that he or she should not ask you to pay for your Amerigroup covered services. The only members who may have to pay anything are some NJ FamilyCare C and D members who have copayments for certain services. Members with AFDC/TANF and ABD-related groups still have a Medicaid card for the services Amerigroup does not cover. Do not throw it away. Carry it with you in case you need those services. NJ FamilyCare members get an ID card from the New Jersey Division of Medical Assistance and Health Services (DMAHS). This card is for services covered by DMAHS that are not covered by Amerigroup. Below is an example of what your Amerigroup member ID card looks like. If you have Medicare coverage, you will also have separate Medicare ID cards. Everyone who has Medicare receives a card from the Centers for Medicare and Medicaid (CMS). This card from CMS is often referred to as the red, white and blue card. If you have Original Medicare, you ll use this card for your benefits. If you have Medicare coverage through a health plan, typically you ll use the ID card from your health plan. So if you have Medicare coverage through Amerigroup, we ll send you an ID card. Keep your CMS card in a safe place and use the ID card we send you to get your benefits. Enrollment in Amerigroup Enrolling takes 30 to 45 days. This is from the time you first apply to your effective enrollment date when you start receiving Amerigroup benefits. During this time, you will continue to receive benefits through Medicaid fee-for-service, or the HMO you are enrolled in, whichever applies. If your effective enrollment date changes during this time, we ll tell you of the change. The New Jersey Division of Medical Assistance and Health Services (DMAHS) must approve your enrollment in Amerigroup. When you enroll in Amerigroup, there is a 12-month enrollment period for all New Jersey Medicaid and NJ FamilyCare members. You can disenroll and choose another HMO for any reason during the first 90 days after your enrollment date or the date we tell you you re enrolled, whichever is later. After this 90-day period, if you remain in Amerigroup, you will be a member of our plan for the rest of the 12-month enrollment period. This is 6

17 known as the lock-in period. During the lock-in period, you can disenroll only for certain reasons. (See page 58 for more about disenrollment.) The Annual Open Enrollment Period occurs from October 1 through November 15 each year. After every 12- month period, you will continue to be enrolled with Amerigroup as long as you are still eligible for New Jersey Medicaid/NJ FamilyCare, or unless you choose a new HMO during the open enrollment period. Information About NJ FamilyCare NJ FamilyCare is a program for adults and children who meet certain state guidelines. There are five different plans: A, B, C, ABP and D. The plan you are eligible for is based on your total family income and household size. If you have questions about NJ FamilyCare and would like to know how to enroll, you can call Amerigroup toll free at (TTY ). You must be enrolled in a health plan that has a contract with the Department of Human Services (DHS), Division of Medical Assistance and Health Services (DMAHS) in order to get services and benefits as a member of NJ FamilyCare. DMAHS approves your enrollment in NJ FamilyCare. GOING TO THE DOCTOR Choosing Your Family Doctor All Amerigroup members must have a family doctor. This doctor is also called your Primary Care Provider (PCP). Your relationship with your family doctor is a very important part of your Amerigroup plan. Your family doctor will provide all of the basic health services you need. Your doctor can also send you to other specialist doctors, hospitals and special care facilities for special care, when needed. You must choose your family doctor from the Amerigroup network. If you do not choose one within your county, Amerigroup will assign you to a family doctor within 10 days of your enrollment. Your Amerigroup ID card has the name and telephone number of your family doctor. If you want a different doctor or need help choosing one, please call Member Services at (TTY You can have someone help you pick a family doctor or set up your first doctor visit. We will try to call you within one month from the time you join Amerigroup. We will help you set up an appointment to get to know your doctor. It is important for you to contact and have a checkup with your new doctor soon after you enroll. Your doctor and his/her office staff will help you find out more about your health. If you need help, don t have a telephone, or changed your telephone number not too long ago, you can call Member Services. Or you can write to us. (See page 5 for address.) You can also call your doctor yourself. Your doctor s telephone number is on your Amerigroup ID card. Since you have benefits such as physical exams, well-woman exams and well-child care, you do not have to wait until you are sick to see your family doctor. You should also get a baseline medical and dental checkup with your new doctor. After you enroll, call to set up a visit within 90 days for children under age 21 and adult DDD members. Set up a visit within 180 days for all other adults age 21 and older. Your family doctor coordinates your care and will help you make decisions about your health care. Your family doctor s staff may include nurse practitioners, physician assistants, registered nurses and licensed practical nurses employed by your doctor to help meet your health care needs. 7

18 How to Get a List of Amerigroup Providers Names of doctors in the Amerigroup network are in our provider directory. You can request a copy of the provider directory by calling Member Services at (TTY ) or access the directory online at Just click on Find a Doctor. If you need help choosing a new doctor, call Member Services. Amerigroup Providers Need to Know Your Health History After You Enroll When the state s Health Benefits Coordinator (HBC) helped you choose Amerigroup, you signed a medical release form. Signing this form allows the release of your medical records. You also had to tell the HBC if you were currently seeing any doctors for care. Your Amerigroup network doctor will have to ask your past doctor(s) to send your medical records. Having those past medical records helps your family doctor give you the care you need. The HBC also asked you questions about your health on the Plan Selection Form. This form was sent to Amerigroup. Your signature or the signature of an authorized person you chose allows the release of your medical records. We will ask you questions about your health during your new member telephone call. You may say that you have a sickness that might need care right away. If so, an Amerigroup care manager or special needs coordinator will help you. Second Opinions You can ask your family doctor to send you to another Amerigroup network doctor for a second opinion. You can do this for several reasons, including: If you have a serious medical condition If you have chosen to have an elective surgery When a provider recommends a treatment you don t think you need If you believe you have a condition that the provider did not diagnose Your family doctor will make this appointment for you. He or she will also make sure all of your records are shared with that doctor with your consent. Please follow up with your family doctor after you have your second opinion visit. You and your doctor can talk about what to do next. It could be that we do not have another doctor in our network who knows about your type of illness. If this is so, your family doctor will work with Amerigroup to find another doctor for you to see. We will still pay for this visit for services covered by Amerigroup. There may be times when we ask for you to have a second opinion. We will set up your appointment and pay for the visit. Changing Family Doctors If you want to change family doctors, you may pick another Amerigroup network doctor. You may want to change family doctors for the following reasons: You just joined Amerigroup and need to pick a family doctor You want a male or a female doctor You want a doctor that speaks your language You are unhappy with your doctor or his or her staff Your doctor is not an Amerigroup network doctor anymore 8

19 Names of doctors in the Amerigroup network are in our provider directory. You can ask for a copy of the provider directory by calling Member Services at (TTY ). Or you can access it online at If you need help choosing a new doctor, call Member Services. If you decide to choose another family doctor, the change will take place the next day after you ask for it. You may not be able to change to a new family doctor for the following reasons: The doctor is not an Amerigroup network doctor The doctor is not accepting new patients at the time The doctor is a specialist If Your Family Doctor Asks You to Change to a New Family Doctor It is important for you to have a good relationship with your doctor. This will help you get the health care you need. Your family doctor may ask us to change you to another doctor if you do the following things: You or a family member hurts a doctor or other provider You or a family member uses very bad language to a doctor or other provider You or a family member damages an office You miss appointments over and over again. You often do not follow your doctor s advice We ask our doctors to tell us if our members are doing things that might cause the doctor to ask to have a member changed to another doctor. If your doctor talks to us about you, we will let you know what you are doing that might cause you to have to change doctors. If your doctor decides that you need to change doctors, he or she will send Amerigroup a letter. This letter will tell Amerigroup why you need to change to a new doctor. Amerigroup will send a copy of this letter to you. We will also call you to help you pick a new doctor. If you do not pick a new doctor, we will pick one for you. You will get a new ID card with the new doctor s name and telephone number on it. Getting to Your Doctor Transportation Services Amerigroup covers ground transportation for members in cases of emergency only. Members receive all other transportation services through fee-for-service Medicaid. To find out more about getting a ride to your nonemergency doctor visits, call LogistiCare at (TTY ) (see page 1 for more details). If you have any problems with the service you receive, you can call the LogistiCare Complaint Hotline at If you need emergency care and have no way to get to the hospital, call 911 for an ambulance. Canceling an Appointment If you make an appointment and then can t go, call your provider s office. Try to call at least 24 hours before your appointment. Tell them to cancel the appointment. If you want us to cancel the appointment, just call Member Services at (TTY ). 9

20 After-hours Care You never know when you will need medical care. Amerigroup requires our providers to have an after-hours service you can call for help. If you call your PCP when the office is closed, leave a message with your name and a telephone number where you can be reached. Your PCP should call you back: The same day if you are not sick (nonsymptomatic) Within minutes if you are sick (symptomatic) and it s not an emergency Within 15 minutes for crisis/emergency situations You may also call our Nurse HelpLine at (TTY ) 24 hours a day, 7 days a week for help. Specialists Your family doctor can take care of many of your health care needs, but you may also need care from some other kind of doctor. Your family doctor can refer you to specialists if you need special care. You can also ask your family doctor about going to a specialist. Specialists are doctors, such as surgeons, OB-GYNs or podiatrists, who focus on a certain illness or part of the body. The specialist will treat you and tell your family doctor about your medical condition. Amerigroup has contracted with many types of doctors and other health care providers. This includes specialists. Your family doctor will refer you to the health care provider you need. Your doctor will tell you who the provider is, where the provider is and the provider s telephone number. If your family doctor refers you to another doctor, it is very important that you go to that doctor. Tell your doctor or Member Services if you think you might not go to the other doctor because getting there is too hard. Amerigroup can help you get to the doctor s office to get the care you need. If you do not see the doctor you were referred to, you may become sicker. Amerigroup recommends that you get a referral from your family doctor to go to a specialist and get most other services. A referral is the approval from your family doctor to see another doctor who specializes in treating a certain kind of illness. These other services may include the following: Another doctor, for example, a specialist Chiropractors Podiatrists Hospital care, except in emergencies or emergency admissions Sometimes you may have an illness for which you may need to see a specialist for a long time. Such illnesses could include cancer, HIV or sickle cell. If you have one of these illnesses, your family doctor may give you or you may ask for a referral that will let you keep going to the specialist for a longer time. This will let you keep going without having to go back to your family doctor. This is called a standing referral. The standing referral will say how long you can keep going to the specialist until your family doctor has to give you another referral. Call Member Services at (TTY ) to talk to a care manager. Sometimes a specialist can be your family doctor. This may happen when you have a special health care need that is being taken care of mostly by a specialist or specialty care center. If one of our care managers has already talked with you about your special needs, he or she can help you make this change if it is best for your care and 10