Solutions. STAR+PLUS Member Handbook. Amerigroup Texas, Inc.

Transcription

1 Real Solutions STAR+PLUS Member Handbook Amerigroup Texas, Inc. Bexar, El Paso, Harris, Jefferson, Lubbock, Tarrant, and Travis Service Areas Members with Medicare and Medicaid Coverage TX-MHB n

2 Thank you for being an Amerigroup member! We want to tell you about an update to your member information. The following sections have been revised dental benefit changes are effective September 1, 2013: What Extra Benefits Do I Get as a Member of Amerigroup? Amerigroup covers extra health-care benefits for our STAR+PLUS members. These extra benefits are also called Value-Added Benefits (VABs). We give you these benefits to help keep you healthy and to thank you for choosing Amerigroup as your health-care plan. Call Member Services for more information on the extra benefits you can get or visit our website at Value-Added Benefit Our 24-hour Nurse HelpLine nurses are available 24 hours a day, 7 days a week for your health-care questions How to Get It Call Amerigroup On Call nurses and/or doctors are available 24 hours a day, 7 days a week for help with an urgent medical issue or setting up an urgent doctor appointment Call Transportation assistance to get to your medical appointments when medical transportation services are not available (members who have Medicare will get transportation to services for their Medicaidcovered long-term services and supports) Free cell phone and up to 250 minutes of services each month if you qualify, plus: 200 extra one-time bonus minutes when you choose to receive free health text messages from Amerigroup Call Call or go to for more information Unlimited inbound text messages plus free health and wellness and renewal reminder texts from Amerigroup Unlimited minutes when calling our Member Services line Minutes include international calling if available Preprogrammed cell phones for high-risk members who have limited or no access to a reliable telephone for emergency or medical use An extra 8 hours of respite services for families and caregivers of members age 21 and older Call or go to for more information Call or go to for more information TX-MHB

3 Value-Added Benefit Smoking/tobacco cessation help telephone support with your own personal coach and a full range of nicotine replacement therapy as needed (not available in Tarrant) Healthy lifestyle coaching for eligible members ages 18 to 64 diagnosed and taking medication for hypertension or Type 2 diabetes mellitus Gift card rewards for reaching health goals (not available in Tarrant) Pest control services every 3 months Disaster Kits personal disaster plan and free first aid kit after completion of plan online How to Get It Call or go to for more information Call or go to for more information Call or go to for more information Call or go to for more information Other Important Phone Numbers Texas Client Notification Line STAR+PLUS Program Help Line Medicaid Managed Care Helpline Medical Transportation Program Dallas/Fort Worth area Houston/Beaumont area All other areas (TDD ) Dental Care for members age 20 and under DentaQuest MCNA Dental Member Services Regular business hours are 7 a.m. to 6 p.m. Central time, Monday through Friday, excluding state-approved holidays Member Services is available 24 hours a day, 7 days a week Information is available in English and Spanish Interpreter services are also available TDD Line for the deaf or hard of hearing is For information on the availability of service coordination To set up transportation to your medical visits For behavioral health and substance abuse care For information about our disease management programs

4 Your Amerigroup ID Card What Information Is on My Amerigroup ID Card? If you do not have your Amerigroup ID card yet, you will get it soon. Please carry it with you at all times. You may also print your ID card from our website at You will need to register and log in to the website to access your ID card information. If you are enrolled in Amerigroup to get long-term services only, show your ID card to any long-term services provider you receive care from. The card tells providers you are a member of Amerigroup for your long-term services benefits and how we pay for your care. It also tells them they should not ask you to pay for the benefits covered by Amerigroup. No primary care doctor will be listed on the card since this is covered through your Medicare insurer. If you are enrolled in the Amerivantage Plan offered by Amerigroup, you will get an ID card to present to providers. You must use your Amerivantage ID card to get covered services. Your Amerivantage ID card will tell providers that you have Medicare, Medicaid, and Medicare Part D prescription drug coverage through Amerivantage. If your Medicare coverage is with another Medicare insurer, you will have a card from them. Your Amerigroup ID card has the date you became an Amerigroup member on it. Your ID card lists many of the important phone numbers you need to know, like our Member Services department and Nurse HelpLine. If I Do Not Have a Car, How Can I Get a Ride to a Doctor s Office? Who Do I Call? If you need transportation for medical appointments, call the Medical Transportation Program (MTP) at for the Dallas/Fort Worth area, for the Houston/Beaumont area, or for all other areas Monday through Friday from 8 a.m. to 5 p.m. MTP will help you get to your doctor appointments and to the hospital for scheduled tests or surgery. What Are the Hours of Operation and Limits for Transportation Services? You can call MTP toll-free Monday through Friday from 8 a.m. until 5 p.m. at for the Dallas/Fort Worth area, for the Houston/Beaumont area, or for all other areas. If MTP is not available or cannot meet special needs you have, call your service coordinator or member advocate to help arrange transportation for you. If you have questions about any of this information, please call Member Services at (TTY ). Thank you for choosing Amerigroup as your health plan. We are glad to serve you.

5 Thank you for being an Amerigroup member! We want to tell you about an update to your member information. The following information has been revised: IMPORTANT PHONE NUMBERS Amerigroup Toll-free Member Services Line If you have any questions about your Amerigroup health plan, you can call our Member Services department toll-free at You can call us Monday through Friday from 7 a.m. to 6 p.m. Central time, except for state-approved holidays. If you call after 6 p.m. or on a weekend or holiday, you can leave a voice mail message. A Member Services representative will call you back the next business day. These are some of the things Member Services can help you with: This member handbook Member ID cards What to do if you think you need long-term services and supports Service coordination and accessing services What to do in an emergency and/or crisis Special kinds of health care Healthy living Complaints and medical appeals Rights and responsibilities For members who do not speak English, we are able to help in many different languages and dialects, including Spanish. This service is also available for visits with your doctor at no cost to you. Please let us know if you need an interpreter at least 24 hours before your appointment. Call Member Services for more information. For members who are deaf or hard of hearing, call the 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 doctor visits. Please let us know if you need an interpreter at least 24 hours before your appointment. TX-MHB

6 Thank you for being an Amerigroup member! We want to tell you about an update to your member handbook. The following section has been revised: STATE FAIR HEARING Can I Ask for a State Fair Hearing? If you, as a member of the health plan, disagree with the health plan s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 90 days of the date on the health plan s letter with the decision. If you do not ask for the fair hearing within 90 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at: Fair Hearing Coordinator Amerigroup 3800 Buffalo Speedway, Suite 400 Houston, TX Or you can call Member Services at We can help you with this request. You have the right to keep getting any service the health plan denied or reduced, at least until the final hearing decision is made, if you ask for a fair hearing by the later of: 10 calendar days following the Amerigroup mailing of the notice of the action or The day the health plan s letter says your service will be reduced or end. If you do not request a fair hearing by this date, the service the health plan denied will be stopped. If you ask for a fair hearing, you will get a packet of information letting you know the date, time, and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing. Can I Ask for a Fair Hearing for Long-term Services and Supports? Yes, you can ask for a fair hearing from the state for long-term services and supports. To request one, see the instructions in the Can I Ask for a State Fair Hearing? section above. TX-MHB

7 Dear Member: Welcome to Amerigroup. We are pleased that you chose us to arrange for your Amerigroup benefits. The member handbook tells you how Amerigroup works and how to help you take good care of your health. It also tells you how to get health care when you need it. You will get your Amerigroup ID card and more information from us in a few days. Your ID card will tell you when your Amerigroup membership starts. We want to hear from you. Call You can talk to a Member Services representative about your benefits. You can also talk to a nurse on our Nurse HelpLine. Thank you for picking us as your health plan. Sincerely, LeAnn Behrens Chief Executive Officer Amerigroup Texas Health Plans Amerigroup is a diverse company and welcomes all eligible people. We do not base membership on health status. If you have questions or concerns, please call and ask for extension Or visit

8 AMERIGROUP STAR+PLUS PROGRAM MEMBER HANDBOOK FOR MEMBERS WITH BOTH MEDICARE AND MEDICAID COVERAGE Bexar Service Area El Paso Service Area Harris and Jefferson Service Areas San Pedro Avenue 7430 Remcon Circle 3800 Buffalo Speedway Suite 400 Building C, Suite 120 Suite 400 San Antonio, TX El Paso, TX Houston, TX Lubbock Service Area Tarrant Service Area Travis Service Area 3223 S. Loop N. Highway Congress Ave. Suite 110 Suite 300 Suite 400 Lubbock, TX Grand Prairie, TX Austin, TX Welcome to Amerigroup! This member handbook will tell you how to use Amerigroup to get the long-term care you need. Table of Contents WELCOME TO AMERIGROUP!... 1 INFORMATION ABOUT YOUR NEW HEALTH PLAN...1 YOUR AMERIGROUP MEMBER HANDBOOK...1 IMPORTANT PHONE NUMBERS... 1 AMERIGROUP MEMBER SERVICES DEPARTMENT...1 AMERIGROUP 24-HOUR NURSE HELPLINE...2 OTHER IMPORTANT PHONE NUMBERS...2 YOUR AMERIGROUP ID CARD... 3 WHAT INFORMATION IS ON MY AMERIGROUP ID CARD?...3 How Do I Read My Amerigroup ID Card?... 3 How Do I Replace My Amerigroup ID Card If It Is Lost or Stolen?... 3 YOUR TEXAS BENEFITS MEDICAID CARD...3 WHAT IF I NEED A TEMPORARY ID MEDICAID CARD?...4 PRIMARY CARE PROVIDERS... 5 WHAT IS A PRIMARY CARE PROVIDER?...5 WHAT DO I NEED TO BRING WITH ME TO MY DOCTOR S APPOINTMENT?...5 PHYSICIAN INCENTIVE PLANS... 5

9 CHANGING HEALTH PLANS... 5 WHAT IF I WANT TO CHANGE HEALTH PLANS?...5 WHO DO I CALL?...5 HOW MANY TIMES CAN I CHANGE HEALTH PLANS?...6 WHEN WILL MY HEALTH PLAN CHANGE BECOME EFFECTIVE?...6 CAN AMERIGROUP ASK THAT I BE DROPPED FROM THEIR HEALTH PLAN (FOR NONCOMPLIANCE, ETC.)?...6 MY BENEFITS... 6 WHAT ARE MY HEALTH-CARE BENEFITS?...6 How Do I Get These Services?... 6 What If Amerigroup Doesn t Have a Provider For One of My Covered Benefits?... 6 Are There Any Limits to Any Covered Services?... 7 WHAT ARE MY ACUTE CARE BENEFITS?...7 WHAT SERVICES ARE COVERED BY MEDICAID?...7 How Do I Get These Services?... 7 What Number Do I Call to Find Out about These Services?... 7 WHAT ARE MY LONG-TERM SERVICES AND SUPPORTS BENEFITS?...7 How Do I Get These Services?... 7 What Number Do I Call to Find Out about These Services?... 8 WHAT IS SERVICE COORDINATION?...8 YOUR AMERIGROUP SERVICE PLAN...8 WHAT IS A SERVICE PLAN?...9 HOW DO I CHANGE MY AMERIGROUP SERVICE PLAN?...9 What Will a Service Coordinator Do for Me?... 9 How Can I Talk with a Service Coordinator?... 9 HOW CAN I MAKE SURE I KEEP GETTING THE COMMUNITY CARE FOR THE AGED AND DISABLED, COMMUNITY BASED ALTERNATIVE WAIVER, OR NURSING HOME SERVICES I AM GETTING NOW?...9 WHAT SERVICES ARE NOT COVERED? WHAT ARE MY PRESCRIPTION DRUG BENEFITS? What if I Also Have Medicare? How Do I Find a Network Drugstore? What If I Go to a Drugstore Not in the Network? What Do I Bring With Me to the Drugstore? What if I Need My Medications Delivered to Me? Who Do I Call If I Have Problems Getting My Medications? What If I Can t Get the Medication My Doctor Ordered Approved? What If I Lose My Medication(s)? What If I Need Durable Medical Equipment or Other Products Normally Found In a Pharmacy? CALL FOR MORE INFORMATION ABOUT THESE BENEFITS WHAT EXTRA BENEFITS DO I GET AS A MEMBER OF AMERIGROUP? How Can I Get These Extra Benefits? WHAT HEALTH EDUCATION CLASSES DOES AMERIGROUP OFFER? WHAT OTHER SERVICES CAN AMERIGROUP HELP ME GET? Community Events Domestic Violence Minors HEALTH-CARE AND OTHER SERVICES WHAT DOES MEDICALLY NECESSARY MEAN? HOW IS NEW TECHNOLOGY EVALUATED? WHAT IS ROUTINE MEDICAL CARE? How Soon Can I Expect to Be Seen?... 14

10 WHAT IS URGENT MEDICAL CARE? How Soon Can I Expect to Be Seen? WHAT IS EMERGENCY MEDICAL CARE? When Can I Expect to Be Seen? HOW SOON CAN I SEE MY DOCTOR? WHAT IS POSTSTABILIZATION? What If I Am out of the Country? HOW CAN I ASK FOR A SECOND OPINION? CAN SOMEONE INTERPRET FOR ME WHEN I TALK WITH MY LONG-TERM SERVICES AND SUPPORTS? Who Do I Call for an Interpreter? How Far in Advance Do I Need to Call? How Can I Get a Face-to-Face Interpreter in the Provider s Office? IF I DO NOT HAVE A CAR, HOW CAN I GET A RIDE TO A DOCTOR S OFFICE? WHO DO I CALL? How Far in Advance Do I Need to Call? How Can Someone I Know Give Me a Ride to My Appointment and Get Money for Mileage? What Are the Hours of Operation and Limits for Transportation Services? Who Do I Call if I Have a Complaint about the Service or Staff? WHAT IF I AM PREGNANT? How Do I Sign Up My Newborn Baby? HOW AND WHEN DO I TELL AMERIGROUP? HOW AND WHEN DO I TELL MY CASEWORKER? WHO DO I CALL IF I HAVE SPECIAL HEALTH-CARE NEEDS AND NEED SOMEONE TO HELP ME? WHAT IF I AM TOO SICK TO MAKE A DECISION ABOUT MY MEDICAL CARE? What Are Advance Directives? How Do I Get an Advance Directive? WHAT HAPPENS IF I LOSE MY MEDICAID COVERAGE? WHAT IF I GET A BILL FROM MY DOCTOR? WHO DO I CALL? CAN MY MEDICARE PROVIDER BILL ME FOR SERVICES OR SUPPLIES IF I AM IN BOTH MEDICARE AND MEDICAID? WHAT INFORMATION WILL THEY NEED? WHAT DO I HAVE TO DO IF I MOVE? WHAT IF I HAVE OTHER HEALTH INSURANCE IN ADDITION TO MEDICAID? Medicaid and Private Insurance WHAT ARE MY RIGHTS AND RESPONSIBILITIES AS AN AMERIGROUP MEMBER? QUALITY MANAGEMENT WHAT IS THE AMERIGROUP QUALITY MANAGEMENT PROGRAM? WHAT ARE CLINICAL PRACTICE GUIDELINES? COMPLAINTS PROCESS WHAT SHOULD I DO IF I HAVE A COMPLAINT? WHO DO I CALL? Can Someone from Amerigroup Help Me File a Complaint? How Long Will It Take to Process My Complaint? What Are the Requirements and Time Frames for Filing a Complaint? How Do I File a Complaint with the Health and Human Services Commission Once I Have Gone through the Amerigroup Complaint Process? APPEALS PROCESS WHAT CAN I DO IF MY DOCTOR ASKS FOR A SERVICE FOR ME THAT S COVERED BUT AMERIGROUP DENIES IT OR LIMITS IT? HOW WILL I FIND OUT IF SERVICES ARE DENIED? What Are the Time Frames for the Appeals Process? How Can I Continue Receiving My Services That Were Already Approved?... 24

11 Can Someone from Amerigroup Help Me File an Appeal? Can Members Request a State Fair Hearing? EXPEDITED APPEALS WHAT IS AN EXPEDITED APPEAL? HOW DO I ASK FOR AN EXPEDITED APPEAL? DOES MY REQUEST HAVE TO BE IN WRITING? WHAT ARE THE TIME FRAMES FOR AN EXPEDITED APPEAL? WHAT HAPPENS IF THE HEALTH PLAN DENIES THE REQUEST FOR AN EXPEDITED APPEAL? WHO CAN HELP ME FILE AN EXPEDITED APPEAL? STATE FAIR HEARING CAN I ASK FOR A STATE FAIR HEARING? CAN I ASK FOR AN APPEAL FOR LONG-TERM SERVICES AND SUPPORTS? FRAUD AND ABUSE DO YOU WANT TO REPORT WASTE, ABUSE, OR FRAUD? INFORMATION THAT MUST BE AVAILABLE ON AN ANNUAL BASIS NOTICE OF PRIVACY PRACTICES... 28

12 WELCOME TO AMERIGROUP! Information about Your New Health Plan Welcome to Amerigroup. Amerigroup is a managed care organization committed to helping you get the right care close to home. You have enrolled in Amerigroup to get STAR+PLUS long-term services and supports through the Texas Medicaid program. To find out about providers in your area, visit or contact Member Services at Our records show you get your acute health care from your primary care provider through original Medicare and a Prescription Drug Plan or a Medicare Advantage Plan that includes Part D coverage. If you live in Bexar, Brazoria, Denton, Fort Bend, Harris, Montgomery, or Tarrant counties, you may have picked the Amerigroup Amerivantage Plan, a Medicare Advantage Plan, for your Medicare benefits. If you are enrolled in the Amerivantage Plan, please also refer to the Amerivantage evidence of coverage and member handbook for complete details on your Medicare and prescription drug benefits and how they work together with the benefits you receive through Medicaid. If you are enrolled with another Medicare insurer, refer to the handbook and information they send you. Your Amerigroup Member Handbook This handbook will help you understand your Amerigroup health plan. If you have questions, call our Member Services department. Amerigroup also has the member handbook in a large print version, an audio-taped version, and a Braille version. The other side of this handbook is in Spanish. IMPORTANT PHONE NUMBERS Amerigroup Member Services Department If you have any questions about your Amerigroup health plan benefits, you can call our Member Services department at You can call us Monday through Friday from 8 a.m. to 5 p.m. local time, except for holidays. If you call after 5 p.m. or on a holiday, you can leave a voice mail message. A Member Services representative will call you back the next business day. Member Services can help you with: This member handbook Member ID cards Your Amerigroup Service Coordination team What to do if you think you need long-term services and supports Special kinds of health care Healthy living Complaints and appeals Rights and responsibilities For members who do not speak English, we are able to help in many different languages and dialects, including Spanish. This service is also available for visits with your doctor at no cost to you. Please let us know if you need an interpreter at least 24 hours before your appointment. Call Member Services for more information. 1

13 For members who are deaf or hard of hearing, call the toll-free AT&T Relay Service at Amerigroup will set up and pay for you to have a person who knows sign language help you during your doctor visits. Please let us know if you need an interpreter at least 24 hours before your appointment. Amerigroup 24-hour Nurse HelpLine The Nurse HelpLine is available to all members 24 hours a day, 7 days a week. You can call the Nurse HelpLine at if you need advice on: How soon you need care for an illness What kind of health care is needed How you can get the care that is needed We want you to be happy with all the services you get through Amerigroup. Please call Member Services if you have any problems. We want to help you correct any problems you may have with your care. If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away. Other Important Phone Numbers Texas Client Notification Line STAR+PLUS Program Help Line Medicaid Managed Care Helpline (TDD ) Medical Transportation Program Monday through Friday 8 a.m. to 5 p.m. Dental Care for members age 20 and under DentaQuest MCNA Dental Dental Care for members age 21 and older (not for members in Tarrant) Member Services Regular business hours are 8 a.m. to 5 p.m. local time for your service area, Monday through Friday, excluding state-approved holidays Member Services is available 24 hours a day, 7 days a week Information is available in English and Spanish Interpreter services are also available TDD Line for hearing impaired is For information on the availability of Service Coordination To set up transportation to your medical visits For behavioral health and substance abuse care For information about our disease management programs

14 YOUR AMERIGROUP ID CARD What Information Is on My Amerigroup ID Card? If you do not have your Amerigroup ID card yet, you will get it soon. Please carry it with you at all times. If you are enrolled in Amerigroup to get long-term care services only, show your ID card to any long-term care provider you receive services from. The card tells providers you are a member of Amerigroup for your long-term care benefits and how we pay for your care. It also tells them they should not ask you to pay for the benefits covered by Amerigroup. No primary care doctor will be listed on the card since this is covered through your Medicare insurer. If you are enrolled in the Amerivantage Plan offered by Amerigroup, you will have 1 ID card to present to providers. You must use your Amerivantage ID card to get covered services. Your Amerivantage ID card will tell providers that you have Medicare, Medicaid, and Medicare Part D prescription drug coverage through Amerivantage. If your Medicare coverage is with another Medicare insurer, you will have a card from them. Your Amerigroup ID card has the date you became an Amerigroup member on it. Your ID card lists many of the important phone numbers you need to know, like our Member Services department and Nurse HelpLine. How Do I Read My Amerigroup ID Card? The card tells providers and hospitals you are a member of Amerigroup. It also says that Amerigroup will pay for the benefits listed in the My Benefits section. Your Amerigroup ID card shows the date you became an Amerigroup member. It also lists many of the important phone numbers you need to know, like our Member Services department and Nurse HelpLine. How Do I Replace My Amerigroup ID Card If It Is Lost or Stolen? If your ID card is lost or stolen, call us right away. We will send you a new one. Your Texas Benefits Medicaid Card When you are approved for Medicaid, you will get a Your Texas Benefits Medicaid card. This plastic card will be your everyday Medicaid ID card. You should carry and protect it just like your driver s license or a credit card. The card has a magnetic stripe that holds your Medicaid ID number. Your doctor can use the card to find out if you have Medicaid benefits when you go for a visit. 3

15 You will get a new Your Texas Benefits Medicaid card every time you change your health plan. If you are not sure if you are covered by Medicaid, you can find out by calling toll-free at You can also call First pick a language and then pick option 2. Your health history is a list of medical services and drugs that you have gotten through Medicaid. We share it with Medicaid doctors to help them decide what health care you need. If you don t want your doctors to see your health history through the secure online network, call toll-free at The Your Texas Benefits Medicaid card has these facts printed on the front: Your name and Medicaid ID number The name of the Medicaid program you re in if you get your Medicaid services through a health plan; this would be STAR, STAR Health, or STAR+PLUS The date HHSC made the card for you Facts your drugstore will need to bill Medicaid The name of the health plan you re in and the plan s phone number The name of your doctor and drugstore if you re in the Medicaid Limited program The back of the Your Texas Benefits Medicaid card has a website you can visit ( and a phone number you can call ( ) if you have questions about the new card. If you forget your card, your doctor, dentist, or drugstore can use the phone or the Internet to make sure you get Medicaid benefits. If you lose the Your Texas Benefits Medicaid card, you can get a new one by calling toll-free at What If I Need a Temporary ID Medicaid Card? If you have lost or do not have access to Your Texas Benefits Medicaid card and need a temporary ID Medicaid card, you can get the Temporary ID Card (Form 1027-A) at your local HHSC benefits office. Present this form as proof of your eligibility for Medicaid in the same way you would present your Texas Benefits Medicaid card as described above. Your provider will accept this form as proof of Medicaid eligibility. 4

16 PRIMARY CARE PROVIDERS What Is a Primary Care Provider? A primary care provider is a family doctor who will provide you with most of your routine care. Your doctor will give you a medical home. That means that he or she will get to know you and your health history and be able to help you get the best possible care. He or she will also send you to other doctors or hospitals when you need special care. Because you have Medicare coverage, your acute care coverage is through your Medicare plan. You pick a primary care provider through your Medicare coverage. Please look at the Evidence of Coverage for your Medicare plan to understand the role of a primary care provider, who can be a primary care provider, how to change your primary care provider, and how to get care. What Do I Need to Bring with Me to My Doctor s Appointment? When you go to the doctor's office for your appointment, bring your Medicare or Medicare plan card, your Amerigroup ID card, and Texas Benefits Medicaid card along with any medicines you are taking and shot records. PHYSICIAN INCENTIVE PLANS Amerigroup rewards doctors for treatments that reduce or limit services for people covered by Medicaid. This is called a physician incentive plan. You have the right to know if your primary care provider (main doctor) is part of this physician incentive plan. You also have the right to know how the plan works. You can call Member Services at to learn more about this. CHANGING HEALTH PLANS What If I Want to Change Health Plans? You can change your health plan by calling the Texas STAR or STAR+PLUS Program Helpline at You can change health plans as often as you want, but not more than once a month. If you are in the hospital, a residential Substance Use Disorder (SUD) treatment facility, or residential detoxification facility for SUD, you will not be able to change health plans until you have been discharged. If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that. For example: If you call on or before April 15, your change will take place on May 1 If you call after April 15, your change will take place on June 1 If you do not like something about Amerigroup, please call Member Services. We will work with you to try to fix the problem. If you are still not happy, you may change to another health plan. Who Do I Call? You can change your health plan by calling the Texas STAR or STAR+PLUS Program Helpline at

17 How Many Times Can I Change Health Plans? You can change plans as many times as you want, but not more than once a month. If you are in the hospital, you cannot change your plan until you are discharged. When Will My Health Plan Change Become Effective? If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that. For example: If you call on or before April 15, your change will take place on May 1 If you call after April 15, your change will take place on June 1 Can Amerigroup Ask That I Be Dropped from Their Health Plan (for Noncompliance, etc.)? There are several reasons you could be disenrolled from Amerigroup without asking to be disenrolled. These are listed below. If you have done something that may lead to disenrollment, we will contact you. We will ask you to tell us what happened. You could be disenrolled from Amerigroup if: You are no longer eligible for Medicaid You let someone else use your Amerigroup ID card You try to hurt a provider, a staff person, or an Amerigroup associate You steal or destroy property of a provider or Amerigroup You go to the emergency room over and over again when you do not have an emergency You try to hurt other patients or make it hard for other patients to get the care they need If you have any questions about your enrollment, call Member Services. MY BENEFITS What Are My Health-care Benefits? Since you have Medicare and Medicaid, you have benefits for acute care and long-term services and supports. Your acute care benefits are covered by Medicare or the Medicare plan you have picked. Your long-term services and supports benefit is covered by Amerigroup. You get long-term services and supports from Amerigroup. How Do I Get These Services? Your primary care provider and your Medicare insurer will help you get the acute care you need. To get longterm services and supports or to learn about benefit limits, call your service coordinator or Member Services at What If Amerigroup Doesn t Have a Provider For One of My Covered Benefits? If a covered benefit is not available to you through a network provider, Amerigroup will arrange services with an out-of-network provider and will reimburse the out-of-network provider according to state rules. You must contact Member Services at to arrange out-of-network services except in case of emergency. 6

18 Are There Any Limits to Any Covered Services? Your Medicare insurer can tell you about the limits to your acute care services. What Are My Acute Care Benefits? Your acute care benefits are covered through your Medicare insurer and are listed in the Evidence of Coverage you received. Some of your Medicare benefits are listed below: Primary care provider office services, when medically necessary Specialist services when referred by your primary care provider and medically necessary Medically necessary inpatient and outpatient medical hospital services Family planning service done by any qualified health-care provider Coverage for pregnancy and newborn baby services Ambulance services in an emergency Chiropractic services treatment period Emergency room and urgent care services Outpatient behavioral health services (mental health) Outpatient behavioral health services (chemical dependency) Inpatient behavioral health services (mental health and chemical dependency) Routine medical care You may also get acute care services from Medicaid, including services, supplies, and outpatient drugs and biologicals that are available under the Texas Medicaid program when: Medicaid covers a service that Medicare does not cover Medicare services become a Medicaid expense due to a benefit limitation on the Medicare side being met What Services Are Covered by Medicaid? Medicaid covers some services, supplies, and medications that are not covered by your Medicare insurer. These are called wrap-around services. These services (like drugs) will be covered by fee-for-service Medicaid. How Do I Get These Services? Call your primary care doctor or your Medicare insurer for help with getting acute care services. What Number Do I Call to Find Out about These Services? Call your Medicare insurer for questions about your acute care benefits. What Are My Long-term Services and Supports Benefits? Some medically necessary long-term care services are for members who need help and have no one to help them. Other long-term services and supports are for members whose care needs would qualify them to be in a facility but who want to stay home. How Do I Get These Services? Some people need help with everyday tasks, like eating or light housekeeping duties, fixing meals, or personal care. If you have no one to help you at home, Amerigroup can help. Call Amerigroup to ask for help. We will send a service coordinator to your home to see what help you need. With your agreement, the service coordinator will talk to your doctors. Then, the service coordinator will tell you about the help Amerigroup can help get for you. If you agree, the service coordinator will help get the services started. And our service 7

19 coordinator will call you to see how well you are doing with the services. To get any long-term services, you must talk to your service coordinator first. Long-term services and supports may include: Day activity and health service Personal attendant services In-home or out-of-home respite services Adaptive aids and medical equipment Adult foster care/personal care home Assisted living/residential care Emergency response system Medical supplies Minor home modifications Transition assistance services Nursing services Dental services Physical therapy Occupational therapy Speech/language therapy Home-delivered meals What Number Do I Call to Find Out about These Services? Call your service coordinator or Member Services at We will find out about your needs and which services you can get. To get any service, you must call your service coordinator first. If we have not talked to you during your first month as a new member, it is very important for you to call Member Services because we need to talk to you. Call sooner if you recently changed your address and/or phone number or think you need long-term services and supports. Your Amerigroup service coordinator will talk with you or visit your home to find out more about your health and need for services. What Is Service Coordination? A service coordinator is assigned to each Amerigroup STAR+PLUS member when requested. The service coordinator will help you get the health care you need. Call Member Services at as soon as you are an Amerigroup member to help you get a service coordinator quickly. Service coordinators work on teams that may consist of: You and a family member or friend An Amerigroup service coordinator Amerigroup telephone/local Member Services representatives Your STAR+PLUS providers Your Amerigroup Service Plan Your service coordinator will work with you to help decide if you need any special services like long-term services or case management. Examples of long-term care services are nursing home or assisted living care and adult day care. We give case management services to members who have conditions such as cancer, HIV, congestive heart failure, end state renal disease, sickle cell, diabetes, and asthma and who need pulmonary and/or wound care. If you need any of these services, your service coordinator will put together a service plan for you. This is a plan for how often and how many services you need. We will develop a plan with you and your caregivers. Once you 8

20 agree on a plan, we will arrange for and approve coverage of the services for you as needed. They may be the same services you have had in the past or they may be a little different. Your service coordinator will tell you about all of the services in your service plan. You will be able to participate in the development of your service plan. Amerigroup wants you to get to know your service coordinator and your service coordinator wants to know about you. Remember, you are the most important part of your Service Coordination team. What Is a Service Plan? Your primary care provider will explain your health-care needs to you and talk to you about the different ways your health-care problems can be treated. Your primary care provider will develop a service plan to meet your specific health-care needs. You will work with your primary care provider in deciding what health care is best for you. Your primary care provider will update your service plan once a year or as your health needs change. How Do I Change My Amerigroup Service Plan? Your service coordinator will call you or visit you periodically to check on you. If something changes in your health or ability to take care of yourself, you should call your service coordinator right away. You do not have to wait for him or her to call or visit you. Your service coordinator wants to know about any changes in your health as soon as possible. The service coordinator also wants to know about any problems you start having with everyday tasks like getting dressed, bathing, or taking your medicines. If you are not doing well, your service coordinator will work with the rest of the team to help you get the care you need. Your service coordinator will also review your service plan yearly or more often if needed. Your service coordinator will change your plan if needed and you agree. Your service coordinator will visit your home if you have a major change in your service plan. If you have a family member or friend who cares for you, the service coordinator will want to talk to him or her also. What Will a Service Coordinator Do for Me? The state sends us information about your health and the services you have been getting from Medicaid. Your service coordinator will read this information to find out more about you. It will tell your service coordinator which providers he or she needs to call to be sure you keep getting the right care. We will ask you how helpful your Medicaid services have been. We will talk to your Medicaid providers about the care you have been getting. And, if you agree, we will talk to your doctors about your health-care needs. How Can I Talk with a Service Coordinator? You can reach your service coordinator by calling When you call, a service coordinator will discuss with you what services you may need. The service coordinator will schedule an appointment to visit you in your home. The service coordinator will plan with you what help you need. If you do not call us or if we cannot reach you by phone, we will come to your home without an appointment. At this home visit, we will ask you about your health and any problems you may have with daily living tasks. You may want a family member or friend to talk with us, too. How Can I Make Sure I Keep Getting the Community Care for the Aged and Disabled, Community Based Alternative Waiver, or Nursing Home Services I Am Getting Now? If you have been getting Medicaid s Community Care for the Aged and Disabled, Community Based Alternative (CBA) HCBS STAR+PLUS Waiver or nursing home services in the past, you will still get the care you need. If you are at home, you may have attendants that come to bathe you, change your bed linens, etc. If your attendant 9

21 does not show up, call our Member Services department right away. Amerigroup will help get the care started again. What Services Are Not Covered? For long-term services and supports, Amerigroup does not offer services that are not covered by fee-for-service Medicaid. Read your Evidence of Coverage from your Medicare insurer or call them to learn what acute care services are not covered. What Are My Prescription Drug Benefits? You should use your Medicare Part D coverage first in getting your medicine. If Medicare does not cover your medicine, Medicaid pays for most medicine your doctor says you need. Your doctor will write a prescription so you can take it to the drugstore or may be able to send the prescription for you. What if I Also Have Medicare? Medicare Part D covers most medicines. Show your Medicare card to the pharmacist so they fill your prescriptions. How Do I Find a Network Drugstore? If you do not know if a drugstore takes Medicare Part D or Amerigroup, ask the pharmacist. You can also call your Medicare Part D insurer or Amerigroup Member Services for help at What If I Go to a Drugstore Not in the Network? The pharmacist will explain that they do not accept Medicare Part D or Amerigroup. You will need to take your prescription to a pharmacy that accepts your coverage. What Do I Bring With Me to the Drugstore? When you go to the drugstore, you should bring: Your prescription(s) or medicine bottles Your Medicare Part D Prescription ID card Your Amerigroup ID card Your Texas Benefits Medicaid card What if I Need My Medications Delivered to Me? Many pharmacies provide delivery services. Ask your pharmacist if they can deliver to your home. Who Do I Call If I Have Problems Getting My Medications? If you have problems getting your medications, please call your Medicare Part D insurer or Amerigroup Member Services at We can work with you and your pharmacy to make sure you get the medicine you need. What If I Can t Get the Medication My Doctor Ordered Approved? Some medicines require prior authorization from Amerigroup. If your doctor cannot be reached to approve a prescription you may be able to get a three-day emergency supply of your medication. Call Amerigroup at for help with your medications and refills. Ask your pharmacist to dispense a 3-day supply. What If I Lose My Medication(s)? If your medicine is lost or stolen, have your pharmacist contact your Medicare Part D insurer or Amerigroup at

22 What If I Need Durable Medical Equipment or Other Products Normally Found In a Pharmacy? Some durable medical equipment and products normally found in a pharmacy are covered by both Medicare and Medicaid. For items both Medicare and Medicaid cover, Medicare will pay first, and your Amerigroup Medicaid plan will pay second. These include items such as nebulizers, ostomy and diabetic supplies, and other covered supplies and equipment if they are medically necessary. Medicaid may also pay for items found in a pharmacy that are not covered by Medicare such as medically necessary prescribed over-the-counter drugs, diapers, and some vitamins and minerals. You should verify your pharmacy is participating with Medicare or is part of your Medicare and/or Medicaid health plan. Call for more information about these benefits. What Extra Benefits Do I Get as a Member of Amerigroup? Amerigroup covers extra health-care benefits for our STAR+PLUS members. These extra benefits are also called value-added services. We give you these benefits to help keep you healthy and to thank you for choosing Amerigroup as your health-care plan. Call Member Services to find out what extra benefits and services are available to you or visit our website at Value-Added Benefit Our 24-hour Nurse HelpLine nurses are available 24 hours a day, 7 days a week for your health-care questions How to Get It Call Amerigroup On Call nurses and/or doctors are available 24 hours a day, 7 days a week for help with an urgent medical issue or setting up an urgent doctor appointment Call Transportation assistance to get to your medical appointments when medical transportation services are not available (members who have Medicare will get transportation to services for their Medicaid-covered longterm services and supports) Call Monday through Friday 8 a.m. to 5 p.m. Enhanced dental benefits for members age 21 and older (not for members in Tarrant) Call Additional 100 one-time Lifeline cell phone minutes and free health-related text messages if you qualify Preprogrammed cell phones for high-risk members who have limited or no access to a reliable telephone for emergency or medical use An extra 8 hours of respite services for families and caregivers of members age 21 and older Smoking/tobacco cessation help (not for members in Tarrant) Call or go to for more information Call or go to for more information Call or go to for more information Call or go to 11

23 Value-Added Benefit How to Get It for more information Healthy lifestyle coaching for eligible members with chronic conditions ages 18 to 64 (not for members in Tarrant) Pest control services every 3 months Call or go to for more information Call or go to for more information How Can I Get These Extra Benefits? To find out more about these benefits, call your service coordinator or Member Services. We will find out about your needs and which services you can get. What Health Education Classes Does Amerigroup Offer? Amerigroup works to help keep you healthy with its health education programs. We can also help you find community health classes near your home. These classes are held at no cost to you. You can call Member Services to find out where and when these classes are held. You can also go to our website at to get information on the classes in your community. Some of the classes include: Childbirth Infant care Parenting Pregnancy Quitting cigarette smoking Protecting yourself from violence Other classes about health topics We will also mail a member newsletter to you once each year. This newsletter gives you health information about well care, taking care of illnesses, how to be a better parent, and many other topics. What Other Services Can Amerigroup Help Me Get? Community Events Amerigroup sponsors and participates in free special community events and family fun days where you can get health information and have a good time. You can learn about topics like healthy eating, asthma, and stress. You and your family can play games, win prizes, or get your face painted. Amerigroup representatives will be there to answer your questions about your benefits, too. Call Member Services or check the member section of our website at to find out when and where these events will be. Domestic Violence Domestic violence is abuse. Abuse is unhealthy. Abuse is unsafe. It is never OK for someone to hit you. It is never OK for someone to make you afraid. Domestic violence causes harm and hurt on purpose. Domestic violence in the home can affect your children, and it can affect you. If you feel you may be a victim of abuse, call or talk to 12

24 your doctor. Your doctor can talk to you about domestic violence. He or she can help you understand you have done nothing wrong and do not deserve abuse. Safety tips for your protection: If you are hurt, call your doctor; call 911 or go to the nearest hospital if you need emergency care; see the section on emergencies for more information Have a plan on how you can get to a safe place (like a women's shelter or a friend or relative's home) Always keep a small bag packed Give your bag to a friend to keep for you until you need it If you have questions, please call the National Domestic Violence hotline number at Minors For most Amerigroup members age 17 and younger, Amerigroup network doctors and hospitals cannot give them care without their parent or legal guardian s consent. This does not apply if emergency care is needed. Parents or legal guardians also have the right to know what is in their child s medical records. Members age 17 and younger can ask their doctor not to tell their parents about their medical records unless the parents ask the doctor to see the medical records. These rules do not apply to emancipated minors. Emancipated minors are members age 17 and younger who: Are married Are pregnant Have a child Emancipated minors can make their own decisions about their medical care and the medical care of their children. Parents no longer have the right to see the medical records of emancipated minors. HEALTH-CARE AND OTHER SERVICES Except in the case of an emergency (see the section on What Is Emergency Care?), you should always call your provider first before you get medical care. If you have a medical concern you need to discuss with the provider after the office is closed, call our Nurse HelpLine 24 hours a day, 7 days a week for help. If you think you need emergency care (see the section What Is Emergency Care?), call 911 or go to the nearest emergency room right away. What Does Medically Necessary Mean? Your primary care provider will help you get the services you need that are medically necessary as defined below. Medically necessary means: 1) For members from birth through age 20, the following Texas Health Steps services: a) Screening, vision, and hearing services b) Other health-care services necessary to correct or ameliorate a defect or physical or mental illness or condition. A determination of whether a service is necessary to correct or ameliorate a defect or physical or mental illness or condition: i) Must comply with the requirements of a final court order that applies to the Texas Medicaid program or the Texas Medicaid managed care program as a whole and 13