CHIP Member Handbook Amerigroup Texas, Inc. Bexar, Dallas, Harris, Jefferson, and Tarrant Service Areas

Transcription

1 CHIP Member Handbook Amerigroup Texas, Inc. Bexar, Dallas, Harris, Jefferson, and Tarrant Service Areas TX-MHB

2 Thank you for being an Amerigroup member! We want to tell you about a few updates to your benefit information. Please read this with care and keep it with your member handbook. The Amerigroup On Call benefit is no longer offered. The 24-hour Nurse HelpLine is still available, and you can call 24 hours a day, 7 days a week with questions about your health. The following section has been revised effective September 1, 2015: What other benefits does a member of Amerigroup get? How can I get these benefits for my child? Amerigroup covers more health-care benefits for CHIP and CHIP Perinatal Newborn members. These benefits are also called Value-added Benefits. 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 benefits you can get or visit our website at Value -added Benefit How to Get It Our 24-hour Nurse HelpLine nurses are available 24 hours a day, 7 days a week for your health-care questions Help getting a ride to doctor visits for members with chronic illnesses One sports or school physical every year for members ages 6 to 18 Boys & Girls Club membership for members ages 6 to 18 where available Cell phone and up to 250 minutes of services each month if you qualify, plus: 200 one-time bonus minutes when you choose to receive health text messages from Amerigroup Call Call or go to for more information See your primary care provider Go to your local Boys & Girls Club Call or go to for more information Unlimited inbound text messages plus health and wellness and renewal reminder texts from Amerigroup Unlimited minutes when calling our Member Services line Minutes include international calling if available Allergy-free pillow cover (1 per year) for members age 18 and younger who have been diagnosed with asthma and participate in a disease/case management program Taking Care of Baby and Me program support, assistance, and educational materials for members during and after pregnancy Call or go to for more information Call or go to for more information TX-MHI

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 Healthy Rewards gift cards for getting certain well-child and pregnancy check-ups, influenza and rotavirus series vaccinations Disaster Kits personal disaster plan and 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 If you have questions about any of this information, please call Member Services at (TTY 711).

4 Thank you for being an Amerigroup member! We want to tell you about an update to your member information. The following information has been added to the member handbook: What is Complex Case Management? Complex Case Management is a program we have in addition to our disease management program. We have case managers available to help manage your health care if you have special needs. A case manager may be able to help you if you have experienced a critical event or have been diagnosed with a serious health condition such as diabetes. We have special case managers for members with a high-risk pregnancy, multiple pregnancy, history of preterm delivery with a past pregnancy, or current preterm labor. How do I get these services? You do not need a referral from your doctor. You can contact the Complex Case Management Program by calling Member Services at and asking to speak to a complex case manager. Our case managers are licensed nurses and social workers, available Monday through Friday from 8 a.m. to 5 p.m. Central time. Case managers also have confidential voic available 24 hours a day. TX-MHI

5 Dear Parent/Guardian: Welcome to Amerigroup, a Children s Health Insurance Program (CHIP) Health Maintenance Organization (HMO). We are pleased that you chose us to arrange for health-care benefits for your child. The member handbook tells you how Amerigroup works and how to help keep your child healthy. It tells you how to get health care when it is needed, too. There is also information included about a free membership for your child to the Boys & Girls Club. This is a special Amerigroup service for members ages 6 to 18. The clubs provide many fun and educational activities for children. They are a great place to go after school. There is something for everyone! You will get your child s Amerigroup ID card and more information from us in a few days. Your ID card will tell you when your child s Amerigroup membership starts; The name of your child s doctor is on the card too; Please check the doctor s name shown on your child s ID card. If it is not right, please call us. You can talk to a Member Services representative at about your child s benefits; You can also talk to a nurse on our Nurse HelpLine by calling if your child is sick or if you need nurse advice about a medical condition. Thank you for picking us as your child s health plan; Sincerely, LeAnn Behrens President Amerigroup Medicaid Health Plans - Texas

6 Ameritips: Health Tips That Make Health Happen Your child needs to go to the doctor now! When is it time for a well-child checkup? Your child needs to have regular checkups. This way, your child s primary care provider can see if there is a problem before it becomes a bad problem. When your child becomes an Amerigroup member, call his or her primary care provider and make the first appointment before the end of 90 days. Well-Child Checkups for Children Children need more well-care checkups than adults. Your child should get checkups at the times listed below. Birth Well - child Checkup Schedule for Your Child 9 months old 3-5 days 12 months old By 1 month old 15 months old 2 months old 18 months old 4 months old 24 months old 6 months old 30 months old After age 2 1/2, your child should visit the doctor every year. Amerigroup encourages and covers annual checkups for members ages Be sure to make these appointments and take your child to his or her doctor when scheduled. Find health problems before they get worse and harder to treat. Prevent health problems that make it hard for your child to learn and grow. If your child s doctor finds a health problem during a checkup, your child can get the care he or she needs such as eye exams and glasses, hearing tests and hearing aids, or dental care. What If My Daughter Becomes Pregnant? If you think your daughter is pregnant, call her doctor 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 your child s doctor or OB/GYN, please call Amerigroup Member Services at ALERT! DO NOT LOSE YOUR HILD S HEALTH-CARE BENEFITS RENEW ELIGIBILITY FOR CHIP BENEFITS ON TIME! 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

7 Amerigroup Member Handbook For CHIP and CHIP Perinate Newborn Members Bexar Service Area Harris/Jefferson Service Areas Dallas/Fort Worth Service Areas San Pedro Ave Buffalo Speedway 2505 N. Highway 360 Suite 400 Suite 400 Suite 300 San Antonio, TX Houston, TX Grand Prairie, TX Table of Contents WELCOME TO AMERIGROUP... 1 INFORMATION ABOUT YOUR CHILD S NEW HEALTH PLAN...1 YOUR AMERIGROUP MEMBER HANDBOOK...1 IMPORTANT PHONE NUMBERS... 1 Amerigroup toll-free Member Services line...1 AMERIGROUP 24-HOUR NURSE HELPLINE...2 BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES...2 OTHER IMPORTANT PHONE NUMBERS...2 YOUR AMERIGROUP ID CARD... 2 WHAT DOES MY CHILD S AMERIGROUP ID CARD LOOK LIKE?...2 HOW DO I READ AND USE MY CHILD S AMERIGROUP ID CARD?...3 HOW DO I REPLACE MY CHILD S AMERIGROUP ID CARD IF IT IS LOST OR STOLEN?...3 PRIMARY CARE PROVIDERS FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS... 3 WHAT IS A PRIMARY CARE PROVIDER?...3 WHAT DO I NEED TO BRING TO MY CHILD S DOCTOR S APPOINTMENT?...3 CAN A CLINIC (LOCAL PUBLIC HEALTH CLINIC, RURAL HEALTH CLINIC, FEDERALLY QUALIFIED HEALTH CENTER) BE MY CHILD S PRIMARY CARE PROVIDER?...4 HOW CAN I CHANGE MY CHILD S PRIMARY CARE PROVIDER?...4 HOW MANY TIMES CAN I CHANGE MY CHILD S PRIMARY CARE PROVIDER?...4 WHEN WILL MY CHILD S PRIMARY CARE PROVIDER CHANGE BECOME EFFECTIVE?...4 ARE THERE ANY REASONS WHY MY REQUEST TO CHANGE MY CHILD S PRIMARY CARE PROVIDER MAY BE DENIED?...4 CAN A PRIMARY CARE PROVIDER MOVE MY CHILD TO ANOTHER PRIMARY CARE PROVIDER FOR NONCOMPLIANCE?...4 WHAT IF I CHOOSE TO GO TO ANOTHER DOCTOR WHO IS NOT MY CHILD S PRIMARY CARE PROVIDER?...4 HOW DO I GET MEDICAL CARE AFTER MY CHILD S PRIMARY CARE PROVIDER S OFFICE IS CLOSED?...5 PHYSICIAN INCENTIVE PLANS... 5

8 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?...5 WHEN WILL MY HEALTH PLAN CHANGE BECOME EFFECTIVE?...5 CAN AMERIGROUP ASK THAT I GET DROPPED FROM THEIR HEALTH PLAN?...5 COVERAGE FOR NEWBORNS... 6 BENEFITS FOR CHIP AND CHIP PERINATE NEWBORN MEMBERS... 6 WHAT ARE MY CHILD S CHIP AND CHIP PERINATE NEWBORN PROGRAM BENEFITS?...6 How do I get these services for my child?...6 Are there any limits to any covered services?...7 What are the CHIP Perinate Newborn benefits? What benefits does my baby receive at birth?...7 What benefits are not covered?...7 What are my prescription drug benefits?...7 WHAT ARE COPAYMENTS?...7 How Much Are They And When Do I Have to Pay Them?...7 WHAT ARE CHIP COST-SHARING CAPS?...8 WHEN WILL I GET AN EXPLANATION OF BENEFITS?...8 WHAT EXTRA BENEFITS DOES A MEMBER OF AMERIGROUP GET? HOW CAN I GET THESE BENEFITS FOR MY CHILD?...8 WHAT HEALTH EDUCATION CLASSES DOES AMERIGROUP OFFER?...9 HEALTH CARE AND OTHER SERVICES FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS...10 WHAT DOES MEDICALLY NECESSARY MEAN? HOW IS NEW TECHNOLOGY EVALUATED? WHAT IS ROUTINE MEDICAL CARE? How soon can I expect my child to be seen?...11 WHAT IS URGENT MEDICAL CARE? How soon can I expect my child to be seen?...11 WHAT IS EMERGENCY MEDICAL CARE? What is an Emergency, an Emergency Medical Condition, or an Emergency Behavioral Health Condition?...11 What are emergency services and/or emergency care?...12 How Soon Can I Expect My Child to Be Seen?...12 ARE EMERGENCY DENTAL SERVICES COVERED? WHAT DO I DO IF I NEED/MY CHILD NEEDS EMERGENCY DENTAL CARE? HOW SOON CAN I SEE MY DOCTOR? WHAT IS POSTSTABILIZATION? HOW DO I GET MEDICAL CARE AFTER MY PRIMARY CARE PROVIDER S OFFICE IS CLOSED? WHAT IF I GET SICK WHEN I AM OUT OF TOWN OR TRAVELING/WHAT IF MY CHILD GETS SICK WHEN HE OR SHE IS OUT OF TOWN OR TRAVELING? What if my child is out of the state?...13 What if my child is out of the country?...14 WHAT IF MY CHILD NEEDS TO SEE A SPECIAL DOCTOR (SPECIALIST)? WHAT IS A REFERRAL? What services do not need a referral?...14 How soon can I expect my child to be seen by a specialist?...14

9 HOW CAN I ASK FOR A SECOND OPINION? HOW DO I GET HELP IF MY CHILD HAS BEHAVIORAL (MENTAL) HEALTH OR DRUG PROBLEMS? Do I need a referral for this?...15 HOW DO I GET MY/MY CHILD S MEDICATIONS? How do I find a network drugstore?...15 What if I go to a drugstore not in the network?...15 What do I bring with me to the drugstore?...15 What if I need my child s medications delivered to me?...15 Who do I call if I have problems getting my medications?...15 What if I can t get the medication my child s doctor ordered approved?...15 What if I lose my child s medications?...15 WHAT IF MY CHILD NEEDS AN OVER-THE-COUNTER MEDICATION FOR CHIP? How do I find out what drugs are covered?...16 How do I transfer my prescriptions to a network pharmacy?...16 What if a copay is required and I am unable to pay it?...16 How do I get my medicine if I am traveling?...16 What if I paid out-of-pocket for a medicine and want to be reimbursed?...16 WHAT IF I NEED/MY CHILD NEEDS BIRTH CONTROL PILLS? HOW DO I GET EYE CARE SERVICES FOR MY CHILD? HOW DO I GET DENTAL CARE SERVICES FOR MY CHILD? CAN SOMEONE INTERPRET FOR ME WHEN I TALK WITH MY CHILD S DOTOR? Who do I call for an interpreter?...17 How far in advance do I need to call?...17 How can I get a face-to-face interpreter in the provider s office?...17 WHAT IF MY DAUGHTER NEEDS OB/GYN CARE? DOES SHE HAVE THE RIGHT TO CHOOSE AN OB/GYN? How do I choose an OB/GYN?...17 If I don t choose an OB/GYN, do I have direct access?...17 Will I need a referral?...17 How soon can my daughter be seen after contacting an OB/GYN for an appointment?...17 Can my daughter stay with an OB/GYN who is not with Amerigroup?...18 WHAT IF MY DAUGHTER IS PREGNANT? Who do I call?...18 What other services/activities/education does Amerigroup offer pregnant women?...18 WHO DO I CALL IF MY CHILD HAS SPECIAL HEALTH-CARE NEEDS AND I NEED SOMEONE TO ASSIST ME? WHAT IF I GET A BILL FROM MY CHILD S DOCTOR? WHO DO I CALL? What information will they need?...19 WHAT DO I HAVE TO DO IF MY CHILD MOVES? RECERTIFY YOUR CHILD S CHIP BENEFITS ON TIME WHAT ARE MY RIGHTS AND RESPONSIBILITIES? QUALITY MANAGEMENT...21 WHAT DOES QUALITY MANAGEMENT DO FOR MEMBERS? WHAT ARE CLINICAL PRACTICE GUIDELINES? COMPLAINT PROCESS...21 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? IF I AM NOT SATISFIED WITH THE OUTCOME, WHO ELSE CAN I CONTACT?... 22

10 DO I HAVE THE RIGHT TO MEET WITH A COMPLAINT APPEAL PANEL? PROCESS TO APPEAL A CHIP ADVERSE DETERMINATION...23 WHAT CAN I DO IF MY CHILD S PROVIDER ASKS FOR A SERVICE FOR MY CHILD THAT IS COVERED BUT AMERIGROUP DENIES OR LIMITS IT? HOW WILL I FIND OUT IF SERVICES ARE DENIED? WHAT ARE THE TIME FRAMES FOR THE APPEAL PROCESS? WHEN DO I HAVE THE RIGHT TO ASK FOR AN APPEAL? DOES MY REQUEST HAVE TO BE IN WRITING? CAN SOMEONE FROM AMERIGROUP HELP ME FILE AN APPEAL? EXPEDITED APPEALS...24 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 AMERIGROUP DENIES THE REQUEST FOR AN EXPEDITED APPEAL? WHO CAN HELP ME IN FILING AN APPEAL? INDEPENDENT REVIEW ORGANIZATION PROCESS...25 WHAT IS AN INDEPENDENT REVIEW ORGANIZATION? HOW DO I ASK FOR A REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION? WHAT ARE THE TIME FRAMES FOR THIS PROCESS? FRAUD AND ABUSE INFORMATION...25 DO YOU WANT TO REPORT CHIP WASTE, ABUSE, OR FRAUD? NOTICE OF PRIVACY PRACTICES...27 ATTACHMENT A - EVIDENCE OF COVERAGE AND SCHEDULE OF BENEFITS AND EXCLUSIONS...31

11 WELCOME TO AMERIGROUP Information about your child s new health plan Welcome to Amerigroup Texas, Inc., doing business as Amerigroup. Amerigroup is a health maintenance organization (HMO) committed to getting your child the right care close to home. As a Children s Health Insurance Program (CHIP) or CHIP Perinate Newborn member, you and your child s providers will work together to help keep your child healthy. Amerigroup helps your child get quality health care. This member handbook will help you understand your child s Amerigroup health plan. To find out about doctors and hospitals in your area, visit or contact Member Services at Your Amerigroup member handbook This member handbook is for CHIP members and CHIP Perinate Newborn members. When there are differences in the way things work between CHIP and CHIP Perinate Newborn members (like in the section on copayments), we will explain those differences. This handbook will help you understand your child s Amerigroup health plan. References to you, my, or I apply if you are a CHIP member. References to my child apply if your child is a CHIP member or a CHIP Perinate Newborn member. If you have questions or need help understanding or reading this member handbook, 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 toll-free Member Services line If you have any questions about your child s 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 Your child s doctors Doctor appointments Transportation Health-care benefits Accessing services What to do in an emergency and/or crisis Cost-sharing information Well care Special kinds of health care Healthy living Complaints and medical appeals 1

12 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 child s 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. Amerigroup 24-hour Nurse HelpLine You can call our 24-hour Nurse HelpLine at if you need advice on: How soon your child needs care for an illness What kind of health care is needed What to do to take care of your child before you see the provider How you can get the care that is needed Behavioral Health and Substance Abuse Services The Behavioral Health and Substance Abuse Services line is available to members 24 hours a day, 7 days a week at It is a free service which you can hear in English or Spanish. For other languages, interpreter services are available. You can call the Behavioral Health and Substance Abuse Services line for help in getting services. If your child has an emergency, you should call 911 or go to the nearest hospital emergency room right away. Other important phone numbers If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away. If you have questions regarding eligibility, call CHIP at If you need help finding a pharmacy or if you have problems getting prescriptions filled, call Amerigroup at If you need help with vision care, call Block Vision at If you have dental questions, call your child s HIP dental plan, DentaQuest at or MCNA Dental at If you have questions about your child s development, call the Texas Early Childhood Intervention Program at YOUR AMERIGROUP ID CARD What does my child s Amerigroup ID card look like? You will get your child s Amerigroup ID card in the mail from us. Please carry it with you at all times. Show it to any provider or hospital you visit. You do not need to show your child s ID card before getting emergency care. Here is what your child s Amerigroup ID card looks like: 2

13 How do I read and use my child s Amerigroup ID card? The card tells providers and hospitals your child is a member of Amerigroup. It also says that Amerigroup will pay for the medically needed benefits listed in the Benefits for CHIP and CHIP Perinate Newborns section of this handbook. Your copayments are listed, too. Your child s Amerigroup ID card lists many of the important phone numbers you need to know, like our Member Services department and Nurse HelpLine. How do I replace my child s Amerigroup ID card if it is lost or stolen? If your child s ID card is lost or stolen, call us toll-free at right away. We will send you a new one. You may also print a new ID card from our website at You will need to register and log in to the website to access ID card information. PRIMARY CARE PROVIDERS FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS What is a primary care provider? Amerigroup members must have a family doctor, also called a primary care provider; Your child s doctor must be in the Amerigroup network; Your child s doctor will give your child a medical home. That means that the doctor will get to know your child and your child s health history and be able to help your child get the best possible care; Your child s doctor will give your child all of the basic health services needed; Your child s doctor will also send your child to other doctors or hospitals when he or she needs special care. When you enrolled your child in Amerigroup, you should have picked a doctor. If you did not, we assigned one. We picked one who should be close to you; This doctor's name and phone number are on your child s Amerigroup ID card. What do I need to bring to my child s doctor s appointment? When you go to the doctor's office for your child s appointment, bring your child's ID card, shot records, and any medicines he or she is taking. 3

14 Can a clinic (local public health clinic, rural health clinic, federally qualified health center) be my child s primary care provider? Yes, clinics listed in the Amerigroup provider directory can be your child s primary care provider. How can I change my child s primary care provider? If you need to change your child s primary care provider, you can visit our website at You can also call Member Services at to request a provider directory or let us help you pick a new doctor. How many times can I change my child s primary care provider? There is no limit on how many times you can change your child s primary care provider; You can change primary care providers by calling us toll-free at or writing to us at the address in the front of the book. When will my child s primary care provider change become effective? We can change your child s primary care provider on the same day you ask for the change. The change will be effective immediately; all 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. Are there any reasons why my request to change my child s primary care provider may be denied? You will not be able to change your child s doctor if: The doctor you have picked cannot take new patients The new doctor is not a part of the Amerigroup network Can a primary care provider move my child to another primary care provider for noncompliance? Yes, your child s doctor may ask for your child to be changed to another doctor; He or she may do this if: You do not follow his or her medical advice over and over again Your child s doctor agrees that a change is best for your child Your child s doctor does not have the right experience to treat your child The assignment to your child s doctor was made in error What if I choose to go to another doctor who is not my child s primary care provider? If you want your child to go to a doctor who is not his or her primary care provider, please talk to your child s doctor first; In most cases, your child s doctor needs to give you a referral so your child can see another doctor; This is done when your child s doctor cannot give him or her the care needed; Please read the What if my child needs to see a special doctor (specialist)? section of this handbook to learn more about referrals. If you go to a doctor that your child s doctor has not referred you to, the care your child receives may not be covered by Amerigroup. Also read the Services that do not need a referral section for more information. 4

15 How do I get medical care after my child s primary care provider s office is closed? If you have a medical concern that you need to discuss with your child s provider after the office is closed, call the number on your child s ID card; If it is not an emergency, someone should call you back within 30 minutes 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 care (see the What is emergency medical care? section), call 911 or go to the nearest emergency room right away. PHYSICIAN INCENTIVE PLANS Amerigroup rewards doctors for treatments that reduce or limit services for people covered by CHIP. This is called a physician incentive plan. You have the right to know if your child s primary care provider (main doctor) is part of this physician incentive plan. You also have a right to know how the plan works. You can call to learn more about this. CHANGING HEALTH PLANS What if I want to change health plans? You are allowed to make health plan changes: For any reason within 90 days of enrollment in CHIP For cause at any time If you move to a different service delivery area During the annual CHIP reenrollment period Who do I call? For more information, call CHIP toll-free at How many times can I change health plans? Generally you can only change health plans once a year during annual CHIP re-enrollment. However, you are also allowed to change health plans for any reason within 90 days of enrollment in CHIP and for cause at any time. You can also change health plans if you move to a different service delivery area. When will my health plan change become effective? Health plan changes become effective the following month if processed prior to the monthly cut-off date. If the change is processed after cut-off, it will become effective the first of the following month. Can Amerigroup ask that I get dropped from their health plan? There are several reasons your child 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. Your child could be disenrolled from Amerigroup if: Your child is no longer eligible for CHIP 5

16 You let someone else use your child s Amerigroup ID card You try to hurt a provider, a staff person, or 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 go to doctors or medical facilities outside the Amerigroup plan over and over again You try to hurt other patients or make it hard for other patients to get the care they need You interfere with the care plan that is being provided If you have any questions about your enrollment, call Member Services. COVERAGE FOR NEWBORNS An unborn child who is enrolled in the CHIP Perinate program will be moved to Medicaid for 12 months of continuous Medicaid coverage, beginning on the date of birth, if the child lives in a family with an income at or below the Medicaid eligibility threshold. An unborn child will continue to receive coverage through the CHIP Perinate Newborn program after birth if the child is born to a family with an income above the Medicaid eligibility threshold. A CHIP Perinate Newborn is eligible for 12 months of continuous enrollment, beginning with the month of enrollment as a CHIP Perinate unborn child. Once a HIP Perinate Newborn member s coverage expires, the child will be added to any active CHIP program case for siblings. If there is not an active case for siblings, the family will receive a CHIP renewal form in the 10th month of the child s HIP Perinate Newborn coverage. The renewal form must be completed and submitted to continue benefits. BENEFITS FOR CHIP AND CHIP PERINATE NEWBORN MEMBERS What are my child s CHIP and CHIP Perinate newborn program benefits? The following list shows some of the health-care benefits covered. For a complete listing of covered benefits, please see the Evidence of Coverage and Schedule of Benefits and Exclusions in Attachment A at the back of this handbook. Regular checkups and office visits Prescription drugs and vaccines Access to medical specialists and mental health care Hospital care and services Medical supplies, X-rays, and lab tests Treatment of special health needs Treatment of pre-existing conditions Coverage for CHIP and CHIP Perinate Newborn members is the same. How do I get these services for my child? Your child s primary care provider will give your child the care needed or refer you to a doctor that can give the care needed. If you have a question or are not sure whether we offer a certain benefit, you can call Member Services for help. 6

17 Are there any limits to any covered services? Yes. Covered services must be medically necessary and in certain cases must be authorized. See the Evidence of Coverage and Schedule of Benefits and Exclusions in Attachment A at the back of this handbook for limits to covered services. What are the CHIP Perinate Newborn benefits? What benefits does my baby receive at birth? If your baby is eligible as a CHIP Perinatal Newborn, he or she is eligible for the same coverage as a CHIP member from the date of birth. Your baby will get 12 months of continuous CHIP Perinatal program coverage through his or her health plan, beginning with the month of enrollment as an unborn child. What benefits are not covered? For a complete listing of benefits that are not covered, please see the Evidence of Coverage and Schedule of Benefits and Exclusions in Attachment A at the back of this handbook. For questions about services not covered by Amerigroup, please call Member Services. What are my prescription drug benefits? Under CHIP, Amerigroup 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 are copayments? Copayments are the amounts that a member is required to pay when getting certain CHIP covered services. You must pay the copayment at the time a health-care service is received. These can be different based on family income and the kind of service. Some services do not have copayments like well-child or well-baby visits or immunizations (shots). No copayments are paid for preventive care and pregnancy-related services. Your child s Amerigroup ID card lists the copayments that apply to your family situation. Present your child s ID card when you get office visit services or have a prescription filled; You do not have to show your child s ID card before he or she gets emergency care. If the cost of a covered service is less than the member s copayment, the member will be required to pay no more than the cost of the covered service. How Much Are They And When Do I Have to Pay Them? The following table shows the CHIP copayment schedule according to family income. Enrollment fees and copayments do not apply for CHIP Perinate Newborn members and CHIP embers who are Native Americans or Alaskan Natives. Federal Poverty Levels At or Below 100% Above 100% up to and including 150% Above 150% up Office Visits $3 $5 Non - emergency Room Visits $3 $5 Hospital Stays (per admission) $15 $35 Prescription Generic Drugs $0 $0 Prescription Brand Drugs $3 $5 Annual Cost Sharing Caps 5% cap of family annual gross income 5% cap of family annual gross income 5% cap of 7

18 Federal Poverty Levels to and including 185% Above 185% up to and including 200% Non - Office Hospital Stays Prescription Prescription Annual Cost emergency Visits (per admission) Generic Drugs Brand Drugs Sharing Caps Room Visits $20 $75 $75 $10 $35 family annual gross income 5% cap of $25 $75 $125 $10 $35 family annual gross income What are CHIP cost-sharing caps? The member guide you received from CHIP when you enrolled includes a tear out form that you should use to track your CHIP expenses. To make sure that you do not exceed your cost-sharing limit, please keep track of your CHIP-related expenses on this form. The enrollment packet welcome letter tells you exactly how much you must spend before you are eligible to mail the form back to CHIP. If you have misplaced your welcome letter, please call CHIP at , and they will tell you what your annual cost-sharing limit is. When you reach your annual cap, please send the form to CHIP, and they will notify Amerigroup. We will send you a new member ID card. This new card will show that no copayments are due when your child gets services. When will I get an explanation of benefits? There may be times when you will need to pay a provider for all or part of the cost for a service your child gets. You may also have to pay part of the cost for a prescription. This will happen if you owe a copayment or if you must meet a deductible. You must also pay a provider for services your child gets that are not covered under CHIP. We will send you an Explanation of Benefits (EOB) only if you must pay the provider a payment to meet your deductible or if the service is not covered. The EOB will tell you how much you owe the provider. It will explain why you owe the provider a payment. We will also let the provider know how much you owe. You will need to make a payment directly to the provider. You will not get an EOB if you only have to pay a copayment. This is because a copayment should be paid at the time that you see the provider or get the prescription. What extra benefits does a member of Amerigroup get? How can I get these benefits for my child? Amerigroup covers extra health-care benefits for CHIP and CHIP Perinate Newborn 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

19 Value - Added Benefit 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 Help getting a ride to doctor visits for members with chronic illnesses One free sports or school physical every year for members age 18 and younger Free Boys & Girls Club membership for members ages 6 to 18 where available 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 How to Get It Call Call or go to for more information See your primary care provider Go to your local Boys & Girls Club 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 Asthma camps for eligible members ages 8 to 12 when and where available Taking Care of Baby and Me program educational materials and gifts for completion of certain prenatal checkups and designated classes Smoking/tobacco cessation help telephone support with your own personal coach and a full range of nicotine replacement therapy as needed Call or go to for more information Call or go to for more information Call or go to for more information What health education classes does Amerigroup offer? Amerigroup works to keep your child healthy with our health education programs. We can help you find classes near your home. You can call Member Services to find out where and when these classes are held. Some of the classes include childbirth, infant care, parenting, pregnancy, and protecting yourself from violence. 9

20 HEALTH CARE AND OTHER SERVICES FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS What does medically necessary mean? Covered services for CHIP members and CHIP Perinate Newborn members must meet the CHIP definition of medically necessary.medically necessary health-care services means: Nonbehaviorial health-care services that are: Reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a member, or endanger life Provided at appropriate facilities and at the appropriate levels of care for the treatment of a member s health conditions Consistent with health-care practice guidelines and standards that are endorsed by professionally recognized health-care organizations or governmental agencies Consistent with the member s diagnoses No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency Not experimental or investigative and Not primarily for the convenience of the member or provider and Behavioral health-care services that: Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder Are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care Are furnished in the most appropriate and least restrictive setting in which services can be safely provided Are the most appropriate level or supply of service that can safely be provided ould not be omitted without adversely affecting the member s mental and/or physical health or the quality of care rendered Are not experimental or investigative and Are not primarily for the convenience of the member or provider If you have questions regarding an authorization, a request for services, or a utilization management question, you can call Member Services at (TTY ). How is new technology evaluated? The Amerigroup Medical Director and participating providers review and evaluate new medical advances in technology (or the new application of existing technology) in medical procedures, behavioral health procedures, pharmaceuticals, and devices to determine their appropriateness for covered benefits. Scientific literature and government approval are reviewed for determining if the treatment is safe and effective. The new medical advance or treatment (or new application of existing technology) must provide equal or better outcomes than the existing covered benefit treatment or therapy for it to be considered for coverage by Amerigroup. 10

21 What is routine medical care? In most cases when your child needs medical care, you call your child s primary care provider to make an appointment. These visits will cover most preventive care, minor illnesses, and injuries. This type of care is known as routine care. How soon can I expect my child to be seen? Your child should be able to see his or her doctor within 2 weeks for routine care. What is urgent medical care? The second type of care is urgent medical care. There are some injuries and illnesses that are not emergencies but can turn into emergencies if they are not treated within 24 hours. Some examples are: Throwing up Minor burns or cuts Earaches Headaches Sore throat Fever over 101 degrees Muscle sprains/strains For urgent care, you should call your child s doctor; Your child s doctor will tell you what to do; The doctor may tell you to go to his or her office right away, or you may be told to go to some other office to get immediate care. You should follow the doctor's instructions. In some cases, the doctor may tell you to go to the emergency room at a hospital for care. See the next section about emergency care for more information. You can also call our 24-hour Nurse HelpLine at for advice about urgent care. How soon can I expect my child to be seen? Your child should be able to see a provider within 24 hours for an urgent care appointment. What is emergency medical care? After routine and urgent care, the third type of care is emergency care. If you need help deciding whether to go to the emergency room, call our 24-hour Nurse HelpLine. The most important thing is to get medical care as soon as possible. What is an Emergency, an Emergency Medical Condition, or an Emergency Behavioral Health Condition? Emergency care is a covered service. Emergency care is provided for emergency medical conditions and emergency behavioral health conditions. An emergency medical condition is a medical condition characterized by sudden acute symptoms, severe enough (including severe pain), that would lead an individual with average knowledge of health and medicine, to expect that the absence of immediate medical care could result in: Placing the member s health in serious jeopardy Serious impairment to bodily functions Serious dysfunction of any bodily organ or body part Serious disfigurement or In the case of a pregnant CHIP member, serious jeopardy to the health of the CHIP member or her unborn child 11

22 Emergency behavioral health condition means any condition, without regard to the nature or cause of the condition, which in the opinion of an individual possessing average knowledge of health and medicine: Requires immediate intervention or medical attention without which the member would present an immediate danger to himself/herself or others or Renders the member incapable of controlling, knowing, or understanding the consequences of his/her actions What are emergency services and/or emergency care? Emergency services and/or emergency care means health-care services provided in an in-network or out-ofnetwork hospital emergency department; free-standing emergency medical facility; or other comparable facility by in-network or out-of-network physicians, providers, or facility staff to evaluate and stabilize emergency medical conditions and/or emergency behavioral health conditions. Emergency services also include any medical screening examination or other evaluation required by state or federal law that is necessary to determine whether an emergency medical condition and/or an emergency behavioral health condition exists. How Soon Can I Expect My Child to Be Seen? Your child should be able to see a doctor immediately for emergency care. Are Emergency Dental Services Covered? Amerigroup will pay for some emergency dental services provided in a hospital, urgent care center, or ambulatory surgical center setting such as services for: Treatment of a dislocated jaw Treatment of traumatic damage to teeth and supporting structures Removal of cysts Treatment of oral abscess of tooth or gum origin Drugs for any of the above conditions Amerigroup also covers other dental services your child gets in a hospital, urgent care center, or ambulatory surgical center setting. This includes services from the doctor and other services your child might need like anesthesia. What do I do if I need/my child needs emergency dental care? During normal business hours, call your child s main dentist to find out how to get emergency services; If your child needs emergency dental services after the main dentist s office has closed, call us toll-free at How soon can I see my doctor? Amerigroup is dedicated to arranging access to care for our members. Our ability to provide quality access depends upon the accessibility of network providers. Providers are required to follow access standards listed below. Standards are measured from the date of presentation or request, whichever occurs first. Emergency Services Urgent Care Standard Name Amerigroup Immediately upon member presentation at the service delivery site Within 24 hours 12

23 Standard Name Routine Primary Care Routine Specialty Care Preventive Health: Child Preventive Health: Newborn Prenatal Care Pregnancy High Risk/3rd trimester Behavioral Health Non-life-threatening Emergency Behavioral Health Urgent Care Behavioral Health-Routine Care After-Hours Care Office Wait Time Amerigroup Within 14 days Within 3 weeks Within 60 days Within 14 days Within 14 days Within 5 days or immediately, if an emergency exists Within 6 hours (NCQA) Within 24 hours The earlier of 10 business days or 14 calendar days For PCPs Practitioners accessible 24/7 directly or through answering service - Answering service or recording assistance in English and Spanish and Member reaches on call physician or medical staff within 30 minutes Within 30 minutes What is poststabilization? Poststabilization care services are services covered by CHIP that keep your child s condition stable following emergency medical care. How do I get medical care after my primary care provider s office is closed? If you have a medical concern that you need to discuss with the provider after the office closed, call the number on your ID card. If it is not an emergency, someone should call you back within 30 minutes 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 you need emergency care (see the What Is Emergency Medical Care? section), call 911 or go to the nearest emergency room right away. What if I get sick when I am out of town or traveling/what if my child gets sick when he or she is out of town or traveling? If you/your child needs medical care when traveling, call us at and we will help you find a doctor. If you/your child needs emergency services while traveling, go to nearest hospital then call us at What if my child is out of the state? If you need emergency care when you are outside of Texas, go to the nearest hospital emergency room or call

24 What if my child is out of the country? Medical services performed outside of the country are not covered by CHIP. What if my child needs to see a special doctor (specialist)? Your child s doctor can take care of most of your child s health-care needs, but he or she may also need care from other kinds of doctors. Amerigroup offers services from many different kinds of doctors that provide other medically needed care. These doctors 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) If your child s doctor cannot give him or her the needed care, your child s doctor will give you a referral to see a specialist; In most cases, you need to have a referral from your child s doctor to see another doctor; Your child s doctor will give you a referral form so you can see the 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. What is a referral? A referral is a request from your child s provider to get care or treatment from a specialist. If your child s provider cannot give the needed care, he or she will give your child a referral to 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 go to the specialist. What services do not need a referral? It is best to ask your child s doctor for a referral for any Amerigroup service. The following services do not require a referral and can be accessed directly: Emergency care Care provided by an Amerigroup network doctor s nurse or doctor assistant CHIP services Amerigroup does not cover (you may have to pay for the service) Yearly exams from an Amerigroup network OB/GYN Prenatal care from an Amerigroup network obstetrician or certified nurse midwife Screening or testing for sexually transmitted diseases, including HIV from an Amerigroup network doctor Well-child preventive health visits, including immunizations (shots) and screenings Behavioral health (mental health and drug and alcohol abuse) services Vision exam and glasses How soon can I expect my child to be seen by a specialist? Your child should be able to see a specialist within 3 weeks. How can I ask for a second opinion? Amerigroup members have the right to ask for a second opinion about the use of any health-care services. You can get a second opinion from a network provider or a non-network provider (if a network provider is not available). Ask your doctor to submit a request for you to have a second opinion. This is at no cost to you. 14

25 How do I get help if my child has behavioral (mental) health or drug problems? Call Member Services toll free at Do I need a referral for this? You do not need a referral from your primary care provider for behavioral health and/or substance use problems. How do I get my/my child s medications? CHIP covers most of the medicine your/your child s doctor says you need; Your/your child s doctor will write a prescription so you can take it to the drugstore or may be able to send the prescription for you. Exclusions include contraceptive medications prescribed only for the purpose to prevent pregnancy and medications for weight loss or gain. You may have to pay a copayment for each prescription filled depending on your income. How do I find a network drugstore? If you do not know if a drugstore takes Amerigroup, ask the pharmacist. You can also call 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 Amerigroup. You will need to take your prescription to a pharmacy that accepts Amerigroup. What do I bring with me to the drugstore? When you go to the drugstore you should bring: Your prescription(s) or medicine bottle(s) Your Amerigroup ID card What if I need my child s 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 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 child s doctor ordered approved? If your child s doctor cannot be reached to approve a prescription, your child may be able to get a 3-day emergency supply of your child s medication; Call Amerigroup at for help with your medication and refills. What if I lose my child s medications? If your child s medicine is lost or stolen, have your pharmacist call Amerigroup at