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STAR+PLUS Member HandbookAmerigroup Texas, Inc.

Bexar, El Paso, Harris, Jefferson, Lubbock, Tarrant, and Travis Service AreasMedicaid Members

Real

Solutions

1-800-600-4441 n www.myamerigroup.com/tx

TX-M

HB-0

054-

12 2

.13

www.myamerigroup.com

TX-MHB-0066-13

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 www.myamerigroup.com/TX.

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

Call 1-866-864-2544

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 1-866-864-2544

Transportation assistance to get to your medical appointments when medical transportation services are not available

Call 1-800-600-4441

Enhanced vision benefits for members age 21 and older Call 1-800-600-4441 or go to www.myamerigroup.com/TX for more information

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

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

Call 1-800-600-4441 or go to www.myamerigroup.com/TX for more information

Preprogrammed cell phone for high-risk members who have limited or no access to a reliable phone for emergency and medical use


An extra 8 hours of respite services for families and caregivers of members age 21 and older


http://www.myamerigroup.com/

Value-Added Benefit How to Get It

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)

Call 1-800-600-4441 or go to

www.myamerigroup.com/TX for more information

Taking Care of Baby and Me® program − educational materials and gifts for completion of certain prenatal checkups and designated classes (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 Call 1-800-600-4441 or go to www.myamerigroup.com/TX for more information

Disaster Kits — personal disaster plan and free first aid kit after completion of plan online


Other Important Phone Numbers If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away. STAR+PLUS Program Help Line 1-800-964-2777 Medicaid Managed Care Help Line 1-866-566-8989 (TDD 1-866-222-4306) Texas Health Steps Program 1-877-847-8377 Block Vision for Eye Care 1-800-428-8789 Dental Care for members age 20 and younger DentaQuest 1-800-516-0165 MCNA Dental 1-800-494-6262 Texas Client Notification Line 1-800-414-3406 Medical Transportation Program – Dallas/Fort Worth area 1-855-687-3255 Houston/Beaumont area 1-855-687-4786 All other areas 1-877-633-8747 Amerigroup on Call/Nurse HelpLine 24 hours a day, 7 days a week 1-866-864-2544 Member Services 1-800-600-4441

For behavioral health and substance abuse care For service coordination For information about our disease management programs For information about prescription drugs

YOUR AMERIGROUP ID CARD

What Does My Amerigroup ID Card Look Like? If you do not have your Amerigroup ID card yet, you will get it soon. Please carry it with you at all times. Show it to any doctor or hospital you visit. You do not need to show your ID card before you get emergency care. The card tells doctors and hospitals that you are a member of Amerigroup and who your primary care provider is. It also tells them that Amerigroup will pay for the medically needed benefits listed in the section My Benefits. Your Amerigroup ID card has the name and phone number of your doctor on it. It also has the date your primary care provider assignment is effective. Your ID card lists many of the important phone numbers you need to know, like our Member Services department and the Nurse HelpLine/Amerigroup on Call. It also has the phone number for you to call to get eye care. If your ID card is lost or stolen, call Amerigroup right away. We will send you a new one. You may also print your ID card from our website at www.myamerigroup.com/TX. You will need to register and log in to the website to access your ID card information.

What Services Do Not Need a Referral?

You can get the following services without a referral from your doctor:

Emergency care

Behavioral health services (mental health and/or substance abuse) from an Amerigroup behavioral health services provider

Family planning from any Amerigroup network or state-approved Medicaid family planning provider

Prenatal care from an Amerigroup network obstetrician or certified nurse midwife

Eye care from an Amerigroup network eye care provider (optometrist)

Screening or testing for sexually transmitted diseases, including HIV, from an Amerigroup network doctor

Texas Health Steps (formerly EPSDT) medical checkups from a Texas Health Steps provider for children, starting from birth through age 20

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 1-855-687-3255 for the Dallas/Fort Worth area, 1-855-687-4786 for the Houston/Beaumont area, or 1-877-633-8747 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 1-855-687-3255 for the Dallas/Fort Worth area, 1-855-687-4786 for the Houston/Beaumont area, or 1-877-633-8747 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 an emergency and need transportation, call 911 for an ambulance.

If you have questions about any of this information, please call Member Services at 1-800-600-4441 (TTY 1-800-855-2880). Thank you for choosing Amerigroup as your health plan. We are glad to serve you.


TX-MHB-0070-13

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 1-800-600-4441. 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

Your doctors

Doctor appointments

Transportation

Health-care benefits

What to do in an emergency and/or crisis

Well care

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 1-800-855-2880. 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-0080-13

Thank you for being an Amerigroup member! We want to tell you about an update to your member handbook.

The following sections have been revised:

What Is Case Management for Children and Pregnant Women?

Case Management for Children and Pregnant Women

Need help finding and getting services? You might be able to get a case manager to help you.

Who can get a case manager? Children, teens, young adults (birth through age 20), and pregnant women who get Medicaid and:

Have health problems or

Are at a high risk for getting health problems What do case managers do?

A case manager will visit with you and then:

Find out what services you need

Find services near where you live

Teach you how to find and get other services

Make sure you are getting the services you need What kind of help can you get?

Case managers can help you:

Get medical and dental services

Get medical supplies or equipment

Work on school or education issues

Work on other problems How can you get a case manager?

Call Texas Health Steps at 1-877-847-8377 toll-free Monday to Friday from 8 a.m. to 8 p.m. To learn more, go to www.dshs.state.tx.us/caseman.

What Services Are Offered by Texas Health Steps? Texas Health Steps is the Medicaid health-care program for children, teens, and young adults, birth through age 20. Texas Health Steps gives your child:

Free regular medical checkups starting at birth

Free dental checkups starting at 6 months of age

A case manager who can find out what services your child needs and where to get these services

Texas Health Steps checkups:

Find health problems before they get worse and are harder to treat

Prevent health problems that make it hard for children to learn and grow like others their age

Help your child have a healthy smile When to set up a checkup:

You will get a letter from Texas Health Steps telling you when it’s time for a checkup; call your child’s doctor to set up the checkup

Set up the checkup at a time that works best for your family If the doctor or dentist finds a health problem during a checkup, your child can get the care he or she needs, such as:

Eye tests and eyeglasses

Hearing tests and hearing aids

Other health and dental care

Treatment for other medical conditions Call Amerigroup Member Services at 1-800-600-4441 (TTY 1-800-855-2880) or Texas Health Steps at 1-877-847-8377 (1-877-THSTEPS) toll-free if you:

Need help finding a doctor or dentist

Need help setting up a checkup

Have questions about checkups or Texas Health Steps

Need help finding and getting other services If you can’t get your child to the checkup, Medicaid may be able to help. Children with Medicaid and their parent can get free rides to and from the doctor, dentist, hospital, or drug store.

Houston/Beaumont area: 1-855-687-4786

Dallas/Ft. Worth area: 1-855-687-3255

All other areas: 1-877-633-8747 (1-877-MED-TRIP)

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 77098

Or you can call Member Services at 1-800-600-4441. 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.


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 tells you how to get health care when it is needed, too. You will get your Amerigroup ID card and more information from us in a few days. Your ID card will tell you when your Amerigroup membership starts and who your primary care provider is. We want to hear from you. Call 1-800-600-4441. You can talk to a Member Services representative about your benefits. You can also talk to a nurse on our Nurse HelpLine by calling 1-866-864-2544. Thank you for picking us as your health plan. Sincerely,

LeAnn Behrens Chief Operating Officer Amerigroup Texas Health Plans

Ameritips: Health Tips That Make Health Happen You need to go to your doctor now!

When Is It Time for a Wellness Visit? All Amerigroup members need to have regular wellness visits. This way your primary care provider can see if you have a problem before it is a bad problem. When you become an Amerigroup member, call your primary care provider and make your first appointment before the end of 90 days.

Well Care for Children, the Texas Health Steps Program Children need more wellness checkups than adults. These medical checkups for children from birth through age 20 who have Medicaid are called Texas Health Steps. When your child becomes an Amerigroup member, we may contact you to remind you to take your child for a medical checkup. Your child should get Texas Health Steps medical checkups at the times listed below.

Texas Health Steps Medical Checkups Schedule for Your Child

Birth 9 months old

3 – 5 days 12 months old

2 weeks old 15 months old

2 months old 18 months old

4 months old 2 years old

6 months old 2 ½ years old

After age 2 1/2, your child should visit the doctor every year. Amerigroup encourages and covers annual checkups for children ages 3 through 20.

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 or dentist 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. If you are a migrant farm worker, your child can receive his or her checkup or service sooner if you are leaving the area.

What If I Become Pregnant? If you think you are pregnant, call your primary care provider or OB/GYN right away. This can help you have a healthy baby. If you have any questions or need help making an appointment with your primary care provider or OB/GYN, please call Amerigroup Member Services at 1-800-600-4441. ALERT! DO NOT LOSE YOUR HEALTH-CARE BENEFITS—RECERTIFY YOUR ELIGIBILITY FOR MEDICAID 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 1-800-600-4441 and ask for extension 34925. Or visit www.myamerigroup.com.

AMERIGROUP STAR+PLUS PROGRAM FOR MEDICAID MEMBERS

MEMBER HANDBOOK

Bexar Service Area 12500 San Pedro Avenue

Suite 400 San Antonio, TX 78216

El Paso Service Area 7430 Remcon Circle Building C, Suite 120

El Paso, TX 79912

Harris and Jefferson Service Areas 3800 Buffalo Speedway

Suite 400 Houston, TX 77098

Lubbock Service Area 3223 S. Loop 289

Suite 110 Lubbock, TX 79423

Tarrant Service Area 2505 N. Highway 360

Suite 300 Grand Prairie, TX 75050

Travis Service Area 823 Congress Ave.

Suite 400 Austin, TX 78701

1-800-600-4441

www.myamerigroup.com/TX Welcome to Amerigroup! This member handbook will tell you how to use Amerigroup to get the care you need.

Table of Contents

INFORMATION ABOUT YOUR 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 Line ...................................................................................................... 2 Other Important Phone Numbers ...................................................................................................................................... 2

YOUR AMERIGROUP ID CARD ...................................................................................... 2

WHAT DOES MY AMERIGROUP ID CARD LOOK LIKE? ................................................................................................2 What Information Is on 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 ......................................................................................... 4

WHAT IS A PRIMARY CARE PROVIDER? ......................................................................................................................4 WHAT DO I BRING WITH ME TO MY DOCTOR’S APPOINTMENT? ..............................................................................5 HOW CAN I CHANGE MY PRIMARY CARE PROVIDER? ................................................................................................5 CAN A CLINIC BE MY PRIMARY CARE PROVIDER? ......................................................................................................5 HOW MANY TIMES CAN I CHANGE MY/MY CHILD’S PRIMARY CARE PROVIDER? .....................................................5

WHEN WILL MY PRIMARY CARE PROVIDER CHANGE BECOME EFFECTIVE? ..............................................................5 ARE THERE ANY REASONS WHY MY REQUEST TO CHANGE A PRIMARY CARE PROVIDER MAY BE DENIED? ......5 CAN MY PRIMARY CARE PROVIDER MOVE ME TO ANOTHER PRIMARY CARE PROVIDER FOR NONCOMPLIANCE? ....................................................................................................................................................5 WHAT IF I CHOOSE TO GO TO ANOTHER DOCTOR WHO IS NOT MY PRIMARY CARE PROVIDER? ............................5 HOW DO I GET MEDICAL CARE AFTER MY PRIMARY CARE PROVIDER’S OFFICE IS CLOSED? ....................................6 WHAT IS THE MEDICAID LIMITED PROGRAM? ...........................................................................................................6

PHYSICIAN INCENTIVE PLAN ........................................................................................ 6

CHANGING HEALTH PLANS .......................................................................................... 6

WHAT IF I WANT TO CHANGE HEALTH PLANS?..........................................................................................................6 WHO DO I CALL? .........................................................................................................................................................7 HOW MANY TIMES CAN I CHANGE HEALTH PLANS? ..................................................................................................7 WHEN WILL MY HEALTH PLAN CHANGE BECOME EFFECTIVE? ..................................................................................7 CAN AMERIGROUP ASK THAT I GET DROPPED FROM THEIR HEALTH PLAN FOR NONCOMPLIANCE? ......................7

MY BENEFITS ............................................................................................................... 7

WHAT ARE MY HEALTH-CARE BENEFITS? ...................................................................................................................7 How Do I Get These Services? ............................................................................................................................................ 7 What If Amerigroup Doesn’t Have a Provider For One of My Covered Benefits? ............................................................. 7

WHAT ARE MY ACUTE CARE BENEFITS? .....................................................................................................................8 How Do I Get These Services? What Number Do I Call to Find Out about These Services? .............................................. 8 Are There Any Limits to Any Covered Services? ................................................................................................................. 9

WHAT SERVICES ARE NOT COVERED BY AMERIGROUP? ...........................................................................................9 WHAT ARE MY LONG-TERM SERVICES AND SUPPORTS BENEFITS? ...........................................................................9

How Do I Get These Services? Who Do I Call? ................................................................................................................. 10 WHAT IS SERVICE COORDINATION? ........................................................................................................................ 10 YOUR AMERIGROUP SERVICE PLAN ........................................................................................................................ 10

What Is a Service Plan? .................................................................................................................................................... 10 How Do I Change My Amerigroup Service Plan? .............................................................................................................. 11 What Will a Service Coordinator Do for Me? ................................................................................................................... 11 How Can I Talk with a Service Coordinator? .................................................................................................................... 11

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? ..................... 11 WHAT ARE MY PRESCRIPTION DRUG BENEFITS? .................................................................................................... 11 WHAT EXTRA BENEFITS DO I GET AS A MEMBER OF AMERIGROUP? ..................................................................... 11

How Do I Get These Extra Benefits? ................................................................................................................................. 12 WHAT HEALTH EDUCATION CLASSES DOES AMERIGROUP OFFER? ....................................................................... 13 WHAT OTHER SERVICES CAN AMERIGROUP HELP ME GET?................................................................................... 13

MY HEALTH-CARE AND OTHER SERVICES .................................................................... 14

WHAT DOES MEDICALLY NECESSARY MEAN? ......................................................................................................... 14 HOW IS NEW TECHNOLOGY EVALUATED? .............................................................................................................. 14 WHAT IS ROUTINE MEDICAL CARE? ........................................................................................................................ 15

How Soon Can I Expect to Be Seen? ................................................................................................................................. 15 WHAT IS URGENT MEDICAL CARE? ......................................................................................................................... 15

How Soon Can I Expect to Be Seen? ................................................................................................................................. 15 WHAT IS EMERGENCY MEDICAL CARE? .................................................................................................................. 15

How Soon Can I Expect to Be Seen? ................................................................................................................................. 16 Are Emergency Dental Services Covered? ........................................................................................................................ 16

WHAT DO I DO IF MY CHILD NEEDS EMERGENCY DENTAL CARE? .......................................................................... 16

HOW SOON CAN I SEE MY DOCTOR? ...................................................................................................................... 16 WHAT IS POSTSTABILIZATION? ............................................................................................................................... 17 HOW DO I GET HEALTH CARE WHEN MY DOCTOR'S OFFICE IS CLOSED? ............................................................... 17 WHAT IF I GET SICK WHEN I AM OUT OF TOWN TRAVELING? ................................................................................ 18

What If I Am out of the State? ......................................................................................................................................... 18 What If I Am out of the Country? ..................................................................................................................................... 18

WHAT IF I NEED TO SEE A SPECIAL DOCTOR (SPECIALIST)? .................................................................................... 18 What Is a Referral? ........................................................................................................................................................... 18 How Soon Can I Expect to Be Seen by a Specialist? ......................................................................................................... 18 What Services Do Not Need a Referral? ........................................................................................................................... 18

HOW CAN I ASK FOR A SECOND OPINION? ............................................................................................................. 19 HOW DO I GET HELP IF I HAVE MENTAL HEALTH, ALCOHOL, OR DRUG PROBLEMS? ............................................. 19

Do I Need a Referral for This? .......................................................................................................................................... 19 HOW DO I GET MY MEDICATIONS? ......................................................................................................................... 19

How Do I Find a Network Drugstore? ............................................................................................................................... 19 What If I Go to a Drugstore Not in the Network? ............................................................................................................ 19 What Do I Bring with Me to the Drugstore? .................................................................................................................... 19 What If I Need My Medications Delivered to Me? ........................................................................................................... 20 Who Do I Call If I Have Problems Getting My Medications? ............................................................................................ 20 What If I Can’t Get the Medication My Doctor Ordered Approved? ............................................................................... 20 What If I Lose My Medication(s)?..................................................................................................................................... 20 How Do I Find Out What Drugs Are Covered?.................................................................................................................. 20 How Do I Transfer My Prescriptions To a Network Pharmacy? ....................................................................................... 20 Will I Have a Copay? ......................................................................................................................................................... 20 How Do I Get My Medicine If I Am Traveling? ................................................................................................................. 20 What If I Paid Out of Pocket For a Medicine and Want To Be Reimbursed? ................................................................... 20 What If I Need Durable Medical Equipment or Other Products Normally Found in a Pharmacy? .................................. 21

HOW DO I GET FAMILY PLANNING SERVICES? ........................................................................................................ 21 Do I Need a Referral for This? .......................................................................................................................................... 21 Where Do I Find a Family Planning Services Provider? .................................................................................................... 21

WHAT IS CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN? ........................................................... 21 What Type of Services Would My Child or I Get? ............................................................................................................ 21

WHAT IS TEXAS HEALTH STEPS? .............................................................................................................................. 21 What Services Are Offered by Texas Health Steps? ......................................................................................................... 22 How and When Do I Get Texas Health Steps Medical and Dental Checkups for My Child? ............................................ 22 Does My Doctor Have to Be Part of the Amerigroup Network? ...................................................................................... 23 Do I Have to Have a Referral? .......................................................................................................................................... 23 What If I Need to Cancel an Appointment? ..................................................................................................................... 23 What If I Am out of Town and My Child is Due for a Texas Health Steps Checkup? ........................................................ 23

WHAT IF I AM A MIGRANT FARM WORKER? .......................................................................................................... 23 When Should Adults Get Checkups? ................................................................................................................................ 23 Wellness Visits Schedule for Adult Members ................................................................................................................... 23 If I Miss My Well-care Visit or Texas Health Steps Checkup, What Do I Do? ................................................................... 24

IF I DO NOT HAVE A CAR, HOW CAN I GET A RIDE TO A DOCTOR’S OFFICE? WHO DO I CALL? .............................. 24 How Far in Advance Do I Need to Call? ............................................................................................................................ 24 How Can Someone I Know Give Me a Ride to My Appointment and Get Money for Mileage? ...................................... 24 Who Do I Call If I Have a Complaint about the Service or Staff? ...................................................................................... 24 What Are the Hours of Operation and Limits for Transportation Services? .................................................................... 24

HOW DO I GET EYE CARE SERVICES? ....................................................................................................................... 24 HOW DO I GET DENTAL CARE SERVICES FOR MY CHILD? ........................................................................................ 25 CAN SOMEONE INTERPRET FOR ME WHEN I TALK TO MY DOCTOR? WHO DO I CALL FOR AN INTERPRETER? .............. 25

How Far in Advance Do I Need to Call? ............................................................................................................................ 25 How Can I Get a Face-to-Face Interpreter in the Provider’s Office? ................................................................................ 25

WHAT IF I NEED OB/GYN CARE? .............................................................................................................................. 25

Do I Have the Right to Choose an OB/GYN? ..................................................................................................................... 25 How Do I Choose an OB/GYN? ......................................................................................................................................... 25 If I Do Not Choose an OB/GYN, Do I Have Direct Access? ................................................................................................ 26 Will I Need a Referral? ...................................................................................................................................................... 26 How Soon Can I Be Seen after Contacting My OB/GYN for an Appointment? ................................................................. 26 Can I Stay with My OB/GYN If He or She Is Not with Amerigroup? .................................................................................. 26

WHAT IF I AM PREGNANT? WHO DO I NEED TO CALL? .......................................................................................... 26 What Other Services/Activities/Education Does Amerigroup Offer Pregnant Women? ................................................. 26 When You Have a New Baby ............................................................................................................................................ 27 Where Can I Find a List of Birthing Centers? .................................................................................................................... 27

HOW DO I SIGN UP MY NEWBORN BABY? .............................................................................................................. 27 How and When Do I Tell Amerigroup? ............................................................................................................................. 28 How and When Do I Tell My Caseworker? ....................................................................................................................... 28

WHO DO I CALL IF I HAVE SPECIAL HEALTH-CARE NEEDS AND NEED SOMEONE TO HELP ME? ............................. 28 WHAT IF I AM TOO SICK TO MAKE A DECISION ABOUT MY MEDICAL CARE? ......................................................... 28

What Are Advance Directives? ......................................................................................................................................... 28 How Do I Get an Advance Directive?................................................................................................................................ 28

WHAT HAPPENS IF I LOSE MY MEDICAID COVERAGE? ........................................................................................... 28 WHAT IF I GET A BILL FROM A DOCTOR? WHO DO I CALL? .................................................................................... 28

What Information Do They Need? ................................................................................................................................... 29 WHAT DO I HAVE TO DO IF I MOVE? ....................................................................................................................... 29 WHAT IF I HAVE OTHER HEALTH INSURANCE IN ADDITION TO MEDICAID? ........................................................... 29 WHAT ARE MY RIGHTS AND RESPONSIBILITIES? ..................................................................................................... 29

QUALITY MANAGEMENT ............................................................................................ 31

WHAT IS THE AMERIGROUP QUALITY MANAGEMENT PROGRAM? ....................................................................... 31 WHAT ARE CLINICAL PRACTICE GUIDELINES? ......................................................................................................... 31

COMPLAINTS PROCESS ............................................................................................... 32

WHAT SHOULD I DO IF I HAVE A COMPLAINT? WHO DO I CALL? ........................................................................... 32 Can Someone from Amerigroup Help Me File a Complaint? ........................................................................................... 32 How Long Will It Take to Process My Complaint? ............................................................................................................ 32 What Are the Requirements and Time Frames for Filing a Complaint? ........................................................................... 32 How Do I File a Complaint with the Health and Human Services Commission Once I Have Gone through the Amerigroup Complaint Process? ...................................................................................................................................... 32

APPEALS PROCESS ...................................................................................................... 32

WHAT CAN I DO IF MY DOCTOR ASKS FOR A SERVICE FOR ME THAT’S COVERED, BUT AMERIGROUP DENIES OR LIMITS IT? ........................................................................................................................................................... 32 HOW WILL I FIND OUT IF SERVICES ARE DENIED? ................................................................................................... 33

What Are the Time Frames for the Appeals Process? ...................................................................................................... 33 How Can I Continue Receiving My Services That Were Already Approved? .................................................................... 33 Can Someone from Amerigroup Help Me File an Appeal? ............................................................................................... 34 Can Members Request a State Fair Hearing? ................................................................................................................... 34

EXPEDITED APPEALS ................................................................................................... 34

WHAT IS AN EXPEDITED APPEAL? ........................................................................................................................... 34 HOW DO I ASK FOR AN EXPEDITED APPEAL? DOES MY REQUEST HAVE TO BE IN WRITING? ................................ 34 WHAT ARE THE TIME FRAMES FOR AN EXPEDITED APPEAL? ................................................................................. 34 WHAT HAPPENS IF AMERIGROUP DENIES THE REQUEST FOR AN EXPEDITED APPEAL? ........................................ 34 WHO CAN HELP ME FILE AN EXPEDITED APPEAL? .................................................................................................. 35

STATE FAIR HEARING .................................................................................................. 35

CAN I ASK FOR A STATE FAIR HEARING? ................................................................................................................. 35 CAN I ASK FOR AN APPEAL FOR LONG-TERM SERVICES AND SUPPORTS? .............................................................. 35

FRAUD AND ABUSE INFORMATION ............................................................................. 35

DO YOU WANT TO REPORT WASTE, ABUSE, OR FRAUD? ....................................................................................... 35

INFORMATION THAT MUST BE AVAILABLE ONCE A YEAR ........................................... 36

NOTICE OF PRIVACY PRACTICES .................................................................................. 38

1 TX-MHB-0054-12 TX STAR+PLUS Nondual MHB 02.13

INFORMATION ABOUT YOUR NEW HEALTH PLAN Welcome to Amerigroup Texas, Inc., doing business as Amerigroup. Amerigroup is a managed care organization committed to helping you get the right care close to home. As a member of the Amerigroup STAR+PLUS program, you and your primary care provider or doctor will work together to help keep you healthy and care for your health problems. Amerigroup helps you get quality health care. To find out about doctors and hospitals in your area, visit www.myamerigroup.com/TX or contact Member Services at 1-800-600-4441.

Your Amerigroup Member Handbook

This handbook will help you understand your Amerigroup health plan. If you have questions or need help understanding or reading your member handbook, call Member Services. 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 Amerigroup health plan benefits, you can call our Member Services department at 1-800-600-4441. You can call us Monday through Friday 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

Your Amerigroup service plan

Your doctors

Going to the doctor

Transportation

Health-care benefits

Well care

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 1-800-855-2880. 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. It is a free service which you can hear in English or Spanish. You can call the Nurse HelpLine toll-free 7 days a week at 1-866-864-2544 if you need advice on:

How soon you need care for an illness

What kind of health care is needed

How to take care of yourself before you see the doctor

How you can get the care that is needed We want you to be happy with 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.

Behavioral Health and Substance Abuse Services Line

The Behavioral Health and Substance Abuse services line is available to members 24 hours a day, 7 days a week at 1-800-600-4441. 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 you have an emergency, you should call 911 or go to the nearest hospital emergency room right away.

Other Important Phone Numbers

STAR+PLUS Program Help Line 1-800-964-2777

Medicaid Managed Care Helpline 1-866-566-8989 (TDD 1-866-222-4306)

Texas Health Steps Program 1-877-847-8377

Block Vision for Eye Care 1-800-428-8789

Dental Care for members age 20 and younger DentaQuest MCNA Dental

Dental Care for members age 21 and older (Not applicable to members in Tarrant)

1-800-516-0165 1-800-494-6262 1-800-365-3527

Texas Client Notification Line 1-800-414-3406

Medical Transportation Program Monday through Friday 8 a.m. to 5 p.m. 1-877-633-8747

Amerigroup on Call/Nurse HelpLine 24 hours a day, 7 days a week 1-866-864-2544

Member Services For behavioral health and substance abuse care For Service Coordination For information about our disease management programs For information about prescription drugs

1-800-600-4441

YOUR AMERIGROUP ID CARD

What Does My Amerigroup ID Card Look Like? If you do not have your Amerigroup ID card yet, you will get it soon. Please carry it with you at all times. Show it to any doctor or hospital you visit. You do not need to show your ID card before you get emergency care. The card tells doctors and hospitals that you are a member of Amerigroup and who your primary care provider is. It also tells them that Amerigroup will pay for the medically needed benefits listed in the section My Benefits.


Your Amerigroup ID card has the name and phone number of your doctor on it. The date you became an Amerigroup member is also shown. This is also the date your primary care provider assignment is effective. Your ID card lists many of the important phone numbers you need to know, like our Member Services department and the Nurse HelpLine. It also has the phone numbers for you to call to get eye and dental care. If your ID card is lost or stolen, call Amerigroup right away. We will send you a new one.

What Information Is on 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 medically needed benefits listed in the My Benefits section on Page 7. 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 child’s ID card is lost or stolen, call us right away at 1-800-600-4441. 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. 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 1-800-252-8263. You can also call 2-1-1. 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 1-800-252-8263.


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 (www.yourtexasbenefits.com) and a phone number you can call (1-800-252-8263) 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 1-855-827-3748.

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.

PRIMARY CARE PROVIDERS

What Is a Primary Care Provider? Amerigroup members must have a family doctor, also called a primary care provider. Your doctor must be in the Amerigroup network. 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. When you enrolled in Amerigroup, you should have picked a primary care provider. If you did not, we assigned one to you. We picked one who should be close to you. This doctor’s name and phone number are on your Amerigroup ID card.


What Do I Bring with Me to My Doctor’s Appointment? When you go to the doctor's office for your appointment, bring your Amerigroup ID card and Texas Benefits Medicaid card, along with any medicines you are taking. If the appointment is for your child, bring your Texas Benefits Medicaid card and your child's Amerigroup ID card, shot records, and any medicines he or she is taking.

How Can I Change My Primary Care Provider? Call Member Services if you need to make a primary care provider change. You can look in the Amerigroup provider directory you got with your STAR+PLUS enrollment package or go to www.myamerigroup.com/TX to see the primary care providers Amerigroup offers.

Can a Clinic Be My Primary Care Provider? Yes, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) listed in the Amerigroup STAR+PLUS provider directory can be your primary care provider.

How Many Times Can I Change My/My Child’s Primary Care Provider? There is no limit on how many times you can change your or your child’s primary care provider. You can change primary care providers by calling us toll-free at 1-800-600-4441 or writing to Amerigroup at the office nearest you listed in the front of this handbook. Please address your written request to the member advocate.

When Will My Primary Care Provider Change Become Effective? We can change your doctor on the same day you ask for the change. The change will be effective immediately. Call the doctor’s office if you want to make an appointment. The phone number is on your Amerigroup ID card. If you need help, call Member Services. We will help you make the appointment.

Are There Any Reasons Why My Request to Change a Primary Care Provider May Be Denied? You will not be able to change your doctor if:

The doctor you have picked cannot take new patients

The new doctor is not a part of the Amerigroup network

Can My Primary Care Provider Move Me to Another Primary Care Provider for Noncompliance? Your primary care provider may ask for you to be changed to another primary care provider. Your doctor may do this if:

You do not follow his or her medical advice over and over again

Your doctor agrees that a change is best for you

Your doctor does not have the right experience to treat you

The assignment to your doctor was made in error (like an adult assigned to a child’s doctor)

What If I Choose to Go to Another Doctor Who Is Not My Primary Care Provider? If you want to go to a doctor who is not your primary care provider, please talk to your primary care provider first. In most cases, your primary care provider needs to give you a referral so you can see another doctor. This is done when your primary care provider cannot give you the care you need. If you go to a doctor that your


primary care provider has not referred you to, the care you receive may not be covered. Also read the section What Services Do Not Need a Referral? on Page 18 for more information.

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. 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 section on What Is Emergency Medical Care?), call 911 or go to the nearest emergency room right away.

What Is the Medicaid Limited Program? You may be put in the Limited Program if you do not follow Medicaid rules. It checks how you use Medicaid pharmacy services. Your Medicaid benefits remain the same. If you are put in the Medicaid Limited Program:

Pick one drugstore at one location to use all the time

Be sure your main doctor, main dentist, or the specialists they refer you to are the only doctors that give you prescriptions

Do not get the same type of medicine from different doctors To learn more, call 1-800-436-6184, Option 4.

PHYSICIAN INCENTIVE PLAN Amerigroup rewards some 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 a right to know how the plan works. You can call Member Services at 1-800-600-4441 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 1-800-964-2777. 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 1-800-964-2777.

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 Get Dropped from Their Health Plan for Noncompliance? 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 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 If you have any questions about your enrollment, call Member Services at 1-800-600-4441.

MY BENEFITS

What Are My Health-care Benefits? You get benefits from Amerigroup for acute care and long-term services and supports.

How Do I Get These Services?

Your primary care provider will help you get the acute care you need. Your service coordinator will help you get long-term services and supports.

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 1-800-600-4441 to arrange out-of-network services except in case of emergency.


What Are My Acute Care Benefits? The following list shows acute care benefits that Amerigroup covers for STAR+PLUS Medicaid program members. Your primary care provider will give you the care you need or refer you to a doctor who can give you the care you need. For a few special Amerigroup benefits, members have to be a certain age or have a certain kind of health problem. If you have a question or are not sure whether Amerigroup offers a certain benefit, you can call Member Services for help at 1-800-600-4441 for more information.

Ambulance services

Birthing services provided by a physician or advanced practice nurse in a licensed birthing center

Chiropractic care

Dialysis

Durable medical equipment and supplies

Emergency room services

Family planning services and supplies

Federally qualified health center services and other ambulatory services covered by federally qualified health centers

Health education

Hearing tests

Hearing aids

Home health-care services

Hospital services

Inpatient behavioral health services

Interpreter services (available through Member Services)

Laboratory

Long-term care (see section on STAR+PLUS Medicaid and Long Term Care Services on Page 9 for details)

Medical equipment and supplies

Mental health and substance abuse services (limited to certain kinds of providers)

Optometry, glasses, and contact lenses, if medically necessary

Podiatry

Prescription drugs

Prenatal care

Preventive services, including an annual adult well-checkup for patients 21 years of age and over

Primary care services

Private-duty nursing (limited to members who need more individual and continual care than they can get from a home health agency, nursing facility, or hospital)

Radiology, imaging, and X-rays

Specialty physician services

Texas Health Steps medical services

Therapies – physical, occupational, and speech

Transplants (if medically necessary, like liver, heart, lung, bone marrow, and kidney)

Vision

How Do I Get These Services? What Number Do I Call to Find Out about These Services?

Your primary care provider will help you get these types of services. You can also call Member Services at 1-800-600-4441 or your service coordinator if you need more information.


Are There Any Limits to Any Covered Services?

There may be some limits to care such as for chiropractic services or number of inpatient or outpatient mental health visits. You can call Member Services at 1-800-600-4441 or your service coordinator (see What Is Service Coordination? on Page 10) for a complete list of benefits and limitations.

What Services Are Not Covered by Amerigroup? These are benefits and services that Amerigroup does not offer. These services are not covered by fee-for-service Medicaid either:

Services that are not medically necessary

Experimental services such as new treatment that is being tested or has not been shown to work

Cosmetic surgery that is not medically necessary

Sterilization for members age 20 and younger

Routine foot care except for members with diabetes or poor circulation

Fertility treatment services

Treatment for disabilities connected to military service

Weight loss program services

Reversal of voluntary sterilization

Private room and personal comfort items when hospitalized

Sex transformation or transsexual surgery For more information about services not covered by Amerigroup, please call Member Services at 1-800-600-4441.

What Are My Long-Term Services and Supports Benefits? 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 get for you. If you agree, the service coordinator will help get the services started. And our service coordinator will call you to see how well you are doing with the services. To get any long-term services and supports, you must talk to your service coordinator first. Long-term services and supports may include:

Day activity and health services

Personal attendant services

Dental 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 (in home)

Physical therapy

Occupational therapy

Speech/language therapy


Home-delivered meals

How Do I Get These Services? Who Do I Call?

To get long-term services and supports, you must call our Service Coordination first. We will find out about your needs and which services you can get. You can call our Member Services department at 1-800-600-4441 to reach your service coordinator. 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 with 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 1-800-600-4441 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 and supports 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 stage renal disease, sickle cell, diabetes, and asthma and who need pulmonary and 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 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 you the care you need. Your service coordinator will also review your service plan annually 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 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 1-800-600-4441. 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 where you live 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 (CCAD), 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 does not show up, call our Member Services department right away. Amerigroup will help get the services started again.

What Are My Prescription Drug Benefits? 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. Adults as well as children can get as many prescriptions as your doctor thinks you need. You are not limited to 3 prescriptions per month under Amerigroup. You may go to any pharmacy that takes Amerigroup to have your prescription filled.

What Extra Benefits Do I Get as a Member of Amerigroup? We offer 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 want extra benefits and services are available to you or visit our website at www.myamerigroup.com/TX.

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

Call 1-866-864-2544

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 1-866-864-2544

Transportation assistance to get to your medical appointments when medical transportation services are not available

Call 1-877-633-8747 Monday through Friday 8 a.m. to 5 p.m.

Enhanced dental benefits for members age 21 and older Call 1-800-365-3527

Enhanced vision benefits for members age 21 and older Call 1-800-600-4441 or go to www.myamerigroup.com/TX for more information

Additional 100 one-time Lifeline cell phone minutes and free health-related text messages if you qualify


Preprogrammed cell phone for high-risk members who have limited or no access to a reliable phone for emergency and medical use


An extra 8 hours of respite services for families and caregivers of members age 21 and older


Smoking/tobacco cessation help Call 1-800-600-4441 or go to

www.myamerigroup.com/TX for more information

Taking Care of Baby and Me® program


Healthy lifestyle coaching for eligible members with chronic conditions ages 18 to 64


Pest control services every 3 months Call 1-800-600-4441 or go to www.myamerigroup.com/TX for more information

How Do I Get These Extra Benefits?

Call Member Services or your service coordinator to find out how to get these services. We will find out about your needs and which services you can get.

http://www.myamerigroup.com/


What Health Education Classes Does Amerigroup Offer? We work to help keep you 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:

Amerigroup services and how to get them

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 wellness, taking care of illnesses, how to be a better parent, and many other topics. Amerigroup has disease management programs to help you better manage your chronic health problems. Your primary care doctor and the Amerigroup Disease Management team will assist you with your health-care needs. Some programs available are for asthma, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, major depressive disorder, diabetes, HIV/AIDS, and schizophrenia. Licensed nurses and social workers support you over the phone. They help arrange other services like smoking cessation, nutrition classes, or other community support activities. If you have a chronic health condition and want to know more about our disease management program, please call Member Services at 1-800-600-4441. Ask to speak to a Disease Management care manager.

What Other Services Can Amerigroup Help Me Get? We can help you get some services covered by fee-for-service Medicaid instead of Amerigroup. You do not need a referral from your primary care provider to get these services. Fee-for-service Medicaid benefits include:

Texas Health Steps dental (including orthodontia): Medicaid members age 20 and younger can get dental benefits through a dental managed care organization

Early childhood intervention case management/service coordination

Department of State Health Services (DSHS) targeted case management coordinated with local mental health authorities

DSHS mental health rehabilitation

DSHS Case Management for Children and Pregnant Women

Texas school health and related services (for children age 20 and younger)

Department of Assistive and Rehabilitative Services Blind Children’s Vocational Discovery and Development Program

Tuberculosis services provided by DSHS-approved providers’ directly observed therapy and contact investigation

Department of Aging and Disability Services (DADS) hospice services for STAR members (STAR members are disenrolled from their health plan upon enrollment into hospice)

Transportation to and from nonemergency medical services: the Medical Transportation Program (MTP) will help you get the transportation you need for doctor appointments; see the section How To Get To a Ride on Page 21 for details about this service

Nursing facility services


MY HEALTH-CARE AND OTHER SERVICES

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 that are 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 ii) May include consideration of other relevant factors, such as the criteria described in parts (2)(b – g)

and (3)(b – g) of this paragraph

2) For members over age 20, nonbehavioral health-related health-care services that are: a) 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

b) Provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s health conditions

c) Consistent with health-care practice guidelines and standards that are endorsed by professionally recognized health-care organizations or governmental agencies

d) Consistent with the member’s diagnoses e) No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness,

and efficiency f) Not experimental or investigative and g) Not primarily for the convenience of the member or provider

3) For members over age 20, behavioral health services that: a) 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 b) Are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral

health care c) Are furnished in the most appropriate and least restrictive setting in which services can be safely provided d) Are the most appropriate level or supply of service that can safely be provided e) Could not be omitted without adversely affecting the member’s mental and/or physical health or the

quality of care rendered f) Are not experimental or investigative and g) 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 1-800-600-4441 (TTY 1-800-855-2880).

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.

What Is Routine Medical Care? In most cases when you need medical care, you call your doctor to make an appointment. Then you go to see the doctor. This will cover most minor illnesses and injuries, as well as regular checkups. This type of care is known as routine care. Your primary care provider is someone you see when you are not feeling well, but that is only part of your primary care provider's job. Your primary care provider also takes care of you before you get sick. This is called well care. See the section on Page 21 in this handbook What Is Texas Health Steps?

How Soon Can I Expect to Be Seen?

You should be able to see your primary care provider within 2 weeks for routine care.

What Is Urgent Medical Care? The second type of care is urgent care. There are some injuries and illnesses that are not emergencies but can turn into emergencies if they are not treated within 48 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 primary care provider. Your primary care provider will tell you what to do. Your primary care provider may tell you to go to his or her office right away. You may be told to go to some other office to get immediate care. You should follow your primary care provider's instructions. In some cases, your primary care provider may tell you to go to the emergency room at a hospital for care. See the next section What Is Emergency Medical Care? for more information. You can also call our 24-hour Nurse HelpLine 7 days a week at 1-866-864-2544 for advice about urgent care.


You should be able to see your primary care 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 have an emergency, you should call 911 or go to the nearest hospital emergency room right away. If you want advice, call your primary care provider or our 24-hour Nurse HelpLine 7 days a week at 1-866-864-2544. The most important thing is to get medical care as soon as possible. Emergency Medical Care Emergency medical care is provided for emergency medical conditions and emergency behavioral health conditions.


Emergency medical condition means: A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in:

The patient’s health being placed in serious jeopardy

Serious impairment to bodily functions

Serious dysfunction of any bodily organ or part

Serious disfigurement

In the case of a pregnant women, serious jeopardy to the health of a woman or her unborn child Emergency behavioral health condition means: Any condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing average knowledge of medicine and health:

Requires immediate intervention and/or medical attention without which the member would present an immediate danger to themselves or others

Renders the member incapable of controlling, knowing or understanding the consequences of their actions Emergency services and emergency care means: Covered inpatient and outpatient services furnished by a provider who is qualified to furnish such services and that are needed to evaluate or stabilize an emergency medical condition and/or emergency behavioral health condition, including poststabilization care services.


You should be able to see your doctor immediately for emergency care.

Are Emergency Dental Services Covered?

Amerigroup covers limited emergency dental services for the following:

Dislocated jaw

Traumatic damage to teeth and supporting structures

Removal of cysts

Treatment of oral abscess of tooth or gum origin

Treatment and devices for craniofacial anomalies

Drugs for any of the above conditions

Amerigroup also covers dental services your child gets in a hospital. This includes services that the doctor provides and other services your child might need, like anesthesia.

What Do I Do If 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 your main dentist’s office has closed, call us toll-free at 1-800-600-4441 or call 911.

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.


Standard Name Amerigroup

Emergency Services Immediately upon member presentation at the service delivery site

Urgent Care Within 24 hours

Routine Primary Care Within 14 days

Routine Specialty Care Within 3 weeks

Preventive Health: Adult Within 90 days

Preventive Health: Child (New Member including Texas Health Steps)

For new member birth through age 20, overdue or upcoming well-child checkups including Texas Health Steps should be offered as soon as practicable and no later than 90 days after enrollment.

Preventive Health: Child Within 60 days

Preventive Health: Newborn Within 14 days

Texas Health Steps Annual Medical Checkup

For an existing member age 36 months or older - due on the child’s birthday. Considered timely if no later than 364 calendar days after the child’s birthday.

Prenatal Care Within 14 days

Pregnancy High Risk/3rd trimester Within 5 days or immediately, if an emergency exists

Behavioral Health Nonlife-threatening Emergency

Within 6 hours (NCQA)

Behavioral Health Urgent Care Within 24 hours

Behavioral Health-Routine Care The earlier of 10 business days or 14 calendar days

After-Hours Care 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

Office Wait Time Within 30 minutes

What Is Poststabilization? Poststabilization care services are services covered by Medicaid that keep your condition stable following emergency medical care. You should call your primary care provider within 24 hours after you visit the emergency room. If you cannot call, have someone else call for you. Your primary care provider will give or arrange any follow-up care you need.

How Do I Get Health Care When My Doctor's Office Is Closed? Except in the case of an emergency (see previous section) or when you need care that does not need a referral (see the section Services That Do Not Need a Referral), you should always call your primary care provider first before you get medical care. Help from your primary care provider is available 24 hours a day. If you call your


primary care provider's office when it is closed, leave a message with your name and a phone number where you can be reached. 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, call 911 or go to the nearest emergency room right away.

What If I Get Sick When I Am out of Town Traveling? If you need medical care when traveling, call us toll-free at 1-800-600-4441 and we will help you find a doctor. If you need emergency services while travelling, go to a nearby hospital. Then call us toll-free at 1-800-600-4441.

What If I Am out of the State?

If you are outside of Texas and need medical care, please call us toll-free at 1-800-600-4441. If you need emergency care, go to the nearest hospital emergency room or call 911.

What If I Am out of the Country?

Medical services performed out of the country are not covered by Medicaid.

What If I Need to See a Special Doctor (Specialist)? Your primary care provider can take care of most of your health-care needs, but you may also need care from other kinds of doctors. 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) Amerigroup offers services from many different kinds of doctors that provide other medically needed care. In most cases, you need to have a referral from your primary care provider to see another doctor. The referral may be a phone call or a paper from your primary care provider telling the specialist what kind of health care you need. Members with disabilities, special health-care needs, or chronic complex conditions have a right to direct access to a specialist. This specialist may serve as your primary care provider. Please call Member Services so this can be arranged.

What Is a Referral?

A referral is when your primary care provider sends you to another doctor or service for care. Your primary care provider may refer you to a specialist in the Amerigroup network if your primary care provider cannot give you the care you need.

How Soon Can I Expect to Be Seen by a Specialist?

Once you talk to your doctor and set up an appointment, you will be able to see the doctor within 3 weeks. In a few cases a referral is not needed. Read the Services That Do Not Need a Referral section below for more information.

What Services Do Not Need a Referral?

You can get the following services without a referral from your doctor:

Emergency care

Behavioral health services (mental health and/or substance abuse) from an Amerigroup behavioral health services provider

Dental care for adults age 21 and older from an Amerigroup network dentist


Family planning from any Amerigroup network or state-approved Medicaid family planning provider

Prenatal care from an Amerigroup network obstetrician or certified nurse midwife

Eye care from an Amerigroup network eye care provider (optometrist)

Screening or testing for sexually transmitted diseases, including HIV, from an Amerigroup network doctor

Texas Health Steps (formerly EPSDT) medical checkups from an Amerigroup network provider for children birth through age 20

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. This does not cost you anything. You can get a second opinion from a network provider or a non-network provider (if a network provider is not available). You should talk to your primary care doctor to get a referral for a second opinion. If a network provider is not available for a second opinion, your primary care doctor can submit a request to Amerigroup to authorize a visit to a non-network provider.

How Do I Get Help If I Have Mental Health, Alcohol, or Drug Problems? Sometimes the stress of handling the many responsibilities of a home and family can lead to depression, anxiety, marriage and family problems, parenting problems, and alcohol and drug abuse. If you or a family member is having these kinds of problems, Amerigroup contracts with doctors who can help. Call Member Services at 1-800-600-4441 for help in getting the name of a doctor who will see you if you need one. All services and treatment are strictly confidential.

Do I Need a Referral for This?

You do not need a referral from your doctor to get these services.

How Do I Get My Medications? 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. Adults as well as children can get as many prescriptions as are medically necessary. You may go to any pharmacy that takes Amerigroup to have your prescription filled. It is a good idea to use the same pharmacy each time you need medicine. This way, your pharmacist will know about problems that may happen when you take more than 1 prescription. If you use another pharmacy, you should tell the pharmacist about any other medicines you are taking.

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 1-800-600-4441.

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 bottles


Your Amerigroup ID card, and

Your Texas Benefits Medicaid card with you when you get your medications

What If I Need My Medications Delivered to Me?

Many pharmacies provide delivery services. Ask you 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 1-800-600-4441. 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 3-day emergency supply of your medication. Call Amerigroup at 1-800-600-4441 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 Amerigroup at 1-800-454-3730.

How Do I Find Out What Drugs Are Covered?

Amerigroup uses the state Vendor Drug Program (VDP) list of drugs that your doctor can choose from. It includes all medicines covered by Medicaid and CHIP. To view the Texas Formulary Drug Search, go to www.txvendordrug.com/formulary/formulary-search.asp. When there is a generic drug available, it will be covered if it is on the VDP formulary. Generic drugs are equal to brand-name drugs as approved by the Food and Drug Administration (FDA).

How Do I Transfer My Prescriptions To a Network Pharmacy?

If you need to transfer your prescriptions, all you need to do is: Call the nearest network pharmacy and give the needed information to the pharmacist or Bring your prescription container to the new pharmacy, and they will handle the rest

Will I Have a Copay?

Medicaid members do not have a copay.

How Do I Get My Medicine If I Am Traveling?

Amerigroup has network pharmacies in all 50 states. If you need a refill while on vacation, call your doctor for a new prescription to take with you.

What If I Paid Out of Pocket For a Medicine and Want To Be Reimbursed?

If you had to pay for a medicine, you may submit a request for reimbursement. Information on how to submit a claim and the required forms can be found within the website listed below. You will need to mail the completed Reimbursement Request Form along with any receipts to:

http://www.myamerigroup.com/English/Documents/Caremark_Claim_Form.pdf


Amerigroup Pharmacy Department PO Box 62509 Virginia Beach, VA 23466-2509 Website: www.txvendordrug.com/claims/pcra.shtml

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 Medicaid. For all members, Amerigroup pays for nebulizers, ostomy supplies, and other covered supplies and equipment if they are medically necessary. For children (birth through age 20), Amerigroup also pays for medically necessary prescribed over-the-counter drugs, diapers, formula, and some vitamins and minerals.

Call 1-800-600-4441 for more information about these benefits.

How Do I Get Family Planning Services? Amerigroup will arrange for counseling and education about planning a pregnancy or preventing pregnancy. You can call your doctor and make an appointment for a visit. You can also go to any Medicaid family planning provider.

Do I Need a Referral for This?

You do not need a referral from your doctor.

Where Do I Find a Family Planning Services Provider?

You can find the locations of family planning providers near you online at www.dshs.state.tx.us/famplan/locator.shtm, or you can call Amerigroup at 1-800-600-4441 for help in finding a family planning provider.

What Is Case Management for Children and Pregnant Women? The Case Management for Children and Pregnant Women program provides services to children from birth through age 20 with a health condition or health risk and to high-risk pregnant women.

What Type of Services Would My Child or I Get?

Case managers help children and pregnant women to get help with:

Access to needed medical services

Family problems

Education/school issues

Financial concerns

Access to providers and services near where they live

Equipment and supplies More information about Case Management for Children and Pregnant Women can be found at www.dshs.state.tx.us/caseman.

What Is Texas Health Steps? Texas Health Steps is the Medicaid program for children, teens, and young adults from birth through 20 years old. Texas Health Steps gives your child health checkups. These checkups are important. Your child may look and feel well, but he or she could still have a health problem.


What Services Are Offered by Texas Health Steps?

Texas Health Steps does these things and more:

Complete physical examination to find and treat your child’s health problems early; if you know your child has a medical problem, talk to your doctor about Texas Health Steps

Assessment of nutritional, developmental, and mental health-care needs

Laboratory tests

Routine immunization

Dental checkups and follow-up care

Referrals for services such as food stamps and WIC

Information about all the special child health services that Amerigroup offers at no cost to you Texas Health Steps will give your child: Medical checkups Dental checkups and treatment starting at 6 months old Eye exams and hearing tests Vaccines A case manager to help you find and get other services

Texas Health Steps will help you: Find a doctor, dentist, or case manager Set up doctor and dentist checkups Learn about services for your child Get a free ride or gas money to get to checkups or the pharmacy

Texas Health Steps medical and dental checkups will: Help find problems before they get worse and are harder to treat Make sure your child is growing and developing like other children their age

Texas Health Steps will send you a letter when your child is due for a medical or dental checkup. Even if your child is not due for a checkup, Medicaid will pay for health services if your child is sick or in pain. Medicaid also will pay to treat other health problems found during a Texas Health Steps checkup. To learn how: Call Texas Health Steps toll-free at 1-877-847-8377 (1-877-THSTEPS) Monday to Friday from 8 a.m. to 8 p.m.,

Central time Visit www.dshs.state.tx.us/thsteps and click on Client Information from the left-hand menu

If your child has special needs or an illness like asthma or diabetes, one of our service coordinators can help your child get his or her Texas Health Steps checkups, tests, and shots.

How and When Do I Get Texas Health Steps Medical and Dental Checkups for My Child?

The first well-baby checkup will happen in the hospital right after the baby is born. For the next 6 visits, you must take your baby to his or her primary care provider office. Children need these checkups even when they are healthy. Your child needs to have checkups at these ages:


Texas Health Steps Medical Checkups Schedule for Your Child

Birth 9 months old

3—5 days 12 months old

2 weeks old 15 months old

2 months old 18 months old

4 months old 2 years old

6 months old 2 ½ years old

After age 2 1/2, your child should visit the doctor every year. Amerigroup encourages and covers annual checkups for children ages 3 through 20.

Be sure to make these appointments. Take your child to his or her primary care provider when scheduled.

Does My Doctor Have to Be Part of the Amerigroup Network?

Your child can see any Texas Health Steps provider for these checkups. The Texas Health Steps provider does not have to be an Amerigroup network provider.

Do I Have to Have a Referral?

You can get Texas Health Steps care without a referral.

What If I Need to Cancel an Appointment?

If you are unable to keep your appointment, you must call your doctor and cancel. You can make a new appointment when you call.

What If I Am out of Town and My Child is Due for a Texas Health Steps Checkup?

If you are out of town and your child is due for a Texas Health Steps checkup, call your primary care provider’s office or Member Services for help.

What If I Am a Migrant Farm Worker? You can get your checkup sooner if you are leaving the area.

When Should Adults Get Checkups?

Staying healthy means going to see your doctor for regular checkups. Use the chart below to make sure you are up-to-date with your yearly well-care exams.

Wellness Visits Schedule for Adult Members

EXAM TYPE WHO NEEDS IT? HOW OFTEN?

Well-care visit Age 21 and older Every year

Pap smear and pelvic exam

Women under age 18 who are sexually active Every year

Age 18 and over Every year

Clinical breast exam

Women age 20 – 39 Every 3 years

Age 40 and over Every year

Breast self-exam Women age 20 and over Once a month


Wellness Visits Schedule for Adult Members

EXAM TYPE WHO NEEDS IT? HOW OFTEN?

Mammograms (breast X-ray) Women age 40 and over Every year

Fecal blood occult test Age 50 and over Every year

Sigmoidoscopy and DRE/PSA or colonoscopy and DRE/PSA Age 50 and over Every 5 years

If I Miss My Well-care Visit or Texas Health Steps Checkup, What Do I Do?

If you or your child does not get a well-care visit on time, make an appointment with your doctor as soon as you can. If you need help setting up the appointment, call Member Services. If your child has not visited his or her doctor on time, Amerigroup will send you a postcard reminding you to make your child’s Texas Health Steps appointment.

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 1-877-633-8747 Monday through Friday, 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. You can call MTP at 1-877-633-8747.

How Far in Advance Do I Need to Call?

For transportation within the county where you live, call the MTP office at least 2 business days before the scheduled appointment. For transportation beyond the county where you live, call the MTP office at least 5 business days before the scheduled appointment. The sooner you call, the easier it should be for you to get transportation.

How Can Someone I Know Give Me a Ride to My Appointment and Get Money for Mileage?

You can also have someone you know help you get to your appointment. This person can get money for mileage. If you are a child age 20 and younger and call MTP at least 5 working days before your appointment, then the person who gives you a ride can get money for mileage before the appointment. If you are an adult age 21 and older, you must sign an individual contract with MTP. The person who gives you a ride will receive money for mileage after your appointment.

Who Do I Call If I Have a Complaint about the Service or Staff?

If you have a complaint about MTP, call and ask for a supervisor. The supervisor can help you with any problems that you may have. To find out if there are any limitations on services, call MTP.

What Are the Hours of Operation and Limits for Transportation Services?

You can call MTP toll-free at 1-877-633-8747, Monday through Friday, from 8 a.m. until 5 p.m. 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 an emergency and need transportation, call 911 for an ambulance.

How Do I Get Eye Care Services? Amerigroup members get eye care benefits. You do not need a referral from your doctor for these benefits. Please call Block Vision at 1-800-428-8789 for help finding a network eye doctor (optometrist) in your area. Children age 20 and younger get coverage for a vision exam and medically necessary frames and lenses once every 12 months from September 1 to August 31, or when otherwise medically necessary. Adult members age


21 years and older get coverage for a vision exam and medically necessary frames and certain plastic lenses every 24 months.

How Do I Get Dental Care Services for My Child? Your child’s Medicaid dental plan provides dental services, including services that help prevent tooth decay and services that fix dental problems. Call your child’s Medicaid dental plan to learn more about the dental services they offer.

DentaQuest 1-800-516-0165

MCNA Dental 1-800-494-6262

Amerigroup covers emergency dental services your child gets in a hospital or ambulatory surgical center. This includes services the doctor provides and other services your child might need like anesthesia.

Can Someone Interpret for Me When I Talk to My Doctor? Who Do I Call for an Interpreter? Call Member Services at 1-800-600-4441 to let us know if you need an interpreter at least 24 hours before your appointment. This service is also available for visits with your doctor at no cost to you.

How Far in Advance Do I Need to Call?

Please let us know if you need an interpreter at least 24 hours before your appointment.

How Can I Get a Face-to-Face Interpreter in the Provider’s Office?

Call Member Services if you need to have an interpreter with you when you talk to your provider.

What If I Need OB/GYN Care? Female members can see an Amerigroup network obstetrician and/or gynecologist (OB/GYN) for OB/GYN health needs. ATTENTION FEMALE MEMBERS: Amerigroup allows you to pick any OB/GYN, whether that doctor is in the same network as your primary care provider or not. While an OB/GYN may not participate in your primary care provider’s network, he or she must still be part of the Amerigroup network of providers.

Do I Have the Right to Choose an OB/GYN?

You have the right to pick an OB/GYN without a referral from your primary care provider. An OB/GYN can give you:

One well-woman checkup each year

Care related to pregnancy

Care for any female medical condition

Referral to special doctor within the network

How Do I Choose an OB/GYN?

You are not required to pick an OB/GYN doctor. However, if you are pregnant, you should pick an OB/GYN to take care of you. You can pick any OB/GYN doctor listed in the Amerigroup provider directory. If you need help picking an OB/GYN, call Member Services at 1-800-600-4441.


If I Do Not Choose an OB/GYN, Do I Have Direct Access?

If you do not want to go to an OB/GYN, your primary care provider may be able to treat you for your OB/GYN health needs. Ask your primary care provider if he or she can give you OB/GYN care. If not, you will need to see an OB/GYN. You will find a list of network OB/GYNs in the Amerigroup provider directory you got with your STAR+PLUS enrollment package.

Will I Need a Referral?

You will not need a referral; however, you can only have 1 OB/GYN visit in a month. You can only see 1 OB/GYN in a month, but you can have more than 1 visit during that month with the same OB/GYN, if needed. While you are pregnant, your OB/GYN can be your primary care provider. The nurses on our 24-hour Nurse HelpLine can help you decide if you should see your primary care provider or an OB/GYN.

How Soon Can I Be Seen after Contacting My OB/GYN for an Appointment?

Your OB/GYN should see you within 2 weeks. We can help you find an Amerigroup OB/GYN, if needed.

Can I Stay with My OB/GYN If He or She Is Not with Amerigroup?

You may have been seeing a doctor who is not in our network for OB/GYN care. In some cases, you may be able to keep seeing this OB/GYN. Please call Member Services to find out more about this.

What If I Am Pregnant? Who Do I Need to Call? If you think you are pregnant, call your primary care provider or OB/GYN doctor right away. You do not need a referral from your doctor to see an OB/GYN doctor.

What Other Services/Activities/Education Does Amerigroup Offer Pregnant Women?

Taking Care of Baby and Me® is the Amerigroup program for all pregnant members. It is very important to see your primary care provider or OB/GYN for care when you are pregnant. This kind of care is called prenatal care. It can help you have a healthy baby. Prenatal care is always important even if you have already had a baby. With our program, members receive health information and baby gifts for getting prenatal care and going to prenatal classes. When you use our Taking Care of Baby and Me program, you will get a care manager. The care manager can work with you to help you get the prenatal care and services you need during your pregnancy and until your 6-week postpartum checkup. Your care manager may call you to see how you are doing with your pregnancy. He or she can help you if you have any questions. Your care manager can also help you find prenatal resources in your community to help you when you are pregnant. To find out more about the Taking Care of Baby and Me program, call Member Services. When you are pregnant, Amerigroup will send you a pregnancy education package. It will include:

A letter welcoming you to the Taking Care of Baby and Me program

A self-care book called Planning a Healthy Pregnancy

Taking Care of Baby and Me reward program brochures

A 1-page education fact sheet on our 24-hour Nurse HelpLine The self-care book gives you information about your pregnancy. You can also use the book to write down things that happen during your pregnancy. The Taking Care of Baby and Me brochures tell you about gifts for getting prenatal care and going to a prenatal class, a parenting class, a childbirth class, or a breastfeeding class. Call Member Services to get these services.


While you are pregnant, you need to take good care of your health. You may be able to get healthy food from the Women, Infants, and Children (WIC) program. Member Services can give you the phone number for the WIC program close to you. Just call us. When you are pregnant, you must go to your primary care provider or OB/GYN at least:

Every 4 weeks for the first 6 months

Every 2 weeks for the 7th and 8th months

Every week during the last month Your primary care provider or OB/GYN may want you to visit more than this based on your health needs.

When You Have a New Baby

When you deliver your baby, you and your baby may stay in the hospital at least:

48 hours after a vaginal delivery

96 hours after a cesarean section (C-section) You may stay in the hospital less time if your primary care provider or OB/GYN and the baby’s doctor see that you and your baby are doing well. If you and your baby leave the hospital early, your primary care provider or OB/GYN may ask you to have an office or in-home nurse visit within 48 hours. After you have your baby, you can fill out a Medicaid application in the hospital to see if your baby can get Medicaid benefits. Check with the hospital social worker before you go home to make sure the application is complete. Remember to call Amerigroup Member Services as soon as you can to let your care manager know that you had your baby. We will need to get information about your baby, too. You may have already picked a doctor for your baby before he or she was born. If not, we can help you pick a doctor for him or her. After you have your baby, Amerigroup will send you the Taking Care of Baby and Me education package. It will include:

A letter welcoming you to the postpartum part of the Taking Care of Baby and Me program

A baby-care book called Caring For Your Newborn

Taking Care of Baby and Me reward program brochure about going to your postpartum visit

A brochure about postpartum depression

A 1-page education fact sheet on our 24-hour Nurse HelpLine

You can use the baby-care book to write down things that happen during your baby’s first year. This book will give you information about your baby’s growth.

Where Can I Find a List of Birthing Centers?

Please contact Member Services at 1-800-600-4441 to find out which birthing centers are in our network.

How Do I Sign Up My Newborn Baby? The hospital where your baby is born should help you start the Medicaid application process for your baby. Check with the hospital social worker before you go home to make sure the application is complete. Also, you should call 2-1-1 to find your local HHSC office to make sure your baby’s application has been received. If you are an Amerigroup member when you have your baby, your baby will be enrolled with Amerigroup on his or her date of birth.


How and When Do I Tell Amerigroup?

Remember to call Amerigroup Member Services as soon as you can to let your care manager know that you had your baby. We will need to get information about your baby, too. You may have already picked a doctor for your baby before he or she was born. If not, we can help you pick a doctor for him or her. You can also call your service coordinator or case manager at Amerigroup.

How and When Do I Tell My Caseworker?

After you have your baby, call your HHSC benefits office to tell them he or she has been born.

Who Do I Call If I Have Special Health-Care Needs and Need Someone to Help Me? Members with disabilities, special health-care needs or chronic complex conditions have a right to direct access to a specialist. This specialist may serve as your primary care provider. Please call your service coordinator or Member Services at 1-800-600-4441 so this can be arranged.

What If I Am Too Sick to Make a Decision about My Medical Care? You can have someone make decisions on your behalf if you are too sick to make decisions for yourself. Please call Member Services at 1-800-600-4441 if you would like more information about the forms you need.

What Are Advance Directives?

Emancipated minors and members 18 years of age or older have rights under advance directive laws. An advance directive talks about making a living will. A living will says you may not want medical care if you have a serious illness or injury and may not get better. To make sure you get the kind of care you want if you are too sick to decide for yourself, you can sign a living will. This is a type of advance directive. It is a paper that tells your doctor and your family what kinds of care you do not want if you are seriously ill or injured.

How Do I Get an Advance Directive?

You can get a living will form from your doctor or by calling Member Services. You can fill it out by yourself or call Member Services for help; however, Amerigroup associates cannot offer legal advice or serve as a witness. According to Texas law, you must either have two witnesses or have your form notarized. After you fill out the form, take it or mail it to your doctor. Your doctor will then know what kind of care you want to get. You can change your mind anytime after you have signed a living will. Call your doctor to remove the living will from your medical record. You can also make changes in the living will by filling out and signing a new one. You can sign a paper called a durable power of attorney, too. This paper will let you name a person to make decisions for you when you cannot make them yourself. Ask your doctor about these forms.

What Happens If I Lose My Medicaid Coverage? If you lose Medicaid coverage but get it back again within 6 months, you will get your Medicaid services from the same health plan you had before losing your Medicaid coverage. You will also have the same primary care provider you had before.

What If I Get a Bill from a Doctor? Who Do I Call? Always show your Amerigroup ID card and Texas Benefits Medicaid card when you see a doctor, go to the hospital, or go for tests. Even if your doctor told you to go, you must show your Amerigroup ID card and Texas Benefits Medicaid card to make sure you are not sent a bill for services covered by Amerigroup. You do not have


to show your Amerigroup ID card before you get emergency care. If you do get a bill, send the bill along with a letter saying that you have been sent a bill to the member advocate in your service area at the Amerigroup location nearest you listed in the front of this book. In the letter, include your name, the telephone number you can be reached at, and your Amerigroup ID number. If you are unable to send the bill, be sure to include in the letter the name of the provider you got services from, the date of service, the provider’s phone number, the amount charged, and the account number, if known. You can also call Member Services at 1-800-600-4441 for help.

What Information Do They Need?

In the letter, include your name, the telephone number you can be reached at, and your Amerigroup ID number. If you are unable to send a copy of the bill, be sure to include in the letter the name of the provider you got services from, the date of service, the provider’s phone number, the amount charged, and the account number, if known.

What Do I Have to Do If I Move? As soon as you have your new address, give it to the local HHSC benefits office and the Amerigroup Member Services department at 1-800-600-4441. Before you get Medicaid services in your new area, you must call Amerigroup, unless you need emergency services. You will continue to get care through Amerigroup until HHSC changes your address.

What If I Have Other Health Insurance in addition to Medicaid? You are required to tell Medicaid staff about any private health insurance you have. You should call the Medicaid Third Party Resources hotline and update your Medicaid case file if:

Your private health insurance is canceled

You get new insurance coverage

You have general questions about third party insurance

You can call the hotline toll-free at 1-800-846-7307. If you have other insurance, you may still qualify for Medicaid. When you tell Medicaid staff about your other health insurance, you help make sure Medicaid only pays for what your other health insurance does not cover. IMPORTANT: Medicaid providers cannot turn you down for services because you have private health insurance as well as Medicaid. If providers accept you as a Medicaid patient, they must also file with your private health insurance company.

What Are My Rights and Responsibilities? MEMBER RIGHTS: 1. You have the right to respect, dignity, privacy, confidentiality, and nondiscrimination. That includes the right to:

a. Be treated fairly and with respect b. Know that your medical records and discussions with your providers will be kept private and confidential

2. You have the right to a reasonable opportunity to choose a health-care plan and primary care provider. This is the doctor or health-care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to: a. Be told how to choose and change your health plan and your primary care provider b. Choose any health plan you want that is available in your area and choose your primary care provider

from that plan


c. Change your primary care provider d. Change your health plan without penalty e. Be told how to change your health plan or your primary care provider

3. You have the right to ask questions and get answers about anything you do not understand. That includes the right to: a. Have your provider explain your health-care needs to you and talk to you about the different ways your

health-care problems can be treated b. Be told why care or services were denied and not given

4. You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to: a. Work as part of a team with your provider in deciding what health care is best for you b. Say yes or no to the care recommended by your provider

5. You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid and get a timely response to complaints, appeals and fair hearings. That includes the right to: a. Make a complaint to your health plan or to the state Medicaid program about your health care, your

provider, or your health plan b. Get a timely answer to your complaint c. Use the plan’s appeal process and be told how to use it d. Ask for a fair hearing from the state Medicaid program and get information about how that process works

6. You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to: a. Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or

urgent care you need b. Get medical care in a timely manner c. Be able to get in and out of a health-care provider’s office; this includes barrier-free access for people

with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act

d. Have interpreters, if needed, during appointments with your providers and when talking to your health plan; interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information

e. Be given information you can understand about your health plan rules, including the health-care services you can get and how to get them

7. You have the right to not be restrained or secluded when it is for someone else’s convenience, or is meant to force you to do something you do not want to do, or is to punish you.

8. You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

9. You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services.

MEMBER RESPONSIBILITIES: 1. You must learn and understand each right you have under the Medicaid program. That includes the

responsibility to: a. Learn and understand your rights under the Medicaid program b. Ask questions if you do not understand your rights c. Learn what choices of health plans are available in your area

2. You must abide by the health plan’s and Medicaid’s policies and procedures. That includes the responsibility to: a. Learn and follow your health plan’s rules and Medicaid rules


b. Choose your health plan and a primary care provider quickly c. Make any changes in your health plan and primary care provider in the ways established by Medicaid

and by the health plan d. Keep your scheduled appointments e. Cancel appointments in advance when you cannot keep them f. Always contact your primary care provider first for your nonemergency medical needs g. Be sure you have approval from your primary care provider before going to a specialist h. Understand when you should and should not go to the emergency room

3. You must share information about your health with your primary care provider and learn about service and treatment options. That includes the responsibility to: a. Tell your primary care provider about your health b. Talk to your providers about your health-care needs and ask questions about the different ways your

health-care problems can be treated c. Help your providers get your medical records

4. You must be involved in decisions relating to service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility to: a. Work as a team with your provider in deciding what health care is best for you b. Understand how the things you do can affect your health c. Do the best you can to stay healthy d. Treat providers and staff with respect e. Talk to your provider about all of your medications

If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

QUALITY MANAGEMENT

What Is the Amerigroup Quality Management Program? Amerigroup has a quality management program that covers many areas of care and service to members. We pay close attention to different kinds of measures to review the care and service to our members. The program covers the make-up and the kinds of diseases and clinical issues of our members. We study different subjects related to the care and service our members receive. This helps us change the program to help our members get the care and service they need. Members and providers can make suggestions to help us do that. If you would like more information about the quality management program goals, our steps to reach those goals, and results, please contact Member Services at 1-800-600-4441.

What Are Clinical Practice Guidelines? Amerigroup uses national clinical practice guidelines for the care of members. Clinical practice guidelines are nationally recognized, scientific, proven standards of care. These guidelines are recommendations for physicians and other health-care providers to diagnose and manage your specific condition. They guide decisions on diagnosis, management, and treatment of patients. If you would like a copy of these guidelines, contact Member Services at 1-800-600-4441.


COMPLAINTS PROCESS

What Should I Do If I Have a Complaint? Who Do I Call? We want to help. If you have a complaint, please call us toll-free at 1-800-600-4441 to tell us about your problem. An Amerigroup Member Services advocate can help you file a complaint. Just call 1-800-600-4441. Most of the time, we can help you right away or at the most within a few days.

Can Someone from Amerigroup Help Me File a Complaint?

Yes, a member advocate or Member Services representative can help you file a complaint. Please call Member Services at 1-800-600-4441.

How Long Will It Take to Process My Complaint?

Amerigroup will answer your complaint within 30 days from the date we get it.

What Are the Requirements and Time Frames for Filing a Complaint?

You can tell us about your complaint by calling us or writing us. We will send you a letter within 5 business days of getting your complaint. This means that we have your complaint and have started to look at it. We may call you to get more information. We will send you a letter within 30 days of when we get your complaint. This letter will tell you what we have done to address your complaint.

How Do I File a Complaint with the Health and Human Services Commission Once I Have Gone through the Amerigroup Complaint Process?

Once you have gone through the Amerigroup complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 1-866-566-8989. If you would like to make your complaint in writing, please send it to the following address: Resolution Services Texas Health and Human Services Commission Health Plan Operations - H-320 PO Box 85200 Austin, TX 78708-5200 If you can get on the Internet, you can send your complaint in an email to [email protected]. If you file a complaint, Amerigroup will not hold it against you. We will still be here to help you get quality health care.

APPEALS PROCESS

What Can I Do If My Doctor Asks for a Service for Me That’s Covered, but Amerigroup Denies or Limits It? There may be times when Amerigroup says it will not pay for or cover all or part of the care that has been recommended. For example, if you ask for a service that is not covered such as cosmetic surgery, Amerigroup is


not allowed to pay for it. You have the right to ask for an appeal. An appeal is when you or your designated representative asks Amerigroup to look again at the care your doctor asked for and we said we will not pay for. You can appeal our decision in 2 ways:

You can call Member Services

− If you call us, you must still send us your appeal in writing

− We will send you an appeal form in the mail after your call

− Fill out the appeal form and send it to us within 10 days of when you call us to Amerigroup Appeals, 2505 N. Highway 360, Suite 300, Grand Prairie, TX 75050

− If you do not return the appeal form within 10 days, Amerigroup will close your appeal (this does not apply to expedited appeals)

− If you need help filling out the appeal form, please call Member Services

You can send us a letter to Amerigroup Appeals, 2505 N. Highway 360, Suite 300, Grand Prairie, TX 75050

How Will I Find Out If Services Are Denied? If we deny services, we will send you a letter.

What Are the Time Frames for the Appeals Process?

You or a designated representative can file an appeal. You must do this within 30 days of when you get the first letter from Amerigroup that says we will not pay for or cover all or part of the care that has been recommended. If you ask someone (a designated representative) to file an appeal for you, you must also send a letter to Amerigroup to let us know you have chosen a person to represent you. Amerigroup must have this written letter to be able to consider this person as your representative. We do this for your privacy and security. When we get your letter or call, we will send you a letter within 5 business days. This letter will let you know we got your appeal. We will also let you know if we need any other information to process your appeal. Amerigroup will contact your doctor if we need medical information about this service. A doctor who has not seen your case before will look at your appeal. He or she will decide how we should handle your appeal. We will send you a letter with the answer to your appeal. We will do this within 30 calendar days from when we get your appeal unless we need more information from you or the person you asked to file the appeal for you. If we need more information, we may extend the appeals process for 14 days. If we extend the appeals process, we will let you know the reason for the delay. You may also ask us to extend the process if you know more information that we should consider.

How Can I Continue Receiving My Services That Were Already Approved?

To continue receiving services that have already been approved by Amerigroup but may be part of the reason for your appeal, you must file the appeal on or before the later of:

10 days after we mail the notice to you to let you know we will not pay for or cover all or part of the care that has already been approved

The date the notice says your service will end If you request that services continue while your appeal is pending, you need to know that you may have to pay for these services.


If the decision on your appeal upholds our first decision, you will be asked to pay for the services you received during the appeals process. If the decision on your appeal reverses our first decision, Amerigroup will pay for the services you received while your appeal was pending.

Can Someone from Amerigroup Help Me File an Appeal?

Yes, a member advocate or Member Services representative can help you file an appeal. Please call Member Services toll-free at 1-800-600-4441.

Can Members Request a State Fair Hearing?

Yes, you can ask for a fair hearing at any time during or after the Amerigroup appeal process unless you have asked for an expedited appeal. See the State Fair Hearing and the Expedited Appeals Sections below for more information.

EXPEDITED APPEALS

What Is an Expedited Appeal? An expedited appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.

How Do I Ask for an Expedited Appeal? Does My Request Have to Be in Writing? You or the person you ask to file an appeal for you (a designated representative) can request an expedited appeal. You can request an expedited appeal in 2 ways, orally or in writing:

You can call Member Services at 1-800-600-4441

You can send us a letter to Amerigroup Appeals, 2505 N. Highway 360, Suite 300, Grand Prairie, TX 75050

What Are the Time Frames for an Expedited Appeal? When we get your letter or call, we will send you a letter with the answer to your appeal. We will do this within 3 business days. If your appeal relates to an ongoing emergency or hospital stay we said we would not pay for, we will call you with an answer within 1 business day. We will also send you a letter with the answer to your appeal within 3 business days.

What Happens If Amerigroup Denies the Request for an Expedited Appeal? If we do not agree that your request for an appeal should be expedited, we will call you right away. We will send you a letter within 3 calendar days to let you know how the decision was made and that your appeal will be reviewed through the standard review process. If the decision on your expedited appeal upholds our first decision and Amerigroup will not pay for the care your doctor asked for, we will call you and send you a letter to let you know how the decision was made. We will also tell you your rights to request an expedited state fair hearing.


Who Can Help Me File an Expedited Appeal? A member advocate or Member Services representative can help you file an expedited appeal. Please call Member Services at 1-800-600-4441.

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 Amerigroup at: Fair Hearing Coordinator Amerigroup 3800 Buffalo Speedway, Suite 400 Houston, TX 77098

Or you can call Member Services at 1-800-600-4441. 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 days from the date you get the health plan’s decision letter 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 an Appeal 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 State Fair Hearing section.

FRAUD AND ABUSE INFORMATION

Do You Want to Report Waste, Abuse, or Fraud? Let us know if you think a doctor, dentist, pharmacist at a drugstore, other health-care provider, or a person getting benefits is doing something wrong. Doing something wrong could be waste, abuse, or fraud, which is against the law. For example, tell us if you think someone is:


Getting paid for services that weren’t given or necessary

Not telling the truth about a medical condition to get medical treatment

Letting someone else use their Medicaid ID

Using someone else’s Medicaid ID

Not telling the truth about the amount of money or resources he or she has to get benefits To report waste, abuse, or fraud, choose one of the following:

Call the OIG Hotline at 1-800-436-6184

Visit https://oig.hhsc.state.tx.us/ and pick “Click Here to Report Waste, Abuse and Fraud Online” to complete the online form

Report directly to your health plan: Corporate Investigations Department Amerigroup 4425 Corporation Lane Virginia Beach, VA 23462 1-800-600-4441

To report waste, abuse, or fraud, gather as much information as possible.

When reporting a provider (a doctor, dentist, counselor, etc.) include:

− Name, address, and phone number of provider

− Name and address of the facility (hospital, nursing home, home health agency, etc.)

− Medicaid number of the provider and facility, if you have it

− Type of provider (doctor, dentist, therapist, pharmacist, etc.)

− Names and phone numbers of other witnesses who can help in the investigation

− Dates of events

− Summary of what happened

When reporting someone who gets benefits, include:

− The person’s name

− The person’s date of birth, Social Security Number, or case number if you have it

− The city where the person lives

− Specific details about the waste, abuse, or fraud

INFORMATION THAT MUST BE AVAILABLE ONCE A YEAR As a member of Amerigroup, you can ask for and get the following information each year:

Information about network providers – at a minimum primary care doctors, specialists, and hospitals in our service area; this information will include names, addresses, telephone numbers, and languages spoken (other than English) for each network provider, plus identification of providers that are not accepting new patients

Any limits on your freedom of choice among network providers

Your rights and responsibilities

Information on complaint, appeal, and fair hearing procedures

Information about benefits available under the Medicaid program, including amount, duration and scope of benefits; this is designed to make sure you understand the benefits to which you are entitled

How you get benefits, including authorization requirements

How you get benefits, including family planning services, from out-of-network providers and/or limits to those benefits

How you get after-hours and emergency coverage and/or limits to those kinds of benefits, including:


− What makes up emergency medical conditions, emergency services, and poststabilization services

− The fact that you do not need prior authorization from your primary care provider for emergency care services

− How to get emergency services, including instructions on how to use the 911 telephone system or its local equivalent

− The addresses of any places where providers and hospitals furnish emergency services covered by Medicaid

− A statement saying you have a right to use any hospital or other settings for emergency care

− Poststabilization rules

Policy on referrals for specialty care and for other benefits you cannot get through your primary care provider

The Amerigroup practice guidelines


NOTICE OF PRIVACY PRACTICES This Notice describes how medical information about you might be used and disclosed and how you can get access to this information. Please review it carefully. This Notice is in effect April 14, 2003.

What Is This Notice? This Notice tells you:

How Amerigroup handles your protected health information

How Amerigroup uses and gives out your protected health information

What your rights are about your protected health information

What the Amerigroup responsibilities are in protecting your protected health information This Notice follows what is known as the HIPAA Privacy Regulations. These regulations were given out by the federal government. The federal government requires companies such as Amerigroup to follow the terms of the regulations and of this Notice. NOTE: You might also get a Notice of Privacy Practices from the state and other organizations.

What Is Protected Health Information? The HIPAA Privacy Regulations define Protected Health Information (PHI) as:

Information that identifies you or can be used to identify you

Information that either comes from you or has been created or received by a health-care provider, a health plan, your employer, or a health-care clearinghouse

Information that has to do with your physical or mental health or condition, providing health care to you, or paying for providing health care to you

In this Notice, Protected Health Information will be written as PHI.

Amerigroup Responsibilities for Your Protected Health Information You and your family’s PHI is private. We have rules to keep it safe and private. These rules follow state and federal laws. Amerigroup must:

Protect the privacy of the PHI we have or keep about you through:

− Staff training

− Secure computer systems and offices

− Secure disposal of written material that includes PHI

− Other technical methods

Provide you with this Notice about how we get and keep PHI about you

Follow the terms of this Notice

Follow state privacy laws that do not conflict with or are stricter than the HIPAA Privacy Regulations We will not use or give out your PHI without your consent, except as described in this Notice.

How Do We Use Your Protected Health Information? The sections that follow tell some of the ways we can use and share PHI without your written authorization.


FOR PAYMENT – We might use PHI about you so that the treatment services you get can be looked at for payment. For example, a bill that your provider sends us might be paid using information that identifies you, your diagnosis, the procedures or tests, and supplies that were used. FOR HEALTH-CARE OPERATIONS – We might use PHI about you for health-care operations. For example, we might use the information in your record to review the care and results in your case and other cases like it. This information will then be used to improve the quality and success of the health care you get. Another example of this is using information to help enroll you for health-care coverage. We might use PHI about you to help provide coverage for medical treatment or services. For example, information we get from a provider (nurse, doctor, or other member of a health-care team) will be logged and used to help decide the coverage for the treatment you need. We might also use or share your PHI to:

Send you information about one of our disease or case management programs

Send reminder cards that let you know that it is time to make an appointment or get services like EPSDT or Child Health Checkup services

Answer a customer service request from you

Make decisions about claims requests and appeals for services you received

Look into any fraud or abuse cases and make sure required rules are followed

Other Uses of Protected Health Information BUSINESS ASSOCIATES – We might contract with business associates that will provide services to Amerigroup using your PHI. Services our business associates might provide include dental services for members, a copy service that makes copies of your record, and computer software vendors. They will use your PHI to do the job we have asked them to do. The business associate must sign a contract to agree to protect the privacy of your PHI. PEOPLE INVOLVED WITH YOUR CARE OR WITH PAYMENT FOR YOUR CARE – We might make your PHI known to a family member, other relative, close friend, or other personal representative that you choose. This will be based on how involved the person is in your care, or payment that relates to your care. We might share information with parents or guardians, if allowed by law. LAW ENFORCEMENT – We might share PHI if law enforcement officials ask us to. We will share PHI about you as required by law or in response to subpoenas, discovery requests, and other court or legal orders. OTHER COVERED ENTITIES – We might use or share your PHI to help health-care providers that relate to health-care treatment, payment, or operations. For example, we might share your PHI with a health-care provider so that the provider can treat you. PUBLIC HEALTH ACTIVITIES – We might use or share your PHI for public health activities allowed or required by law. For example, we might use or share information to help prevent or control disease, injury, or disability. We also might share information with a public health authority allowed to get reports of child abuse, neglect, or domestic violence. HEALTH OVERSIGHT ACTIVITIES – We might share your PHI with a health oversight agency for activities approved by law, such as audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Oversight agencies include government agencies that look after the health-care system; benefit programs, including Medicaid, CHIP, or Healthy Kids; and other government regulation programs.


RESEARCH – We might share your PHI with researchers when an institutional review board or privacy board has followed the HIPAA information requirements. CORONERS, MEDICAL EXAMINERS, FUNERAL DIRECTORS, AND ORGAN DONATION – We might share your PHI to identify a deceased person, determine a cause of death, or do other coroner or medical examiner duties allowed by law. We also might share information with funeral directors, as allowed by law. We might also share PHI with organizations that handle organ, eye, or tissue donation and transplants. TO PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY – We might share your PHI if we feel it is needed to prevent or reduce a serious and likely threat to the health or safety of a person or the public. MILITARY ACTIVITY AND NATIONAL SECURITY – Under certain conditions, we might share your PHI if you are, or were, in the Armed Forces. This might happen for activities believed necessary by appropriate military command authorities. DISCLOSURES TO THE SECRETARY OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES – We are required to share your PHI with the Secretary of the U.S. Department of Health and Human Services. This happens when the Secretary looks into or decides if we are in compliance with the HIPAA Privacy Regulations.

What Are Your Rights Regarding Your Protected Health Information? We want you to know your rights about your PHI and your Amerigroup family members’ PHI.

Right to Get Amerigroup Notice of Privacy Practices We are required to send each Amerigroup head of case or head of household a printed copy of this Notice on or before April 14, 2003. After that, each head of case or head of household will get a printed copy of the Notice in the New Member Welcome package. We have the right to change this Notice. Once the change happens, it will apply to PHI that we have at the time we make the change and to the PHI we had before we made the change. A new Notice that includes the changes and the dates they are in effect will be mailed to you at the address we have for you. The changes to our Notice will also be included on our website. You might ask for a paper copy of the Notice of Privacy Practices at any time. Call Member Services toll-free at 1-800-600-4441. If you are deaf or hard of hearing and want to talk to Member Services, call the toll-free AT&T Relay Service at 1-800-855-2880.

Right to Request a Personal Representative You have the right to request a personal representative to act on your behalf, and Amerigroup will treat that person as if the person were you. Unless you apply restrictions, your personal representative will have full access to all of your Amerigroup records. If you would like someone to act as your personal representative, Amerigroup requires you to submit your request in writing. A personal representative form must be completed and mailed back to the Amerigroup Member Privacy Unit. To request a personal representative form, please contact Member Services. We will send you a form to complete. The address and phone number are at the end of this Notice.


Right to Access You have the right to look at and get a copy of your enrollment, claims, payment, and case management information on file with Amerigroup. This file of information is called a designated record set. We will provide the first copy to you in any 12-month period without charge. If you would like a copy of your PHI, you must send a written request to the Amerigroup Member Privacy Unit. The address is at the end of this Notice. We will answer your written request in 30 calendar days. We might ask for an extra 30 calendar days to process your request if needed. We will let you know if we need the extra time.

We do not keep complete copies of your medical records; if you would like a copy of your medical record, contact your doctor or other provider; follow the doctor or provider's instructions to get a copy; your doctor or other provider can charge a fee for the cost of copying and/or mailing the record

We have the right to keep you from having or seeing all or part of your PHI for certain reasons; for example, if the release of the information could cause harm to you or other persons; or, if the information was gathered or created for research or as part of a civil or criminal proceeding; we will tell you the reason in writing; we will also give you information about how you can file an Administrative Review if you do not agree with us

Right to Amend You have the right to ask that information in your health record be changed if you think it is not correct. To ask for a change, send your request in writing to the Amerigroup Member Privacy Unit. We can send you a form to complete. You can also call Member Services to request a form. The address and phone number are at the end of this Notice.

State the reason why you are asking for a change

If the change you ask for is in your medical record, get in touch with the doctor who wrote the record; the doctor will tell you what you need to do to have the medical record changed

We will answer your request within 30 days of when we receive it. We can ask for an extra 30 days to process your request if needed. We will let you know if we need the extra time. We can deny the request for change. We will send you a written reason for the denial if:

The information was not created or entered by Amerigroup

The information is not kept by Amerigroup

You are not allowed, by law, to see and copy that information

The information is already correct and complete

Right to an Accounting of Certain Disclosures of Your Protected Health Information You have the right to get an accounting of certain disclosures of your PHI. This is a list of times we shared your information when it was not part of payment and health-care operations. Most disclosures of your PHI by our business associates or us will be for payment or health-care operations. To ask for a list of disclosures, please send a request in writing to the Amerigroup Member Privacy Unit. We can send you a form to complete. For a copy of the form, contact Member Services. The address and phone number are at the end of this Notice. Your request must give a time period that you want to know about. The time period cannot be longer than 6 years and cannot include dates before April 14, 2003.


Right to Request Restrictions You have the right to ask that your PHI not be used or shared. You do not have the right to ask for limits when we share your PHI if we are asked to do so by law enforcement officials, court officials, or state and federal agencies in keeping with the law. We have the right to deny a request for restriction of your PHI. To ask for a limit on the use of your PHI, send a written request to the Amerigroup Member Privacy Unit. We can send you a form to fill out. You can contact Member Services for a copy of the form. The address and phone number are at the end of this Notice. The request should include:

The information you want to limit and why you want to restrict access

Whether you want to limit when the information is used, when the information is given out, or both

The person or persons that you want the limits to apply to We will look at your request and decide if we will allow or deny the request within 30 days. If we deny the request, we will send you a letter and tell you why.

Right to Cancel a Privacy Authorization for the Use or Disclosure of Protected Health Information We must have your written permission (authorization) to use or give out your PHI for any reason other than payment and health-care operations or other uses and disclosures listed under Other Uses of Protected Health Information. If we need your authorization, we will send you an authorization form explaining the use for that information. You can cancel your authorization at any time by following the instructions below. Send your request in writing to the Amerigroup Member Privacy Unit. We can send you a form to complete. You can contact Member Services for a copy of the form. The address and phone number are at the end of this Notice. This cancellation will only apply to requests to use and share information asked for after we get your cancellation request.

Right to Request Confidential Communications You have the right to ask that we communicate with you about your PHI in a certain way or in a certain location. For example, you may ask that we send mail to an address that is different from your home address. Requests to change how we communicate with you should be submitted in writing to the Amerigroup Member Privacy Unit. We can send you a form to complete. For a copy of the form, contact Member Services. The address and phone number are at the end of this Notice. Your request should state how and where you want us to contact you.

What Should You Do If You Have a Complaint about the Way Your Protected Health Information Is Handled by Amerigroup or Our Business Associates? If you believe that your privacy rights have been violated, you may file a complaint with Amerigroup or with the Secretary of Health and Human Services. To file a complaint with Amerigroup or to appeal a decision about your PHI, send a written request to the Amerigroup Member Privacy Unit or call Member Services. The address and phone number are at the end of this Notice. To file a complaint with the Secretary of Health and Human Services, send your written request to:


Office for Civil Rights U.S. Department of Health and Human Services 1301 Young St., Suite 1169 Dallas, TX 75202 You will not lose your Amerigroup membership or health-care benefits if you file a complaint. Even if you file a complaint, you will still get health-care coverage from Amerigroup as long as you are a member.

Where Should You Call or Send Requests or Questions about Your Protected Health Information? You may call us toll-free at 1-800-600-4441. Or you may send questions or requests, such as the examples listed in this Notice, to the address below: Member Privacy Unit Amerigroup 4425 Corporation Lane Virginia Beach, VA 23462 Send your request to this address so that we can process it timely. Requests sent to persons, offices, or addresses other than the address listed above might be delayed. If you are deaf or hard of hearing, you may call the toll-free AT&T Relay Service at 1-800-855-2880. We hope this book has answered most of your questions about Amerigroup. For more information, you can call the Amerigroup Member Services department.