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Member HandbookVirginia

FAMIS

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Solutions

If You Do Not Understand English If you do not understand English, please call 1-800-600-4441, and we will provide information about your benefits in your language. We can also help you talk to your doctor. Si no entiende el inglés, llame al 1-800-600-4441 y le brindaremos información en español acerca de sus beneficios. También podemos ayudarlo si necesita hablar con su médico. Neáu quyù vò khoâng hieåu tieáng Anh, xin goïi soá 1-800-600-4441, chuùng toâi seõ cung caáp thoâng tin veà caùc quyeàn lôïi cuûa quyù vò baèng tieáng Vieät. Chuùng toâi cuõng coù theå giuùp quyù vò noùi chuyeän vôùi baùc só.

تماس بگيريد و ما اطالعات مربوط به مزاياي شما را به فارسي ٤-٠٦٦-٠٦٦-٤٤٤لطفأ با شماره ٬اگر شما به زبان انگليسي صحبت نمي کنيد

در اختيارتان قرار خواهيم داد. ما همينطور مي توانيم به شما کمک کنيم که با دکترتان صحبت کنيد.

دك بمعلومات عن مستحقاتك باللغة العربية. كذلك يمكننا ، وسوف نزو4441-600-800-1إذا كنت ال تفهم اللغة اإلنجليزية، يرجى االتصال بـ

أيضاً مساعدتك في التحدث مع طبيبك.

www.myamerigroup.com/VA

Dear Parent/Guardian: Welcome to Amerigroup Virginia. We are pleased that you chose us to arrange for health care services for your child. This member handbook tells you how Amerigroup works and how to help keep your child healthy. It tells you how to get health care when it is needed, too. There is also information included about a free membership for your child to the Boys & Girls Club. This is a special Amerigroup benefit for members, ages 5 to 18. The clubs provide many fun and educational activities for children. They are a great place to go after school. There is something for everyone! You will get your child’s Amerigroup ID card and more information from us in a few days. The ID card will tell you when your child’s Amerigroup membership starts. The name of your child’s primary care provider is on the card, too. Please check the provider’s name shown on your child’s ID card. If this is not right, please call us. We want to hear from you. You can call toll free at 1-800-600-4441 to talk to a Member Services representative about your child’s benefits. You can also talk to a nurse on our 24-hour Nurse HelpLine toll free at 1-800-600-4441. Thank you for choosing us as your child’s health plan. Sincerely,

Renee Maccannon Chief Executive Officer Amerigroup Virginia

Ameritips

Health Tips That Make Health Happen

You Need To Go To Your PCP Now!

When Is It Time For A Wellness Visit? Your child needs to have regular wellness visits. This way your child’s Primary Care Provider (PCP) can see if your child has a problem before it is a bad problem. When your child becomes an Amerigroup Virginia member, call his or her PCP and make the first appointment before the end of 90 days.

Wellness Visits for Children Children need more wellness visits than adults. Your child should get wellness visits at the times listed below. Newborn 2 months old 6 months old 12 months old 18 months old Before 6 weeks 4 months old 9 months old 15 months old 24 months old

After age 2, your child should keep going to the PCP every year. Amerigroup encourages and reimburses for checkups every year for children age 3 through age 18. What If Your Child Becomes Pregnant? If you think your child is pregnant, call her PCP or OB/GYN right away. This can help her have a healthy baby. If you have any questions or need help making an appointment with her PCP or OB/GYN, please call Amerigroup Virginia Member Services at 1-800-600-4441.

ALERT! Keep your child’s health care benefits. Renew your child’s eligibility for FAMIS benefits on time. See the Renew Your Child’s FAMIS Benefits on Time section for more details.

AMERIGROUP VIRGINIA FAMIS PROGRAM MEMBER HANDBOOK

2600 Park Tower Drive, Suite 600 • Vienna, VA 22180 1-800-600-4441 • (TTY 1-800-855-2880)

www.myamerigroup.com/VA Welcome to Amerigroup Virginia! Your child will get most of his or her health care services through Amerigroup. This member handbook will tell you how to use Amerigroup to get the health care your child needs. For other questions about FAMIS, please call FAMIS at 1-866-87FAMIS (1-866-873-2647) or visit FAMIS at www.famis.org.

WELCOME TO AMERIGROUP VIRGINIA ....................................................... 1

Information about Your Child’s New Health Plan ...................................................... 1

How to Get Help ....................................................................................................... 1

Amerigroup Member Services Department ...................................................................................... 1

Amerigroup Virginia 24-Hour Nurse Helpline ................................................................................... 1

Other Important Phone Numbers ..................................................................................................... 2

Your Child’s Amerigroup Virginia Member Handbook ...................................................................... 2

Your Child’s Amerigroup Virginia ID Card .................................................................. 2

YOUR CHILD’S PRIMARY CARE PROVIDER ................................................... 2

Choosing a Primary Care Provider ............................................................................. 2

Second Opinion ........................................................................................................ 3

If Your Child Had a Different Primary Care Provider before Joining Amerigroup Virginia ..................................................................................................................... 3

If Your Child’s Primary Care Provider’s Office Moves, Closes or Leaves the Amerigroup Virginia Network ................................................................................... 3

How to Change Your Child’s Primary Care Provider ................................................... 3

If Your Child’s Primary Care Provider Asks for Your Child to Be Changed to another Primary Care Provider ............................................................................................... 4

If You Want Your Child to Go To A Provider Who Is Not the Primary Care Provider ... 4

Picking an OB/GYN ................................................................................................... 4

Specialists ................................................................................................................. 4

GOING TO THE PRIMARY CARE PROVIDER .................................................. 5

Your Child’s First Primary Care Provider Appointment .............................................. 5

How to Make an Appointment .................................................................................. 5

Wait Times For Appointments .................................................................................. 5

What to Bring When You Go for Your Child’s Appointment ...................................... 5

How to Cancel an Appointment ................................................................................ 6

How to Get to a Provider Appointment or to the Hospital ........................................ 6

Table of Contents

Disability Access to Amerigroup Virginia Network Providers and Hospitals ............... 6

WHAT DOES MEDICALLY NECESSARY MEAN? .............................................. 6

AMERIGROUP VIRGINIA COVERED SERVICES .............................................. 7

FAMIS COPAYMENTS ................................................................................ 10

EXTRA AMERIGROUP VIRGINIA BENEFITS ................................................. 11

SERVICES COVERED BY FEE-FOR-SERVICE .................................................. 11

SERVICES THAT DO NOT NEED A REFERRAL ............................................... 12

BENEFITS AND SERVICES NOT OFFERED BY AMERIGROUP VIRGINIA OR FAMIS ...................................................................................................... 12

DIFFERENT TYPES OF HEALTH CARE .......................................................... 12

Routine, Urgent And Emergency Care: What Is The Difference? .............................. 12

Routine Care .................................................................................................................................... 12

Urgent Care ..................................................................................................................................... 12

Emergency Care ............................................................................................................................... 13

How to Get Health Care When Your Child’s Primary Care Provider’s Office Is Closed14

How to Get Health Care for Your Child When He or She Is Out of Town .................. 14

WELLNESS CARE FOR YOUR CHILD ............................................................ 14

Why Wellness Care Is Important For Children ......................................................... 14

When Your Child Should Go For Wellness Visits ............................................................................. 15

Blood Lead Screening ...................................................................................................................... 15

Eye Exams ........................................................................................................................................ 15

Hearing Exams ................................................................................................................................. 15

Dental Care ...................................................................................................................................... 15

Immunizations ................................................................................................................................. 15

When Your Child Misses a Wellness Visit ................................................................ 19

SPECIAL KINDS OF HEALTH CARE .............................................................. 19

Eye Care .................................................................................................................. 19

Behavioral Health (Mental Health) Services ............................................................ 19

Special Care for Pregnant Members ........................................................................ 19

How to Get Care When You Cannot Leave Your Home ............................................ 21

Medicines ............................................................................................................... 21

SPECIAL AMERIGROUP VIRGINIA SERVICES FOR HEALTHY LIVING ............. 22

Health Information ................................................................................................. 22

Health Education Classes ........................................................................................ 22

Community Events .................................................................................................. 22

Power Zone® ........................................................................................................... 22

Boys & Girls Clubs ................................................................................................... 23

Disease Management ............................................................................................. 23

Minors .................................................................................................................... 24

COMPLAINTS, GRIEVANCES AND MEDICAL APPEALS ................................. 24

Important Information Regarding Your Child’s Insurance ....................................... 24

Complaints and Grievances ..................................................................................... 25

Medical Appeals ..................................................................................................... 26

Expedited Appeals .................................................................................................. 27

External Review ...................................................................................................... 28

Payment Appeals .................................................................................................... 28

OTHER INFORMATION .............................................................................. 28

If You Move ............................................................................................................ 28

Local Department of Social Services Offices ............................................................ 28

Renew Your Child’s FAMIS Benefits on Time ........................................................... 31

If Your Child Is No Longer Eligible For FAMIS ........................................................... 31

How to Disenroll Your Child from Amerigroup Virginia ........................................... 31

Reasons Why Your Child Can Be Disenrolled from Amerigroup Virginia (Termination of Coverage) ...................................................................................... 32

If You Get A Bill ....................................................................................................... 32

Changes in Your Child’s Amerigroup Virginia Coverage ........................................... 32

How to Tell Amerigroup Virginia about Changes You Think We Should Make ......... 33

How Amerigroup Virginia Pays Providers ................................................................ 33

Financial Incentives................................................................................................. 33

New Technology ..................................................................................................... 33

YOUR RIGHTS AND RESPONSIBILITIES AS AN AMERIGROUP VIRGINIA MEMBER .................................................................................................. 34

Your Rights ............................................................................................................. 34

Your Responsibilities............................................................................................... 34

HOW TO REPORT SOMEONE WHO IS MISUSING THE FAMIS PROGRAM .... 35

NOTICE OF PRIVACY PRACTICES ................................................................ 36

1 IVA-MHB-0004-13 VA MHB ENG 2.13

WELCOME TO AMERIGROUP VIRGINIA

Information about Your Child’s New Health Plan

Welcome to Amerigroup Virginia. Amerigroup is a managed care organization committed to helping you find real solutions to your health care needs. We provide FAMIS services to Amerigroup members. As a member of the FAMIS program, you and your child’s Primary Care Provider (PCP) will work together to help keep your child healthy and care for his or her health problems. Amerigroup helps your child get quality health care. This member handbook will help you understand your child’s Amerigroup health plan.

How to Get Help

Amerigroup Member Services Department

If you have any questions about your child’s Amerigroup health plan, you can call our Member Services department at 1-800-600-4441. You can call us Monday through Friday 8:00 a.m. to 6:00 p.m., except for holidays. If you call after 6:00 p.m., 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:

How Amerigroup works

Choosing your primary care provider

What to do in an emergency or urgent medical situation

Making appointments

Health care benefits

Complaints and grievances Please also call Member Services if you:

Want to request a copy of the Amerigroup Notice of Privacy Practices. This notice describes how medical information about your child may be used and disclosed and how you can get access to this information.

Move. We will need to know your new address and phone number. You must also call FAMIS toll free at 1-866-873-2647 to let them know your new address.

For members who do not speak English, we are able to help in many different languages and dialects. This service is also available for visits with your child’s providers at no cost to you. Please let us know if you need an interpreter at least 24 hours before the appointment. Call Member Services for more information. For members who are deaf or hard of hearing, call the toll free AT&T Relay Service 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 child’s provider visits. Please let us know if you need an interpreter at least 24 hours before the appointment.

Amerigroup Virginia 24-Hour Nurse Helpline

You can call our 24-hour Nurse HelpLine at 1-800-600-4441 if you need advice on:

How soon your child needs care when he or she is sick

What kind of health care is needed

What to do to take care of your child before you see the provider

How you can get the care that is needed


We want you to be happy with all the services your child gets from the Amerigroup network of providers and hospitals. Please call Member Services if you have any problems. We want to help you correct any problems you may have with your child’s care.

Other Important Phone Numbers

The FAMIS Helpline is 1-866-873-2647 (toll free). TDD users only can call 1-888-221-1590 (toll free)

If you need dental care for your children, call the Smiles For Children Dental Program at 1-888-912-3456

If your child needs routine eye care, please call Block Vision Service Plan toll free at 1-800-428-8789

If your child needs mental health care, please call Member Services at 1-800-600-4441 If you have an emergency and need transportation, call 911 for an ambulance.

Your Child’s Amerigroup Virginia Member Handbook

This handbook will help you understand your child’s Amerigroup health plan. If you have questions, or need help understanding or reading your child’s 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 book is in Spanish.

Your Child’s Amerigroup Virginia ID Card

If you do not have your child’s Amerigroup ID card yet, you will get it soon. Please carry it with you at all times. Show it to any provider or hospital you visit. The card tells providers and hospitals that your child is a member of Amerigroup and who his or her Primary Care Provider (PCP) is. It also tells them that Amerigroup will pay for the medically needed benefits listed in the section Amerigroup Covered Services. If your child’s Amerigroup ID card is lost or stolen, call us right away. We will send you a new one. Your child’s Amerigroup ID card has the name and phone number of his or her PCP on it. His or her FAMIS identification number and the date your child became an Amerigroup member are also shown. Your child’s ID card lists our Member Services department/Nurse HelpLine, behavioral health services and pharmacy (provided by Caremark) phone number. It also has the phone number for you to call to get eye care for your child. Your child’s card will list the copayments you are responsible for paying for your child’s health care. Along with your Amerigroup ID card, you must also carry and present your blue and white plastic FAMIS ID card each time you get medical services. Never throw this card away; because it is your child’s permanent FAMIS ID card. Even if your child loses FAMIS eligibility, keep the card in case he or she becomes eligible again in the future.

YOUR CHILD’S PRIMARY CARE PROVIDER

Choosing a Primary Care Provider

All Amerigroup Virginia members must have a Primary Care Provider (PCP). Your child’s PCP must be in the Amerigroup network. Your child’s PCP will give him or her a medical home. That means that he or she will get to know your child and your child’s health history, and be able to help your child get quality care. Your child’s PCP will give him or her all of the basic health services needed. He or she will also send your child to other providers or hospitals when he or she needs special care. When you enrolled your child in Amerigroup, you picked a PCP for him or her. If you did not, we assigned one for you. We picked one who should be close by you. This PCP’s name and phone number are on your child’s Amerigroup ID card.


If we assigned your child a PCP, and you wish to change the PCP, you can pick another one. Just look in the provider directory that came with your child’s FAMIS enrollment package. We can also help you pick a PCP. Call Member Services for help. If your child is already seeing a PCP, you can look in the provider directory to see if that provider is in our network. If so, you can tell us you want to keep that PCP. Family members do not have to have the same PCP. PCPs can be any of the following as long as they are in the Amerigroup network:

General practitioners

Family practitioners

Internists

Pediatricians

Specialists who provide primary care (surgeons, obstetrician/gynecologists)

Federally Qualified Health Centers, Rural Health Clinics, etc. Each family member can have a different primary care physician.

Second Opinion

Amerigroup Virginia members have the right to ask for a second opinion about the use of any health care services. You can get a second opinion from a network provider or a non-network provider if a network provider is not available. Ask your child’s Primary Care Provider (PCP) to submit a request for you to have a second opinion. Once approved, your child’s PCP will let you know the date and time of the appointment. Your child’s PCP will also send copies of all related records to the provider who will provide the second opinion. Your child’s PCP will let you and Amerigroup know the outcome of the second opinion.

If Your Child Had a Different Primary Care Provider before Joining Amerigroup Virginia

Your child may have been seeing a Primary Care Provider (PCP) who is not in our network for an illness or injury before he or she joined Amerigroup. In some cases, your child may be able to keep seeing this provider for care while you pick a new PCP. For example, your child may be able to keep seeing the PCP if she is in her third trimester of pregnancy or if he or she has a terminal illness. Please call Member Services to find out more about this. Amerigroup will make a plan with you and your child’s provider so we all know when he or she needs to start seeing his or her new Amerigroup network PCP.

If Your Child’s Primary Care Provider’s Office Moves, Closes or Leaves the Amerigroup Virginia Network

Your child’s Primary Care Provider (PCP) office may move, close or leave the Amerigroup network. If this happens, Amerigroup will call or send you a letter to tell you about this. In some cases, your child may be able to keep seeing this PCP for care while you pick a new PCP. Please call Member Services for more information about this. Amerigroup will make a plan with you and your child’s PCP so we all know when your child needs to start seeing his or her new Amerigroup network PCP. We can also help you pick a new PCP for your child. Call Member Services for help. Once you have picked a new PCP, Amerigroup will send you a new ID card within 10 working days.

How to Change Your Child’s Primary Care Provider

If you need to change your child’s PCP, you may pick another Primary Care Provider (PCP) from our network. Just look in the Amerigroup provider directory that came with your child’s FAMIS enrollment package. You can also find the provider directory online at www.myamerigroup.com/VA.


We can also help you pick a PCP. Call Member Services. We will help you pick a new PCP. You can change your child’s PCP at any time. Once your child’s PCP has been changed, you will get a new ID card in the mail within 10 working days.

If Your Child’s Primary Care Provider Asks for Your Child to Be Changed to another Primary Care Provider

Your child’s Primary Care Provider (PCP) may ask for your child to be changed to another PCP. His or her PCP may do this if:

You fail to keep your child’s appointments

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

Your child’s PCP agrees that a change is best for your child

Your child’s PCP does not have the right experience to treat your child

The assignment to your child’s PCP was made in error

If You Want Your Child to Go To A Provider Who Is Not the Primary Care Provider

If you want your child to go to a provider who is not his or her Primary Care Provider (PCP), please talk to your child’s PCP first. In most cases, your child’s PCP needs to give you a referral so your child can see another provider. This is done when your child’s PCP cannot give him or her the care that is needed. Please read the section Specialists to learn more about referrals. If you go to a specialist that your child’s PCP has not referred you to, the care your child receives may not be covered by Amerigroup. Also read the section Services That Do Not Need A Referral for more information.

Picking an OB/GYN

Female members age 13 and older can see an Amerigroup Virginia network obstetrician and/or gynecologist (OB/GYN) for OB/GYN health needs. These services include well-woman visits, prenatal care, care for any female medical condition, family planning and referral to a specialist within the network. Your child does not need a referral from her Primary Care Provider (PCP) to see an OB/GYN. If you do not want your child to go to an OB/GYN, her PCP may be able to treat her OB/GYN health needs. Ask your child’s PCP if he or she gives OB/GYN care. If not, your child will need to see an OB/GYN. You will find a list of network OB/GYNs in the Amerigroup provider directory that came with your child’s FAMIS enrollment package. You can also find the provider directory online at www.myamerigroup.com/VA. While your child is pregnant, her OB/GYN can be her PCP. The nurses on our 24-hour Nurse HelpLine can help you decide if your child should see her PCP or an OB/GYN. If you need help picking an OB/GYN, call Member Services. Please see the section on Special Care for Pregnant Members for more information.

Specialists

Your child’s Primary Care Provider (PCP) can take care of most of his or her health care needs, but your child may also need care from other kinds of providers. Amerigroup Virginia offers services from many different kinds of providers that provide other medically needed care. These providers are called specialists because they have training in a special area of medicine. Examples of specialists are:

Allergists (allergy specialists)

Dermatologists (skin specialists)

Cardiologists (heart specialists)


If your child’s PCP cannot give him or her the needed care, your child’s PCP will give you a referral to see a specialist. In most cases, you need to have a referral from your child’s PCP to see another provider. Your child’s PCP will give you a referral form so you can see the specialist. The referral form tells you and the specialist what kind of health care your child needs. Be sure to take the referral form with you when you take your child to the specialist. In a few cases, a referral is not needed. Read the section in this handbook Services That Do Not Need a Referral for more information.

GOING TO THE PRIMARY CARE PROVIDER

Your Child’s First Primary Care Provider Appointment

You can call your child’s Primary Care Provider (PCP) to set up his or her first appointment. Your child should see his or her PCP for a wellness visit (a general checkup) within 90 days of enrolling in Amerigroup Virginia. By finding out more about your child’s health now, your child’s PCP can take better care of your child if he or she gets sick.

We can help you set up your child’s first appointment. Just call Member Services toll free at 1-800-600-4441 if you want our help.

If your child has already been seeing the PCP who is now his or her Amerigroup network PCP, call the PCP to see if it is time for your child to get a checkup. If it is, make an appointment for your child to see the PCP as soon as possible.

How to Make an Appointment

It is easy to make an appointment with your child’s Primary Care Provider (PCP). Just call the PCP’s office. The phone number is on your child’s Amerigroup Virginia ID card. If you need help, call Member Services. We will help you make the appointment.

When you call, let the person you talk to know what you need (for example, a checkup or a follow-up visit). Also, tell the PCP’s office if your child is not feeling well. This will let the PCP’s office know how soon your child needs to be seen. It may also shorten the wait before your child sees his or her PCP.

Wait Times For Appointments

We want your child to be able to get care at any time. Your child will be able to see a provider as follows:

Routine care Within 2 weeks

Emergency care Immediately

Urgent care Within 24 hours

Maternity care: First trimester Second trimester Third trimester High-risk pregnancies

Within 14 days Within 7 days Within 3 business days Within 3 business days

What to Bring When You Go for Your Child’s Appointment

When you go to the provider’s office for your child’s appointment, bring your child’s Amerigroup Virginia ID card, the blue and white plastic FAMIS ID card, shot records and any medicines he or she is taking.


How to Cancel an Appointment

If you make an appointment with your child’s provider and then cannot go, call the provider’s office. Tell the office to cancel the appointment. You can make a new appointment when you call. Try to call at least 24 hours before the appointment. This will let someone else see the provider during that time. If you want us to cancel your child’s appointment, call Member Services. If you do not call to cancel your child’s provider appointments, your provider may ask for your child to be changed to another provider.

How to Get to a Provider Appointment or to the Hospital As an added benefit, you and your child can get transportation to and from your child’s medical and dental appointments. Amerigroup covers up to 10 round-trips (20 one-way trips) per member per year. All you have to do is call LogistiCare to establish transportation to medical and dental appointments. • Call toll-free 1-800-894-8139 for services covered by FAMIS • Call 1-866-386-8331 toll free for waiver services in the home and community-based If you have special transportation needs, such as a stretcher van or door-to-door services, call Member Services at 1-800-600-4441 and ask for Case Management. A case manager can help arrange these types of transportation. Transportation services are only provided to and from a physician, hospital or other medical service appointment. Transportation vendors cannot drop off or pick up from a location other than your home, physician office, hospital or other medical place of service. If you have an emergency and need transportation, call 911 for an ambulance. LogistiCare can drop off and pick from the following locations: • Your home • A clinic or hospital • A medical or dental care • Another place of service

Disability Access to Amerigroup Virginia Network Providers and Hospitals

Amerigroup network providers and hospitals should help members with disabilities get the care they need. Members who use wheelchairs, walkers or other aids may need help getting into an office. If you or your child needs a ramp or other help, make sure your child’s provider’s office knows this before you go there. By doing this, they will be ready for your visit. If you want help talking to your provider about your child’s special needs, call Member Services.

WHAT DOES MEDICALLY NECESSARY MEAN?

Your child’s Primary Care Provider (PCP) will help you get the services your child needs that are medically necessary as defined below:

Medically necessary behavioral health services means those behavioral health services which: 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 which 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


Medically necessary health services mean those health services other than behavioral health services which are: a) Reasonable and necessary to prevent illness or medical conditions, or provide early screening, interventions,

and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, 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 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 diagnosis of the conditions e) No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness and

efficiency

AMERIGROUP VIRGINIA COVERED SERVICES

The following list shows the health care services and benefits that FAMIS members can get through Amerigroup when they need them. Your child’s Primary Care Provider (PCP) will give your child the care he or she needs or refer you to a specialist that can give your child the care that is needed. In some cases, your child’s provider may need to get preauthorization from Amerigroup before your child can receive these benefits. Your child’s provider can call 1-800-454-3730 to do this. 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 we cover a certain benefit, you can call Member Services for help. If your child’s benefits change for any reason, we will tell you about the change before it happens. Some benefits require copayments from you. A copayment (or copay) is the amount you need to pay for a covered service. Your child’s provider will collect copayments from you. The services that you need to pay copayments for are listed in the section FAMIS Copayments under the heading Cost-Sharing Information. Below is a list of the services that are covered by Amerigroup: Chiropractic Services — Amerigroup covers medically necessary spinal manipulation and outpatient chiropractic services to treat an illness or injury. Benefits are limited to $500 per year. Clinic Services — Amerigroup covers all medically necessary clinic services that are preventive, diagnostic, therapeutic, rehabilitative or palliative. Renal dialysis clinic visits are also covered. Dental Services — Amerigroup covers dental services that are medically necessary as a result of an accidental injury for which treatment is covered as a basic health service. The treatment must be requested within 60 days of the injury. Your children can get routine dental care through the Smiles for Children Program. Call 1-888-912-3456. See the section Services Covered by Fee-For-Service for more information. Durable Medical Equipment — Amerigroup covers medically necessary durable medical equipment and supplies. Prosthetic devices and eyeglasses are covered when medically necessary. Emergency and Post-stabilization Services — Emergency and medically necessary post-stabilization services do not need a referral or prior authorization. Your child does not have to get emergency and post-stabilization services from an Amerigroup network provider. Please see the section on Emergency Care for more information.


Family Planning Services and Supplies — Amerigroup covers family planning services and supplies (including all FDA-approved contraceptives) for all members of childbearing age. This includes services and supplies that delay or prevent pregnancy but not services to treat infertility or promote fertility. Your child is free to choose the method of family planning to be used, without being pressured by anyone. Your child does not have to get family planning services and supplies from an Amerigroup network provider. Your child does not need a referral to obtain these services. See the section Family Planning Services for more information. Hearing Aids and Supplies — Amerigroup covers hearing aids twice every five years. Home Health Services — Amerigroup covers the following medically necessary home health services:

Nursing Occupational therapy

Personal care services Speech therapy

Home health aide services Hearing therapy

Physical therapy Inhalation therapy

Amerigroup covers up to 90 home health visits per year. Hospice Services — Amerigroup covers medically necessary hospice care for members with a life expectancy of six months or less. Immunizations — See the section Immunization (Shot) Schedule for Children for more information. Inpatient Hospital Services — Amerigroup covers these services for up to 365 days per stay in general acute care and rehabilitation hospitals. Preauthorization is required for these stays. Inpatient Mental Health Services — Amerigroup covers inpatient mental health services for medically necessary stays in the psychiatric unit of a general acute care hospital. Preauthorization is required for these stays. Amerigroup does not cover inpatient mental health services provided by free-standing psychiatric hospitals to members up to age 19. Inpatient Rehabilitation Hospitals Inpatient Substance Abuse Services — Amerigroup covers these services in a substance abuse treatment facility. Preauthorization is required for these stays. Laboratory and X-ray Services Lead Testing Mammograms — as medically needed. Organ Transplants — Amerigroup covers medically necessary transplant services that are not experimental or investigational. Services to identify a donor are limited to $25,000 per member. Transplantation services require preauthorization. Outpatient Hospital Services — Amerigroup covers outpatient hospital services that are preventive, diagnostic, therapeutic, rehabilitative or palliative.

Outpatient Mental Health and Substance Abuse Services — Amerigroup covers medically necessary visits. Coverage of outpatient mental health services includes individual therapy, group therapy and family therapy.


Physical Therapy, Occupational Therapy and Speech-language Pathology and Audiology Services — Amerigroup covers medically necessary services that are provided at an inpatient or outpatient hospital or by a home health service. Preauthorization is required. Services provided by school-based clinics are not covered. Early Intervention services provided to Part C eligible children (including therapy services) are covered by fee-for-service and not Amerigroup. Provider Services — See the section Wellness Care for Your Child for more information. Pregnancy-related Services — Amerigroup covers services for pregnant women, including prenatal care. See the section Special Care for Pregnant Members for information about pregnancy-related care. Prescription Drugs — See the Medicines section for more information. Private Duty Nursing — Amerigroup covers medically necessary private duty nursing services if provided by a registered or licensed practical nurse. You must get preauthorization for private duty nursing. Prosthetic/Orthotic Services — Amerigroup covers medically necessary prosthetic services and devices that include artificial arms, legs and their attachments. Medically necessary orthotic services and devices are also covered. Second Opinions — See the Second Opinions section for more information. Skilled Nursing Facility Services — Amerigroup covers medically necessary nursing facility services for up to 180 days per stay. Telemedicine Services — Communication technology that helps your child’s provider diagnose and treat an illness. Therapy Services — Amerigroup covers renal dialysis, chemotherapy and radiation therapy, and intravenous and inhalation therapy. Transportation — Amerigroup only covers professional ambulance services when medically necessary. See the section How to Get to a Provider Appointment or to the Hospital for more information. Vision Services — Amerigroup covers routine eye exams and refractions for all enrollees once every 24 months. Eyeglasses and contact lenses are covered when medically necessary. See the section Eye Care for more information. Well-baby and Well-child Care — See the section Wellness Care for Your Child for more information. Women’s Health Care Services — For female members age 13 and over, Amerigroup covers annual exams and routine health care services without preauthorization from your Primary Care Provider. These services include:

Mammograms (as medically appropriate)

Pap smears (can be performed by any FDA-approved gynecologic cytology screening technologies)


Services to pregnant women, including: – Services to treat a medical condition that may complicate the pregnancy – Smoking cessation counseling, and prescription and nonprescription smoking cessation drugs – Prenatal services (patient education, counseling, etc.) – Postpartum (after-birth) services until the end of the second month after the pregnancy ends

FAMIS COPAYMENTS

No copayments will be charged to American Indians and Alaska Natives. The following table lists the FAMIS copayment schedule according to family income. Copayments for medical services or prescription drugs are paid to the health care provider at the time of service. No copayments are paid for preventive care, such as:

Pregnancy-related care

Well-child or well-baby visits

Immunizations (shots)

Dental checkups

Federal Poverty Levels American Indians and Alaska Natives

At or Below 150%

Above 150%

Ambulance Services $0 $2 $5

Chiropractic Services $0 $2 $5

Clinic Services $0 $2 $5

Emergency Use of Emergency Room $0 $2 per visit $5 per visit

Family Planning Services $0 $2 per visit $5 per visit

Hearing Aids $0 $2 $5

Home Health Services $0 $2 per visit $5 per visit

Inpatient Hospital $0 $15 per admission $25 per admission

Laboratory and X-ray Services $0 $2 per visit $5 per visit

Medical Equipment Including prosthetics and orthotics

$0 $2 per item $5 per item

Non-emergency Use of Emergency Room $0 $10 per visit $25 per visit

Outpatient Hospital or Provider $0 $2 per visit $5 per visit

Physical Therapy/Occupational Therapy/Speech Pathology/Audiology

$0 $2 per visit $5 per visit

Prescription Drugs (including contraceptives)

Up to a 34-day supply

35 to 90-day supply

$0 $2 per prescription $4 per prescription

$5 per prescription $10 per prescription

Private Duty Nursing $0 $2 per visit $5 per visit

Second Opinions $0 $2 per visit $5 per visit

Skilled Nursing Facility Care $0 $15 per admission $25 per admission

Therapy Services

Inpatient

Outpatient

$0 $0

$15 per admission $2 per visit

$25 per admission $5 per visit

Vision Services*

Routine exam

$0

$2 $5

Yearly Copayment Limit per Family $0 $180 $350


*See Eye Care section for more details on covered services.

Your child’s health plan ID card lists the copayments that apply to your family situation. Present your child’s ID card when you get office visit services or have a prescription filled. You do not have to show your child’s ID card before he or she gets emergency care.

After you meet your family cost-share (the yearly copayment limit on the chart above), you will not have to pay a copayment when your child gets more services. Your child will also get a new member ID card from Amerigroup after your family cost-share is met. You should always ask for a receipt when you pay a copayment. Keep track of what you spend on copayments. Once you reach your family’s yearly copayment limit, call FAMIS at 1-866-873-2647 for help.

EXTRA AMERIGROUP VIRGINIA BENEFITS

Amerigroup covers the following extra benefits:

Transportation benefit. See the section How to Get to a Provider Appointment or to the Hospital for more information.

Free Boys & Girls Club membership for children between the ages of 5 and 18 (see the section Boys & Girls Clubs for details).

A free sports physical each year for children between the ages of 10 and 18.

A special program called Power Zone® for members from 7 to 11 years old. This program teaches children about healthy eating and fun physical activities.

Taking Care of Baby and Me®, the Amerigroup program for all pregnant members. See the section on Special Care for Pregnant Members for details.

Added programs like disease management and health education that Amerigroup provides for the benefit of its members. See the sections Disease Management and Special Amerigroup Virginia Services for Healthy Living.

We give your child these benefits to help keep him or her healthy and to thank you for choosing Amerigroup as your child’s health care plan.

SERVICES COVERED BY FEE-FOR-SERVICE

Some services are covered by fee-for-service instead of Amerigroup Virginia. These services are called carved-out services. Your child does not need a referral from the Primary Care Provider (PCP) to get these services. Fee-for-service FAMIS benefits include:

Community mental health rehabilitative services

School-based services

Dental services through Smiles for Children Dental Program. Smiles for Children members are covered for all medically necessary dental services. A description of services available for children is covered in the Smiles for Children handbook. Call 1-888-912-3456 for help finding a dentist.

Specialized infant formula for children under age 5 through Virginia Department of Health WIC clinics

Enteral nutrition/medical foods for children under age 21

Early Intervention services provided to Part C eligible children (for more information about these services, please contact the Infant & Toddler Connection of Virginia at 804-786-3710 or visit www.infantva.org)


SERVICES THAT DO NOT NEED A REFERRAL

It is always best to ask your child’s Primary Care Provider (PCP) for a referral for any Amerigroup Virginia covered service. But your child can get the following services without a referral from his or her PCP:

Care provided by your child’s Amerigroup network PCP’s nurse or physician assistant

Emergency services

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

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

FAMIS services Amerigroup does not cover

Prenatal care from an Amerigroup network obstetrician or certified nurse midwife

Yearly exams from an Amerigroup network OB/GYN

BENEFITS AND SERVICES NOT OFFERED BY AMERIGROUP VIRGINIA OR FAMIS

These are benefits and services that Amerigroup does not offer. These services are not covered by fee-for-service FAMIS either.

Abortions for any reason other than to save the life of the mother

Anything experimental such as a new treatment that is being tested or has not been shown to work

Anything that is not medically necessary

Cosmetic surgery that is not medically necessary

Court-ordered services unless the service is both medically necessary and a FAMIS covered service

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Fertility treatment services

Inpatient mental health services in a freestanding psychiatric hospital

Sterilization

Temporary detention orders For more information about services not covered by Amerigroup, please call Member Services.

DIFFERENT TYPES OF HEALTH CARE

Routine, Urgent And Emergency Care: What Is The Difference?

Routine Care

In most cases when your child needs medical care, you call your child’s Primary Care Provider (PCP) to make an appointment. Then you go to see the PCP. This will cover most minor illnesses and injuries, as well as regular checkups. This type of care is known as routine care. A PCP is someone you see when your child is not feeling well, but that is only part of your child’s PCP’s job. A PCP also takes care of your child before he or she gets sick. This is called wellness care. See the section in this handbook Wellness Care for Your Child. Your child should be able to see his or her PCP within two weeks for routine care.

Urgent Care

The second type of care is urgent care. There are some injuries and illnesses that are not emergencies but can turn into an emergency if they are not treated within 24 hours.


Some examples are: • Throwing up • Minor burns or cuts • Earaches • Headaches • Sore throat • Fever over 101 degrees • Muscle sprains/strains For urgent care, you should call your child’s PCP. Your child’s PCP will tell you what to do. The PCP may tell you to bring your child 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 child’s PCP’s instructions. In some cases, your PCP may tell you to go to the emergency room at a hospital for care. See the next section about emergency care for more information. You can also call our 24-hour Nurse HelpLine at 1-800-600-4441 for advice about urgent care. Your child should be able to see his or her PCP within 24 hours for an urgent care appointment.

Emergency Care

After routine and urgent care, the third type of care is emergency care. If your child has an emergency, you should call 911 or go to the nearest hospital emergency room right away. If you want advice, call your child’s PCP or our 24-hour Nurse HelpLine at 1-800-600-4441. The most important thing is to get medical care as soon as possible. Your child should be able to see a provider immediately for emergency care. What are emergency services? Emergency services are services provided by an in-network or out-of-network provider after the sudden start of a medical condition with symptoms so severe (including severe pain) that someone with an average knowledge of health and medicine can tell that, without medical care, the problem could result in serious jeopardy to your child’s mental/physical health, serious impairment of bodily functions, serious dysfunction of any bodily organ (or, with respect to a pregnant woman, the health of the woman or her unborn child). Emergency services in the Amerigroup service area provided by an out-of-network provider will be covered when a delay in care from a network provider could make your child’s condition worse. Here are some examples of problems that are most likely emergencies:

Severe pain

Trouble breathing

Chest pains

Loss of consciousness

Very bad bleeding that does not stop

Very bad burns

Shakes called convulsions or seizures What is post-stabilization? Post-stabilization care services are FAMIS covered services that your child receives after emergency medical care. Your child gets these services to help keep his or her condition stable. You should call your child’s PCP within 24 hours after your child visits the emergency room. If you cannot call, have someone else call for you. Your child’s PCP will give or arrange for any follow-up care you need.


How to Get Health Care When Your Child’s Primary Care Provider’s Office Is Closed

Except in the case of an emergency (see previous section), or when your child needs care that does not need a referral (see the section Services That Do Not Need a Referral), you should always call your child’s Primary Care Provider (PCP) first before you get medical care. Help from your child’s PCP is available 24 hours a day. If you call your child’s PCP’s office when it is closed, leave a message with your name and a phone number where you can be reached. If it is not an emergency, someone should call you back soon. You may also call our Nurse HelpLine 24 hours a day, 7 days a week for help. If you think your child needs emergency care (see previous section), call 911 or go to the nearest emergency room right away.

How to Get Health Care for Your Child When He or She Is Out of Town

If your child needs emergency care when he or she is out of town or outside of Virginia*, go to the nearest hospital emergency room or call 911. If your child needs urgent care, call his or her Primary Care Provider (PCP). See the section Urgent Care for more information. If your child’s PCP office is closed, leave a phone number where you can be reached. Your child’s PCP or someone else should call you back soon. Follow the PCP’s instructions. You may be told to get care where you are if your child needs it very quickly. You can also call our 24-hour Nurse HelpLine for help. If your child needs routine care like a checkup or prescription refill when you are out of town, call your PCP or our 24-hour Nurse HelpLine. If you are outside of the U.S. and get health care services for your child, they will not be covered by Amerigroup or fee-for-service FAMIS.

WELLNESS CARE FOR YOUR CHILD

All Amerigroup Virginia members need to have regular wellness care visits with their Primary Care Provider (PCP). During a wellness care visit, your PCP can see if your child has a problem before it is a bad problem. When your child becomes an Amerigroup member, call your child’s PCP and make his or her first appointment within 90 days.

Why Wellness Care Is Important For Children

Children need more wellness visits than adults. Babies need to see their Primary Care Provider (PCP) at least seven times by the time they are 12 months old and more times if they get sick. If your child has special needs or an illness like asthma or diabetes, one of our care coordinators can help your child get his or her wellness checkups, tests and shots. Your child must see a PCP for these wellness visits. At these wellness visits, the PCP will:

Make sure your baby is growing well

Help you care for your baby

Talk to you about what to feed your baby and how to help your baby go to sleep

Answer questions you have about your baby

See if your baby has any problems that may need more health care

Give your baby shots that will help protect him or her from illnesses


When Your Child Should Go For Wellness Visits

The first wellness visit will happen in the hospital right after the baby is born. For the next six visits, you must take your baby to his or her Primary Care Provider’s office. You must set up a wellness visit with the PCP when the baby is:

1 month old 6 months old

2 months old 9 months old

4 months old 12 months old In your baby’s second year of life, he or she should see the PCP at least three more times at 15 months, 18 months and 24 months. Your child should see the PCP again every year from age 3 through age 18 for wellness checkups. Take your child to his or her PCP when scheduled.

Blood Lead Screening

Your child’s Primary Care Provider (PCP) will screen your child for lead poisoning if he or she is at risk of being exposed to lead. A blood lead test will be done for your child between 9 and 12 months, and at 24 months. For the blood test, your child’s PCP will take a blood sample by pricking the child’s finger or taking blood from the vein. This test will tell if your child has harmful lead in his or her blood.

Eye Exams

Your child’s primary care provider will check your child’s vision at every wellness visit. Please see the section Eye Care, under the heading Special Kinds of Health Care, for more information.

Hearing Exams

Infants will be given a hearing screening before discharge from the hospital after birth. Your child’s primary care provider will check your child’s hearing at every wellness visit.

Dental Care

Your child will have his or her teeth and gums checked by his or her provider as a part of the regular wellness visits.

Immunizations

It is important for your child to get his or her immunizations (shots) on time. Take your child to the doctor when his or her PCP says a shot is needed. Use the chart listed next to help you keep track of the shots your child needs.


When Your Child Misses a Wellness Visit

In your baby’s second year of life, he or she should see the PCP at least three more times at 15 months, 18 months and 24 months. Your child should see the PCP again every year from age 3 through age 18 for wellness checkups. Take your child to his or her PCP when scheduled.

SPECIAL KINDS OF HEALTH CARE

Eye Care

Amerigroup Virginia members do not need a referral from their primary care providers for eye care benefits. All members can get covered routine refractions and routine eye exams every 24 months. Your child can also get eyeglasses (one pair of frames and one pair of lenses) or contact lenses when medically necessary. Amerigroup will pay for frames and lenses up to the amounts listed below. Members pay for costs above these amounts:

Eyeglass Frames: $25

Single vision lenses: $25

Bifocal Lenses: $37

Trifocal Lenses: $45

Contact Lenses: As medically necessary

Please call Block Vision at 1-800-428-8789 for help finding an Amerigroup network eye care provider (optometrist) in your area.

Behavioral Health (Mental Health) Services

Sometimes the stress of handling the many responsibilities of a job, home and family can lead to depression, anxiety, family problems, and alcohol and drug abuse. If your child is having these kinds of problems, Amerigroup Virginia contracts with providers who can help. You can call Amerigroup Member Services for help. You can also get the name of a provider who will see your child if he or she needs one. All services and treatments are strictly confidential. Your child does not need a referral from your primary care provider to get these services. Mental health services are covered, including:

Inpatient mental health care (in a general acute care hospital)

Outpatient mental health care and substance abuse services

Special Care for Pregnant Members

Taking Care of Baby and Me® is the Amerigroup Virginia program for all pregnant members. It’s very important to see your child’s Primary Care Provider (PCP) or OB/GYN for care when your child is pregnant. This kind of care is called prenatal care. It can help your child have a healthy baby. Prenatal care is always important even if your child has already had a baby. With our program, members receive health information and baby gifts for getting prenatal care and postpartum care. Our program also helps pregnant members with complex health care needs. Nurse case managers work closely with these members to help teach them about these needs. They also give emotional support and help members to follow their provider’s care plan. Our nurses also work with providers. They help with other services members may need. The goal is to promote better health for members and the birth of healthy babies.


When Your Child Becomes Pregnant If you think your child is pregnant, call her PCP or OB/GYN provider right away. You do not need a referral from her PCP to see an OB/GYN provider. Her OB/GYN should see her within 14 days. We can help you find an OB/GYN in the Amerigroup network, if needed. You must also call Amerigroup Member Services when you find out your child is pregnant. This will help you make sure you choose a PCP for her baby. If she is a new Amerigroup member who is pregnant and has been seen by a non-Amerigroup provider for at least one complete prenatal checkup before you joined Amerigroup, then she may be able to keep seeing that provider throughout her pregnancy, delivery and up to two months after her baby is born. When your child is pregnant, Amerigroup will send her a pregnancy education package. It will include:

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

A self-care book

Taking Care of Baby and Me® reward program brochure

A Nurse HelpLine Ameritips fact sheet The self-care book gives her information about her pregnancy. She can also use the book to write down things that happen during her pregnancy. The Taking Care of Baby and Me® brochure tells your child how to get her gift for getting prenatal care. When your child is pregnant, she must go to her PCP 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 child’s PCP or OB/GYN may want her to visit more than this based on her health needs. While your child is pregnant, she needs to take good care of her health. She may be able to get healthy food from the Women, Infants and Children Program (WIC). Call Member Services to get the phone number for the WIC program close to you. When You Have a New Baby When your child delivers her baby, she and her baby may stay in the hospital at least:

Two days (not including the day of delivery) after a vaginal delivery

Four days (not including the day of delivery) after a cesarean section (C-section)

She may stay in the hospital less time if her PCP or OB/GYN and the baby’s provider see that she and her baby are doing well. She and her baby should stay in the hospital until her provider says they can leave. They can leave the hospital before your provider releases them but it is best not to do this. If she and her baby leave the hospital early, the provider may ask her to have an office or in-home nurse visit within 48 hours.

Your child’s new baby will get FAMIS benefits through Amerigroup for his or her birth month plus two additional months. After she has her baby, you should call FAMIS as soon as possible. Tell them your child had her baby. They will make sure her baby gets FAMIS benefits for his or her first year. After your child has her baby, you must call Amerigroup Member Services as soon as you can to let us know she had her baby. We will need to get information about the baby, too. You may have already picked a PCP for the baby before he or she was born. If not, we can help you pick a PCP for him or her.


When your child has had her baby, Amerigroup will send her the Taking Care of Baby and Me® postpartum education package. It will include:

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

A baby-care book

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

A brochure about postpartum depression

A Nurse HelpLine Ameritips fact sheet She can use the baby-care book to write down things that happen during her baby’s first year. This book will give her information about her baby’s growth.

How to Get Care When You Cannot Leave Your Home

Amerigroup Virginia will find a way to help take care of your child. Call Member Services right away if you cannot leave your home. We will put you in touch with a case manager who will help your child get the medical care he or she needs.

Medicines

Amerigroup Virginia has a list of drugs your child’s Primary Care Provider (PCP) or specialist can choose from to help your child get well. This list is called a formulary. It is updated every year by practicing licensed pharmacists, physicians and other licensed providers. All Amerigroup network providers and pharmacists get a copy of this drug list. Your child’s PCP or specialist should use this list when he or she writes a prescription for your child. If we make a change in our formulary that affects your child, we will send you and your child’s PCP a letter to tell you about the change. There may be times when a drug on the formulary is not the right drug for your child’s condition. If a prescribed drug not on the formulary is medically needed, the copayment will not be more than that of the drug on the formulary. Also, if your child has been receiving a drug not on the formulary for at least six months before the formulary was developed or revised, he or she will be able to keep taking the prescribed non-formulary drug if the formulary drug is not appropriate or if a change in prescription would not be in your child’s best interest. If your child’s PCP or specialist thinks your child needs a drug that is not on the formulary, he or she can ask us for an exception. We will respond to the providers request within 24 hours. Your child can get prescriptions and medicines from approved pharmacies in the Amerigroup network or from pharmacies that will accept our rates as payment in full. You will find a list of Amerigroup network pharmacies in the provider directory that came with your child’s new member packet. If you do not know if a pharmacy is in the Amerigroup network, ask the pharmacist. You can also call Member Services for help.

It is good to use the same pharmacy each time your child needs medicine. This way, your pharmacist will know about problems that may happen when your child takes more than one prescription. If you use another pharmacy, you should tell the pharmacist about any other medicines your child is taking. You should always show your child’s Amerigroup member ID card when you have a prescription filled. Amerigroup will not deny coverage of a medically needed drug (including drugs for the treatment of cancer) that is provided inpatient or outpatient as long as it has been approved by the FDA and if the drug is recognized by a standard reference compendium or accepted peer-reviewed medical literature for the treatment of the condition for which it was prescribed.


Amerigroup will not deny coverage for any FDA-approved drug correctly prescribed (inpatient or outpatient) for the treatment of cancer pain on the basis that the dosage is more than the recommended dosage of the drug.

SPECIAL AMERIGROUP VIRGINIA SERVICES FOR HEALTHY LIVING

Health Information

Learning more about your child’s health and healthy living can help your child stay healthy. One way to get health information is to ask your child’s Primary Care Provider (PCP). Another way is to call us. Our Nurse HelpLine is available 24 hours a day, 7 days a week to answer your health questions. They can tell you if your child needs to see the PCP. They can also tell you how you can help take care of some health problems your child may have.

Health Education Classes

Amerigroup Virginia works to keep your child healthy with its Healthy Connection health education program. 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 Some of the larger medical offices (like clinics) in our network show health videos that talk about immunizations (shots), prenatal care and other important health topics. We hope you will learn more about staying healthy by watching these videos. We will also mail a member newsletter to you once a year. This newsletter provides health information about wellness care, taking care of illnesses, how to be a better parent and many other topics.

Community Events

Amerigroup Virginia sponsors and participates in special community events and family fun days where you can get health information and have a good time. Your child can learn about topics like healthy eating, asthma and stress. You and your family can play games and win prizes. People from Amerigroup will be there to answer your questions about your child’s benefits, too. Call Member Services to find out when and where these events will be.

Power Zone®

Amerigroup Virginia wants to give children the power to learn and start healthy habits. Healthy habits can help your child reach his or her goals in life. We have a special education program called Power Zone for members from 7 to 11 years old. This program is free and teaches your child about healthy eating and fun physical activities.


Amerigroup sends your child Power Paks that are full of fun activities that teach your child how to stay healthy. Power Paks include:

A letter to you and your child that tells you about Power Zone

Ameritip one-page fact sheet focused on a healthy lifestyle

Power Up nutrition activity sheet

Power Play physical activity sheet

Power Zone refrigerator chart to record the food your child eats and the activities that he or she does each day

Power Zone recipe book with healthy recipes

Boys & Girls Clubs

Amerigroup Virginia offers this special benefit to members ages 5 to 18 years old. Children can join their neighborhood Boys & Girls Clubs for free. The clubs are a great place for children to go after school. They have computers, homework help, sports, business training and much more. There is something for everyone! Please call Member Services to learn how to join.

Disease Management

Amerigroup Virginia has Disease Management Programs to help you better understand and manage your chronic health problem. Your Primary Care Provider (PCP) and our team will assist you with your health care needs. Licensed nurses or social workers called Disease Management care managers support you over the phone. They help teach you how to manage your chronic condition. Care managers also help you better understand your condition and will work with you to set up a plan to meet your health care needs. Amerigroup has received NCQA (National Committee for Quality Assurance) Patient and Practitioner Oriented Accreditation for our Disease Management Programs. Earning NCQA accreditation for Disease Management represents our continued commitment to help you receive quality health care coverage. Amerigroup Disease Management Programs include:

Asthma

Chronic obstructive pulmonary disease

Congestive heart failure

Coronary artery disease

Major Depressive disorder

Diabetes

HIV/AIDS

Schizophrenia As an Amerigroup member enrolled in Disease Management, you have certain rights and responsibilities. You have the right to:

Have information about Amerigroup. This includes programs and services, our staff’s education and work experience. It also includes contracts we have with other businesses or agencies.

Refuse to take part in or disenroll from programs and services we offer

Know which staff members arrange your health care services and who to ask for a change

Have Amerigroup help you make choices with your providers about your health care


Learn about all Disease Management related treatment options. These include anything mentioned in clinical guidelines, whether covered by Amerigroup or not. You have the right to discuss all options with your doctors.

Have personal and medical information kept private under HIPAA; know who has access to your information; know what Amerigroup does to keep it private and confidential

Be treated with courtesy and respect by Amerigroup staff

File a complaint with Amerigroup and be told how to make a complaint: this includes knowing the Amerigroup standards of timely response to complaints and resolving issues of quality

Get information that you can understand

Have Amerigroup act as an advocate for you if needed You have the responsibility to:

Listen to and know the effects of accepting or rejecting health care advice

Provide Amerigroup with information needed to carry out our services

Tell Amerigroup and your doctors if you decide to disenroll from the Disease Management program If you have one of the above conditions or would like more information about our Disease or Case Management programs, please call 1-800-600-4441, Monday through Friday from 8:30 a.m. to 5:30 p.m. Eastern Time. Ask to speak with a disease care manager or a case manager. You can also visit our website for more information about these programs at www.myamerigroup.com/VA.

Minors

For most Amerigroup Virginia members under age 18, Amerigroup network providers and hospitals cannot give them care without their parent’s or legal guardian’s consent. This does not apply if emergency care is needed. Parents or legal guardians also have the right to know what is in their child’s medical records. Members under age 18 can ask their provider not to tell their parents about their medical records unless the parents ask the provider to see the medical records. These rules do not apply to emancipated minors. Members under age 18 may be emancipated minors if they are married, pregnant or have a child. Emancipated minors may make their own decisions about their medical care and the medical care of their children. Parents no longer have the right to see the medical records of emancipated minors. Your child can sign a paper called a durable power of attorney too. This paper will let him or her name a person to make decisions when he or she cannot make them. Ask your child’s provider about these forms.

COMPLAINTS, GRIEVANCES AND MEDICAL APPEALS

Important Information Regarding Your Child’s Insurance

If you need to contact someone about this insurance for any reason, you may call Member Services at 1-800-600-4441 or write to Amerigroup Virginia at:

Amerigroup Virginia Member Advocate 2600 Park Tower Drive, Suite 600 Vienna, VA 22180


We recommend that you familiarize yourself with our grievance procedure, and make use of it before taking any other action. It is preferred that you write so Amerigroup can have a record of your inquiry. When you contact Amerigroup, please have your child’s FAMIS identification number available.

Complaints and Grievances

If you have any questions or problems with your child’s Amerigroup Virginia services or network providers and would like to tell us about it, please call Member Services. You can also file a complaint with the state. To file a complaint about a provider, call the Virginia Department of Health Professionals toll free at 1-800-533-1560. To file a complaint about a managed care organization, call the FAMIS Central Processing Unit at 1-866-873-2647. To file a complaint about the quality of your health care services with the Virginia Department of Health, you may contact the Office of Licensure and Certification at: Office of Licensure and Certification Virginia Department of Health 9960 Mayland Drive, Suite 401 Richmond, VA 23233-1463 Phone: 804-367-2106 Toll free: 1-800-955-1819 Email: [email protected] First Level Grievance Amerigroup Virginia will try to solve your complaint on the phone. If we cannot take care of the problem during your call, you can file a grievance. You may call Member Services for help with writing a letter. Please include information such as the date the problem happened and the people involved. Send your letter to:

Amerigroup Virginia Member Advocate 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 Amerigroup will send you a letter to let you know that we received your grievance within three business days. Amerigroup will look into your grievance when we get it. We will send you a letter within 14 days of when you told us about your grievance. This letter will tell you our decision. With our letter, we will include information on how to file an appeal and a grievance appeal form.

Second Level Grievance If you do not agree with our decision, please fill out the grievance appeal form and send it back to us. You must mail or fax this form to us within 10 days of when you get the letter with our decision. We need this form to look into your grievance. Mail this form to:



We will send you an acknowledgement letter within three business days. This letter will let you know we got your appeal form. A committee of Amerigroup staff and network providers will meet to look at your grievance appeal. We will let you know the date, time and place of the meeting at least seven days before the meeting. You can bring someone to the meeting if you want to. You do not have to come to the meeting. You or someone you would like to represent you may attend. We will send you a letter within 30 days of when you sent us your grievance appeal form. This letter will tell you our final decision about the grievance appeal.

Medical Appeals

There may be times when Amerigroup Virginia says it will not pay, in whole or in part, for care that has been recommended by your child’s provider. If we do this, you or your child’s provider can appeal the decision. An appeal is when you ask Amerigroup to look again at the care your provider asked for and we said we will not pay for. You must file for an appeal within 90 calendar days from the date you get our first letter that says we will not pay for a service. To continue receiving services that have already been approved by Amerigroup but may be part of the reason for your appeal, you or your child’s provider must file the appeal on or before the later of:

Ten days after we mail the notice to you to let you know we will not pay for the care that has already been approved

The date the notice says your service will end

First Level Appeal You, a person helping you, your primary care provider or the provider taking care of you at the time can file a first level appeal. You must do this within 90 calendar days from when you get the first letter from Amerigroup Virginia that says we will not pay for the service. You can appeal our decision in two ways:

You can call Member Services, and we will send you an appeal form. If you want someone else to help you with the appeal process such as a family member, friend or your child’s provider, let us know. Fill out the entire form and mail it back to us. You must mail it back to us within 10 days of your call.

You can send us a letter or the appeal form to the address below. Include information such as the care you are looking for and the people involved. Have your child’s provider send us his or her medical information about this service.

Amerigroup Virginia Appeals Unit 2600 Park Tower Drive, Suite 600 Vienna, VA 22180

When we get your letter or forms, we will send you a letter within 10 days. This letter will let you know we got your appeal. Your appeal and the first decision Amerigroup made will be looked at by a different provider than the one who made the first decision. We will send you and your child’s provider a letter within 14 days of when we get your appeal. This letter will let you and your child’s provider know what Amerigroup decides about your appeal. The letter will also tell you and your child’s provider how to find out more about the decision and your rights to a second level appeal.


There may be times when 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 in writing the reason for the delay. You may also ask us to extend the process if you know more information that we should consider.

Second Level Appeal If you are not happy with the answer to your first level appeal, you can ask us to look at your appeal again. This is called a second level appeal. You or the person you ask to file an appeal for you must send us a letter to ask for a second level appeal. This letter must be sent within 10 days from the date you get our letter with the answer to your first level appeal. Send this letter to:

Amerigroup Virginia Appeals Unit 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 When we receive the second level appeal, we will have a meeting with Amerigroup staff and specialty network providers to look at your appeal. We will try to find a day and time for the meeting so you can be there. You can bring someone to the meeting if you want to. You do not have to come to the meeting. We will let you know the date, time and place of the meeting at least five days before the meeting. We will send you a letter within 15 business days of the time your appeal was filed to tell you what the group decides about your appeal. 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 in writing the reason for the delay. You may also ask us to extend the process if you know more information that we should consider.

Expedited Appeals

You or the person you ask to file an appeal for you can request an expedited appeal. You can request an expedited appeal if you or your child’s provider feels that taking the time for the standard appeals process could seriously harm your child’s life or health. You can request an expedited appeal in two ways:

You can call Member Services

You can send us a letter to the address below:

Amerigroup Virginia Appeals Unit 2600 Park Tower Drive, Suite 600 Vienna, VA 22180

When we get your letter or call, we will send you a letter with the answer to your appeal. We will do this within 48 hours after we get your appeal and all the information we need to make a decision. 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 two 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 child’s provider asked for, we will call you and send you a letter to let you know how the decision was made and your rights to request an expedited state fair hearing.


External Review

Requests for external review cannot be submitted until after you have exhausted Amerigroup’s appeals process. Requests for external review must always be submitted in writing within 30 days of Amerigroup’s final appeal decision to:

Department of Medical Assistance Services FAMIS External Review Request Health Care Services Division 600 East Broad Street Richmond, VA 23219 Fax: 804-786-5799

Payment Appeals

If your child receives a service from a provider and Amerigroup Virginia does not pay for that service, you may receive a notice from Amerigroup called an Explanation Of Benefits (EOB). This is not a bill. The EOB will tell you the date your child received the service, the type of service and the reason we cannot pay for the service. The provider, health care place or person who gave you this service will get a notice called an Explanation of Payment. If you receive an EOB, you do not need to call or do anything at that time, unless you or your provider wants to appeal the decision. An appeal is when you ask Amerigroup to look again at the service we said we would not pay for. You must ask for an appeal within 90 days of receiving the EOB. To appeal, you or your child’s provider can call Member Services or mail your request and medical information for the service to:

Payment Appeals Amerigroup Virginia P.O. Box 5448 Richmond, VA 23220-0448 Amerigroup can accept your appeal by phone, but you must follow up in writing.

OTHER INFORMATION

If You Move

You should call the FAMIS Helpline at 1-866-87FAMIS as soon as you move to report your new address. Once you call FAMIS, you should then call Amerigroup Virginia Member Services. Your child will continue to get health care services through us, in your current area, until the address is changed. You must call Amerigroup before your child can get any services in your new area unless it is an emergency.

LOCAL DEPARTMENT OF SOCIAL SERVICES OFFICES

Alexandria Division of Human Services

2525 Mount Vernon Ave.

Alexandria, VA 22301

703-746-5700

Albemarle County DSS

1600 Fifth St., Suite A

Charlottesville, VA 22902

434-972-4010 Bath County DSS

65 Courthouse Hill Road

Warm Springs, VA 24484

540-839-7271

Alleghany-Covington DSS

110 Rosedale Ave., Suite B

Covington, VA 24426-1244

540-965-1780


Bland County DSS

612 Main St., Suite 208

Bland, VA 24315

276-688-4111

Arlington County DSS

2100 Washington Blvd.

Arlington, VA 22204

703-228-1550 Bristol City DSS

621 Washington St.

Bristol, VA 24201-4644

276-645-7450

Bedford DSS

119 E. Main St.

Bedford, VA 24523-7750

540-586-7750 Buchanan County DSS

3174 Slate Creek Road

Grundy, VA 24614-0674

276-935-8106

Botetourt County DSS

20 S. Roanoke St., Suite 102

Fincastle, VA 24090-0160

540-473-8210 Carroll County DSS

605-8 Pine St.

Hillsville, VA 24343

276-730-3130

Buckingham County DSS

13360 W. James Anderson Hwy.

Buckingham Court House, VA 23921

434-969-4246 Clarke County DSS

311 E. Main St.

Berryville, VA 22611

540-955-3700

Charlottesville DSS

120 Seventh St. NE

Charlottesville, VA 22902-0911

434-970-3400 Culpeper County Human Services

219 E. Davis St., Suite 10

Culpeper, VA 22701

540-727-0372

Dickenson County DSS

120 Clover St.

Clintwood, VA 24228-0417

276-926-1661 Fairfax County Department of Family Services

12011 Government Center Parkway, Suite 232

Fairfax, VA 22035

703-324-7500

Fauquier County DSS

320 Hospital Drive, Suite 11

Warrenton, VA 20186-3037

540-422-8400 Floyd County DSS

120 W. Oxford St.

Floyd, VA 24091-2222

540-745-9316

Fluvanna County DSS

8880 B James Madison Hwy.

Fork Union, VA 23055

434-842-8221 Frederick County DSS

107 N. Kent St., Third Floor

Winchester, VA 22601

540-665-5688

Franklin County DSS

11161 Virgil H. Goode Hwy.

Rocky Mount, VA 24151

540-483-9247 Galax City DSS

105 E. Center St.

Galax, VA 24333-0166

276-236-8111

Giles County DSS

211 Main St., Suite 109

Narrows, VA 24124

540-726-8315 Grayson County DSS

129 Davis St.

Independence, VA 24348-0434

276-773-2452

Highland County DSS

Courthouse Annex

Monterey, VA 24465-0247

540-468-2199


Harrisonburg-Rockingham County DSS

110 N. Mason St.

Harrisonburg, VA 22803

540-574-5100

Lee County DSS

Main St.

Jonesville, VA 24263-0346

276-346-1010 Henry-Martinsville DSS

20 Progress St.

Martinsville, VA 24114

276-656-4300

Manassas City DSS

9324 West St.

Manassas, VA 20110

703-361-8277 Loudoun County Department of Family Services

102 Heritage Way NE, Suite 200

Leesburg, VA 20176

703-777-0353

Nelson County DSS

203 Front St.

Lovingston, VA 22949

434-263-7160 Madison County DSS

101 S. Main St.

Madison, VA 22727-0176

540-948-5521

Norton City DSS

938 Park Ave.

Norton, VA 24273-0378

276-679-4393 Manassas Park DSS

1 Park Center Court

Manassas Park, VA 20111

703-335-8898

Orange County DSS

146 Madison Road, Suite 201

Orange, VA 22960

540-672-1155 Montgomery County DSS

210 S. Pepper St.

Christiansburg, VA 24073

540-382-6990

Patrick County DSS

106 Rucker St., Suite 128

Stuart, VA 24171

276-694-3328 Page County DSS

215 W. Main St., Suite A

Stanley, VA 22851

540-778-1053

Pulaski County DSS

53 Commerce St.

Pulaski, VA 24301-0110

540-980-7995 Prince William County DSS

7987 Ashton Ave., Suite 200

Manassas, VA 20109

703-792-7500

Rappahannock County DSS

354 Gay St.

Washington, VA 22747-0087

540-675-3313 Radford City DSS

928 W. Main St.

Radford, VA 24141

540-731-3663

Roanoke County DSS

220 E. Main St.

Salem, VA 24153-1127

540-387-6087 Roanoke City DSS

1510 Williamson Road NE

Roanoke, VA 24012

540-853-2591

Russell County DSS

79 Rogers St.

Lebanon, VA 24266-1207

276-889-2679 Rockbridge-Buena Vista-Lexington Social Services

20 E. Preston St.

Lexington, VA 24450

540-463-7143

Shenandoah County DSS

494 N. Main St., Suite 200

Woodstock, VA 22664

540-459-6226


Scott County DSS

190 Beech St., Suite 101

Gate City, VA 24251-0637

276-386-3631

Shenandoah Valley Waynesboro Office DSS

1200 Shenandoah Ave.

Waynesboro, VA 22980

540-942-6646 Shenandoah Valley Staunton-Augusta DSS

68 Dick Huff Lane

Verona, VA 24482-0007

540-245-5800

Tazewell County DSS

253 Chamber Drive

Tazewell, VA 24651

276-988-8500 Smyth County DSS

121 Bagley Circle, Suite 200

Marion, VA 24354

276-783-8148

Warren County DSS

912 Warren Ave.

Front Royal, VA 22630-0506

540-635-3430 Washington County DSS

15068 Lee Highway, Suite 100

Bristol, VA 24202

276-645-5000

Winchester DSS

24 Baker St.

Winchester, VA 22601

540-662-3807 Wise County DSS

5612 N. Bear Creek Road

Wise, VA 24293-0888

276-328-8056

Wythe County DSS

275 S. Fourth St.

Wytheville, VA 24382

276-228-5493

Renew Your Child’s FAMIS Benefits on Time

Keep your child’s health care benefits! Your child could lose his or her benefits even if he or she still qualifies. Every 12 months you will need to renew your child’s benefits. The Department of Medical Assistance Services (DMAS) will send you a letter telling you it is time to renew your child’s FAMIS benefits. If you do not renew your child’s eligibility by the date in the letter, your child will lose his or her health care benefits. Your FAMIS caseworker can answer your questions about renewing your child’s benefits. Call the FAMIS Helpline at 1-866-87FAMIS. We want your child to keep getting health care benefits from us if he or she still qualifies. Your child’s health is very important to us.

If Your Child Is No Longer Eligible For FAMIS

Your child will be disenrolled from Amerigroup Virginia if he or she is no longer eligible for FAMIS benefits. If your child is ineligible for FAMIS for a period of time and then becomes eligible again, if possible, he or she will be given the same PCP your child had when he or she was in Amerigroup before.

How to Disenroll Your Child from Amerigroup Virginia

If you do not like something about Amerigroup Virginia, please call Member Services. We will work with you to try to fix the problem. Your child will be able to change health plans without cause during the first 90 days after signing up with a health plan and when your FAMIS coverage renews. To change your child’s health plans, call the FAMIS Helpline toll free at 1-866-873-2647. Changes are usually effective on the first day of the month after the month of your request to change. For example, if you ask for your child to be disenrolled during the first half of the month, your child’s new plan will be effective on the 1st of the next month.


If the change is made during the second half of the month, the change will be effective on the 1st of the next subsequent month. FAMIS will tell you when your child’s new plan will be effective.

Reasons Why Your Child Can Be Disenrolled from Amerigroup Virginia (Termination of Coverage)

There are several reasons your child could be disenrolled from Amerigroup Virginia without asking to be disenrolled. Some of these are listed below. If you have done something that may lead to disenrollment, we will contact you. We will ask you to tell us what happened. Your child could be disenrolled from Amerigroup if:

Your child is disenrolled by DMAS

Your child is no longer eligible for Medicaid or the FAMIS program

Your child dies

Your child becomes eligible for FAMIS Select

You let someone else use your child’s Amerigroup ID card. If your child’s coverage is terminated for this reason, Amerigroup will send you a letter to tell you about this 31 days before your child’s coverage ends

You or your child steals or destroys property of a provider or Amerigroup

Your child goes to providers or medical facilities outside the Amerigroup plan over and over again

You or your child tries to hurt other patients or make it hard for other patients to get the care they need

The agreement between Amerigroup and DMAS is terminated. In this case, your child’s coverage will end on the date the contract is terminated. If this happens, Amerigroup will send you a letter to tell you about this 31 days before your child’s coverage ends.

If you have any questions about your child’s enrollment, call Member Services.

If You Get A Bill

Always show your child’s Amerigroup Virginia ID card and plastic FAMIS ID card when you see a provider, go to the hospital or go for tests. Even if your child’s provider told you to go, you must show your child’s Amerigroup ID card to make sure you are not sent a bill for services covered by Amerigroup. If you do get a bill, send it to us with a letter saying that you have been sent a bill. Send the letter to the address below:


You can also call Member Services for help at 1-800-600-4441.

Changes in Your Child’s Amerigroup Virginia Coverage

Sometimes Amerigroup may have to make changes in the way it works, its covered services or its network providers and hospitals. We will mail you a letter when we make changes in the services that are covered. Your child’s Primary Care Provider (PCP) office may move, close or leave our network. If this happens, we will call or send you a letter to tell you about this. Your child may be able to keep seeing this provider for up to 90 days if she is in her second trimester of pregnancy or if he or she has a terminal illness or is in some other active course of treatment with the provider. Please call Member Services if you want to ask for this continuation. We can also help you pick a new PCP for your child. You can call Member Services if you have any questions. Member Services can also send you a current list of our network providers.


How to Tell Amerigroup Virginia about Changes You Think We Should Make

We want to know what you like and do not like about Amerigroup. Your ideas will help us make Amerigroup better. Please call Member Services to tell us your ideas. You can also send a letter to:

Amerigroup Virginia Member Advocate 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 Amerigroup has a group of members who meet quarterly to give us their ideas; these meetings are called Member Advisory Meetings. This is a chance for you to find out more about us, ask questions and give us suggestions for improvement. If you would like to be part of this group, call Member Services. Amerigroup also sends surveys to some members. The surveys ask questions about how you like Amerigroup. If we send you a survey, please fill it out and send it back. Our staff may also call to ask how you like Amerigroup. Please tell them what you think. Your ideas can help us make Amerigroup better.

How Amerigroup Virginia Pays Providers

Different providers in our network have agreed to be paid in different ways by us. Your child’s provider may be paid each time he or she treats your child (fee-for-service). Or, your child’s provider may be paid a set fee each month for each member whether or not the member actually gets services (capitation). These kinds of pay may include ways to earn more money. This kind of pay is based on different things like how happy a member is with the care or quality of care. It is also based on how easy it is to find and get care. If you want more information about how our contracted providers or any other providers in our network are paid, please call our Member Services department. You may also write us at:

Amerigroup Virginia Provider Relations Department 2600 Park Tower Drive, Suite 600 Vienna, VA 22180

Financial Incentives

Different providers in the Amerigroup network have agreed to be paid in different ways by us. We expect decision makers on coverage of care and services to understand and follow these principles:

Amerigroup Utilization Management decision-making is based only on appropriateness of care and service, and on existence of coverage.

Amerigroup does not reward practitioners or other individuals for issuing denials of coverage or service.

Financial incentives for Amerigroup Utilization Management decision makers do not encourage decisions that result in underutilization.

If you need help understanding this information, please call Member Services at 1-800-600-4441.

New Technology

We constantly look at new medical advances and treatments to see if they can improve your covered benefits. Working with providers like yours, we look at scientific literature and government reviews to help decide whether these new medical advances and treatments are safe and helpful. If they have equal or better outcomes than the current covered benefit treatment or therapy, we may include them in your covered benefits.


YOUR RIGHTS AND RESPONSIBILITIES AS AN AMERIGROUP VIRGINIA MEMBER

Your Rights

As an Amerigroup member, you have the right to: Receive information in accordance with federal guidelines

Receive information about Amerigroup and our policies, services, practitioners and providers, and members’ rights and duties

Be treated with respect and with due consideration for your dignity and privacy

Receive information from your provider on available treatment options and alternatives presented in a manner appropriate to your condition and ability to understand, regardless of cost or benefit coverage

Participate in decisions regarding your health care, including the right to refuse treatment

Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion

Request and receive a copy of your medical records and request that they be amended or corrected as specified by 45 CFR 134.524 and 164. 526 records

Freely exercise rights; the exercise of these rights do not adversely affect the way you are treated by Amerigroup and our providers

Voice complaints or appeals about Amerigroup or the care given by our providers

Make recommendations regarding the health plan’s members rights and responsibilities policy

Receive health care services in accordance with contractual requirements

Be free from any liability for payment of any services received if Amerigroup becomes insolvent

Your Responsibilities

Each month, FAMIS pays a premium to the MCO for your child’s FAMIS coverage. If your child is not eligible for FAMIS because you did not report truthful information or failed to report required changes in your family size or income, you may have to repay the monthly premiums paid to your MCO. You may have to repay these premiums even if your child received no medical services during those months.

As an Amerigroup member, you have the responsibility to: Supply information that the health plan and its practitioners and providers need in order to provide care

Follow plans and instructions for care that you have agreed to with your provider

Understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible

Call Amerigroup Member Services at 1-800-600-4441 if you have a problem and need help. Amerigroup provides health coverage to our members on a nondiscriminatory basis, according to state and federal law, regardless of gender, race, age, religion, national origin, physical or mental disability, or type of illness or condition.


HOW TO REPORT SOMEONE WHO IS MISUSING THE FAMIS PROGRAM

If you know someone who is misusing (through fraud, abuse and/or overpayment) the FAMIS program, you can report him or her. To report PCPs, clinics, hospitals, nursing homes or FAMIS enrollees, write or call Amerigroup Virginia at:

Amerigroup Virginia Compliance Department 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 1-800-600-4441 Suspicions of fraud and abuse can be emailed directly to the Plan Compliance Officer at [email protected] or anonymously through the external hotline at 1-888-800-4030. You can also contact the Attorney General’s Office at:

Medicaid Fraud Control Unit Office of the Attorney General 900 East Main Street Richmond, VA 23219 1-800-371-0824 1-888-323-0587 (TDD/TTY) To report FAMIS enrollees, write or call the Department of Medical Assistance Services at:

Department of Medical Assistance Services Recipient Fraud and Recovery Unit 600 E. Broad Street Suite 1300 Richmond, VA 23219 1-866-873-2647

Or contact your local Department of Social Services (DSS). The DSS offices are listed in the Local Department of Social Services Offices section.

We hope this book has answered most of your questions about Amerigroup. For more information, you can call the Amerigroup Member Services department at 1-800-600-4441.


NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may 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

Your rights about your protected health information

Our responsibilities 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 may also get a Notice of Privacy Practices from the state and other organizations.

What Is Protected Health Information? Protected Health Information (PHI) — The HIPAA Privacy Regulations define protected health information 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.

The Responsibilities Amerigroup Has to You about Your Protected Health Information Your/your family’s PHI is personal. We have rules about keeping this information private. These rules are designed to follow state and federal requirements. Amerigroup must:

Protect the privacy of the PHI that we have or keep about you

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 authorization, 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 may use PHI about you so that the treatment services you get may be looked at for payment. For example, a bill that your provider sends us may be paid using information that identifies you, your diagnosis, the procedures or tests, and supplies that were used.


For Health Care Operations — We may use PHI about you for health care operations. For example, we may 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 may 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 may 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 may contract with Business Associates that will provide services to Amerigroup using your PHI. Services our business associates may 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 may 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 may share information with parents or guardians, if allowed by law. Law Enforcement — We may 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 may use or share your PHI to help health care providers that relate to health care treatment, payment, or operations. For example, we may share your PHI with a health care provider so that the provider can treat you. Public Health Activities — We may use or share your PHI for public health activities allowed or required by law. For example, we may use or share information to help prevent or control disease, injury, or disability. We also may share information with a public health authority allowed to get reports of child abuse, neglect, or domestic violence. Health Oversight Activities — We may 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, SCHIP or Healthy Kids; and other government regulation programs. Research — We may 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 may share your PHI to identify a deceased person, determine a cause of death, or to do other coroner or medical examiner duties allowed by law. We also may share information with funeral directors, as allowed by law. We may also share PHI with organizations that handle organ, eye, or tissue donation and transplants. To Prevent a Serious Threat to Health or Safety — We may 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 may share your PHI if you are, or were, in the Armed Forces. This may 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 the 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 may 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 hearing impaired 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 they 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 your request in writing. A personal representative form must be completed and mailed back to the Amerigroup Compliance Department. 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 Compliance Department. The address is at the end of this Notice. We will answer your written request in 30 calendar days. We may 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’s or provider's instructions to get a copy. Your doctor or other provider may 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 appeal 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 Compliance Department. 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 may ask for an extra 30 days to process your request if needed. We will let you know if we need the extra time. We may 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 Compliance Department. 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 may not be longer than six years and may not 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 Compliance Department. 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 Compliance Department. 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 Notice.

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 Compliance Department. 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 That 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 Compliance Department 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 & Human Services 150 S. Independence Mall West – Suite 372 Philadelphia, PA 19106-3499 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. If you are deaf or hard of hearing, you may call the toll-free AT&T Relay Service at 1-800-855-2880.


Or, you may send questions or requests, such as the examples listed in this Notice, to the address below:

Amerigroup Virginia Compliance Department 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 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 hearing impaired, you may call the toll-free AT&T Relay Service at 1-800-855-2880.

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