Member Handbook STAR Bexar, Dallas, Harris, Jefferson, Lubbock, Medicaid Rural Central, Medicaid Rural Northeast, Medicaid Rural West, and Tarrant Service Areas December 2017
1-800-600-4441 (TTY 711) TX-MHB-0103-17
www.myamerigroup.com/tx
Amerigroup
STAR Member Handbook Bexar, Dallas, Harris, Jefferson, Lubbock, Medicaid Rural Central, Medicaid Rural Northeast, Medicaid Rural West, and Tarrant Service Areas
1-800-600-4441 (TTY 711) www.myamerigroup.com/TX
December 2017
TX-MHB-0103-17
www.myamerigroup.com Dear Member: Welcome! Thank you for choosing us as your STAR health plan. At Amerigroup, we’re always working to make health care less complicated for you. One way is to provide you with information you need to get the most from your benefits. This member handbook helps you understand how to work with us and help keep your family healthy. This handbook includes information about your benefits and how to use them. We also include information about extra benefits just for our members, like our Real Solutions® Healthy Rewards program and Boys & Girls Club memberships for children ages 6 to 18. Boys & Girls clubs provide many fun and educational activities for kids and are a great place to go after school. These benefits are meant to make a difference for you and your family. You will get your Amerigroup ID card from us in a few days. Your ID card includes the name and phone number of your primary care provider. Please check the information on it right away. If any of the information isn’t right, please call us at 1-800-600-4441 (TTY 711). We’ll send you a new, corrected ID card. You can also register online at www.myamerigroup.com/TX to update your address and change your primary care provider. We’re a click or call away Call 1-800-600-4441 (TTY 711) Monday through Friday from 7 a.m. to 6 p.m. Central time if you need to reach us for any reason. You can talk to a Member Services representative about your benefits. If you are sick and need medical advice or want to speak to a licensed nurse, call our 24-hour Nurse HelpLine at the same toll-free number — any time, day or night. You can search for network providers with our online provider directory tool. Visit www.myamerigroup.com/TX and go to Find a Doctor to search by provider name or specialty type. We make it easy to find a doctor near you. If you need help finding a doctor or would like a printed directory at no cost, call Member Services. Thanks again for being our member. We look forward to working with you. Sincerely,
Tisch Scott President Amerigroup Medicaid Health Plans — Texas
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AMERITIPS: HEALTH TIPS THAT MAKE HEALTH HAPPEN You need to go to your doctor now! When is it time for a well-care visit? All Amerigroup members need to have regular Texas Health Steps checkups or adult well-care visits. This way your primary care provider or doctor can see if you have a problem before it is a bad problem. When you become an Amerigroup member, call your doctor and make the first appointments for you and your child within 90 days. Well care for children: The Texas Health Steps Program Children need more wellness checkups than adults. These medical checkups, for children birth through age 20 who have Medicaid, are called Texas Health Steps. When your child becomes an Amerigroup member, we may contact you to remind you to take your child for a medical checkup. Your child should get Texas Health Steps medical checkups at the times listed below: Texas Health Steps medical checkups schedule for your child Birth
9 months old
3-5 days old
12 months old
2 weeks old
15 months old
2 months old
18 months old
4 months old
2 years old
6 months old
2 1/2 years old
After age 2 ½, your child should visit the doctor every year. Amerigroup encourages and covers annual checkups for children ages 3 through 20. Be sure to make these appointments and take your child to his or her doctor when scheduled. Find health problems before they get worse and harder to treat. Prevent health problems that make it hard for your child to learn and grow. If your child’s doctor or dentist finds a health problem during a checkup, your child can get the care he or she needs such as eye exams and glasses, hearing tests and hearing aids, or dental care. Are you a migrant farmworker? We will help you find doctors and clinics and help you set up appointments for your children. Your child can receive his or her checkup or service sooner if you are leaving the area. What if I become pregnant? If you think you are pregnant, call your doctor or OB/GYN right away. You don’t need a referral to see an OB/GYN. This can help you have a healthy baby. If you have any questions or need help making an appointment with your doctor or OB/GYN, please call Member Services at 1-800-600-4441 (TTY 711). ALERT! DO NOT LOSE YOUR HEALTH-CARE BENEFITS — RENEW YOUR ELIGIBILITY FOR MEDICAID BENEFITS ON TIME. TX-MHB-0103-17
AMERIGROUP MEMBER HANDBOOK Bexar Service Area 12500 San Pedro Ave. Suite 400 San Antonio, TX 78216
Dallas and Tarrant Service Areas 2505 N. Highway 360 Suite 300 Grand Prairie, TX 75050
Harris and Jefferson Service Areas 3800 Buffalo Speedway Suite 400 Houston, TX 77098
Medicaid Rural Service Area 2505 N. Highway 360 Suite 300 Grand Prairie, TX 75050
Lubbock Service Area 3223 S. Loop 289 Suite 110 Lubbock, TX 79423
1-800-600-4441 www.myamerigroup.com/TX
Welcome to Amerigroup! You will get most of your health care through Amerigroup. This member handbook will tell you how we can help you get the health care you need.
Table of Contents INFORMATION ABOUT YOUR NEW HEALTH PLAN ........................................................ 1 YOUR AMERIGROUP MEMBER HANDBOOK.................................................................................................................1
IMPORTANT PHONE NUMBERS.................................................................................... 1 AMERIGROUP TOLL-FREE MEMBER SERVICES LINE.....................................................................................................1 AMERIGROUP 24-HOUR NURSE HELPLINE ...................................................................................................................2 BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES LINE .................................................................................2 OTHER IMPORTANT PHONE NUMBERS ........................................................................................................................2
YOUR AMERIGROUP ID CARD ...................................................................................... 3 WHAT DOES MY AMERIGROUP ID CARD LOOK LIKE? HOW DO I USE IT?.................................................................3 How do I read my Amerigroup ID card? ............................................................................................. 4 How do I replace my Amerigroup ID card if it is lost or stolen? ......................................................... 4 YOUR TEXAS BENEFITS MEDICAID CARD .......................................................................................................................4 WHAT IF I NEED A TEMPORARY ID VERIFICATION FORM? .........................................................................................5
PRIMARY CARE PROVIDERS ......................................................................................... 6 WHAT IS A PRIMARY CARE PROVIDER? .........................................................................................................................6 CAN A SPECIALIST EVER BE CONSIDERED A PRIMARY CARE PROVIDER? ..................................................................6 WHAT DO I NEED TO BRING WITH ME TO MY DOCTOR’S APPOINTMENT?.............................................................6 HOW CAN I CHANGE MY PRIMARY CARE PROVIDER?.................................................................................................6 CAN A CLINIC BE MY PRIMARY CARE PROVIDER? ........................................................................................................6 HOW MANY TIMES CAN I CHANGE MY/MY CHILD’S PRIMARY CARE PROVIDER?...................................................7 TX-MHB-0103-17
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WHEN WILL MY PRIMARY CARE PROVIDER CHANGE BECOME EFFECTIVE? ............................................................7 ARE THERE ANY REASONS WHY A REQUEST TO CHANGE A PRIMARY CARE PROVIDER MAY BE DENIED? .........7 CAN MY PRIMARY CARE PROVIDER MOVE ME TO ANOTHER PRIMARY CARE PROVIDER FOR NONCOMPLIANCE?........................................................................................................................................................7 WHAT IF I CHOOSE TO GO TO ANOTHER DOCTOR WHO IS NOT MY PRIMARY CARE PROVIDER? ........................7 HOW DO I GET MEDICAL CARE AFTER MY PRIMARY CARE PROVIDER’S OFFICE IS CLOSED? .................................7 WHAT IS THE MEDICAID LOCK-IN PROGRAM? .............................................................................................................7
PHYSICIAN INCENTIVE PLANS....................................................................................... 8 CHANGING HEALTH PLANS .......................................................................................... 8 WHAT IF I WANT TO CHANGE HEALTH PLANS? ...........................................................................................................8 WHO DO I CALL?...............................................................................................................................................................8 HOW MANY TIMES CAN I CHANGE HEALTH PLANS?...................................................................................................9 WHEN WILL MY HEALTH PLAN CHANGE BECOME EFFECTIVE? .................................................................................9 CAN AMERIGROUP ASK THAT I GET DROPPED FROM THEIR HEALTH PLAN (FOR NONCOMPLIANCE, ETC.)? ............................................................................................................................................................................................9
BENEFITS ..................................................................................................................... 9 WHAT ARE MY HEALTH-CARE BENEFITS? .....................................................................................................................9 How do I get these services? ............................................................................................................ 11 What if Amerigroup doesn’t have a provider for one of my covered benefits? .............................. 11 Are there any limits to any covered services? .................................................................................. 11 WHAT IS PREAPPROVAL? ............................................................................................................................................. 11 WHAT SERVICES ARE NOT COVERED BY AMERIGROUP? ......................................................................................... 12 WHAT ARE MY PRESCRIPTION DRUG BENEFITS? ...................................................................................................... 12 HOW MUCH DO I HAVE TO PAY FOR MY HEALTH CARE? ........................................................................................ 12 WHAT EXTRA BENEFITS DO I GET AS A MEMBER OF AMERIGROUP? HOW CAN I GET THESE SERVICES? ........ 12 WHAT HEALTH EDUCATION CLASSES DOES AMERIGROUP OFFER?....................................................................... 14 WHAT IS THE DISEASE MANAGEMENT CENTRALIZED CARE UNIT? ........................................................................ 15 WHAT IS A MEMBER WITH SPECIAL HEALTH CARE NEEDS (MSHCN)?................................................................... 16 What is service management for Members with Special Health Care Needs? ................................ 17 What will a case manager do for me? .............................................................................................. 17 How can I talk with a case manager?................................................................................................ 17 WHAT IS CASE MANAGEMENT? .................................................................................................................................. 17 WHAT OTHER SERVICES CAN AMERIGROUP HELP ME GET?................................................................................... 18
HEALTH-CARE AND OTHER SERVICES ..........................................................................18 WHAT DOES MEDICALLY NECESSARY MEAN? ........................................................................................................... 18 HOW IS NEW TECHNOLOGY EVALUATED? ................................................................................................................ 19 WHAT IS ROUTINE MEDICAL CARE?............................................................................................................................ 20 How soon can I expect to be seen? .................................................................................................. 20 WHAT IS URGENT MEDICAL CARE?............................................................................................................................. 20 What should I do if my child or I need urgent medical care? ........................................................... 20 How soon can I expect to be seen? .................................................................................................. 20 WHAT IS EMERGENCY MEDICAL CARE? ..................................................................................................................... 20 How soon can I expect to be seen? .................................................................................................. 21 TX-MHB-0103-17
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WHAT IS POST-STABILIZATION? .................................................................................................................................. 21 ARE EMERGENCY DENTAL SERVICES COVERED BY THE HEALTH PLAN? ................................................................ 21 WHAT DO I DO IF MY CHILD NEEDS EMERGENCY DENTAL CARE?.......................................................................... 21 HOW SOON CAN I SEE MY DOCTOR? ......................................................................................................................... 22 HOW DO I GET MEDICAL CARE AFTER MY PRIMARY CARE PROVIDER’S OFFICE IS CLOSED? .............................. 22 WHAT IF I GET SICK WHEN I AM OUT OF TOWN OR TRAVELING?.......................................................................... 23 What if I am out of the state? ........................................................................................................... 23 What if I am out of the country? ...................................................................................................... 23 WHAT IF I NEED TO SEE A SPECIAL DOCTOR (SPECIALIST)? ..................................................................................... 23 What is a referral? ............................................................................................................................ 23 How soon can I expect to be seen by a specialist? ........................................................................... 23 WHAT SERVICES DO NOT NEED A REFERRAL? ........................................................................................................... 24 HOW CAN I ASK FOR A SECOND OPINION? ............................................................................................................... 24 HOW DO I GET HELP IF I HAVE BEHAVIORAL (MENTAL) HEALTH, ALCOHOL, OR DRUG PROBLEMS?................ 24 Do I need a referral for this? ............................................................................................................. 24 WHAT ARE MENTAL HEALTH REHABILITATIVE SERVICES AND MENTAL HEALTH TARGETED CASE MANAGEMENT? ............................................................................................................................................................ 24 How do I get these services? ............................................................................................................ 24 HOW DO I GET MY MEDICATIONS? ............................................................................................................................ 25 How do I find a network drugstore? ................................................................................................. 25 What if I go to a drugstore that is not in the network? .................................................................... 25 What do I bring with me to the drugstore? ...................................................................................... 25 What if I need my medications delivered to me?............................................................................. 25 Who do I call if I have problems getting my medications?............................................................... 25 What if I can’t get the medication my doctor ordered approved? .................................................. 25 What if I lose my medications? ......................................................................................................... 25 How do I find out what drugs are covered? ..................................................................................... 26 How do I transfer my prescriptions to a plan pharmacy? ................................................................ 26 Will I have a copay? .......................................................................................................................... 26 How do I get my medicine if I am traveling? .................................................................................... 26 What if I paid out of pocket for a medicine and want to be reimbursed? ....................................... 26 What if I need durable medical equipment (DME) or other products normally found in a pharmacy?......................................................................................................................................... 26 HOW DO I GET FAMILY PLANNING SERVICES? .......................................................................................................... 27 Do I need a referral for this? ............................................................................................................. 27 Where do I find a family planning services provider? ...................................................................... 27 WHAT IS CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN? ......................................................... 27 Case management for children and pregnant women ..................................................................... 27 WHAT IS EARLY CHILDHOOD INTERVENTION (ECI)? ................................................................................................. 28 Do I need a referral for this? ............................................................................................................. 28 Where do I find an ECI provider? ...................................................................................................... 28 WHAT IS HEAD START? ................................................................................................................................................. 28 WHAT IS TEXAS HEALTH STEPS? .................................................................................................................................. 28 What services are offered by Texas Health Steps? ........................................................................... 28 How and when do I get Texas Health Steps medical and dental checkups for my child? ................ 29 Does my doctor have to be part of the Amerigroup plan?............................................................... 30 TX-MHB-0103-17
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Do I have to have a referral?............................................................................................................. 30 What if I need to cancel an appointment? ....................................................................................... 30 What to do if you are out of town and your child is due for a Texas Health Steps visit? ................ 30 What if I am a migrant farmworker? ................................................................................................ 30 When should adults get checkups? .................................................................................................. 30 If I miss my well-care visits or my child’s Texas Health Steps checkup, what do I do? .................... 31 WHAT IS HHSC’S MEDICAL TRANSPORTATION PROGRAM (MTP)? ........................................................................ 31 What is MTP? .................................................................................................................................... 31 What services are offered by MTP? .................................................................................................. 31 How to get a ride? ............................................................................................................................. 32 What if I can’t be transported by taxi, van, or other standard Medical Transportation Program vehicles to get to health-care appointments? .................................................................................. 32 HOW DO I GET EYE CARE SERVICES?........................................................................................................................... 32 WHAT DENTAL SERVICES DOES AMERIGROUP COVER FOR CHILDREN? ............................................................... 33 CAN SOMEONE INTERPRET FOR ME WHEN I TALK WITH MY DOCTOR? WHO DO I CALL FOR AN INTERPRETER? ............................................................................................................................................................... 33 How far in advance do I need to call? ............................................................................................... 33 How can I get a face-to-face interpreter in the provider’s office? ................................................... 33 WHAT IF I NEED OB/GYN CARE?.................................................................................................................................. 33 Do I have the right to choose an OB/GYN?....................................................................................... 34 How do I choose an OB/GYN?........................................................................................................... 34 If I do not choose an OB/GYN, do I have direct access? ................................................................... 34 Will I need a referral? ....................................................................................................................... 34 How soon can I be seen after contacting my OB/GYN for an appointment? ................................... 34 Can I stay with my OB/GYN if he or she is not with Amerigroup? ................................................... 34 WHAT IF I AM PREGNANT? WHO DO I NEED TO CALL? ........................................................................................... 34 What other services/activities/education does Amerigroup offer pregnant women? .................... 34 Where can I find a list of birthing centers? ....................................................................................... 36 CAN I PICK A PRIMARY CARE PROVIDER FOR MY BABY BEFORE THE BABY IS BORN?.......................................... 36 When you have a new baby .............................................................................................................. 36 How and when can I switch my baby’s primary care provider? ....................................................... 36 Can I switch my baby’s health plan? ................................................................................................. 36 HOW DO I SIGN UP MY NEWBORN BABY? ................................................................................................................ 36 How and when do I tell Amerigroup? ............................................................................................... 37 How can I receive health care after my baby is born (and I am no longer covered by Medicaid)? ........................................................................................................................................................... 37 How and when do I tell my caseworker? .......................................................................................... 39 WHO DO I CALL IF I HAVE SPECIAL HEALTH-CARE NEEDS AND NEED SOMEONE TO HELP ME?......................... 39 WHAT IF I AM TOO SICK TO MAKE A DECISION ABOUT MY MEDICAL CARE? ....................................................... 39 What are advance directives?........................................................................................................... 39 How do I get an advance directive? .................................................................................................. 39 RECERTIFY YOUR MEDICAID BENEFITS ON TIME....................................................................................................... 39 What do I have to do if I need help with completing my renewal application? .............................. 39 WHAT HAPPENS IF I LOSE MY MEDICAID COVERAGE? ............................................................................................ 40 WHAT IF I GET A BILL FROM MY DOCTOR? WHO DO I CALL? WHAT INFORMATION WILL THEY NEED? .......... 40 WHAT DO I HAVE TO DO IF I MOVE? .......................................................................................................................... 41 TX-MHB-0103-17
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WHAT IF I HAVE OTHER HEALTH INSURANCE IN ADDITION TO MEDICAID? ......................................................... 41 WHAT ARE MY RIGHTS AND RESPONSIBILITIES?....................................................................................................... 41
HOW WE MAKE DECISIONS ABOUT YOUR CARE .........................................................44 COMPLAINT PROCESS .................................................................................................44 WHAT SHOULD I DO IF I HAVE A COMPLAINT? WHO DO I CALL? ........................................................................... 44 Can someone from Amerigroup help me file a complaint? ............................................................. 44 How long will it take to process my complaint? ............................................................................... 44 What are the requirements and time frames for filing a complaint? .............................................. 44 How do I file a complaint with the Health and Human Services Commission once I have gone through the Amerigroup complaint process?................................................................................... 45
APPEAL PROCESS ........................................................................................................46 WHAT CAN I DO IF MY DOCTOR ASKS FOR A SERVICE OR MEDICINE FOR ME THAT’S COVERED BUT AMERIGROUP DENIES OR LIMITS IT?.......................................................................................................................... 46 How will I find out if services are denied? ........................................................................................ 46 What are the time frames for the appeals process? ........................................................................ 46 How can I continue receiving services that were already approved? .............................................. 47 Can someone from Amerigroup help me file an appeal? ................................................................. 47 Can I request a state fair hearing? .................................................................................................... 47
EXPEDITED APPEALS ...................................................................................................47 WHAT IS AN EXPEDITED APPEAL? ............................................................................................................................... 47 HOW DO I ASK FOR AN EXPEDITED APPEAL? DOES MY REQUEST HAVE TO BE IN WRITING? ............................ 48 WHAT ARE THE TIME FRAMES FOR AN EXPEDITED APPEAL?.................................................................................. 48 WHAT HAPPENS IF AMERIGROUP DENIES THE REQUEST FOR AN EXPEDITED APPEAL? ..................................... 48 WHO CAN HELP ME FILE AN EXPEDITED APPEAL? .................................................................................................... 48
STATE FAIR HEARINGS ................................................................................................48 CAN I ASK FOR A STATE FAIR HEARING?..................................................................................................................... 48
FRAUD AND ABUSE INFORMATION.............................................................................49 DO YOU WANT TO REPORT WASTE, ABUSE, OR FRAUD? ........................................................................................ 49
QUALITY MANAGEMENT ............................................................................................50 WHAT DOES QUALITY MANAGEMENT DO FOR YOU? ............................................................................................. 50 WHAT ARE CLINICAL PRACTICE GUIDELINES?............................................................................................................ 51
INFORMATION THAT MUST BE AVAILABLE ONCE A YEAR ...........................................51 HIPAA NOTICE OF PRIVACY PRACTICES .......................................................................52
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INFORMATION ABOUT YOUR NEW HEALTH PLAN Welcome to Amerigroup! We are a managed care organization, and we want to help you get the right care close to home. As an Amerigroup STAR program member, you and your primary care provider will work together to get and keep you healthy. Amerigroup members in the Medicaid Rural Service Area and the STAR Kids program are served by Amerigroup Insurance Company. All other Amerigroup members in Texas are served by Amerigroup Texas, Inc. To find doctors and hospitals in your area, visit www.myamerigroup.com/TX or contact Member Services at 1-800-600-4441 (TTY 711).
Your Amerigroup member handbook This handbook will help you understand your Amerigroup health plan. If you have questions or need help understanding or reading your member handbook, call Member Services. You can request this handbook in large print, audio, Braille, or another language. The other side of this handbook is in Spanish.
IMPORTANT PHONE NUMBERS Amerigroup toll-free Member Services Line If you have any questions about your Amerigroup health plan, you can call our Member Services department toll-free at 1-800-600-4441 (TTY 711). You can call us Monday through Friday from 7 a.m. to 6 p.m. Central time, except for state-approved holidays. If you call after 6 p.m. or on a weekend or holiday, you can leave a voice mail message. A Member Services representative will call you back the next business day. These are some of the things Member Services can help you with: This member handbook Member ID cards Your doctors Doctor appointments Transportation Health-care benefits Accessing services What to do in an emergency or crisis Well care Special kinds of health care Healthy living Complaints and medical appeals Rights and responsibilities
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For members who don’t speak English, we can help you in many different languages and dialects, including Spanish. You may also get an interpreter for visits with your doctor at no cost to you. Please let us know if you need an interpreter at least 24 hours before your appointment. Call Member Services to learn more. For members who are deaf or hard of hearing, call 711 toll-free. If you need someone who knows sign language to help you at your doctor visits, we’ll set up and pay for a sign language interpreter. Please let us know if you need an interpreter at least 24 hours before your appointment. If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away. If you need advice, call your primary care provider or our 24-hour Nurse HelpLine 7 days a week at 1-800-600-4441 (TTY 711). For urgent care (see What is urgent medical care? section of this handbook), you should call your primary care provider, even on nights and weekends. Your primary care provider will tell you what to do. Call us to find an urgent care clinic near you. Or call our 24-hour Nurse HelpLine at 1-800-600-4441 (TTY 711) for advice anytime, day or night.
Amerigroup 24-hour Nurse HelpLine You can call our 24-hour Nurse HelpLine 24 hours a day, 7 days a week. Call toll-free at 1-800-600-4441 (TTY 711) if you need advice on: How soon you need care for an illness What kind of health care you need What to do to take care of yourself before you see the doctor How you can get the care you need We want you to get the best care you can. Please call us if you have any problems with your services. We want to help you correct any problems you may have with your care.
Behavioral Health and Substance Abuse services line The Behavioral Health and Substance Abuse services line is available to members 24 hours a day, 7 days a week at 1-800-600-4441. The call is free, and you can talk to someone in English or Spanish. For other languages, interpreter services are available. You can call the Behavioral Health and Substance Abuse services line for help in getting services. If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away.
Other important phone numbers If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away.
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STAR Program Help Line Ombudsman Managed Care Assistance Team Medicaid Hotline Texas Early Childhood Intervention Program Texas Health Steps Eye care through Superior Vision of Texas Dental care for members age 20 and younger through: DentaQuest MCNA Dental Medical Transportation Program — Dallas/Fort Worth area Houston/Beaumont area All other areas Member Services To set up transportation to your medical visits For behavioral health and substance abuse care For information about our disease management programs
1-800-964-2777 1-866-566-8989 1-800-252-8263 1-800-628-5115 1-877-847-8377 1-800-428-8789 1-800-516-0165 1-800-494-6262 1-855-687-3255 1-855-687-4786 1-877-633-8747 1-800-600-4441 (TTY 711)
YOUR AMERIGROUP ID CARD What does my Amerigroup ID card look like? How do I use it? If you don’t have your Amerigroup ID card yet, you’ll get it soon. Please carry it with you at all times. Show it to any doctor or hospital you visit. You don’t need to show your ID card before you get emergency care. The card tells doctors and hospitals you’re an Amerigroup member and who your doctor is. It also tells them Amerigroup will pay for the medically needed services listed in the Benefits section. You may also print your ID card from our website at www.myamerigroup.com/TX. You’ll need to register and log in to the website to access your ID card information.
Sample Amerigroup ID card for STAR members
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Sample Amerigroup ID card for STAR members in the Medicaid Rural Service Area
How do I read my Amerigroup ID card? Your Amerigroup ID card has the name and phone number of your doctor on it. Your ID card lists many of the important phone numbers you need to know, like our Member Services department and 24-hour Nurse HelpLine. It also lists the numbers for vision care and pharmacy services. How do I replace my Amerigroup ID card if it is lost or stolen? If your ID card is lost or stolen, call us right away at 1-800-600-4441 (TTY 711). We’ll send you a new one. You may also print your ID card from our website at www.myamerigroup.com/TX. You’ll need to register and log in to the website to access your ID card information.
Your Texas Benefits Medicaid card When you are approved for Medicaid, you will get a Your Texas Benefits Medicaid card. This plastic card will be your everyday Medicaid ID card. You should carry and protect it just like your driver’s license or a credit card. The card has a magnetic strip that holds your Medicaid ID number. Your doctor can use the card to find out if you have Medicaid benefits when you go for a visit. You will only be issued one card and will only receive a new card in the event of the card being lost or stolen. If your Medicaid ID card is lost or stolen, you can get a new one by calling tollfree 1-855-827-3748. If you are not sure if you are covered by Medicaid, you can find out by calling toll-free at 1-800-252-8263. You can also call 2-1-1. First pick a language and then pick option 2. Your health history is a list of medical services and drugs that you have gotten through Medicaid. We share it with Medicaid doctors to help them decide what health care you need. If you don’t want your doctors to see your health history through the secure online network, call toll-free at 1-800-252-8263. TX-MHB-0103-17
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The Your Texas Benefits Medicaid card has these facts printed on the front: Your name and Medicaid ID number The date the card was sent to you The name of the Medicaid program you’re in if you get: o Medicare (QMB, MQMB) o Healthy Texas Women Program (TWHP) o Hospice o STAR Health o Emergency Medicaid o Presumptive Eligibility for Pregnant Women (PE) Facts your drugstore will need to bill Medicaid The name of your doctor and drugstore if you’re in the Medicaid Lock-in Program The back of the Your Texas Benefits Medicaid card has a website you can visit (www.YourTexasBenefits.com) and a phone number you can call toll-free (1-800-252-8263) if you have questions about the new card. If you forget your card, your doctor, dentist, or drugstore can use the phone or the Internet to make sure you get Medicaid benefits.
What if I need a temporary ID verification form? If you’ve lost or do not have access to Your Texas Benefits Medicaid card and need a temporary Medicaid ID card, you need to fill out a temporary ID verification form (Form 1027-A). You can get this form by calling your local HHSC benefits office. To find your local HHSC benefits office, call 2-1-1, pick a language, and then select option 2. Show this form to your provider the same way you would present Your Texas Benefits Medicaid card. Your doctor will accept this form as proof of Medicaid eligibility. You can also go online at YourTexasBenefits.com and print a temporary ID card after logging in to your account.
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PRIMARY CARE PROVIDERS What is a primary care provider? A primary care provider, also called a family doctor, is the main doctor you see for most of your regular health care. When you enrolled in Amerigroup, you should have picked a primary care provider in our plan. If you didn’t, we assigned you one who should be located close to you. Your primary care provider’s name and phone number are printed on your Amerigroup ID card. If you or your child have been getting care from a doctor who treats children and need to change to a doctor who provides care to adults, you can switch your primary care provider. We can help you choose a doctor for adults and transfer your medical records. Call Member Services toll-free at 1-800-600-4441 (TTY 711). Your primary care provider will also send you to specialists, other doctors, or hospitals when you need special care or services he or she can’t provide.
Can a specialist ever be considered a primary care provider? If you need regular specialist care, we may approve a specialist to serve as your primary care provider. A specialist can serve as a primary care provider if you have a disability, special health-care needs, or a chronic, life-threatening illness or condition where: You may need to be hospitalized many times for your condition You need to get most of your care from a specialist Your primary care provider isn’t able to arrange the care you need
What do I need to bring with me to my doctor’s appointment? When you go to your doctor's appointment, bring: Your Amerigroup ID card Your Texas Benefits Medicaid card Any medicines you’re taking and your shot records Any questions you want to ask your doctor If the appointment is for your child, bring the same items listed above.
How can I change my primary care provider? Call Member Services if you need to change your primary care provider. You can go to www.myamerigroup.com/TX to find a new one.
Can a clinic be my primary care provider? Yes, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) in our plan can serve as your primary care provider.
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How many times can I change my/my child’s primary care provider? There is no limit on how many times you can change your or your child’s primary care provider. You can change primary care providers by calling us toll-free at 1-800-600-4441 (TTY 711) or writing to us at one of our offices near you. Office locations are listed in the front of this handbook. Please address your written request to the member advocate.
When will my primary care provider change become effective? We can change your doctor on the same day you ask for the change. The change will be effective immediately. Call the doctor’s office if you want to make an appointment.
Are there any reasons why a request to change a primary care provider may be denied? You won’t be able to change your doctor if: The doctor you picked doesn’t take new patients The new doctor isn’t in our plan
Can my primary care provider move me to another primary care provider for noncompliance? Your primary care provider may ask for you to change to another primary care provider if: You don’t follow his or her medical advice over and over again Your doctor agrees a change is best for you Your doctor doesn’t have the right experience to treat you You were assigned to the doctor by mistake (like an adult assigned to a child’s doctor)
What if I choose to go to another doctor who is not my primary care provider? Talk to your primary care provider first about any care you need from other doctors. He or she can refer you to other doctors in our plan and help coordinate all the care you need.
How do I get medical care after my primary care provider’s office is closed? If you need to talk to your primary care provider after the office is closed, call his or her phone number on your ID card. Someone should call you back within 30 minutes to tell you what to do. You may also call our 24-hour Nurse HelpLine 24 hours a day, 7 days a week for help. If you think you need emergency care, see the What is emergency medical care? section of this handbook, call 911, or go to the nearest emergency room right away.
What is the Medicaid Lock-in Program? You may be put in the Lock-in Program if you do not follow Medicaid rules. It checks how you use Medicaid pharmacy services. Your Medicaid benefits remain the same. Changing to a different MCO will not change the Lock-in status.
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To avoid being put in the Medicaid Lock-in Program: Pick one drugstore at one location to use all the time Be sure your main doctor, main dentist, or the specialists they refer you to are the only doctors that give you prescriptions Do not get the same type of medicine from different doctors To learn more, call Member Services at 1-800-600-4441 (TTY 711). In some cases, you may be approved to get medication from another pharmacy, such as: You move out of the geographical area (more than 15 miles from the lock-in pharmacy) The lock-in pharmacy doesn’t have the prescribed medication and it won’t be available for more than 2-3 days The lock-in pharmacy is closed for the day and you need the medication right away You should call Member Services at 1-800-600-4441 (TTY 711) if you need approval to receive a medication at a pharmacy other than the lock-in pharmacy.
PHYSICIAN INCENTIVE PLANS Amerigroup cannot make payments under a physician incentive plan if the payments are designed to induce providers to reduce or limit medically necessary covered services to members. You have the right to know if your primary care provider (main doctor) is part of this physician incentive plan. You also have a right to know how the plan works. You can call 1-800-600-4441 (TTY 711) to learn more about this.
CHANGING HEALTH PLANS What if I want to change health plans? You can change your health plan by calling the Texas STAR Program Helpline at 1-800-964-2777. You can change health plans as often as you want. If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that. For example: If you call on or before April 15, your change will take place on May 1 If you call after April 15, your change will take place on June 1 If you aren’t happy with us, please call Member Services. We’ll work with you to try to fix the problem. If you’re still not happy, you can change to another health plan.
Who do I call? You can change your health plan by calling the Texas STAR Program Helpline at 1-800-964-2777. TX-MHB-0103-17
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How many times can I change health plans? You can change health plans as often as you want.
When will my health plan change become effective? If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that. For example: If you call on or before April 15, your change will take place on May 1 If you call after April 15, your change will take place on June 1
Can Amerigroup ask that I get dropped from their health plan (for noncompliance, etc.)? There are several reasons you could be dropped from Amerigroup, including: You’re no longer eligible for Medicaid You let someone else use your Amerigroup ID card You try to hurt a provider, a staff person, or an Amerigroup associate You steal or destroy provider or Amerigroup property You go to the emergency room over and over again when you don’t have an emergency You go to doctors or medical facilities outside the Amerigroup plan over and over again You try to hurt other patients or make it hard for other patients to get the care they need If you’ve done something that may lead to being dropped from our plan, we’ll contact you. We’ll ask you to tell us what happened. If you have any questions about your enrollment, call Member Services at 1-800-600-4441 (TTY 711).
BENEFITS What are my health-care benefits? Your primary care provider will give you the care you need or refer you to another doctor. Some Amerigroup benefits are only for members who are a certain age or have a certain kind of health problem. If you have a question or aren’t sure if we offer a certain benefit, call Member Services. STAR covered services include, but are not limited to, medically necessary: ● Emergency and nonemergency ambulance services ● Audiology services, including hearing aids, for adults and children ● Behavioral health services, including: - Inpatient mental health services - Outpatient mental health services - Psychiatry services - Mental health rehabilitative services TX-MHB-0103-17
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- Counseling services for adults (21 years of age and older) - Outpatient substance use disorder treatment services, including: − Assessment − Detoxification − Counseling − Medication-assisted therapy - Residential substance use disorder treatment (including room and board and ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ●
detoxification services) Birthing services provided by a doctor or certified nurse-midwife in a licensed birthing center Birthing services provided by a licensed birthing center Cancer screening, diagnosis, and treatment Chiropractic services Dialysis Durable medical equipment and supplies Early childhood intervention Emergency services Family planning Home health care Hospital services, including inpatient and outpatient Laboratory services Mastectomy, breast reconstruction, and related follow-up procedures, including: o Inpatient services; outpatient services provided at an outpatient hospital or ambulatory health-care center, as clinically appropriate; and physician and professional services provided in an office, inpatient, or outpatient setting for: All stages of reconstruction on the breast(s) on which medically necessary mastectomy procedure(s) have been performed Surgery and reconstruction on the other breast to produce symmetrical appearance Treatment of physical complications from the mastectomy and treatment of lymphedemas Prophylactic mastectomy to prevent the development of breast cancer o External breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed Medical checkups and Comprehensive Care Program services for children (from birth through age 20) through the Texas Health Steps program Mental health targeted case management Oral evaluation and fluoride varnish in the medical home in conjunction with Texas Health Steps medical checkup for children 6 months through 35 months of age Outpatient drugs and biologicals, including those dispensed by a pharmacy or administered by a provider Drugs and biologicals provided in an inpatient setting Podiatry Prenatal care Primary care
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● ● ● ● ● ● ● ● ●
Preventive services, including an annual adult well check for patients 21 years of age and older Radiology, imaging, and X-rays Specialty physician services Telehealth Telemedicine Telemonitoring, to the extent covered by Texas Government Code §531.01276 Therapies — physical, occupational, and speech Transplantation of organs and tissues Vision (includes optometry and glasses; contact lenses are only covered if they are medically necessary for vision correction that cannot be accomplished by glasses)
How do I get these services? Your primary care provider will help you get these types of services or you can call Member Services at 1-800-600-4441 (TTY 711). What if Amerigroup doesn’t have a provider for one of my covered benefits? If a plan benefit isn’t available through a doctor in our plan, we’ll arrange for you to see one outside of the plan. We’ll reimburse him or her according to state rules. You must call Member Services at 1-800-600-4441 (TTY 711) to arrange services with a doctor outside of our plan except in an emergency. Are there any limits to any covered services? There may be some limits to care, such as for chiropractic services, based on Medicaid covered benefits. You can call Member Services at 1-800-600-4441 (TTY 711) for a complete list of benefits and limitations.
What is preapproval? Some treatment, care, or services may need our approval before your or your child’s doctor can provide them. This is called preapproval. Your or your child’s doctor will work directly with us to get the approval. The following require preapproval: Most surgeries, including some outpatient surgeries All elective and nonurgent inpatient services and admissions Chiropractic services Most behavioral health and substance abuse services (except routine outpatient and emergency services) Certain prescriptions Certain durable medical equipment, including prosthetics and orthotics Certain gastroenterology procedures Digital hearing aids Home health services Hospice services Rehabilitation therapy (physical, occupational, respiratory, and speech therapies) Sleep studies TX-MHB-0103-17
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Out-of-area or out-of-network care except in an emergency Advanced imaging (things like MRAs, MRIs, CT scans, and CTA scans) Certain pain management testing and procedures
This list is subject to change without notice and isn’t a complete list of covered plan benefits. Please call Member Services with questions about specific services.
What services are not covered by Amerigroup? Amerigroup doesn’t offer the benefits and services below. These services aren’t covered by feefor-service Medicaid either. Anything that is not medically necessary Anything experimental such as a new treatment being tested or hasn’t been shown to work Cosmetic surgery that isn’t medically necessary Sterilization for members under age 21 Routine foot care except for members with diabetes or poor circulation Fertility treatment services Treatment for disabilities connected to military service Weight loss program services Reversal of voluntary sterilization Private room and personal comfort items when hospitalized Sex reassignment surgery To learn more about services not covered by Amerigroup, please call Member Services at 1-800-600-4441.
What are my prescription drug benefits? Medicaid pays for most medicine your doctor prescribes. Adults as well as children can get as many prescriptions as are medically necessary for medicines found on the Vendor Drug Program (VDP) list of drugs. Your doctor will use the VDP when writing your prescriptions. You may fill your prescription at any pharmacy in our plan unless you’re in the Medicaid Lock-in Program.
How much do I have to pay for my health care? You don’t have to pay for plan health-care benefits. You don’t pay any premiums, enrollment fees, deductibles, copays, or cost sharing.
What extra benefits do I get as a member of Amerigroup? How can I get these services? Amerigroup gives you extra health-care benefits just for being our STAR member. These extra benefits are also called value-added benefits. We give you these benefits to help keep you healthy and to thank you for choosing Amerigroup as your health-care plan. Call Member Services to learn more about these extra benefits and how to get them, or visit our website at www.myamerigroup.com/TX.
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Value-added benefit
How to get it
24-hour Nurse HelpLine — nurses are available 24 hours a day, 7 days a week for your health-care questions
Call 1-800-600-4441 (TTY 711)
Help getting rides to: Medical appointments when the State Medical Transportation Program is not available
Call 1-800-600-4441 (TTY 711)
Pregnancy, birthing, or newborn classes
One sports or school physical every year for members ages 6 to 18
See your primary care provider
Up to $50 each school year for a Boys & Girls Club basic membership for members ages 6 to 18 where available
Go to your local Boys & Girls Club
Free cellphone/smartphone through the Lifeline program with monthly minutes, data, and texts.
Call 1-800-600-4441 (TTY 711) or go to www.myamerigroup.com/TX to learn more
Allergy-free pillow cover (1 per year) for members age 20 and younger who have been diagnosed with asthma and participate in a disease/case management program
Call 1-800-600-4441 (TTY 711) or go to www.myamerigroup.com/TX to learn more
Taking Care of Baby and Me® program — A rewarding way to keep our pregnant members, new moms, and their babies healthy and happy. When pregnant members join, they get: A special self-care book with tips on caring for yourself and your baby while you’re pregnant
Call 1-800-600-4441 (TTY 711) or go to www.myamerigroup.com/TX to learn more
A congratulations letter and booklet about caring for your new baby and yourself after you give birth Help quitting smoking — education and telephone support with your own personal coach and a full range of nicotine replacement therapies as needed for members age 18 and older (when no other Medicaid benefits are available to help you quit smoking)
Call 1-800-600-4441 (TTY 711) or go to www.myamerigroup.com/TX to learn more
Real Solutions® Healthy Rewards debit card for completing these healthy activities:
Call 1-877-868-2004 or go to www.myamerigroup.com/HealthyRewards to learn more
$120 for completing 6 well-child checkups per the Texas Health Steps visit schedule, for children ages 015 months (refer to the What is Texas Health Steps? section of this handbook)
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Value-added benefit
How to get it
$20 per visit for well-child checkups at ages 18, 24, or
30 months $20 each year for completing well-child checkups, for ages 3-20 years old $20 for getting a full series of the rotavirus vaccinations (2-3 visits on different days depending on type of vaccine), for children ages 42 days through 24 months of age $20 for getting a full series of flu (influenza) vaccinations (2 vaccinations on different days), for children ages 6 months through 24 months of age $25 for a woman who has a prenatal checkup in her first trimester of pregnancy or within 42 days of enrollment $50 for a woman who has a postpartum checkup within 21 to 56 days after giving birth $20 each year for having a retinopathy eye exam, for members age 18-75 with diabetes $20 every 6 months for getting a blood sugar test (HbA1c) for members age 18 or older with diabetes $20 every 6 months for getting a blood sugar test (HbA1c) with a result less than 8, for members age 18 or older with diabetes $20 each year for getting a cholesterol exam, for members age 21 or older with cardiovascular disease $20 each year getting a flu (influenza) vaccination, for members age 18 or older
Disaster Kit — complete a personal disaster plan online so you’ll be ready in an emergency, and get a free first aid kit (1 kit per member per lifetime)
Call 1-800-600-4441 (TTY 711) or go to www.myamerigroup.com/TX to learn more
Dental hygiene kit for members age 21 and older — 1 kit per year
Call 1-800-600-4441 (TTY 711) or go to www.myamerigroup.com/TX to learn more
What health education classes does Amerigroup offer? We work to help keep you healthy by holding educational events in your area and by helping you find community health education programs close to you. These events and community
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programs may include: Amerigroup services and how to get them Childbirth Infant care Parenting Pregnancy Quitting cigarette smoking Protecting yourself from violence Other classes or events about health topics For events in your area, check the Community Resources page at www.myamerigroup.com/TX. For help finding a community program, call Member Services or dial 2-1-1. Please note: some community organizations may charge a fee for their programs.
What is the Disease Management Centralized Care Unit? If you have a long-term health issue, you don’t have to go it alone. Our disease management program can help you get more out of life. The program is private and on hand at no cost to you. It’s called the Disease Management Centralized Care Unit (DMCCU) program. A team of licensed nurses and social workers, called DMCCU case managers, are available to teach you about your health issue and help you learn how to manage your health. Your primary care provider and our DMCCU team are here to help you with your health-care needs. You can join the program if you have one of these conditions: Asthma Diabetes Bipolar disorder HIV/AIDS Chronic obstructive pulmonary disease Hypertension (COPD) Major depressive disorder Congestive heart failure (CHF) Schizophrenia Coronary artery disease (CAD) Substance use disorder Our case managers help with weight management and smoking cessation services. DMCCU case managers work with you to make health goals and help you build a plan to reach them. As a member in the program, you’ll benefit from having a case manager who: Listens to you and takes the time to understand your specific needs. Helps you make a care plan to reach your health-care goals. Gives you the tools, support, and community resources that can help you improve your quality of life. Gives you health information that can help you make better choices. Helps you coordinate care with your providers. As an Amerigroup member enrolled in the DMCCU program, you have certain rights and responsibilities.
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You have the right to: Have information about Amerigroup. This includes: o All Amerigroup programs and services o Our staff’s education and work experience o Contracts we have with other businesses or agencies Refuse to take part in or leave programs and services we offer. Know who your case manager is and how to ask for a different case manager. Have Amerigroup help you make choices with your doctors about your health care. Learn about all DMCCU-related treatments; these include anything stated in the clinical guidelines, whether covered by Amerigroup or not. You have the right to talk about all options with your doctors. Have personal data and medical information kept private. Know who can access your information and know our procedures used to ensure security, privacy, and confidentiality. Be treated with courtesy and respect by Amerigroup staff. File complaints with Amerigroup and get guidance on how to use the complaint process, including how long it will take us to respond and resolve issues of quality and complaints. Get information that is clear and easy to understand. You should: Follow health-care advice offered by Amerigroup. Give Amerigroup information needed to carry out our services. Tell Amerigroup and your doctors if you decide to disenroll from the DMCCU program. If you have one of these health issues or would like to know more about DMCCU, please call 1-888-830-4300 Monday through Friday from 8:30 a.m. to 5:30 p.m. local time. Ask to speak with a DMCCU case manager. You can also visit our website at www.myamerigroup.com/TX or call DMCCU if you would like a copy of DMCCU information you find online. Calling can be your first step on the road to better health.
What is a Member with Special Health Care Needs (MSHCN)? A Member with Special Health Care Needs (MSHCN) is someone who both: Has a serious ongoing illness, a chronic or complex condition, or a disability that will likely last for a long period of time Requires regular, ongoing treatment and evaluation for the condition by appropriate health-care personnel MSHCN include: Early Childhood Intervention (ECI) program participants Farmworker’s children Former foster care children
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Pregnant women who have a high risk pregnancy such as a multiple pregnancy, history of preterm delivery with past pregnancy, or current preterm labor. People who have a mental Illness with substance abuse People with behavioral health issues that affect their physical health and ability to follow treatment plans Adoption Assistance and Permanency Care Assistance (AAPCA) program members
We have a system for identifying and contacting MSHCN. You may also request an assessment to find out if you meet the criteria for MSHCN. What is service management for Members with Special Health Care Needs? Service management for MSHCN is when you work with a case manager to help you get covered care and services to treat a health condition. A case manager is a licensed nurse or social worker who will work with you to develop a service plan and make sure all your care and services work together. Your case manager will work with you and your doctors to make sure you get the care and services you need. You may also have a specialist serve as your primary care provider. What will a case manager do for me? They’ll help you get the services you need by: Identifying your health-care needs through an assessment Creating a service plan to meet those needs Discussing the service plan with you, your family, and your representative (if needed) to make sure you understand and agree with it Helping you get needed services Working as a team with you and your doctors Making sure all health-care and other services you can get outside of Amerigroup are coordinated How can I talk with a case manager? You don’t need a referral from a doctor to talk to a case manager. Call Member Services at 1-800-600-4441 (TTY 711), and ask to speak to one. Case managers are available Monday through Friday from 8 a.m. to 5 p.m. Central time. If one isn’t available, you can leave a confidential voice mail.
What is Case Management? If you don’t qualify for MSHCN service management, we also have a case management program. Through this program, we have case managers who can help you manage critical events and health issues that may last for a while. A case manager will help you manage your health care needs. To contact a case manager, call Member Services at 1-800-600-4441 (TTY 711) and ask to speak to one. They’re available Monday through Friday from 8 a.m. to 5 p.m. Central time. If you need to leave a message, they have confidential voice mail available 24 hours a day. TX-MHB-0103-17
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What other services can Amerigroup help me get? We can help you with services covered by fee-for-service Medicaid instead of Amerigroup. You don’t need a referral from your doctor to get these services. Fee-for-service Medicaid benefits include: Texas Health Steps dental (including orthodontia) — Medicaid members age 20 and younger can get dental benefits through a dental managed care organization Texas Health Steps environmental lead investigation (ELI) Texas Health Steps Personal Care Services for members birth through age 20 Early Childhood Intervention (ECI) case management/service coordination ECI Specialized Skills Training Case Management for Children and Pregnant Women Texas School Health and Related Services (SHARS) Department of Assistive and Rehabilitative Services Blind Children’s Vocational Discovery and Development Program Tuberculosis services provided by Department of State Health Services (DSHS)-approved providers (directly observed therapy and contact investigation) Community First Choice (CFC) services Transportation to and from nonemergency medical services — Health and Human Services Commission’s Medical Transportation will help you get the transportation you need for doctor’s appointments. Call toll-free: Dallas/Fort Worth area: 1-855-687-3255 Houston/Beaumont area: 1-855-687-4786 All other areas: 1-877-633-8747
HEALTH-CARE AND OTHER SERVICES What does medically necessary mean? Your doctor will help you get the services you need that are medically necessary as defined below. Medically necessary means: 1) For members from birth through age 20, the following Texas Health Steps services: a) Screening, vision, and hearing services b) Other health-care services, including behavioral health services, that are necessary to correct or ameliorate a defect or physical or mental illness or condition. A determination of whether a service is necessary to correct or ameliorate a defect or physical or mental illness or condition: i) Must comply with the requirements of the Alberto N., et al. v. Traylor, et al. partial settlement agreements, and ii) May include consideration of other relevant factors, such as the criteria described in parts (2)(b-g) and (3)(b- g) of this definition 2) For members over age 20, nonbehavioral health-related health-care services that are: TX-MHB-0103-17
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a) Reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a member, or endanger life b) Provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s health conditions c) Consistent with health-care practice guidelines and standards that are endorsed by professionally recognized health-care organizations or governmental agencies d) Consistent with the diagnoses of the conditions e) No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency f) Not experimental or investigative and g) Not primarily for the convenience of the member or provider 3) For members over age 20, behavioral health services that: a) Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder b) Are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care c) Are furnished in the most appropriate and least restrictive setting in which services can be safely provided d) Are the most appropriate level or supply of service that can safely be provided e) Could not be omitted without adversely affecting the member’s mental and/or physical health or the quality of care rendered f) Are not experimental or investigative and g) Are not primarily for the convenience of the member or provider If you have questions regarding an authorization, a request for services or a utilization management question, you can call us at 1-800-600-4441 (TTY 711).
How is new technology evaluated? The Amerigroup Medical Director and our providers look at advances in medical technology and new ways to use existing medical technology. We look at advances in: Medical procedures Behavioral health procedures Medicines Devices We review scientific information and government approvals to find out if the treatment works and is safe. We’ll consider covering new technology only if it provides equal or better outcomes than the existing covered treatment or therapy.
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What is routine medical care? Routine care includes regular check-ups, preventive care and appointments for minor injuries and illnesses. Your primary care provider sees you when you’re not feeling well, but that’s only part of his or her job. He or she also takes care of you before you get sick. This is called well care. See the What services are offered by Texas Health Steps? and When should adults get checkups? sections of this handbook to learn more. How soon can I expect to be seen? You should be able to see your doctor within 2 weeks for routine care.
What is urgent medical care? Another type of care is urgent care. There are some injuries and illnesses that are probably not emergencies but can turn into emergencies if they are not treated within 24 hours. Some examples are: Minor burns or cuts Earaches Sore throat Muscle sprains/strains What should I do if my child or I need urgent medical care? For urgent care, you should call your doctor’s office, even on nights and weekends. Your doctor will tell you what to do. In some cases, your doctor may tell you to go to an urgent care clinic. If your doctor tells you to go to an urgent care clinic, you don’t need to call the clinic before going. You need to go to a clinic that takes Amerigroup Medicaid. For help, call us toll-free at 1-800-600-4441. You also can call our 24-hour Nurse HelpLine at the same number for help with getting the care you need. How soon can I expect to be seen? You should be able to see your doctor within 24 hours for an urgent care appointment. If your doctor tells you to go to an urgent care clinic, you do not need to call the clinic before going. The urgent care clinic must take Amerigroup Medicaid.
What is emergency medical care? After routine and urgent care, the third type of care is emergency care. If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away. If you want medical advice, call your primary care provider or our 24-hour Nurse HelpLine 7 days a week at 1-800-600-4441 (TTY 711). Please get medical care as soon as possible. Emergency medical care Emergency medical care is provided for emergency medical conditions and emergency behavioral health conditions. Emergency medical condition means: A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain) such that a prudent layperson, who possesses an average
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knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in: 1. Placing the patient’s health in serious jeopardy 2. Serious impairment to bodily functions 3. Serious dysfunction of any bodily organ or part 4. Serious disfigurement 5. In the case of a pregnant woman, serious jeopardy to the health of a woman or her unborn child Emergency behavioral health condition means: Any condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing average knowledge of medicine and health: 1. Requires immediate intervention and/or medical attention without which the member would present an immediate danger to themselves or others 2. Which renders the member incapable of controlling, knowing, or understanding the consequences of their actions Emergency services and emergency care means: Covered inpatient and outpatient services furnished by a provider that is qualified to furnish such services and that are needed to evaluate or stabilize an emergency medical condition and/or emergency behavioral health condition, including post-stabilization care services. How soon can I expect to be seen? You should be able to see your doctor immediately for emergency care.
What is post-stabilization? Post-stabilization care services are services covered by Medicaid that keep your condition stable following emergency medical care.
Are emergency dental services covered by the health plan? Amerigroup covers limited emergency dental services in a hospital or ambulatory surgical center, including payment for the following: Treatment for dislocated jaw Treatment for traumatic damage to teeth and supporting structures Removal of cysts Treatment of oral abscess of tooth or gum origin Hospital, physician, and related medical services such as drugs for any of the above conditions
What do I do if my child needs emergency dental care? During normal business hours, call your child’s main dentist to find out how to get emergency services. If your child needs emergency dental services after the main dentist’s office has closed, call us toll-free at 1-800-600-4441 (TTY 711) or call 911.
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How soon can I see my doctor? We know how important it is for you to see your doctor. We work with the providers in our plan to make sure you can see them when you need to. Our providers are required to follow the access standards listed below. Standard name Emergency services Urgent care Routine primary care Routine specialty care After-hours care
Amerigroup As soon as you arrive at the provider for care Within 24 hours of request Within 14 days of request Within 3 weeks of request Primary care providers are available 24/7 directly or through an answering service. Refer to the How do I get medical care after my primary care provider’s office is closed? section of this handbook.
Preventive health Children (new member) Children less than 6 months old Members age 6 months through 20 years Prenatal care Initial visit Initial visit for high risk or 3rd trimester After initial visit Behavioral health Non-life-threatening emergency Urgent care Initial visit for routine care Follow-up visit for routine care
New members birth through age 20, as soon as possible and no later than 90 days after enrollment Within 14 days of request Within 60 days of request
Within 14 days of request Within 5 days of request or immediately, if an emergency exists Based on the provider’s treatment plan Within 6 hours of request Within 24 hours of request The earlier of 10 business days or 14 calendar days from request Within 3 weeks of request
You should call your primary care provider within 24 hours after you visit the emergency room. If you can’t call, have someone else call for you. Your doctor will give or arrange any follow-up care you need.
How do I get medical care after my primary care provider’s office is closed? Help from your primary care provider is available 24 hours a day. If you call your primary care provider’s office when it’s closed, leave a message with your name and a phone number where you can be reached. Someone should call you back within 30 minutes to tell you what to do. You may also call our 24-hour Nurse HelpLine to talk to a nurse anytime. TX-MHB-0103-17
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If you think you need emergency care, call 911 or go to the nearest emergency room right away. Refer to the What is emergency medical care? section of this handbook to help you decide if you need emergency care.
What if I get sick when I am out of town or traveling? If you need medical care when traveling, call us toll-free at 1-800-600-4441 (TTY 711) and we will help you find a doctor. If you need emergency services while travelling, go to a nearby hospital, and then call us toll-free at 1-800-600-4441 (TTY 711). What if I am out of the state? If you are outside of Texas and need medical care, please call us toll-free at 1-800-600-4441 (TTY 711). If you need emergency care, go to the nearest hospital emergency room or call 911. What if I am out of the country? Medical services performed out of the country are not covered by Medicaid.
What if I need to see a special doctor (specialist)? Your primary care provider can take care of most of your health-care needs, but you may also need care from other kinds of doctors. These doctors are called specialists because they have training in a special area of medicine. Examples of specialists are:
Allergists (allergy doctors) Dermatologists (skin doctors) Cardiologists (heart doctors) Podiatrists (foot doctors)
We cover services from many different kinds of doctors who provide specialist care. If your primary care provider can’t give you needed care, he or she can refer you to a specialist in our plan. If you have disabilities, special health-care needs, or chronic complex conditions, you can have a specialist as your primary care provider. Please call Member Services so we can arrange this for you. What is a referral? A referral is when your primary care provider sends you to another doctor or service for care. Your primary care provider may refer you to a specialist in our plan if he or she can’t give you the care you need. How soon can I expect to be seen by a specialist? You’ll be able to see a specialist within 3 weeks from when you call the specialist’s office.
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What services do not need a referral? You don’t need a referral from your primary care provider in order to get needed care from providers in our plan. It’s always best to talk to your primary care provider first about any additional care you need. Your primary care provider can tell you about other doctors in our plan and help coordinate all the care you receive.
How can I ask for a second opinion? You have the right to ask for a second opinion about the health-care services you need. This doesn’t cost you anything. You can get a second opinion from a doctor in our plan. If one isn’t available for a second opinion, your primary care provider can submit a request to us to authorize a visit to a non-network provider.
How do I get help if I have behavioral (mental) health, alcohol, or drug problems? Sometimes the stress of life can lead to depression, anxiety, marriage and family problems, or alcohol and drug abuse. If you or a family member is having these kinds of problems, we have doctors who can help. Call Member Services at 1-800-600-4441 (TTY 711) for help finding a doctor who will help you. All services and treatment are strictly confidential. Do I need a referral for this? You don’t need a referral to get help for behavioral health, alcohol, or drug problems.
What are Mental Health Rehabilitative Services and Mental Health Targeted Case Management? Mental Health Rehabilitative Services help you stay independent in your home and the community, such as: Medication training and support Psychosocial rehabilitative services Skills training and development Crisis intervention Day program for acute needs Mental Health Targeted Case Management helps you access medical, social, educational, and other services and supports that can help improve your health and your ability to function. These services are available if you need them based on an appropriate standardized assessment by a mental health professional. How do I get these services? If you or a family member has been diagnosed with or has shown signs of this type of condition, we have doctors who can help. Call Member Services at 1-800-600-4441 (TTY 711) to get the name of a doctor near you.
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How do I get my medications? Medicaid pays for most medicine your doctor says you need. Your doctor will write a prescription so you can take it to the drugstore, or may be able to send the prescription for you. You or your children can get as many prescriptions as medically necessary from the Vendor Drug Program (VDP) list of drugs. You may go to any pharmacy in the Amerigroup network to have your prescription filled, unless you’re in the Medicaid Lock-in Program. You should use the same pharmacy each time you need medicine. This way, your pharmacist will know all the drugs you’re taking. He or she can tell you about drug interactions and side effects. If you use another pharmacy, you should tell the pharmacist about any other medicines you’re taking. How do I find a network drugstore? To find a pharmacy in our plan, go to our website at www.myamerigroup.com/TX and click on Find a Doctor. Then click the Express Scripts Pharmacy Locator Tool. You can search for a pharmacy near you. You can also ask the pharmacist or call Member Services for help. What if I go to a drugstore that is not in the network? The pharmacist will explain that they don’t accept Amerigroup. You’ll need to take your prescription to a pharmacy in our plan. What do I bring with me to the drugstore? When you go to the drugstore, you should bring: Your prescription(s) or medicine bottle(s) Your Amerigroup ID card Your Texas Benefits Medicaid card What if I need my medications delivered to me? Many pharmacies provide delivery services. Ask your pharmacist if they can deliver to your home. Who do I call if I have problems getting my medications? If you have problems getting your Amerigroup-covered medications, please call us at 1-800-600-4441 (TTY 711). We can work with you and your pharmacy to make sure you get the medicine you need. What if I can’t get the medication my doctor ordered approved? Some medicines require our preapproval. If your doctor cannot be reached to approve a prescription, you may be able to get a 3-day emergency supply of your medication. Call us at 1-800-600-4441 (TTY 711) for help with your medications and refills. Ask your pharmacist to dispense a 3-day supply. What if I lose my medications? If your medicine is lost or stolen, have your pharmacist call Provider Services at 1-800-454-3730.
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How do I find out what drugs are covered? Amerigroup uses the Vendor Drug Program (VDP) list of drugs your doctor can choose from. It includes all medicines covered by Medicaid. To view this list, go to the Texas Formulary Drug Search at www.txvendordrug.com/formulary/index.asp. When there is a generic drug available, we’ll cover it instead of the brand-name drug if it’s on the VDP formulary. Generic drugs are equal to brand-name drugs as approved by the Food and Drug Administration (FDA). How do I transfer my prescriptions to a plan pharmacy? If you need to transfer your prescriptions, all you need to do is: Call the nearest network pharmacy and give the needed information to the pharmacist, or Bring your prescription container to the new pharmacy, and they’ll handle the rest Will I have a copay? Medicaid members don’t have copays. How do I get my medicine if I am traveling? If you need a refill while on vacation, call your doctor for a new prescription to take with you. If you get medication from a pharmacy that’s not in the Amerigroup plan, then you’ll have to pay for that medication. If you pay for medication, you may submit a request for reimbursement. Call us at 1-800-600-4441 (TTY 711) to get information on how to get a reimbursement form and submit a claim. What if I paid out of pocket for a medicine and want to be reimbursed? If you had to pay for a medicine, you may submit a request for reimbursement. Call us at 1-800-600-4441 (TTY 711) to get a reimbursement form and submit a claim. The reimbursement form is also available online at www.myamerigroup.com/TX under Plans and Benefits for STAR. What if I need durable medical equipment (DME) or other products normally found in a pharmacy? Some durable medical equipment (DME) and products normally found in a pharmacy are covered by Medicaid. For all members, Amerigroup pays for nebulizers, ostomy supplies, and other covered supplies and equipment if they are medically necessary. For children (birth through age 20), Amerigroup also pays for medically necessary prescribed over-the-counter drugs, diapers, formula, and some vitamins and minerals. Call 1-800-600-4441 (TTY 711) for more information about these benefits.
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How do I get family planning services? Amerigroup will arrange for counseling and education about planning a pregnancy or preventing pregnancy. You can call your primary care provider for help or go to any Medicaid family planning provider. A doctor can’t require parental consent for minors to receive family planning services and must keep family planning use confidential. Do I need a referral for this? You do not need a referral from your doctor. Where do I find a family planning services provider? You can find the locations of family planning providers near you online at https://www.healthytexaswomen.org/family-planning-program, or you can call Amerigroup at 1-800-600-4441 (TTY 711) for help in finding a family planning provider.
What is case management for children and pregnant women? Case management for children and pregnant women Need help finding and getting services? You might be able to get a case manager to help you. Who can get a case manager? Children, teens, young adults (birth through age 20) and pregnant women who get Medicaid and: Have health problems or Are at a high risk for getting health problems What do case managers do? A case manager will visit with you and then: Find out what services you need Find services near where you live Teach you how to find and get other services Make sure you are getting the services you need What kind of help can you get? Case managers can help you: Get medical and dental services Get medical supplies or equipment Work on school or education issues Work on other problems How can you get a case manager? Call Texas Health Steps at 1-877-847-8377 toll-free Monday to Friday from 8 a.m. to 8 p.m. To learn more, go to www.dshs.state.tx.us/caseman.
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What is Early Childhood Intervention (ECI)? ECI is a statewide program for families with children birth to age 3 with disabilities and developmental delays. ECI helps families support their children through developmental services. ECI evaluates and assesses, at no cost to families, to see if they are eligible and what services they’ll need. Families and professionals work together to plan services based on the unique needs of the child and family. The Department of Assistive and Rehabilitative Services (DARS) is the state agency responsible for ECI. A local ECI program will determine if a child can get ECI services, and it will develop a child’s individual service plan. Amerigroup is responsible for paying for the services in the plan. Do I need a referral for this? You don’t need a referral from your child’s doctor to get these services. Where do I find an ECI provider? To get information about ECI services and other resources, call the DARS Inquiries Line at 1-800-628-5115. You can also search online for an ECI program near you. Go to https://dmzweb.dars.state.tx.us/prd/citysearch. Participation in an ECI program is voluntary. If you choose not to use a local ECI program, Amerigroup must provide medically necessary services for your child. Call us at 1-800-600-4441 (TTY 711) if you need help getting these services.
What is Head Start? Head Start is a program to help children age 5 or younger get ready for school. This program can help with: Language Literacy Social and emotional development To find a Head Start program near you, call toll-free 1-866-763-6481 or go to http://www.benefits.gov/benefits/benefit-details/1941.
What is Texas Health Steps? What services are offered by Texas Health Steps? Texas Health Steps is the Medicaid health-care program for STAR children, teens, and young adults, birth through age 20. Texas Health Steps gives your child: Free regular medical checkups starting at birth Free dental checkups starting at 6 months of age A case manager who can find out what services your child needs and where to get these services
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Texas Health Steps checkups: Find health problems before they get worse and are harder to treat Prevent health problems that make it hard for children to learn and grow like others their age Help your child have a healthy smile When to set up a checkup: You will get a letter from Texas Health Steps telling you when it’s time for a checkup. Call your child’s doctor or dentist to set up the checkup. Set up the checkup at a time that works best for your family If the doctor or dentist finds a health problem during a checkup, your child can get the care he or she needs, such as: Eye tests and eyeglasses Hearing tests and hearing aids Dental care Other health care Treatment for other medical conditions Call Amerigroup Member Services at 1-800-600-4441 (TTY 711) or Texas Health Steps at 1-877-847-8377 (1-877-THSTEPS) toll-free if you: Need help finding a doctor or dentist Need help setting up a checkup Have questions about checkups or Texas Health Steps Need help finding and getting other services If you can’t get your child to the checkup, Medicaid may be able to help. Children with Medicaid and their parent can get free rides to and from the doctor, dentist, hospital, or drug store. Houston/Beaumont area: 1-855-687-4786 Dallas/Ft. Worth area: 1-855-687-3255 All other areas: 1-877-633-8747 (1-877-MED-TRIP) How and when do I get Texas Health Steps medical and dental checkups for my child? The first well-child visit will happen in the hospital right after your baby is born. For the next 6 visits, you must take your baby to his or her doctor's office. Children need these checkups even when they’re healthy. Your child needs to have checkups at these ages.
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Texas Health Steps medical checkup schedule for your child Birth
9 months old
3-5 days
12 months old
2 weeks old
15 months old
2 months old
18 months old
4 months old
2 years old
6 months old
2 ½ years old
After age 2 ½, your child should visit the doctor every year. Amerigroup encourages and covers annual checkups for children ages 3 through 20. Be sure to make these appointments. Take your child to his or her doctor when scheduled. Does my doctor have to be part of the Amerigroup plan? Your child can see any Texas Health Steps doctor for these checkups. The Texas Health Steps doctor doesn’t have to be in our plan. Do I have to have a referral? Your child can get Texas Health Steps care without a referral. What if I need to cancel an appointment? If you’re unable to keep your appointment, you must call your doctor and cancel. You can make a new appointment when you call. What to do if you are out of town and your child is due for a Texas Health Steps visit? If you’re out of town and your child is due for a Texas Health Steps visit, call your doctor’s office or Member Services for help. What if I am a migrant farmworker? Migrant farmworkers move to different places to follow seasonal farm work. They could work on farms, in fields, as a food processor or packer, or with dairy products, poultry, or livestock during certain times of the year. You can get your checkups sooner if you are leaving the area. If you call us and tell us you’re a farmworker, we’ll: Help you find doctors and clinics and help you set up appointments Let doctors know you need to be seen quickly because you may have to leave the area to go to your next job When should adults get checkups? Staying healthy means getting regular checkups. Use the chart below to make sure you’re upto-date with your yearly well-care exams.
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Well-care visit schedule for adult members EXAM TYPE Well-care visit Pelvic exam Pap smear Clinical breast exam
WHO NEEDS IT? Age 21 and over Women age 18 and over Women ages 21-29 Women ages 30-65 Women age 20-39 Age 40 and over Women age 20 and over Women age 40 and over Age 50 and over
Breast self-exam Mammograms (breast X-ray) Fecal blood occult test Sigmoidoscopy and DRE/PSA Age 50 and over or colonoscopy and DRE/PSA
HOW OFTEN? Every year Every year Pap smear only — every 3 years Pap smear only — every 3 years Pap smear/human papillomavirus (HPV) co-testing — every 5 years Every 3 years Every year Once a month Every year Every year Every 5 years
If I miss my well-care visits or my child’s Texas Health Steps checkup, what do I do? If you or your child doesn’t get a well-care visit on time, make an appointment with your doctor as soon as you can. If you need help setting up the appointment, call Member Services. If your child hasn’t visited his or her doctor on time, we’ll send you a postcard reminding you to make your child’s Texas Health Steps appointment.
What is HHSC’s Medical Transportation Program (MTP)? What is MTP? MTP is an HHSC program that helps with non-emergency transportation to health-care appointments for eligible Medicaid clients who have no other transportation options. MTP can help with rides to the doctor, dentist, hospital, drug store, and any other place you get Medicaid services. What services are offered by MTP?
Passes or tickets for transportation such as mass transit within and between cities Air travel Taxi, wheelchair van, and other transportation Mileage reimbursement for enrolled individual transportation participant (ITP). The enrolled ITP can be the responsible party, family member, friend, neighbor, or client. Meals at a contracted vendor (such as a hospital cafeteria) Lodging at a contracted hotel and motel Attendant services (responsible party such as a parent/guardian, etc. who accompanies the client to a health-care service)
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How to get a ride? If you live in the Dallas/Ft. Worth area: Call LogistiCare Phone Reservations: 1-855-687-3255 Phone Ride Help Line: 1-877-564-9834 Hours: LogistiCare takes requests for routine transportation by phone Monday through Friday from 8 a.m. to 5 p.m. Routine transportation should be scheduled 48 hours (2 business days) before your appointment. If you live in the Houston/Beaumont area: Call MTM Phone Reservations: 1-855-687-4786 Where’s My Ride: 1-888-513-0706 Hours: 7 a.m. to 6 p.m., Monday-Friday/Call (855) MTP-HSTN or (855) 687-4786 at least 48 hours before your visit. If it’s less than 48 hours until your appointment and it’s not urgent, MTM might ask you to set up your visit at a different date and time. All other areas of the state: Call MTP Phone Reservations: 1-877-633-8747 (1-877-MED-TRIP) All requests for transportation services should be made within 2-5 days of your appointment. If you have an emergency and need transportation, call 911 for an ambulance. You can also refer to the What is emergency medical care? section of this handbook to learn more. What if I can’t be transported by taxi, van, or other standard Medical Transportation Program vehicles to get to health-care appointments? If you have a medical condition that causes you to need an ambulance to get to health-care appointments, your doctor can send a request to Amerigroup. Call Member Services at 1-800-600-4441 (TTY 711) for information about how your doctor can send a request. If you need an ambulance for an emergency, your doctor does not need to send a request.
How do I get eye care services? You get eye care benefits. You do not need a referral from your doctor for these benefits. Please call Superior Vision of Texas at 1-800-428-8789 for help finding a network eye doctor (optometrist) in your area. Children age 20 and younger get coverage for a vision exam and medically necessary frames and lenses once every 12 months from September 1 to August 31, or when otherwise medically necessary. Adult members age 21 years and older get coverage for a vision exam and medically necessary frames and certain plastic lenses every 24 months.
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What dental services does Amerigroup cover for children? Amerigroup covers emergency dental services in a hospital or ambulatory surgical center, including, but not limited to, payment for the following: Treatment of dislocated jaw Treatment for traumatic damage to teeth and supporting structures Removal of cysts Treatment of oral abscess of tooth or gum origin Amerigroup covers hospital, physician, and related medical services for the above conditions. This includes services the doctor provides and other services your child might need, like anesthesia or other drugs. Amerigroup is also responsible for paying for treatment and devices for craniofacial anomalies. Your child’s Medicaid dental plan provides all other dental services, including services that help prevent tooth decay and services that fix dental problems. Call your child’s Medicaid dental plan to learn more about the dental services they offer. DentaQuest 1-800-516-0165 MCNA Dental 1-800-494-6262
Can someone interpret for me when I talk with my doctor? Who do I call for an interpreter? Call Member Services at 1-800-600-4441 (TTY 711) to tell us if you need an interpreter at least 24 hours before your appointment. This service is also available for visits with your doctor at no cost to you. How far in advance do I need to call? Please let us know at least 24 hours before your appointment if you need an interpreter. How can I get a face-to-face interpreter in the provider’s office? Call Member Services if you need an interpreter when you talk to your provider at his or her office.
What if I need OB/GYN care? Female members can see any Amerigroup network obstetrician or gynecologist (OB/GYN) for female health-care needs. ATTENTION FEMALE MEMBERS: Amerigroup allows you to pick any OB/GYN, whether that doctor is in the same network as your primary care provider or not. While an OB/GYN might not participate in the same practice as your primary care provider, he or she must still be a doctor in our plan.
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Do I have the right to choose an OB/GYN? You have the right to pick an OB/GYN without a referral from your primary care provider. An OB/GYN can give you: One well-woman checkup per year Care related to pregnancy Care for any female medical condition Referral to special doctor within the network How do I choose an OB/GYN? You’re not required to pick an OB/GYN. However, if you’re pregnant, you should pick one to care for you. You can pick any OB/GYN listed in the Amerigroup provider directory. If you need help choosing one, call Member Services at 1-800-600-4441 (TTY 711). If I do not choose an OB/GYN, do I have direct access? If you don’t want to go to an OB/GYN, your primary care provider may be able to treat you for female health-care needs. Ask your primary care provider if he or she can give you OB/GYN care. If not, you need to see an OB/GYN. You will find a list of OB/GYNs in the Amerigroup provider directory. You can also search for one on our website at www.myamerigroup.com/TX under the Find a Doctor tab. Will I need a referral? You don’t need a referral. You can see only 1 OB/GYN in a month, but you can visit the same one more than once during that month, if needed. How soon can I be seen after contacting my OB/GYN for an appointment? Your OB/GYN should see you within 2 weeks. We can help you find an OB/GYN in our plan, if needed. Can I stay with my OB/GYN if he or she is not with Amerigroup? In some cases, you may be able to keep seeing an OB/GYN who isn’t in our plan. Please call Member Services to learn more.
What if I am pregnant? Who do I need to call? If you think you’re pregnant, call your primary care provider or OB/GYN right away. You don’t need a referral from your primary care provider. What other services/activities/education does Amerigroup offer pregnant women? It’s very important to see your doctor or OB/GYN for care when you’re pregnant. This kind of care is called prenatal care. It can help you have a healthy baby. Prenatal care is always important even if you’ve already had a baby. Our Taking Care of Baby and Me® program gives pregnant women health information and rewards for getting prenatal and postpartum care. You get a care manager to help you get the prenatal care and services you need during your pregnancy and up to your 6-week postpartum
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checkup. Your care manager may call to check on you and answer questions. He or she can also help you find prenatal resources in your community. To find out more about the Taking Care of Baby and Me® program, call Member Services. When you’re pregnant, Amerigroup will send you a pregnancy education package. It will include: A letter welcoming you to the Taking Care of Baby and Me® program A self-care book for tips on taking care of yourself during pregnancy Taking Care of Baby and Me® Healthy Rewards program brochures Having a Healthy Baby brochure After you deliver your baby, Amerigroup will send you a postpartum education package. It will include: A congratulation letter Caring for you and your baby booklet Taking Care of Baby and Me® Healthy Rewards program brochure Postpartum depression brochure My Advocate™ As part of Taking Care of Baby and Me®, you are also part of My Advocate™ which delivers prenatal, postpartum and well child health education by phone, text messaging, and smartphone app that is both helpful and fun. You will get to know Mary Beth, the My Advocate™ automated personality. Mary Beth will respond to your changing needs as your baby grows and develops. You can count on: Education you can use Communication with your case manager based on My Advocate™ messaging should questions or issues arise An easy communication schedule No cost to you With My Advocate™, your information is kept secure and private. Each time Mary Beth calls, she’ll ask you for your year of birth. Please don’t hesitate to tell her. She needs the information to be sure she’s talking to the right person. To learn more about My Advocate, visit www.myadvocatehelps.com. While you’re pregnant, it’s especially important to take care of your health. You may be able to get healthy food from the Women, Infants, and Children (WIC) program. Member Services can give you the phone number for the WIC program close to you. Just call us. When you’re pregnant, you must go to your doctor 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
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Your doctor or OB/GYN may want you to visit more often based on your health needs. Where can I find a list of birthing centers? Please call us at 1-800-600-4441 (TTY 711) to find out which birthing centers are in our network.
Can I pick a primary care provider for my baby before the baby is born? Yes, you can pick a primary care provider for your baby before the baby is born. When you have a new baby When you deliver your baby, you and your baby may stay in the hospital at least: 48 hours after a vaginal delivery 96 hours after a cesarean section (C-section) You may stay in the hospital less time if your doctor and the baby’s doctor see that you and your baby are doing well. If you and your baby leave the hospital early, your doctor may ask you to have an office or in-home nurse visit within 48 hours. How and when can I switch my baby’s primary care provider? To switch your baby’s primary care provider, go to the “Find a Doctor” link at www.myamerigroup.com/TX. While there, you can search for a new one in our plan and change your primary care provider. To make the change online, you’ll need to register first. Once you register, login and update your primary care provider. You can also call Member Services if you need help finding a new one. We can change your child’s primary care provider on the same day you ask for the change. The change will be effective immediately. Call the primary care provider’s office if you want to make an appointment. If you need help making an appointment, call Member Services. Can I switch my baby’s health plan? For at least 90 days from the date of birth, your baby will be covered by the same health plan that you are enrolled in. You can ask for a health plan change before the 90 days is up by calling the Enrollment Broker at 1-800-964-2777. You cannot change health plans while your baby is in the hospital.
How do I sign up my newborn baby? The hospital where your baby is born should help you start the Medicaid application process for your baby. Check with the hospital social worker before you go home to make sure the application is complete. You should also call 2-1-1 to find your local Health and Human Services Commission (HHSC) office to make sure your baby’s application has been received. If you’re an Amerigroup member when you have your baby, your baby will be enrolled with Amerigroup on his or her date of birth.
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How and when do I tell Amerigroup? Remember to call Amerigroup Member Services as soon as you can to let your care manager know you had your baby. We will need to get information about your baby, too. You may have already picked a primary care provider for your baby before he or she was born. If not, we can help you pick a primary care provider for him or her. How can I receive health care after my baby is born (and I am no longer covered by Medicaid)? After your baby is born, you may lose Medicaid coverage. You may be able to get some healthcare services through the Healthy Texas Women Program and the Department of State Health Services (DSHS). These services are for women who apply for the services and are approved. Healthy Texas Women Program The Healthy Texas Women Program provides family planning exams, related health screenings and birth control to women ages 18 to 44 whose household income is at or below the program’s income limits (185 percent of the federal poverty level). You must submit an application to find out if you can get services through this program. To learn more about services available through the Healthy Texas Women Program, write, call, or visit the program’s website: Healthy Texas Women Program P.O. Box 14000 Midland, TX 79711-9902 Phone: 1-800-335-8957 Website: www.texaswomenshealth.org Fax: (toll-free) 1-866-993-9971 DSHS Primary Health Care Program The DSHS Primary Health Care Program serves women, children, and men who are unable to access the same care through insurance or other programs. To get services through this program, a person’s income must be at or below the program’s income limits (200 percent of the federal poverty level). A person approved for services may have to pay a copayment, but no one is turned down for services because of a lack of money. Primary Health Care focuses on prevention of disease, early detection, and early intervention of health problems. The main services provided are:
Diagnosis and treatment Emergency services Family planning Preventive health services, including vaccines (shots) and health education, as well as laboratory, X-ray, nuclear medicine, or other appropriate diagnostic services.
Secondary services that may be provided are nutrition services, health screening, home health care, dental care, rides to medical visits, medicines your doctor orders (prescription drugs), TX-MHB-0103-17
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durable medical supplies, environmental health services, treatment of damaged feet (podiatry services), and social services. You will be able to apply for Primary Health Care services at certain clinics in your area. To find a clinic where you can apply, visit the DSHS Family and Community Health Services Clinic Locator at http://txclinics.com. To learn more about services you can get through the Primary Health Care program, email, call, or visit the program’s website: Website: www.dshs.state.tx.us/phc Phone: 512- 776-7796 Email:
[email protected] DSHS Expanded Primary Health Care Program The Expanded Primary Health Care program provides primary, preventive, and screening services to women age 18 and above whose income is at or below the program’s income limits (200 percent of the federal poverty level). Outreach and direct services are provided through community clinics under contract with DSHS. Community health workers will help make sure women get the preventive and screening services they need. Some clinics may offer help with breastfeeding. You can apply for these services at certain clinics in your area. To find a clinic where you can apply, visit the DSHS Family and Community Health Services Clinic Locator at http://txclinics.com. To learn more about services you can get through the DSHS Expanded Primary Health Care program, visit the program’s website, call, or email: Website: www.dshs.state.tx.us/ephc/Expanded-Primary-Health-Care.aspx Phone: 512-776-7796 Fax: 512-776-7203 Email:
[email protected] DSHS Family Planning Program The Family Planning Program has clinic sites across the state that provide quality, low-cost, and easy-to-use birth control for women and men. To find a clinic in your area visit the DSHS Family and Community Health Services Clinic Locator at http://txclinics.com. To learn more about services you can get through the Family Planning program, visit the program’s website, call, or email: Website: https://www.healthytexaswomen.org/family-planning-program Phone: 512-776-7796 Fax: 512-776-7203 Email:
[email protected]
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How and when do I tell my caseworker? After you have your baby, call your HHSC benefits office to tell them your baby was born.
Who do I call if I have special health-care needs and need someone to help me? Members with disabilities, special health-care needs or chronic complex conditions have a right to direct access to a specialist. This specialist may serve as your primary care provider. Please call Member Services at 1-800-600-4441 (TTY 711) so this can be arranged.
What if I am too sick to make a decision about my medical care? You can have someone make decisions on your behalf if you’re too sick to make decisions for yourself. Please call Member Services at 1-800-600-4441 (TTY 711) if you would like more information about the forms you need. What are advance directives? Emancipated minors and members age 18 and over have rights under advance directive laws. An advance directive talks about making a living will. A living will says you may not want medical care if you have a serious illness or injury and may not get better. To make sure you get the kind of care you want if you’re too sick to decide for yourself, you can sign a living will. This is a type of advance directive. It’s a paper telling your doctor and your family what kinds of care you don’t want if you’re seriously ill or injured. How do I get an advance directive? You can get an advance directive form from your doctor or by calling Member Services. Amerigroup associates can’t offer legal advice or serve as a witness. According to Texas law, you must either have two witnesses or have your form notarized. After you fill out the form, take it or mail it to your doctor. Your doctor will then know what kind of care you want to get. You can change your mind any time after you’ve signed an advance directive. Call your doctor to remove the advance directive from your medical record. You can also make changes in the advance directive by filling out and signing a new one. You can sign a paper called a durable power of attorney, too. This paper will let you name a person to make decisions for you when you can’t make them yourself. Ask your doctor about these forms.
Recertify your Medicaid benefits on time What do I have to do if I need help with completing my renewal application? Don’t lose your health-care benefits! You could lose your benefits even if you still qualify. Every 12 months you need to renew your benefits. The Health and Human Services Commission (HHSC) will send you a letter telling you it’s time to renew your Medicaid benefits. The letter will have instructions to tell you how to renew. If you don’t renew by the date in the letter, you’ll lose your health-care benefits. TX-MHB-0103-17
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You can apply for and renew benefits online at www.YourTexasBenefits.com. Click on “Manage your account” and set up an account to get easy access to the status of your benefits. If you have any questions, you can call 2-1-1, pick a language, and then select option 2 or visit the HHSC benefits office near you. To find the office nearest your home, call 2-1-1, pick a language, and then select option 2 or you can go to YourTexasBenefits.com and click on “Find an Office” at the bottom of the page. We want you to keep getting your health-care benefits from us if you still qualify. To renew, go to www.yourtexasbenefits.com and click on “Manage your account”. Follow the directions there to renew.
What happens if I lose my Medicaid coverage? If you lose Medicaid coverage but get it back again within six (6) months, you will get your Medicaid services from the same health plan you had before losing your Medicaid coverage. You will also have the same primary care provider you had before. If you’re no longer eligible for Medicaid based on income, your children may be eligible for the Children's Health Insurance Program (CHIP). To find out more, call 2-1-1, pick a language, and select option 2.
What if I get a bill from my doctor? Who do I call? What information will they need? Always show your Amerigroup ID card and Your Texas Benefits Medicaid card when you see a doctor, go to the hospital, or go for tests. Even if your doctor told you to go, you must show your Amerigroup ID card and current Your Texas Benefits Medicaid card to make sure you’re not sent a bill for services Amerigroup covers. You don’t have to show your Amerigroup ID card before you get emergency care. If you do get a bill, send the bill with a letter saying you have been sent a bill to the member advocate in your service area at the Amerigroup location nearest you listed in the front of this book. In the letter, include: Your name Your telephone number Your Amerigroup ID number If you can’t send the bill, be sure to include in the letter: The name of the provider you got services from The date of service The provider’s phone number The amount charged The account number, if known You can call us at 1-800-600-4441 (TTY 711) for help.
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What do I have to do if I move? As soon as you have your new address, give it to the local HHSC benefits office and Amerigroup Member Services department at 1-800-600-4441 (TTY 711). Before you get Medicaid services in your new area, you must call Amerigroup, unless you need emergency services. You will continue to get care through Amerigroup until HHSC changes your address. What if I need to update my address or phone number and I’m in the Adoption Assistance and Permanency Care Assistance Program? The adoptive parent or permanency care assistance caregiver should contact the DFPS regional adoption assistance eligibility specialist assigned to his or her case. If the parent or caregiver doesn’t know who the assigned eligibility specialist is, they can contact the DFPS hotline, 1-800233-3405, to find out. The parent or caregiver should contact the adoption assistance eligibility specialist to assist with the address change.
What if I have other health insurance in addition to Medicaid? Medicaid and private insurance You are required to tell Medicaid staff about any private health insurance you have. You should call the Medicaid Third Party Resources hotline and update your Medicaid case file if:
Your private health insurance is canceled You get new insurance coverage You have general questions about third party insurance
You can call the hotline toll-free at 1-800-846-7307. If you have other insurance you may still qualify for Medicaid. When you tell Medicaid staff about your other health insurance, you help make sure Medicaid only pays for what your other health insurance does not cover. IMPORTANT: Medicaid providers cannot turn you down for services because you have private health insurance as well as Medicaid. If providers accept you as a Medicaid patient, they must also file with your private health insurance company.
What are my rights and responsibilities? MEMBER RIGHTS: 1. You have the right to respect, dignity, privacy, confidentiality, and nondiscrimination. That includes the right to: a. Be treated fairly and with respect b. Know that your medical records and discussions with your providers will be kept private and confidential 2. You have the right to a reasonable opportunity to choose a health-care plan and primary care provider. This is the doctor or health-care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to: TX-MHB-0103-17
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3.
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a. Be told how to choose and change your health plan and your primary care provider b. Choose any health plan you want that is available in your area and choose your primary care provider from that plan c. Change your primary care provider d. Change your health plan without penalty e. Be told how to change your health plan or your primary care provider You have the right to ask questions and get answers about anything you do not understand. That includes the right to: a. Have your provider explain your health-care needs to you and talk to you about the different ways your health-care problems can be treated b. Be told why care or services were denied and not given You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to: a. Work as part of a team with your provider in deciding what health care is best for you b. Say yes or no to the care recommended by your provider You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid, and get a timely response to complaints, appeals, and fair hearings. That includes the right to: a. Make a complaint to your health plan or to the state Medicaid program about your health care, your provider, or your health plan b. Get a timely answer to your complaint c. Use the plan’s appeal process and be told how to use it d. Ask for a fair hearing from the state Medicaid program and get information about how that process works You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to: a. Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need b. Get medical care in a timely manner c. Be able to get in and out of a health-care provider’s office; this includes barrier-free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act d. Have interpreters, if needed, during appointments with your providers and when talking to your health plan; interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information e. Be given information you can understand about your health plan rules, including the health-care services you can get and how to get them You have the right to not be restrained or secluded when it is for someone else’s convenience, or is meant to force you to do something you do not want to do, or is to punish you. You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.
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9. You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services. MEMBER RESPONSIBILITIES: 1. You must learn and understand each right you have under the Medicaid program. That includes the responsibility to: a. Learn and understand your rights under the Medicaid program b. Ask questions if you do not understand your rights c. Learn what choices of health plans are available in your area 2. You must abide by the health plan’s and Medicaid’s policies and procedures. That includes the responsibility to: a. Learn and follow your health plan’s rules and Medicaid rules b. Choose your health plan and a primary care provider quickly c. Make any changes in your health plan and primary care provider in the ways established by Medicaid and by the health plan d. Keep your scheduled appointments e. Cancel appointments in advance when you cannot keep them f. Always contact your primary care provider first for your nonemergency medical needs g. Be sure you have approval from your primary care provider before going to a specialist h. Understand when you should and should not go to the emergency room 3. You must share information about your health with your primary care provider and learn about service and treatment options. That includes the responsibility to: a. Tell your primary care provider about your health b. Talk to your providers about your health-care needs and ask questions about the different ways your health-care problems can be treated c. Help your providers get your medical records 4. You must be involved in decisions relating to service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility to: a. Work as a team with your provider in deciding what health care is best for you b. Understand how the things you do can affect your health c. Do the best you can to stay healthy d. Treat providers and staff with respect e. Talk to your provider about all of your medications If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr. You and your doctors can get a copy of these rights and responsibilities by mail, fax, or e-mail. Call Member Services at 1-800-600-4441 (TTY 711), and ask for a copy. You can also download a copy from our website by going to www.myamerigroup.com/TX to Member Rights & Responsibilities.
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HOW WE MAKE DECISIONS ABOUT YOUR CARE Sometimes, we need to make decisions about how we cover care and services. This is called Utilization Management (UM). All UM decisions are based on your medical needs and current benefits. We don’t encourage doctors to underuse services. And we don’t create barriers to getting health care. Providers don’t get rewarded for limiting or denying care. Doctors in our plan use clinical practice guidelines to determine necessary treatments and services. When you or your doctor asks for certain care that needs a pre-approval, our Utilization Review team decides if the service is medically necessary and one of your benefits. If you disagree with our decision, you or your doctor can request an appeal. To speak with someone on our UM team, call Member Services at 1-800-600-4441 (TTY 711) Monday through Friday from 7 a.m. to 6 p.m. Central time.
COMPLAINT PROCESS What should I do if I have a complaint? Who do I call? We want to help. If you have a complaint, please call us toll-free at 1-800-600-4441 (TTY 711) to tell us about your problem. An Amerigroup Member Services representative or a member advocate can help you file a complaint. Just call 1-800-600-4441 (TTY 711). Most of the time, we can help you right away or at the most within a few days. Amerigroup can’t and won’t take any action against you if you file a complaint. Can someone from Amerigroup help me file a complaint? Yes, a member advocate or a Member Services representative can help you file a complaint with us or the appropriate state program. Please call Member Services at 1-800-600-4441 (TTY 711). How long will it take to process my complaint? Amerigroup will answer your complaint within 30 days from the date we get it. What are the requirements and time frames for filing a complaint? You can tell us about your complaint by calling us or writing us. We’ll send you a letter within 5 business days of getting your complaint. This means that we have your complaint and have started to look at it. We’ll include a complaint form with our letter if your complaint was made by telephone. You must fill out this form and mail it back to us. If you need help filling out the complaint form, please call Member Services. We’ll send you a letter within 30 days of when we get your complaint. This letter will tell you what we have done to address your complaint.
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If your complaint is about an ongoing emergency or hospital stay, it will be resolved as quickly as needed for the urgency of your case and no later than 1 business day from when we receive your complaint. How do I file a complaint with the Health and Human Services Commission once I have gone through the Amerigroup complaint process? Once you have gone through the Amerigroup complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 1-866-566-8989. If you would like to make your complaint in writing, please send it to the following address: Texas Health and Human Services Commission Health Plan Operations - H-320 PO Box 85200 Austin, TX 78708-5200 ATTN: Resolution Services If you can get on the Internet, you can send your complaint in an email to
[email protected] If you file a complaint, Amerigroup won’t hold it against you. We’ll still be here to help you get quality health care. Do I have the right to meet with a complaint appeal panel? Yes. If you’re not happy with the answer to your complaint, you can ask us to look at it again. You must ask for a complaint appeal panel in writing. Write to us at: Member Advocates Amerigroup 823 Congress Ave., Suite 400 Austin, TX 78701 When we get your request, we’ll send you a letter within 5 business days. This means we have your request and started to work on it. You can also call us at 1-800-600-4441 (TTY 711) to ask for a complaint appeal panel request form. You must complete the form and return it to us. We’ll have a meeting with Amerigroup staff, providers in the health plan, and other Amerigroup members to look at your complaint. We’ll 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 don’t have to come to the meeting. We’ll send you a letter at least 5 business days before the complaint appeal panel meeting. The letter will have the date, time, and place of the meeting. We’ll send you all of the information the panel will look at during the meeting. We’ll send you a letter within 30 days of getting your written request. The letter will tell you the complaint panel’s final decision. This letter will also give you the information the panel used to make its decision. TX-MHB-0103-17
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APPEAL PROCESS What can I do if my doctor asks for a service or medicine for me that’s covered but Amerigroup denies or limits it? There may be times when we say we won’t pay for all or part of the care that has been recommended. You have the right to ask for an appeal. An appeal is when you or your designated representative asks Amerigroup to look again at the care your doctor asked for and we said we won’t pay for. You can appeal our decision 2 ways: • You can call Member Services − If you call us, you must still send us your appeal in writing − We’ll send you an appeal form in the mail after your call − Fill out the appeal form and send it to us, within 60 days of the date of the letter telling you we were denying your request, at: Amerigroup Appeals 2505 N. Highway 360, Suite 300 Grand Prairie, TX 75050 − The appeal form must be signed by you or your authorized representative − If you need help filling out the appeal form, please call Member Services • You can send us a letter to: Amerigroup Appeals 2505 N. Highway 360, Suite 300 Grand Prairie, TX 75050 How will I find out if services are denied? If we deny benefits, we’ll send you a letter at the same time the denial is made. What are the time frames for the appeals process? You or a designated representative can file an appeal. You must do this within 60 days of the date of the first letter from Amerigroup saying we won’t pay for or cover all or part of the recommended care. If you ask someone (a designated representative) to file an appeal for you, you must also send a letter to Amerigroup to let us know you have chosen a person to represent you. Amerigroup must have this written letter to be able to consider this person as your representative. We do this for your privacy and security. When we get your letter or call, we’ll send you a letter within 5 business days. This letter will let you know we got your appeal. We will also let you know if we need any other information to process your appeal. Amerigroup will contact your doctor if we need medical information about this service.
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A doctor who hasn’t seen the case before will look at your appeal. He or she will decide how we should handle the appeal. We’ll send you a letter with the answer to your appeal. We’ll do this within 30 calendar days from when we get your appeal unless we need more information from you or the person you asked to file the appeal for you. If we need more information, we may extend the appeals process for 14 days. If we extend the appeals process, we’ll let you know the reason for the delay. You may also ask us to extend the process if you know more information we should consider. How can I continue receiving services that were already approved? To continue receiving services Amerigroup already approved, but may be part of the reason for your appeal, you must file the appeal on or before the later of: Ten days after we mail the notice to you to let you know we won’t pay for or cover all or part of the care that has already been approved The date the notice says the service will end If you ask for services to continue while your appeal is pending, you may have to pay for these services. If the decision on your appeal upholds our first decision, you’ll be asked to pay for the services you received during the appeals process. If the decision on your appeal reverses our first decision, Amerigroup will pay for the services you received while your appeal was pending. Can someone from Amerigroup help me file an appeal? Yes, a member advocate or Member Services representative can help you file an appeal with us or the appropriate state program. Please call Member Services toll-free at 1-800-600-4441 (TTY 711). Can I request a state fair hearing? Yes, you can ask for a fair hearing at any time during or after the Amerigroup appeal process unless you have asked for an expedited appeal. See the State Fair Hearings and the Expedited Appeals sections below for more information.
EXPEDITED APPEALS What is an expedited appeal? An expedited appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.
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How do I ask for an expedited appeal? Does my request have to be in writing? You or the person you ask to file an appeal for you (a designated representative) can request an expedited appeal. You can request an expedited appeal orally or in writing, either: Call Member Services at 1-800-600-4441 (TTY 711) Send a letter to: Amerigroup Appeals 2505 N. Highway 360, Suite 300 Grand Prairie, TX 75050
What are the time frames for an expedited appeal? After we get your letter or call and agree your request should be expedited, we’ll send you a letter with the answer to your appeal. We’ll do this within 72 hours from receipt of your appeal request. If your appeal is about an ongoing emergency or hospital stay, we’ll call you with an answer within 1 business day or 72 hours, whichever is shorter. We’ll also send you a letter with the answer to your appeal within 3 business days.
What happens if Amerigroup denies the request for an expedited appeal? If we don’t agree your appeal request should be expedited, we’ll call you right away. We’ll send you a letter within 2 calendar days to let you know how the decision was made and your appeal will be reviewed through the standard review process. If the decision on your expedited appeal upholds our first decision and Amerigroup won’t pay for the care your doctor asked for, we’ll call you and send you a letter to let you know how the decision was made. We’ll also tell you about your right to request an expedited state fair hearing.
Who can help me file an expedited appeal? A member advocate or Member Services representative can help you file an expedited appeal. Please call Member Services toll-free at 1-800-600-4441 (TTY 711).
STATE FAIR HEARINGS Can I ask for a state fair hearing? If you, as a member of the health plan, disagree with the health plan’s decision about an appeal, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 120 days of the date on the health plan’s letter with the appeal decision. If you do not
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ask for the fair hearing within 120 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at: Fair Hearing Coordinator Amerigroup 3800 Buffalo Speedway, Suite 400 Houston, TX 77098 Or you can call Member Services at 1-800-600-4441 (TTY 711). We can help you with this request. You have the right to keep getting any service the health plan denied or reduced, at least until the final hearing decision is made, if you ask for a fair hearing by the later of: 10 calendar days following the Amerigroup mailing of the notice of the action or The day the health plan’s letter says your service will be reduced or end If you do not request a fair hearing by this date, the service the health plan denied will be stopped. If you ask for a fair hearing, you will get a packet of information letting you know the date, time, and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing.
FRAUD AND ABUSE INFORMATION Do you want to report waste, abuse, or fraud? Let us know if you think a doctor, dentist, pharmacist at a drugstore, other health-care providers, or a person getting benefits is doing something wrong. Doing something wrong could be waste, abuse, or fraud, which is against the law. For example, tell us if you think someone is: Getting paid for services that weren’t given or necessary Not telling the truth about a medical condition to get medical treatment Letting someone else use their Medicaid ID Using someone else’s Medicaid ID Not telling the truth about the amount of money or resources he or she has to get benefits To report waste, abuse, or fraud, choose one of the following: Call the OIG Hotline at 1-800-436-6184 Visit https://oig.hhsc.state.tx.us and click the red “Report Fraud” box to complete the online form Report directly to your health plan:
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Compliance Officer Amerigroup 823 Congress Ave., Suite 400 Austin, TX 78701 1-800-315-5385 Other reporting options include: External Anonymous Compliance Hotline: 1-877-660-7890 or amerigroup.silentwhistle.com Email:
[email protected] [email protected] To report waste, abuse, or fraud, gather as much information as possible. When reporting about a provider (a doctor, dentist, counselor, etc.), include: − Name, address, and phone number of provider − Name and address of the facility (hospital, nursing home, home health agency, etc.) − Medicaid number of the provider and facility, if you have it − Type of provider (doctor, dentist, therapist, pharmacist, etc.) − Names and phone numbers of other witnesses who can help in the investigation − Dates of events − Summary of what happened When reporting someone who receives benefits, include: − The person’s name − The person’s date of birth, Social Security number, or case number, if you have it − The city where the person lives − Specific details about the waste, abuse, or fraud
QUALITY MANAGEMENT What does quality management do for you? The Amerigroup Quality Management program is here to make sure you are being cared for. We look at services you’ve received to check if you’re getting the best preventive health care. If you have a chronic disease, we check if you’re getting help managing your condition. The Quality Management department develops programs to help you learn more about your health care. We have member outreach teams to help you schedule appointments for the care you need and arrange transportation if you need it. These services are free because we want to help you get and stay healthy. We work with our network providers to teach them and help them care for you. You may get mailings from us about taking preventive health steps or managing an illness. We want you to help us improve by telling us what we can do better. To learn more about our Quality Management program, please call Member Services at 1-800-600-4441 (TTY 711). TX-MHB-0103-17
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What are clinical practice guidelines? Amerigroup uses national clinical practice guidelines for your care. Clinical practice guidelines are nationally recognized, scientific, proven standards of care. These guidelines are recommendations for physicians and other health-care providers to diagnose and manage your specific condition. If you would like a copy of these guidelines, call Member Services at 1-800-600-4441 (TTY 711). INFORMATION THAT MUST BE AVAILABLE ONCE A YEAR As a member of Amerigroup, you can ask for and get the following information each year. Information about network providers — at a minimum, primary care doctors, specialists, and hospitals in our service area; this information will include names, addresses, telephone numbers, and languages spoken (other than English) for each network provider, plus identification of providers that are not accepting new patients Any limits on your freedom of choice among network providers Your rights and responsibilities Information on complaint, appeal, and fair hearing procedures Information about benefits available under the Medicaid program, including amount, duration, and scope of benefits; this is designed to make sure you understand the benefits to which you are entitled How you get benefits, including authorization requirements How you get benefits, including family planning services, from out-of-network providers, and/or limits to those benefits How you get after-hours and emergency coverage and/or limits to those kinds of benefits, including: - What makes up emergency medical conditions, emergency services, and poststabilization services - The fact that you do not need prior authorization from your primary care provider for emergency care services - How to get emergency services, including instructions on how to use the 911 telephone system or its local equivalent - The addresses of any places where providers and hospitals furnish emergency services covered by Medicaid - A statement saying you have a right to use any hospital or other settings for emergency care - Poststabilization rules Policy on referrals for specialty care and for other benefits you cannot get through your primary care provider The Amerigroup practice guidelines We hope this book has answered most of your questions about Amerigroup. To learn more, call Amerigroup Member Services.
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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION WITH REGARD TO YOUR HEALTH BENEFITS. PLEASE REVIEW IT CAREFULLY.
HIPAA NOTICE OF PRIVACY PRACTICES The original effective date of this notice was April 14, 2003. The most recent revision date is shown at the end of this notice. Please read this notice carefully. This tells you who can see your protected health information (PHI). It tells you when we have to ask for your OK before we share it. It tells you when we can share it without your OK. It also tells you what rights you have to see and change your information. Information about your health and money is private. The law says we must keep this kind of information, called PHI, safe for our members. That means if you’re a member right now or if you used to be, your information is safe. We get information about you from state agencies for Medicaid and the Children’s Health Insurance Program after you become eligible and sign up for our health plan. We also get it from your doctors, clinics, labs and hospitals so we can OK and pay for your health care. Federal law says we must tell you what the law says we have to do to protect PHI that’s told to us, in writing or saved on a computer. We also have to tell you how we keep it safe. To protect PHI: On paper (called physical), we: – Lock our offices and files – Destroy paper with health information so others can’t get it Saved on a computer (called technical), we: – Use passwords so only the right people can get in – Use special programs to watch our systems Used or shared by people who work for us, doctors or the state, we: – Make rules for keeping information safe (called policies and procedures) – Teach people who work for us to follow the rules When is it OK for us to use and share your PHI? We can share your PHI with your family or a person you choose who helps with or pays for your health care if you tell us it’s OK. Sometimes, we can use and share it without your OK: For your medical care – To help doctors, hospitals and others get you the care you need
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For payment, health care operations and treatment – To share information with the doctors, clinics and others who bill us for your care – When we say we’ll pay for health care or services before you get them – To find ways to make our programs better, as well as giving your PHI to health information exchanges for payment, health care operations and treatment. If you don’t want this, please visit www.myamerigroup.com/pages/privacy.aspx for more information. For health care business reasons – To help with audits, fraud and abuse prevention programs, planning, and everyday work – To find ways to make our programs better For public health reasons – To help public health officials keep people from getting sick or hurt With others who help with or pay for your care – With your family or a person you choose who helps with or pays for your health care, if you tell us it’s OK – With someone who helps with or pays for your health care, if you can’t speak for yourself and it’s best for you
We must get your OK in writing before we use or share your PHI for all but your care, payment, everyday business, research or other things listed below. We have to get your written OK before we share psychotherapy notes from your doctor about you. You may tell us in writing that you want to take back your written OK. We can’t take back what we used or shared when we had your OK. But we will stop using or sharing your PHI in the future. Other ways we can — or the law says we have to — use your PHI: To help the police and other people who make sure others follow laws To report abuse and neglect To help the court when we’re asked To answer legal documents To give information to health oversight agencies for things like audits or exams To help coroners, medical examiners or funeral directors find out your name and cause of death To help when you’ve asked to give your body parts to science For research To keep you or others from getting sick or badly hurt To help people who work for the government with certain jobs To give information to workers’ compensation if you get sick or hurt at work What are your rights? You can ask to look at your PHI and get a copy of it. We don’t have your whole medical record, though. If you want a copy of your whole medical record, ask your doctor or health clinic. You can ask us to change the medical record we have for you if you think something is wrong or missing. TX-MHB-0103-17
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Sometimes, you can ask us not to share your PHI. But we don’t have to agree to your request. You can ask us to send PHI to a different address than the one we have for you or in some other way. We can do this if sending it to the address we have for you may put you in danger. You can ask us to tell you all the times over the past six years we’ve shared your PHI with someone else. This won’t list the times we’ve shared it because of health care, payment, everyday health care business or some other reasons we didn’t list here. You can ask for a paper copy of this notice at any time, even if you asked for this one by email. If you pay the whole bill for a service, you can ask your doctor not to share the information about that service with us.
What do we have to do? The law says we must keep your PHI private except as we’ve said in this notice. We must tell you what the law says we have to do about privacy. We must do what we say we’ll do in this notice. We must send your PHI to some other address or in a way other than regular mail if you ask for reasons that make sense, like if you’re in danger. We must tell you if we have to share your PHI after you’ve asked us not to. If state laws say we have to do more than what we’ve said here, we’ll follow those laws. We have to let you know if we think your PHI has been breached. We may contact you You agree that we, along with our affiliates and/or vendors, may call or text any phone numbers you give us, including a wireless phone number, using an automatic telephone dialing system and/or a pre-recorded message. Without limit, these calls or texts may be about treatment options, other health-related benefits and services, enrollment, payment, or billing. What if you have questions? If you have questions about our privacy rules or want to use your rights, please call Member Services at 1-800-600-4441. STAR Kids members, call 1-844-756-4600. If you’re deaf or hard of hearing, call TTY 711. What if you have a complaint? We’re here to help. If you feel your PHI hasn’t been kept safe, you may call Member Services or contact the Department of Health and Human Services. Nothing bad will happen to you if you complain. Write to or call the Department of Health and Human Services: Office for Civil Rights U.S. Department of Health and Human Services 1301 Young St., Suite 1169 Dallas, TX 75202 Phone: 1-800-368-1019 TDD: 1-800-537-7697 Fax: 214-767-0432 TX-MHB-0103-17
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We reserve the right to change this Health Insurance Portability and Accountability Act (HIPAA) notice and the ways we keep your PHI safe. If that happens, we’ll tell you about the changes in a newsletter. We’ll also post them on the Web at ww.myamerigroup.com/pages/privacy.aspx. Race, ethnicity and language We receive race, ethnicity and language information about you from the state Medicaid agency and the Children’s Health Insurance Program. We protect this information as described in this notice. We use this information to: Make sure you get the care you need Create programs to improve health outcomes Develop and send health education information Let doctors know about your language needs Provide translator services We do not use this information to: Issue health insurance Decide how much to charge for services Determine benefits Disclose to unapproved users Your personal information We may ask for, use and share personal information (PI) as we talked about in this notice. Your PI is not public and tells us who you are. It’s often taken for insurance reasons. We may use your PI to make decisions about your: – Health – Habits – Hobbies We may get PI about you from other people or groups like: – Doctors – Hospitals – Other insurance companies We may share PI with people or groups outside of our company without your OK in some cases. We’ll let you know before we do anything where we have to give you a chance to say no. We’ll tell you how to let us know if you don’t want us to use or share your PI. You have the right to see and change your PI. We make sure your PI is kept safe. Revised January 15, 2016 TX-MEM-1017-17 Amerigroup members in the Medicaid Rural Service Area and the STAR Kids program are served by Amerigroup Insurance Company; all other Amerigroup members in Texas are served by Amerigroup Texas, Inc.
TX-MHB-0103-17
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Amerigroup follows Federal civil rights laws. We don’t discriminate against people because of their: Race Color
National origin Age
Disability Sex or gender identity
That means we won’t exclude you or treat you differently because of these things. Communicating with you is important For people with disabilities or who speak a language other than English, we offer these services at no cost to you: Qualified sign language interpreters Written materials in large print, audio, electronic, and other formats Help from qualified interpreters in the language you speak Written materials in the language you speak To get these services, call the Member Services number on your ID card. Or you can call our Member Advocates at 1-800-600-4441 (TTY 711). STAR Kids members, call 1-844-756-4600 (TTY 711). Your rights Do you feel you didn’t get these services or we discriminated against you for reasons listed above? If so, you can file a grievance (complaint). File by mail, email, fax, or phone: Member Advocates — Amerigroup 823 Congress Ave., Suite 400 Austin, TX 78701
Phone: 1-800-600-4441 (TTY 711) STAR Kids members, call 1-844-756-4600 (TTY 711) Fax: 512-382-4965 Email:
[email protected]
Need help filing? Call our Member Advocates at the number above. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:
On the Web: By mail:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf U.S. Department of Health and Human Services 200 Independence Ave. SW Room 509F, HHH Building Washington, DC 20201
By phone:
1-800-368-1019 (TTY/TDD 1-800-537-7697)
For a complaint form, visit www.hhs.gov/ocr/office/file/index.html.
TX-MEM-1000-17
TX HHS Final Rule Notice
Do you need help with your health care, talking with us, or reading what we send you? We provide our materials in other languages and formats at no cost to you. Call us toll free at 1-800-600-4441(TIY711). STAR Kids members, call 1-844-756-4600 (TTY 711).
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