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Member Handbook
B-TXMHB-0004-11 05.11 B-FLMHB-0002-11 7.11
Amerigroup Florida, Inc. Florida Medicaid/MediKids Program

1-800-600-4441
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www.myamerigroup.com
www.myamerigroup.com
Dear Member: Welcome to Amerigroup Community Care. We are happy you chose us to arrange for quality health care benefits for your family. This member handbook tells you how Amerigroup works and how to keep your family healthy. It also explains how to get health care when you need it. You will get your Amerigroup ID card and more information from us in a few days. Your ID card tells you when your Amerigroup membership starts. The name of your family doctor is on the card, too. Please check your ID card right away. If the name of your doctor or any other information is not right, please call us at 1-800-600-4441. We will send you a new ID card with the correct information. You can call 1-800-600-4441 and talk to a Member Services representative about your benefits or visit our web site at www.myamerigroup.com. You can also talk to a nurse on our 24-hour Nurse HelpLine if you need advice. We are here to help you get quality health care coverage. Thank you again for choosing us as your familys health plan. Sincerely,
William L. McHugh Chief Executive Officer Amerigroup Community Care
Amerigroup is a company of all kinds of people. We welcome all into our health plans. We do not base membership on health status. If you have questions or concerns, please call 1-800-600-4441 and ask for extension 34925. Or visit www.myamerigroup.com.
B-FLMHB-0002-11
AMERITIPS: HEALTH TIPS THAT MAKE HEALTH HAPPEN

YOU NEED TO GO TO YOUR DOCTOR NOW!
WHEN IS IT TIME FOR A WELLNESS VISIT?

All Amerigroup members need to have regular wellness visits. This way, your Primary Care Physician (PCP) can see if you have a problem before it gets worse. When you become an Amerigroup member, call your doctor and make the first appointment for you and your child before the end of 90 days.
WELLNESS CARE FOR CHILDREN, THE CHILD HEALTH CHECK-UP PROGRAM

Children need more wellness visits than adults. These wellness visits for children are part of Floridas Child Health Check-Up Program. Your child should get wellness visits at the times listed below: Newborn 9 months old 1 month old 12 months old 2 months old 15 months old 4 months old 18 months old 6 months old 24 months old After age 2, you and your child should keep going to your PCP every year for wellness visits.
WHAT IF I BECOME PREGNANT?

If you think you are pregnant, call your PCP or OB/GYN right away. This can help you have a healthy baby. If you have any questions or need help making an appointment with your PCP or OB/GYN, please call Amerigroup Community Care Member Services at 1-800-600-4441.
ALERT! Keep the Right Care. Do Not Lose Your Health care Benefits Recertify Your Eligibility for Medicaid Benefits on Time. See Page 38 for More Details.
B-FLMHB-0002-11 FL Medicaid 01.11 ENG
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AMERIGROUP MEMBER HANDBOOK

AMERIGROUP COMMUNITY CARE 4200 W. Cypress Street, Suite 900 Tampa, Florida 33607-4173 1-800-600-4441 www.myamerigroup.com
WELCOME TO AMERIGROUP COMMUNITY CARE!

You will get most of your health care services through Amerigroup Community Care. This member handbook will tell you how to use Amerigroup to get the health care you need.
Table of Contents AMERITIPS: HEALTH TIPS THAT MAKE HEALTH HAPPEN ...................................... 2
WHEN IS IT TIME FOR A WELLNESS VISIT? ............................................................................................... 2 WELLNESS CARE FOR CHILDREN, THE CHILD HEALTH CHECK-UP PROGRAM .......................................... 2 WHAT IF I BECOME PREGNANT? .............................................................................................................. 2
WELCOME TO AMERIGROUP COMMUNITY CARE! .............................................. 6

INFORMATION ABOUT YOUR NEW HEALTH PLAN ................................................................................... 6 HOW TO GET HELP.................................................................................................................................... 6 Amerigroup Member Services Department ......................................................................................... 6 Amerigroup 24-Hour Nurse HelpLine................................................................................................... 7 Other Important Phone Numbers ........................................................................................................ 7 Your Amerigroup Member Handbook ................................................................................................. 7 YOUR IDENTIFICATION CARDS (ID CARDS) ............................................................................................... 8
YOUR DOCTORS .................................................................................................. 8

PICKING A PRIMARY CARE PHYSICIAN ...................................................................................................... 8 SECOND MEDICAL OPINION ..................................................................................................................... 9 IF YOU HAD A DIFFERENT DOCTOR BEFORE YOU JOINED AMERIGROUP ................................................ 9 IF YOUR PCPS OFFICE MOVES, CLOSES OR LEAVES THE AMERIGROUP NETWORK................................. 9 HOW TO CHANGE YOUR PCP .................................................................................................................... 9 IF YOUR PCP ASKS FOR YOU TO BE CHANGED TO ANOTHER PCP ............................................................ 9 IF YOU WANT TO GO TO A DOCTOR WHO IS NOT YOUR PCP ................................................................ 10 PICKING AN OB/GYN ............................................................................................................................... 10 SPECIALISTS............................................................................................................................................. 10
GOING TO THE DOCTOR .................................................................................... 11

YOUR FIRST DOCTORS APPOINTMENT .................................................................................................. 11 HOW TO MAKE AN APPOINTMENT ........................................................................................................ 11 WAIT TIMES FOR APPOINTMENTS.......................................................................................................... 11 WHAT TO BRING WHEN YOU GO FOR YOUR APPOINTMENT ................................................................ 11 HOW TO CANCEL AN APPOINTMENT ..................................................................................................... 11 HOW TO GET TO A DOCTORS APPOINTMENT OR TO THE HOSPITAL.................................................... 12 DISABILITY ACCESS TO AMERIGROUP NETWORK DOCTORS AND HOSPITALS ....................................... 12 WHAT DOES MEDICALLY NECESSARY MEAN? ........................................................................................ 12
AMERIGROUP COVERED SERVICES .................................................................... 12

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INPATIENT HOSPITAL STAY (INCLUDING BEHAVIORAL HEALTH CARE) .................................................. 13 OUTPATIENT SERVICES ........................................................................................................................... 13 EMERGENCY MEDICAL SERVICES AND CARE .......................................................................................... 13 DOCTOR SERVICES .................................................................................................................................. 13 FAMILY PLANNING SERVICES .................................................................................................................. 14 MATERNITY CARE ................................................................................................................................... 14 PRESCRIPTION BENEFIT .......................................................................................................................... 14 BEHAVIORAL HEALTH CARE SERVICES .................................................................................................... 14 VISION SERVICES ..................................................................................................................................... 15 HEARING SERVICES ................................................................................................................................. 15 DENTAL SERVICES ................................................................................................................................... 16 LAB AND X-RAY SERVICES ....................................................................................................................... 16 HOME HEALTH CARE .............................................................................................................................. 16 TRANSPLANT SERVICES........................................................................................................................... 16
EXTRA AMERIGROUP BENEFITS......................................................................... 16 SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID ......................................... 17 DIFFERENT TYPES OF HEALTH CARE................................................................... 18
ROUTINE, URGENT AND EMERGENCY CARE: WHAT IS THE DIFFERENCE? ............................................. 18 Routine Care ....................................................................................................................................... 18 Urgent Care ........................................................................................................................................ 18 Emergency Care ................................................................................................................................. 18 WHAT IS AN EMERGENCY MEDICAL CONDITION? ................................................................................. 18 WHAT IS AN EMERGENCY BEHAVIORAL HEALTH CONDITION?.............................................................. 19 WHAT IS POST-STABILIZATION? ............................................................................................................. 19 HOW TO GET HEALTH CARE WHEN YOUR DOCTORS OFFICE IS CLOSED............................................... 19 HOW TO GET HEALTH CARE WHEN YOU ARE OUT OF TOWN................................................................ 19 HOW TO GET CARE WHEN YOU CANNOT LEAVE YOUR HOME .............................................................. 20
WELLNESS CARE FOR CHILDREN AND ADULTS ................................................... 20

WELLNESS CARE FOR CHILDREN, THE CHILD HEALTH CHECK-UP PROGRAM ........................................ 20 Why Well-Child Visits Are Important For Children............................................................................. 20 When Your Child Should Get Well-Child Visits ................................................................................... 21 Blood Lead Testing ............................................................................................................................. 21 Vision Screening ................................................................................................................................. 21 Hearing Screening .............................................................................................................................. 21 Dental Screening ................................................................................................................................ 21 Immunizations (Shots)........................................................................................................................ 21
WELLNESS CARE FOR ADULTS ........................................................................... 23

WHEN YOU MISS ONE OF YOUR WELLNESS VISITS ................................................................................ 23
SPECIAL CARE FOR PREGNANT MEMBERS ......................................................... 24

WHEN YOU BECOME PREGNANT ........................................................................................................... 24 When You Have A New Baby ............................................................................................................. 25
DISEASE MANAGEMENT ................................................................................... 25 SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING .................................... 26
HEALTH INFORMATION .......................................................................................................................... 26 HEALTH EDUCATION CLASSES ................................................................................................................ 27 COMMUNITY EVENTS ............................................................................................................................. 27
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DOMESTIC VIOLENCE .............................................................................................................................. 27 MINORS .................................................................................................................................................. 28
STATEMENT OF ADVANCE DIRECTIVE OR LIVING WILLS .................................... 28

A LIVING WILL ......................................................................................................................................... 28 A DURABLE POWER OF ATTORNEY FOR HEALTH CARE .......................................................................... 29 IS A LIVING WILL BETTER THAN A DURABLE POWER OF ATTORNEY FOR HEALTH CARE? ..................... 29
GRIEVANCES AND APPEALS............................................................................... 29

GRIEVANCES ........................................................................................................................................... 29 First Level Grievance .......................................................................................................................... 29 Second Level Grievance...................................................................................................................... 30 External Grievance Review ................................................................................................................. 30 MEDICAL APPEALS .................................................................................................................................. 31 First Level Appeal ............................................................................................................................... 31 Second Level Appeal .......................................................................................................................... 31 External Appeals Review .................................................................................................................... 32 EXPEDITED APPEALS ............................................................................................................................... 32 MEDICAID FAIR HEARING ....................................................................................................................... 33 CONTINUATION OF BENEFITS ................................................................................................................. 33 PAYMENT APPEALS ................................................................................................................................. 33
OTHER INFORMATION ...................................................................................... 34

IF YOU MOVE .......................................................................................................................................... 34 RECERTIFY YOUR MEDICAID BENEFITS ON TIME .................................................................................... 34 ENROLLMENT LOCK-IN ........................................................................................................................... 35 DISENROLLING FROM AMERIGROUP ..................................................................................................... 35 REASONS WHY YOU CAN BE DISENROLLED FROM AMERIGROUP ......................................................... 36 IF YOU GET A BILL ................................................................................................................................... 36 CHANGES IN YOUR AMERIGROUP COVERAGE ....................................................................................... 36 HOW TO TELL AMERIGROUP ABOUT CHANGES YOU THINK WE SHOULD MAKE .................................. 37 HOW AMERIGROUP PAYS PROVIDERS ................................................................................................... 37
SUMMARY OF THE FLORIDA PATIENTS BILL OF RIGHTS AND RESPONSIBILITIES37

RIGHTS .................................................................................................................................................... 38 RESPONSIBILITIES ................................................................................................................................... 39
HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID PROGRAM ...... 39 NOTICE OF PRIVACY PRACTICES ........................................................................ 43
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WELCOME TO AMERIGROUP COMMUNITY CARE!

Information about Your New Health Plan
Welcome to Amerigroup Florida, Inc., doing business as Amerigroup Community Care. Amerigroup is a Health Maintenance Organization (HMO) committed to helping you get the right care close to home. As a member of Amerigroup, you and your Primary Care Physician (PCP) will work together to help keep you healthy and care for your health problems. Amerigroup helps you get quality health care. This member handbook is for all Amerigroup members who are eligible for Medicaid and MediKids. It will help you understand your health plan.
How to Get Help

Amerigroup Member Services Department If you have any questions about your Amerigroup health plan, you can call our Member Services department at 1-800-600-4441. You can call us Monday through Friday 8:00 a.m. to 7:00 p.m., Eastern time, except for holidays. If you call after 7:00 p.m., you can leave a voice mail message. A Member Services representative will call you back the next working day. Member Services can help you with: This member handbook Member ID cards Health care benefits Choosing or changing your doctor What services are offered at Amerigroup network hospitals Going to the emergency room Doctors appointments Finding an Amerigroup network pharmacy Grievances and appeals Health education Please also call Member Services: If you wish to request a copy of the Amerigroup Notice of Privacy Practices. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. When you move. We will need to know your new address and phone number. You should also call the Medicaid Options Hotline at 1-888-367-6554 to let them know your new address. For members who do not speak English, we can help in many different languages and dialects. This service is also available for visits with your doctor at no cost to you. Please let us know if you need an interpreter at least 24 hours before your appointment. Call Member Services for more information.
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For members who are hearing impaired, call the toll-free AT&T Relay Service at 1-800-855-2880. Amerigroup will set up and pay for you to have a person who knows sign language help you during your doctor visits. Please let us know if you need an interpreter at least 24 hours before your appointment. Amerigroup 24-Hour Nurse HelpLine You can call our 24-hour Nurse HelpLine at 1-800-600-4441 if you need advice on: How soon you need to get care for an illness What kind of health care is needed What to do to take care of yourself before you see the doctor How you can get the care that is needed We want you to be happy with all the services you get from the Amerigroup network of doctors and hospitals. Please call Member Services if you have any problems. We want to help you correct any problems you may have with your care. Other Important Phone Numbers If you have an emergency, call 911 or go to the nearest hospital emergency room right away If you want information about enrollment or disenrollment, you can call the Medicaid Options Hotline at 1-888-367-6554 The Department of Children and Families (DCF) Automated ACCESS Information and Customer Call Center number is 1-866-762-2237 The Subscriber Assistance Program number is 1-850-412-4502, and the statewide Consumer Call Center number is 1-888-419-3456 (toll free) If you would like to contact your Area Medicaid Office: For Citrus, Hernando, Lake, Marion and Sumter counties, call 1-877-724-2358 For Pasco and Pinellas counties, call 1-800-299-4844 For Hardee, Highlands, Hillsborough, Manatee and Polk counties, call 1-800-226-2316 For Orange, Osceola, Seminole, and Brevard counties, call 1-877-254-1055 For Charlotte, Collier, DeSoto, Glades, Hendry, and Sarasota counties, call 1-800-226-6735 For Indian River, Martin, Okeechobee and St. Lucie counties, call 1-800-226-5082 For Broward County, call 1-866-875-9131 For Dade and Monroe counties, call 1-800-953-0555 For Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia counties, call 1-800-273-5880 If you need a ride to a covered medical or dental appointment, please see the section How To Get To A Doctors Appointment Or To The Hospital for the phone number for your county If you need behavioral health care, please call Member Services at 1-800-600-4441 If you need eye care, call CompBenefits toll free at 1-800-491-9222 If you need hearing care, call HEARx toll free at 1-800-698-6767 If you would like information about our Disease Management programs, please call 1-800-600-4441 and ask to speak with a Disease Management care manager Your Amerigroup Member Handbook This handbook will help you understand your health plan. If you have questions, or need help understanding or reading your member handbook, call Member Services. Amerigroup also has the member handbook in a large print version, an audio taped version and a Braille version. The other side of this handbook is in Spanish.
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Your Identification Cards (ID Cards)

Each Medicaid-eligible member has a plastic Gold card as ID from the Department of Children and Families (DCF) office. To learn more about the Gold card, please get in touch with your areas DCF office. You will also get an Amerigroup ID card. If you do not have your ID card yet, you will get it soon. Please carry your Amerigroup ID card and your Gold card with you at all times. The card tells doctors and hospitals that you are a member of our health plan and who your PCP is. It also tells them that we will pay for the medically needed benefits listed in the section Amerigroup Covered Services. Your Amerigroup ID card has your PCPs name and phone number on it. The date you became a member is also shown. Your ID card lists many of the important phone numbers you need to know, like our Member Services department and Nurse HelpLine. It also has the phone numbers for you to call to get dental, vision, hearing and behavioral health care. If your Amerigroup ID card is lost or stolen, call us right away at 1-800-600-4441. We will send you a new one.
YOUR DOCTORS
Picking a Primary Care Physician
All Amerigroup members must have a family doctor, also called a Primary Care Physician (PCP). Your PCP must be in the Amerigroup network. Your PCP will give you a medical home. That means he or she will get to know you and your health history and be able to help you get quality care. Your PCP will give you all of the basic health services you need. He or she will also send you to other doctors or hospitals when you need special care. When you enrolled in Amerigroup Community Care, you should have picked a PCP. If you did not, we assigned one to you. We picked one who should be close by you. This doctors name and phone number are on your Amerigroup ID card. If we assigned a PCP to you, you can pick another one. Just look in the provider directory that came with your enrollment package. We can also help you pick a doctor. Call Member Services for help. If you are already seeing a doctor, you can look in the provider directory to see if that doctor is in our network. If so, you can tell us you want to keep that doctor. PCPs can be any of the following, as long as they are in the Amerigroup network: General Practitioners Family Practitioners Internists Pediatricians Obstetrician/Gynecologists (OB/GYNs) (for women when they are pregnant) Advanced Registered Nurse Practitioners Physician Assistants A household may choose the same PCP for all household members enrolled with Amerigroup Community Care. They can also choose a different PCP based on each members needs.
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Second Medical Opinion

Amerigroup members have the right to ask for a second opinion about the use of any covered health care services. You can get a second opinion from a network provider or a non-network provider (if a network provider is not available). Ask your PCP to submit a request for you to have a second opinion. If a non-network doctor gives a second medical opinion, the member may have to pay up to 40 percent of the payment. Once approved, your PCP will let you know the date and time of the appointment. Your PCP will also send copies of all related records to the doctor who will provide the second opinion. Your PCP will let you and Amerigroup know the outcome of the second opinion.
If You Had a Different Doctor Before You Joined Amerigroup

You may have been seeing a doctor who is not in our network for an illness or injury before you joined Amerigroup Community Care. In some cases, you may be able to keep seeing this doctor for care while you pick a new doctor. Please call Member Services to find out more about this. We will make a plan with you and your doctor so we all know when you need to start seeing your new Amerigroup network doctor.
If Your PCPs Office Moves, Closes or Leaves the Amerigroup Network

Your PCPs office may move, close or leave the Amerigroup network. If this happens, we will call or send you a letter to tell you about this. In some cases, you may be able to keep seeing this PCP for care for up to six months if you are in a course of treatment. Please call Member Services for more information about this. Amerigroup will make a plan with you and your PCP so we all know when you need to start seeing your new Amerigroup network PCP. We can also help you pick a new PCP. Call Member Services for help. Once you have picked a new PCP, we will send you a new ID card within 10 working days.
How to Change Your PCP

If you need to change your PCP, you may pick another PCP from the network. Just look in the Amerigroup provider directory that came with your enrollment package. You can also find the provider directory online at www.myamerigroup.com. Amerigroup can also help you pick a doctor. Call Member Services at 1-800-600-4441. We can change your PCP on the same day you ask for the change. The change will be effective immediately. You can also change your PCP online at www.myamerigroup.com. Call the doctors office if you want to make an appointment. If you need help, call Member Services. We will help you make the appointment.
If Your PCP Asks for You to Be Changed to Another PCP

Your PCP may ask for you to be changed to another PCP. Your doctor may do this if: Your doctor does not have the right experience to treat you The assignment to your doctor was made in error (like an adult assigned to a childs doctor) You fail to keep your appointments You do not follow his or her medical advice over and over again Your doctor agrees that a change is best for you
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If You Want to Go to a Doctor Who Is Not Your PCP

If you want to go to a doctor who is not your PCP, please talk to your PCP first. In most cases, your PCP needs to give you a referral so you can see another doctor. This is done when your PCP cannot give you the care you need. Please read the section Specialists to learn more about referrals. If you go to a doctor that your PCP has not referred you to, the care you receive may not be covered by Amerigroup.
Picking an OB/GYN
Female members can see an Amerigroup network obstetrician and/or gynecologist (OB/GYN) for OB/GYN health needs. These services include well-woman visits, prenatal care, care for any female medical condition, family planning and referral to a special doctor within the network. You do not need a referral from your PCP to see your OB/GYN. If you do not want to go to an OB/GYN, your PCP may be able to treat you for your OB/GYN health needs. Ask your PCP if he or she can give you OB/GYN care. If not, you will need to see an OB/GYN. You will find a list of network OB/GYNs in the Amerigroup provider directory that came with your enrollment package. You can also find the provider directory online at www.myamerigroup.com. While you are pregnant, your OB/GYN can become your PCP. The nurses on our 24-hour Nurse HelpLine can help you decide if you should see your PCP or an OB/GYN. If you need help picking an OB/GYN, call Member Services.
Specialists
Your PCP can take care of most of your health care needs, but you may also need care from other kinds of doctors. Amerigroup offers services from many different kinds of doctors who provide other medically needed care. These doctors are called specialists, because they have training in a special area of medicine. Examples of specialists are: Allergists (allergy doctors) Dermatologists (skin doctors) Cardiologists (heart doctors) Podiatrists (foot doctors) Your PCP will refer you to a specialist in the network if your PCP cannot give you the care you need. In most cases, you need to have a referral from your PCP to see another doctor. Your PCP will give you a referral form so you can see the specialist. The referral form tells you and the specialist what kind of health care you need. Be sure to take the referral form with you when you go to the specialist. Members identified by Amerigroup to have special health care needs do not need a referral to see a specialist. This is done through a standing referral or an approved number of visits. Members with special health care needs are adults and children who face daily physical, mental or environmental challenges. These challenges risk the members ability to fully function in society. If you believe you have special health care needs, please call Member Services.
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GOING TO THE DOCTOR

Your First Doctors Appointment
You can call your doctor to set up your first appointment. You should see your PCP for a wellness visit (a general checkup) within 90 days of enrolling in Amerigroup. By finding out more about your health now, your PCP can take better care of you if you get sick. We can also help you set up your first appointment. Just call Member Services if you want our help. If you have already been seeing the doctor who is now your Amerigroup network doctor, call the doctor to see if it is time for you to get a checkup. If it is, make an appointment to see the doctor as soon as possible.
How to Make an Appointment

It is easy to make an appointment with your PCP. Just call the doctors office. The phone number is on your Amerigroup ID card. If you need help, call Member Services. We will help you make the appointment. When you call to make an appointment, let the person you talk to know what you need (for example, a checkup or a follow-up visit). Also, tell the doctors office if you are not feeling well. This will let the doctors office know how soon you need to be seen.
Wait Times for Appointments

We want you to be able to get care at any time. When your PCPs office is closed, an answering service will take your call. Your doctor should call you back within 30 minutes. Once you talk to your doctor and set up an appointment, you will be able to see the doctor as follows: Urgent Care Routine Sick Patient Care Wellness Visit Within 1 day Within 1 week Within 1 month
What to Bring When You Go for Your Appointment

When you go to the doctors office for your appointment, bring your Amerigroup ID card, your plastic Gold card and any medicines you are taking, along with any questions you may want to talk to your doctor about. If the appointment is for your child, bring his or her ID cards, shot records and any medicine he or she is taking.
How to Cancel an Appointment

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

You can get a ride to and from your medical appointments. All you have to do is call the number for your county below. Please call three to five days in advance. County Brevard, Broward, Manatee and Sarasota Counties Dade County Hernando County Hillsborough County Lake County Orange, Osceola and Seminole Counties Pasco County Pinellas County Polk County Volusia County Phone Number 1-866-867-0729 1-866-726-1457 352-799-5177 813-253-3618 352-326-2278 407-423-8747 727-834-3200 727-545-2100 863-534-5500 1-866-289-1520
If you have an emergency and need transportation, call 911 for an ambulance. Be sure to tell the hospital staff you are an Amerigroup member. Get in touch with your PCP as soon as you can so your doctor can arrange your treatment and help you get the needed hospital care.
Disability Access to Amerigroup Network Doctors and Hospitals

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

Your PCP will help you get the services you need that are medically necessary as defined below: Medically necessary health services means health services which are: a) Necessary to protect life, to prevent significant illness or disability, or to lessen severe pain b) Consistent with the symptoms or diagnosis of the illness or injury under treatment c) Consistent with generally accepted professional medical standard (i.e., not experimental or investigational) d) Furnished at the most appropriate level that can be provided safely and effectively to the member e) Not primarily for the convenience of the member, the members caregiver or the provider
AMERIGROUP COVERED SERVICES

The following list shows a summary of the health care services and benefits Amerigroup will cover when you need them. Your PCP will give you the care you need or refer you to a doctor who can give you the care you need. For a few special benefits, members have to be a certain age or have a certain kind of health problem. In some cases, your doctor may need to get prior authorization from Amerigroup before you can receive a benefit. Your doctor will work with Amerigroup to get approval. If you have a question or are not sure whether we offer a certain benefit, you can call Member Services for help.
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Inpatient Hospital Stay (including Behavioral Health Care)

Inpatient hospital stay is the care you get when you are in a hospital. This includes all items and services you need to get the right care during your stay. Room and board Nursing care Medical supplies Diagnostic and therapeutic services Adults age 21 and older are covered for no more than 45 days. Children under age 21 are covered for 365 days. Amerigroup covers no more than 45 days. Medicaid covers the other 320 days. Inpatient behavioral health care services are included. These services include up to 28 inpatient hospital days for pregnant members in an inpatient hospital substance abuse treatment program.
Outpatient Services
Outpatient services include all medically needed diagnostic services, therapeutic care and services provided in an outpatient hospital setting. Some outpatient services may have a dollar limit. Outpatient services must be ordered by your Amerigroup network doctor. Outpatient behavioral health services are included.
Emergency Medical Services and Care

Emergency medical services mean all emergency care available 24 hours a day, 7 days a week. This includes emergency care at a facility that is not part of the network, until the member can be safely moved to a network facility. Emergency service and care include a medical screening, exam and review by a doctor or, when allowed by law, by proper personnel managed by a doctor. The purpose of this service is to find out if there is an emergency medical condition. If there is, the doctor decides the care, treatment or surgery needed to ease or end the condition, within the service means of a hospital. See the section Emergency Care for the definition of an emergency medical condition. Emergency behavioral health care services are offered 24 hours a day, 7 days a week.
Doctor Services
Doctor services include all services and procedures you get from an Amerigroup network doctor when medically needed for preventive, diagnostic, therapeutic or palliative (pain relief) care, or to treat a certain illness or disease. These services also include immunizations (shots). Doctor services do not include: Nonclinically proven procedures Cosmetic surgery Abortions, unless the life of the mother is or would be in danger, or if the woman is a victim of rape or incest
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Family Planning Services

Family planning services let you plan family size or think about when you want to have children. These services include: Information and referral for learning and counseling Diagnostic procedures Contraceptive drugs and supplies Sterilization and follow-up care You may use these services if you wish. You can choose the method and the family planning service. Norplant is covered. You do not need prior approval to get family planning services if you get these services from a provider who participates in Medicaid.
Maternity Care
Maternity services include nursing review and counseling, nutrition review, prenatal care, OB delivery and follow-up care. See the section Special Care For Pregnant Members for more information.
Prescription Benefit
You will get covered prescription drugs at no cost when written by a licensed prescriber. Plus, you can choose from several community pharmacies and major drugstore chains. You can look in the provider directory that came with your enrollment package for a list of network pharmacies. There is no copayment for prescription drugs. In addition to the over-the-counter products covered on our formulary, you also have an over-thecounter drug benefit. Your household can get up to $10 worth of certain over-the-counter products per month at any Amerigroup network pharmacy that takes part in this benefit. Just pick the product and show the pharmacist your Amerigroup ID card. The pharmacist will let you know when your household has reached the $10 limit for the month. Some of the types of over-the-counter drugs you can get include: Vitamins and minerals Pain relievers First aid supplies Cough, cold and allergy medicine
Behavioral Health Care Services

Sometimes the stress of handling the many responsibilities of a home and family can lead to depression, anxiety, marriage and family problems, parenting problems, and alcohol and drug abuse. If you or family members are having these kinds of problems, you can get help. You can call Amerigroup Member Services for help. You can also get the name of a doctor who will see you if you need one. We will set up all outpatient behavioral health care services and inpatient hospital stays. You DO NOT need a referral from your PCP to get behavioral health services.
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A behavioral health care provider is a licensed doctor, nurse, psychologist or social worker who is trained and skilled to provide behavioral health care. If you need to change your behavioral health care case manager or behavioral health care doctor, please call Member Services. You can get these nonemergent services within the service area by calling Member Services. Member Services will help arrange for the following care: Planning and review Evaluation and testing services Counseling services Therapy and treatment services provided by a psychiatrist Therapy and treatment services provided by a behavioral health care provider Rehabilitation services Childrens behavioral health care services Day-treatment services Amerigroup is not responsible for nonemergency behavioral health care services you get from an out-ofnetwork provider, unless we approve coverage of such services.
Vision Services
Amerigroup members do not need a referral from their PCPs for medically needed eye care benefits. Vision services include: Medically needed eye exams One pair of eyeglasses per year if medically needed Up to two additional pairs of eyeglasses per year if medically needed Eyeglass repairs and adjustments Contact lenses if medically needed Please call CompBenefits toll free at 1-800-491-9222 for help finding a network eye doctor (optometrist) in your area. As an extra vision benefit, Amerigroup does not limit eye exams and eyeglasses if medically needed.
Hearing Services
Amerigroup covers the following hearing services: Hearing evaluation and diagnostic testing One standard hearing aid per ear every three years (includes fitting and dispensing). Members can get up to $500 for the upgrade from a standard medically needed (behind the ear) hearing aid to a digital canal hearing aid. Hearing aid repairs Cochlear implant (limit of one) and cochlear implant repairs You can look in the provider directory that came with your enrollment package for a list of network hearing providers. Please call HEARx toll free at 1-800-698-6767 for help finding a HEARx center near you.
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Dental Services
Regular preventive dental care is the best way to fight and prevent gum disease and cavities. Eligible children under age 21 may go to any dentist who accepts Medicaid and MediKids. Your childs Gold card will let him or her get this service. Your child does not need prior approval from Amerigroup for dental care. Adults 21 and older may contact their local Medicaid Area Office for any dental problems. Dental care includes: Adult full and partial denture services Medically needed emergency dental care to help lessen pain or infection (limited to oral exams, Xrays, extractions and treatment of abscesses)
Lab and X-ray Services

These services include medically needed lab and radiology services ordered by an Amerigroup network doctor. These services are also part of emergency care.
Home Health Care

Home health care coverage includes medically needed: Short-term or part-time nursing services by a registered nurse or licensed practical nurse Personal care services by a home health aide Medical items Medical items are limited to approved supplies, appliances and durable medical gear fit for use in the home. All services, supplies and gear must be ordered by an Amerigroup network doctor in a written plan.
Transplant Services
Transplant services include evaluations for a transplant and care before and after a transplant is performed. The types of medically necessary transplants covered are: Bone marrow Cornea Kidney Heart Lung Liver Pancreas Intestinal/multivisceral
EXTRA AMERIGROUP BENEFITS

Amerigroup covers extra benefits eligible members cannot get from fee-for-service Medicaid or MediKids. These extra benefits are called value-added services. Amerigroup offers the following: Additional vision benefit Members can get unlimited eye exams and eyeglasses, if medically needed. See the section Vision Services under Amerigroup Covered Services for more information
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Enhanced Hearing aid benefit Members can get up to $500 for the upgrade from a standard medically needed (behind the ear) hearing aid to a digital canal hearing aid; see the section Hearing Services under Amerigroup Covered Services for more information Over-the-counter drug benefit Your household can get up to $10 worth of certain over-thecounter products per month at any Amerigroup network pharmacy that takes part in this benefit; see the section Prescription Benefit under Amerigroup Covered Services for more information Respite care services If medically needed, members can get an initial home health visit by a registered nurse and 8 follow-up visits (each lasting 4 hours) by an aid; this extra benefit includes a maximum of 16 hours in a given month and 32 hours per year; see the section Home Health Care under Amerigroup Covered Services for more information Added programs like Disease Management and health education that Amerigroup provides for the benefit of its members See the sections Disease Management and Special Amerigroup Services For Healthy Living for more information We give you these benefits to help keep you healthy and to thank you for choosing Amerigroup as your health care plan.
SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID

Some services are covered by fee-for-service Medicaid instead of Amerigroup Community Care. If you think you need these services, please call Member Services. We can help to refer you to the right provider. Nonemergency Transportation (see the section How To Get To A Doctors Appointment Or To The Hospital for more information) Specialized Therapeutic Foster Care Therapeutic Group Care Services Behavioral Health Overlay Services Certain Community Substance Abuse Services Residential Care Sub-acute Inpatient Psychiatric Program (SIPP) Services Clubhouse Services Comprehensive Behavioral Assessment Florida Assertive Community Treatment Services (FACT) Long Term Care Institutional Services in: A Nursing Facility An Institution for Persons with Developmental Disabilities Specialized Therapeutic Foster Care Childrens Residential Treatment Services State Hospital Services
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DIFFERENT TYPES OF HEALTH CARE

Routine, Urgent and Emergency Care: What Is the Difference?
Routine Care In most cases when you need medical care, you call your doctor to make an appointment. Then you go to see the doctor. This will cover most minor illnesses and injuries, as well as regular checkups. This type of care is known as routine care. Your PCP is someone you see when you are not feeling well, but that is only part of your PCPs job. Your PCP also takes care of you before you get sick. This is called wellness care. See the section in this handbook Wellness Care For Children And Adults. You should be able to see your PCP within 1 week for routine care. Urgent Care The second type of care is urgent care. There are some injuries and illnesses that are not emergencies but can turn into an emergency if they are not treated within 24 hours. Some examples are: High fever Animal bites Fractures Severe pain Infectious or respiratory illnesses Flu For urgent care, you should call your PCP. Your PCP will tell you what to do. Your PCP may tell you to go to his or her office right away. You may be told to go to some other office to get immediate care. You should follow your PCPs instructions. In some cases, your PCP may tell you to go to the emergency room at a hospital for care. See the next section about emergency care for more information. You can also call our 24-hour Nurse HelpLine at 1-800-600-4441 for advice about urgent care. You should be able to see your PCP within 1 day for an urgent care appointment. Emergency Care After routine and urgent care, the third type of care is emergency care. If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away. If you want advice, call your PCP or our 24-hour Nurse HelpLine at 1-800-600-4441. The most important thing is to get medical care as soon as possible. You should be able to see a physician immediately for emergency care. When you go to the hospital, you will get a medical screening. After the medical screening, you will need to present your Amerigroup ID card and your Gold card. Ask the hospital to call Amerigroup Community Care. The process for providers to follow is on your ID card.
What is an emergency medical condition?

An emergency medical condition is when not seeing a doctor for care right away could result in death or very bad harm to your body. The problem is so bad that a person with an average knowledge of health and medicine can tell the problem may result in death or may cause bad damage to any organ or part of the body (or, in the case of a pregnant woman, the health of the woman or her unborn child).
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In the case of a pregnant woman, an emergency medical condition is when: There is not enough time to safely move her to a new hospital before delivery. A transfer may pose a threat to the health and safety of the patient or her unborn child. There is proof of prolonged uterine contractions or rupture of the membranes. Here are some examples of problems that are most likely emergencies: Trouble breathing Chest pains Loss of consciousness Very bad bleeding that does not stop Very bad burns Shakes called convulsions or seizures
What is an emergency behavioral health condition?

An emergency behavioral health condition meets the standard described above. Examples of an emergency behavioral health condition include: Likely danger to self and others So much functional harm that the person is not able to carry out actions of daily life Functional harm that will likely cause death or serious harm to the body
What is post-stabilization?
Post-stabilization services are covered services you receive after emergency medical care. You get these services to help keep your condition stable. Medical emergencies and post-stabilization care that have to do with your emergency do not need prior approval by Amerigroup Community Care. You should call your PCP as soon as you can after you visit the emergency room. If you cannot call, have someone else call for you. Your PCP will give or arrange any follow-up care you need.
How to Get Health Care When Your Doctors Office Is Closed

Except in the case of an emergency (see previous section) or when you need care that does not need a referral, you should always call your PCP first before you get medical care. If you call your PCPs office when it is closed, leave a message with your name and a phone number where you can be reached. If it is not an emergency, someone should call you back soon to tell you what to do. You may also call our Nurse HelpLine 24 hours a day, 7 days a week for help. If you think you need emergency services (see previous section), call 911 or go to the nearest emergency room right away.
How to Get Health Care When You Are Out of Town

If you need emergency services when you are out of town or outside of Florida*, go to the nearest hospital emergency room or call 911. You must get in touch with your PCP as soon as you can about your out-of-area emergency care. This will allow your PCP to set up follow-up care. If you are placed in
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the hospital, have the hospital call Amerigroup Community Care. This call should be made within 24 hours of admission or as soon as possible to confirm coverage. Any nonemergency care you get outside the service area is not covered unless you get prior approval from Amerigroup Community Care. If you need urgent care when you are out of town, call your PCP. If your PCPs office is closed, leave a phone number where you can be reached. Your PCP or someone else should call you back soon. Follow the doctors instructions. You may be told to get care where you are if you need it very quickly. You can also call our 24-hour Nurse HelpLine for help. If you need routine care like a checkup or a prescription refill when you are out of town, call your PCP or our 24-hour Nurse HelpLine. *If you are outside of the U.S. and get health care services, they will not be covered by Amerigroup or fee-for-service Medicaid.
How to Get Care When You Cannot Leave Your Home

Amerigroup will find a way to help take care of you. Call Member Services right away if you cannot leave your home. We will put you in touch with a case manager who will help you get the medical care you need.
WELLNESS CARE FOR CHILDREN AND ADULTS

All Amerigroup members need to have regular wellness visits with their PCP. During a wellness visit, your PCP will check your overall health. Many health problems can be treated and controlled if found early. Your PCP can also answer your medical questions and help you stay healthy. When you become an Amerigroup member, call your PCP and make your first appointment within 90 days.
Wellness Care for Children, the Child Health Check-up Program

Why Well-Child Visits Are Important For Children Babies need to see their PCP 7 times by the time they are 12 months old and more times if they get sick. If your child has special needs or an illness like asthma or diabetes, one of our care coordinators can help your child get checkups, tests and shots. Your child can get well-child visits from his or her PCP or any Amerigroup network provider. Your child does not need a referral for these visits. These well-child visits will include: A comprehensive review of your childs physical and mental growth A complete unclothed physical exam Nutritional and developmental assessment Vision, hearing and dental screenings Laboratory tests (including blood lead testing for children ages 12 and 24 months) Immunizations (shots) for your child that will help protect him or her from illnesses Health education and help with preventive care Diagnosis and treatment Referral and follow-up, as needed
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When Your Child Should Get Well-Child Visits The first well-child visit will happen in the hospital right after the baby is born. For the next 6 visits, you must take your baby to his or her PCPs office. You must set up a well-child visit with the doctor when the baby is: 1 month old 12 months old 2 months old 15 months old 4 months old 18 months old 6 months old 24 months old 9 months old Be sure to make these appointments. Take your child to his or her PCP when scheduled. Blood Lead Testing Your childs PCP should test your child for lead poisoning. Many items are being found to contain high levels of lead, including childrens toys, jewelry, clothes and even mini blinds. A blood lead test should be done for your child at these ages: 12 months 24 months Between 24 and 72 months if the child has not been tested before For the blood test, your childs doctor will take a blood sample by pricking the childs finger or taking blood from the vein. This test will tell if your child has harmful lead in his or her blood. Vision Screening Your childs PCP should check your childs vision at every well-child visit. Please see the section Vision Services under the heading Amerigroup Covered Services for more information. Hearing Screening Your childs PCP should check your childs hearing at every well-child visit. Dental Screening Your child should have his or her teeth and gums checked by his or her PCP as a part of the regular wellchild visits. At age 3, your child should begin seeing a dentist every six months. Please see the section Dental Services under Amerigroup Covered Services for more information. Immunizations (Shots) It is important for your child to get his or her immunizations on time. Take your child to the doctor when his or her PCP says a shot is needed. Use the chart below to help keep track of the shots your child needs.
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IMMUNIZATION (SHOT) SCHEDULE FOR CHILDREN AGE VACCINE Birth 1 2 mo mo 4 mo 6 mo 12 mo 15 mo 18 mo 19-23 2-3 mo yrs 4-6 yrs 7-10 11-12 13-18 yrs yrs yrs
Hepatitis B
HepB
HepB
HepB if HepB needed
HepB Series if not given
Rotavirus
Rota Rota
Rota
Diphtheria, Tetanus, Pertussis
DTaP DTaP
DTaP
DTaP
DTaP
Tdap
Tdap if not given
Haemophilus influenzae type b
Hib
Hib
Hib if Hib needed
Hib if not given
PCV if high-risk Pneumococcal PCV PCV PCV PCV PPV if highrisk PPV if high-risk
Inactivated Poliovirus
IPV
IPV
IPV
IPV
IPV Series if not given
Influenza
Influenza (Yearly)
Influenza (Yearly) if high-risk
Measles, Mumps, Rubella
MMR
MMR
MMR Series if not given
Varicella Hepatitis A
Varicella
Vari- Varicella Series cella if not given
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HepA (2 doses)
HepA Series if high-risk
MCV4 at 15 if not given Meningococcal MPSV4 if high-risk MCV4 MCV4 if highrisk
Human Papillomavirus
HPV HPV Series (3 if not doses) given
WELLNESS CARE FOR ADULTS

Staying healthy means seeing your PCP for regular checkups. Use the chart above to make sure you are up to date with your yearly wellness exams. WELLNESS VISITS SCHEDULE FOR ADULT MEMBERS EXAM TYPE WHO NEEDS IT? WELLNESS VISIT Age 21 - 39 Age 40 and over PAP SMEAR AND PELVIC EXAM Women: Under age 18 who are sexually active Age 18 and over CLINICAL BREAST EXAM Women: Age 20 - 39 Age 40 and over BREAST SELF-EXAM Women: Age 20 and over MAMMOGRAMS (BREAST X-RAY) Women: Age 40 and over FECAL BLOOD OCCULT TEST Age 50 and over SIGMOIDOSCOPY & DRE/PSA Age 50 and over OR COLONOSCOPY & DRE/PSA
HOW OFTEN? Every 3 years Every year Every year Every year Every 3 years Every year Once a month Every year Every year Every 5 years
When You Miss One of Your Wellness visits

If you or your child does not get a wellness care visit on time, make an appointment with the PCP as soon as you can. If you need help setting up the appointment, call Member Services. If your child has not visited his or her PCP on time, Amerigroup will send you a postcard reminding you to make your childs well-child appointment.
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SPECIAL CARE FOR PREGNANT MEMBERS

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

If you think you are pregnant, call your PCP or OB/GYN doctor right away. You do not need a referral from your PCP to see an OB/GYN doctor. Your OB/GYN should see you within 2 weeks. We can help you find an OB/GYN in the Amerigroup network, if needed. You must also call Amerigroup Member Services and your DCF case worker when you find out you are pregnant. This will help your baby get Amerigroup health care benefits when he or she is born. You will need to choose a PCP for your baby in your last trimester of pregnancy. The third trimester begins in week 28 through the end of your pregnancy. If you dont choose a PCP for your baby during this time, well choose one for you. When you are pregnant, Amerigroup will send you a pregnancy education package. It will include: A letter welcoming you to the Taking Care of Baby and Me program A self-care book Taking Care of Baby and Me reward program brochure A Nurse HelpLine AMERITIPS fact sheet A Healthy Start Hot Tip fact sheet The self-care book gives you information about your pregnancy. You can also use the book to write down things that happen during your pregnancy. The Taking Care of Baby and Me brochure tells you how to get your gift for getting prenatal care. While you are pregnant, you need to take good care of your health. You may be able to get healthy food from the Women, Infants and Children Program (WIC). Member Services can give you the phone number for the WIC program close to you. Just call us. When you are pregnant, you must go to your PCP or OB/GYN at least: Every 4 weeks for the first 32 weeks Then every 2 weeks until the 36th week Then weekly until delivery Your PCP or OB/GYN may want you to visit more than this based on your health needs.
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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 PCP or OB/GYN and the babys doctor see that you and your baby are doing well. If you and your baby leave the hospital early, your PCP or OB/GYN may ask you to have an office or in-home nurse visit within 48 hours. After you have your baby, 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 PCP for your baby before he or she was born. If not, we can help you pick a PCP for him or her. You must also call your DCF case worker when you have your baby. This will help make sure he or she gets Amerigroup health care benefits for 90 days. If you do not wish for the baby to become a member, you must call the Medicaid Options Hotline at 1-888-367-6554 to make another managed care choice for your baby. After you have your baby, Amerigroup will send you the Taking Care of Baby and Me postpartum education package. It will include: A letter welcoming you to the postpartum part of the Taking Care of Baby and Me program A baby-care book Taking Care of Baby and Me reward program brochure about going to your postpartum visit A brochure about postpartum depression A Nurse HelpLine AMERITIPS fact sheet A Healthy Start Hot Tip fact sheet You can use the baby-care book to write down things that happen during your babys first year. This book will give you information about your babys growth.
DISEASE MANAGEMENT
Amerigroup has a disease management program to help you better understand and manage your chronic health problem. Your Primary Care Physician (PCP) and our team will assist you with your health care needs. They will arrange for home health visits and medical support items needed to help manage your health condition. Licensed nurses or social workers called disease management care managers support you over the phone. They also help to arrange other services like smoking cessation, nutrition classes or other community support activities. Care managers also help you better understand your condition and will work with you to develop a plan to address your special needs. We can help arrange your health care by working with your PCP to help make sure you get the follow-up care that you need. An example of this is setting up rides to your doctors visits and arranging referrals to specialists as needed. Amerigroup has received NCQA (National Committee for Quality Assurance) Patient and Practitioner Oriented Accreditation for the following programs. Earning NCQA accreditation for Disease Management represents our continued commitment to help you receive quality health care coverage. Asthma
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Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Major Depressive Disorder Diabetes HIV/AIDS Schizophrenia As an Amerigroup member enrolled in disease management, you have certain rights and responsibilities. You have the right to: Have information about Amerigroup; this includes programs and services, our staffs education and work experience. It also includes contracts we have with other businesses or agencies Refuse to take part in or disenroll from programs and services we offer Know which staff members arrange your health care services and who to ask for a change Have Amerigroup help you to make choices with your doctors about your health care Know about all disease management related treatments; these include anything stated in the clinical guidelines, whether covered by Amerigroup or not; you have the right to discuss all options with your doctors Have personal and medical information kept confidential under HIPAA; know who has access to your information; know what Amerigroup does to ensure privacy Be treated with courtesy and respect by Amerigroup staff File a complaint with Amerigroup and be told how to make a complaint; this includes knowing about the Amerigroup standards of timely response to complaints and resolving issues of quality Get information that you can understand You have the responsibility to: Listen to and know the effects of accepting or rejecting health care advice Provide Amerigroup with information needed to carry out our services Tell Amerigroup and your doctors if you decide to disenroll from the disease management program If you have one of the these conditions or would like to know more about our disease management programs, please call 1-888-830-4300 Monday through Friday 8:30 a.m. to 5:30 p.m. Eastern time. Ask to speak with a Disease Management care manager. You can also visit our web site at www.myamerigroup.com.
SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING

Health Information
Learning more about health and healthy living can help you stay healthy. One way to get health information is to ask your PCP. Another way is to call us. Our Nurse HelpLine is available 24 hours a day, 7 days a week to answer your questions. They can tell you if you need to see the doctor. They can also tell you how you can help take care of some health problems you may have.
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Health Education Classes

Amerigroup works to keep you healthy with its health education programs. We can help you find classes near your home. You can call Member Services to find out where and when these classes are held. Some of the classes include: Amerigroup services and how to get them Childrens programs Childbirth Infant care Parenting Pregnancy Quitting cigarette smoking Protecting yourself from violence Substance abuse programs Other classes about health topics Some of the larger medical offices (like clinics) in our network show health videos that talk about immunizations (shots), prenatal care and other important health topics. We hope you will learn more about staying healthy by watching these videos.
Community Events
Amerigroup sponsors and participates in special community events and family fun days where you can get health information and have a good time. You can learn about topics like healthy eating, asthma and stress. You and your family can play games and win prizes. People from Amerigroup will be there to answer your questions. Call Member Services to find out when and where these events will be.
Domestic Violence
Domestic violence is abuse. Abuse is unhealthy. Abuse is unsafe. It is never OK for someone to hit you. It is never OK for someone to make you afraid. Domestic violence causes harm and hurt on purpose. Domestic violence in the home can affect your children and it can affect you. If you feel you may be a victim of abuse, call or talk to your doctor. Your doctor can talk to you about domestic violence. He or she can help you understand you have done nothing wrong and do not deserve abuse. Safety tips for your protection: If you are hurt, call your doctor; call 911 or go to the nearest hospital if you need emergency care; please see the section Emergency Care for more information Have a plan on how you can get to a safe place (like a womens shelter or a friends or relatives home) Pack a small bag, and give it to a friend to keep until you need it If you have questions or need help, please call our Nurse HelpLine at 1-800-600-4441 or call the National Domestic Violence hotline number at 1-800-799-7233 (TTY 1-800-787-3224).
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Minors
For most Amerigroup members under age 18, the Amerigroup Community Care network doctors and hospitals cannot give them care without a parents or legal guardians consent. This does not apply if emergency care is needed. Parents or legal guardians also have the right to know what is in their childs medical records. Members under age 18 can ask their doctor not to tell their parents about their medical records, but the parents can still ask the doctor to see the medical records. These rules do not apply to emancipated minors. Members under age 18 may be emancipated minors if they: Are married Are pregnant or Have a child Emancipated minors may make their own decisions about their medical care and the medical care of their children. Parents no longer have the right to see the medical records of emancipated minors.
STATEMENT OF ADVANCE DIRECTIVE OR LIVING WILLS

This section tells you about Florida law on advance directives or living wills. Under Florida Law (see note below), every adult age 18 and older has the right to make certain decisions about his or her medical treatment. The law allows for the respect of your rights and personal wishes, even if you are too sick to make choices yourself. You have the right, under certain cases, to choose whether to accept or reject medical treatment, including whether to keep getting medical treatment and other procedures that would keep you alive by artificial means. You have the right to participate in decisions regarding your health care, including the right to refuse treatment. You may spell out these rights in a living will. Your living will has your personal orders about treatment to keep you alive in the case of serious illness that could cause death. You may also choose another person, or surrogate, who may decide for you if you become mentally or physically unable to do so. This surrogate may act on your behalf for the life-threatening or nonlifethreatening illness. Any limits to the power of the surrogate to decide for you should be clearly expressed. You have the right to file a complaint if you think any of the laws about advance directives or living wills are not being followed. To file a complaint, call the Consumer Hotline toll free at 1-888-419-3456. The Living Will and Designation of Health Care Surrogate forms are in this handbook.
A Living Will
A living will is a statement that lets your doctor and family know your wishes if there were no hope for you to recover, and you cannot make your own choices. An example of this would be whether to keep using a breathing machine to stay alive if you were in a permanent coma after a car accident.
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A Durable Power of Attorney for Health Care

A Durable Power of Attorney for Health Care is a statement in which you choose a person to make medical judgments for you if you cannot make those choices for yourself. That person should be someone you trust to make health choices like the ones you would make if you were able. Usually, that person would be a relative or close friend.
Is a Living Will Better Than a Durable Power of Attorney for Health Care?
A living will and a durable power of attorney for health care are not the same and are used for different things. For these reasons, they both are good. These statements are to help your family and your doctor make choices about your health care at a time when you are not able to. You may use one or both of these forms of advance directives to provide the course for your medical care. You may combine them into one statement that appoints a person to make medical choices for you but also tells that person of your wishes if there is no hope for reasonable survival. You can change your mind or cancel your statements at any time. Changes should be written, signed and dated. You can also change your mind by telling someone (an oral statement). Give your PCP a copy of the new living will or durable power of attorney for health care to keep with your medical records. The only time an advance directive can be used is when you are mentally disabled and cannot make health care choices. Once you are able to make choices again, the advance directive is not in effect. It will be on standby should you ever become disabled again and cannot make choices for yourself. Note: The legal basis for this right can be found in the Florida Statutes: Life-Prolonging Procedure Act, Chapter 765; Health Care Surrogate Act, Chapter 745; Durable Power of Attorney Section 709.08; and Court Appointed Guardianship, Chapter 744; and in the Florida Supreme Court, decision on the constitutional right of privacy, Guardianship of Estelle Browning, 1990. If you have any questions about the legal requirements or issues with these forms, you should talk to a licensed attorney in the state of Florida. Amerigroup cannot provide you with any legal advice.
GRIEVANCES AND APPEALS

If you have any questions or concerns with your Amerigroup benefits, please call Member Services.
Grievances
If you have a problem with the Amerigroup Community Care services or network providers and would like to tell us about it, please call us. First Level Grievance You (or your doctor on your behalf and with your written consent) have the right to file a grievance. Amerigroup will not hold it against your doctor for helping you file a grievance or for filing a grievance for you. The request must be made within 1 year of the event that started your grievance. If you wish to file a formal grievance, you or your doctor can write us a letter or call our Member Services department. Your letter should include your name, address, member number, signature and the date. Let us know about your problem and the action you wish to be taken. Write to Amerigroup at:
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Member Grievance Coordinator Amerigroup Community Care 4200 W. Cypress Street, Suite 900 Tampa, FL 33607-4173 Member Services will be happy to help you prepare and submit this concern. The grievance coordinator will look into your problem and send you a written decision within 30 days of when we first get your request. We may also need to extend our resolution time frame by up to 30 days if we feel there is a need for more information, and it is in your best interest that we have this information. We will let you know in writing the reason for the delay. You can reach the grievance coordinator by calling Member Services Monday through Friday between 8:00 a.m. and 5:00 p.m. Second Level Grievance If you are not happy with the grievance coordinators decision, you may appeal to the Grievance Committee within 10 days of when you get your grievance decision from Amerigroup Community Care. Send a written request for review to the above address, Attention: Grievance Committee. The Grievance Committee will review the first decision of the grievance coordinator and any other evidence you may have submitted. The committee will make a decision within 30 days after it gets your request for review. External Grievance Review If you are still not pleased with the Amerigroup Community Care decision on your appeal, you have the right to ask for a review of this decision by the Subscriber Assistance program. You must ask for this review within 365 days of when you get the committees decision. The address to file your appeal is: Subscriber Assistance Program Agency for Health care Administration 2727 Mahan Drive, Building 1, MS #26 Tallahassee, FL 32308 You may also call the Subscriber Assistance program at 850-412-4502 or the statewide Consumer Call Center toll free at 1-888-419-3456. You can request a Fair Hearing by sending a letter to: The Office of Public Assistance Appeals Hearings Department of Children and Families 1317 Winewood Blvd., Building 5, Room 203 Tallahassee, FL 32399-0700 Note: If you ask for a fair hearing, the Subscriber Assistance program will not review your request. MediKids members do not have the right to request a fair hearing.
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Medical Appeals
There may be times when Amerigroup says it will not pay, in whole or in part, for care that your doctor recommended. If we do this, you (or your doctor on your behalf and with your written consent) can appeal the decision. A medical appeal is when you ask Amerigroup to look again at the care your doctor asked for, and we said we will not pay for. You must file for an appeal within 30 days from the date on the letter that says we will not pay for a service. Amerigroup will not hold it against you or your doctor for helping you file an appeal or for filing an appeal for you. First Level Appeal You or your representative can file a First Level Appeal. You must do this within 30 days from when you get the first letter from Amerigroup that says we will not pay for the service. If you ask someone (a personal 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. If you would like to do this, you must write this persons name on the appeal form and fill out a request to designate a personal representative form. You can appeal our decision in two ways: You can call Member Services; if you call us, we will send you a letter to let you know we got your request for an appeal; we will include an appeal form for you to fill out and mail back to us; Amerigroup can accept your appeal by phone, but you must follow up in writing within 10 days of calling us You can send us a letter or the appeal form to the address below: Medical Appeals Amerigroup Community Care P.O. Box 62429 Virginia Beach, VA 23466-1599 Member Services will be happy to help you prepare and submit this concern. You can also request to meet or present information in person. Call Member Services to find out how to arrange a meeting. When we get your letter or appeal form, we will send you a letter within 5 days. This letter will let you know we got your appeal. We will tell you what we decide about your appeal within 30 days of when we get your appeal. We will give you and your representative a chance before and during your appeal to look at your case file and medical records. If we need more information and it is in your best interest that we have this information, we may extend the appeal process for 14 days. If we extend the appeal process, we will let you know in writing the reason for the delay. You may also ask us to extend the process if you know more information that we should consider. Second Level Appeal If you are not happy with the answer to your First Level Appeal, you can ask us to look at your appeal again. This is called a Second Level Appeal/Committee Review. You can ask for this review within 10 days from the date on the letter that says we still will not pay for the service. You can write to us at the address above or call Member Services to ask for this review.
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When we get your letter, we will send you a letter within five days. This letter will let you know we got your appeal. It will also let you know if we need more information from you. The committee will meet to review your appeal and will have an answer for you in 15 days unless more information is needed. Then we will let you know that we will extend the appeal process for 14 days. External Appeals Review If you are still not pleased with the Amerigroup Community Care decision on your appeal, you have the right to ask for a review of this decision by the Subscriber Assistance program. You must ask for this review within one year of the date of the event or problem that caused you to appeal. The address to file your appeal is: Subscriber Assistance Program Agency for Health Care Administration 2727 Mahan Drive, Building 1, MS #26 Tallahassee, FL 32308 You may also call the Subscriber Assistance program at 850-921-5458 or the statewide Consumer Call Center toll free at 1-888-419-3456.
Expedited Appeals
You or the person you ask to file an appeal for you can request an expedited appeal. You can request an expedited appeal if you or your provider feels that taking the time for the standard appeals process could seriously harm your life or your health. You or your doctor can request an expedited appeal in 2 ways: You can call Member Services. You can mail your request and medical information for the service to: Medical Management Amerigroup Community Care 4200 W. Cypress Street, Suite 900 Tampa, FL 33607-4173 If we approve your request for an expedited appeal, we will respond orally and in writing to your appeal within 72 hours. There may be times when we need more information from you or the person you asked to file the appeal for you. If we need more information, and it is in your best interest that we have this information, we may extend the appeal process for 14 days. If we extend the appeal process, we will let you know in writing the reason for the delay. You may also ask us to extend the process if you know more information that we should consider. You or your doctor should send us this information right away in the case of an expedited appeal. If we do not approve your request for an expedited appeal, we will also let you know orally and in writing within two days. We will then resolve your appeal within 45 days, the normal appeal time frame.
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Medicaid Fair Hearing

You (or your doctor or legal representative on your behalf with your written consent) also have the right to ask for a Medicaid fair hearing during the grievance or appeal process. Amerigroup will not hold it against you for a fair hearing or against your doctor for helping you to ask for a fair hearing. You can request a fair hearing by sending a letter to: The Office of Public Assistance Appeals Hearings Department of Children and Families 1317 Winewood Blvd., Building 5, Room 203 Tallahassee, FL 32399-0700 You or your provider must ask for a fair hearing within 90 days from the date you get the letter telling you the reason we cannot pay for the service. If you have any questions about your request for a fair hearing, call Member Services. Note: If you ask for a fair hearing, the Subscriber Assistance program will not review your request. MediKids members do not have the right to request a fair hearing.
Continuation of Benefits
You may ask Amerigroup to continue to cover your benefits during the appeal or fair hearing process. If coverage of a service you are receiving is reduced and you want to continue that service during your appeal or fair hearing, you can call Member Services to request it. We must continue coverage of your benefits until: You withdraw the appeal 10 days from the date of our first decision if you have not requested a fair hearing A fair hearing decision is reached and is not in your favor Authorization expires or your service limits are met You may have to pay for the cost of any continued benefit if the fair hearing determination is not in your favor. If a decision is made in your favor as a result of your appeal or fair hearing, Amerigroup will authorize and pay for the services we denied coverage of before.
Payment Appeals
If you receive a service from a provider and Amerigroup does not pay for that service, you may receive a notice from Amerigroup called an Explanation Of Benefits (EOB). This is not a bill. The EOB will tell you the date you received the service, the type of service and the reason we cannot pay for the service. The provider, health care place or person who gave you this service will get a notice called an Explanation of Payment. If you receive an EOB, you do not need to call or do anything at that time, unless you or your provider wants to appeal the decision. An appeal is when you ask Amerigroup to look again at the service we said we would not pay for. You must ask for an appeal within 30 days of receiving the EOB. To appeal, you or your doctor can call Member Services at 1-800-600-4441 or mail your request and medical information for the service to:
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Payment Appeals Amerigroup Community Care P.O. Box 61599 Virginia Beach, VA 23466-1599 If you call us, we will send you a letter to let you know we got your request for an appeal. We will include an appeal form for you to fill out and mail back to us. We can accept your appeal by phone, but you must follow up in writing within 15 days of calling us. You have the right to ask for a fair hearing during the Amerigroup Community Care appeal process. You can request a fair hearing by sending a letter to: The Office of Public Assistance Appeals Hearings Department of Children and Families 1317 Winewood Blvd., Building 5, Room 203 Tallahassee, FL 32399-0700 You must ask for a fair hearing within 90 days from the date you get the letter from Amerigroup that tells you the result of your payment appeal. If you have any questions about your rights to appeal or request a fair hearing, call Member Services.
OTHER INFORMATION
If You Move
Report your new address as soon as possible to the Medicaid Options Hotline and the Amerigroup Member Services department at 1-800-600-4441. If you move out of our service area, you will be disenrolled. To choose another health plan, you can call the Medicaid Options Hotline at 1-888-367-6554.
Recertify Your Medicaid Benefits on Time

Keep the right care. Do not lose your health care benefits! You could lose your Medicaid benefits even if you still qualify. For example, you could lose your benefits if you move or fail to recertify on time. If you lose your Medicaid benefits, Amerigroup cannot arrange for your health care coverage until you become eligible for Medicaid again. If you become eligible for Medicaid again within 6 months or less, your membership in Amerigroup will start again. If possible, you will be given the same PCP you had when you were in Amerigroup before. The good news is that recertifying has been made easier. Now you can do it online. Go to www.myflorida.com/accessflorida, or visit a Department of Children and Families ACCESS location near you. You can call the Automated ACCESS Information and Customer Call Center at 1-866-762-2237, 24 hours a day, 7 days a week. We want you to keep getting your health care benefits from us if you still qualify. Your health is very important to us.
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Enrollment Lock-In
Enrollment: If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Amerigroup or the state enrolls you in a health plan, you will have 90 days from the date of your first enrollment to try the plan. During the first 90 days you can change health plans for any reason. After the 90 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next nine months. This is called lock-in. Open Enrollment: If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your enrollment year telling you that you can change plans if you want to. This is called open enrollment. You do not have to change plans. If you choose to change plans during open enrollment, you will begin in the new plan at the end of your current enrollment year. Whether you pick a new plan or stay in the same plan, you will be locked into that plan for the next 12 months. Every year you can change health plans during your 60-day open enrollment period.
Disenrolling from Amerigroup

If you are a mandatory enrollee and you want to change plans after the initial 90-day period ends or after your open enrollment period ends, you must have a state-approved good cause reason to change plans. The following are state-approved cause reasons to change health plans: You move out of the county, or your address is incorrect and you dont live in a county where Amerigroup is authorized to provide services Your provider is no longer with the Amerigroup You are excluded from enrollment A substantiated marketing or community outreach violation has occurred You are prevented from participating in the development of your treatment plan You have an active relationship with a provider who is not on the Amerigroup panel but is on the panel of another health plan You are in the wrong health plan as determined by AHCA Amerigroup no longer participates in the county The state has imposed intermediate sanctions upon Amerigroup (this is explained in 42 CFR 438.702(a)(3) in the Code of Federal Regulations) You need related services to be performed concurrently, but not all related services are available within the Amerigroup network; or your PCP has determined that receiving the services separately would subject you to unnecessary risk Amerigroup does not, because of moral or religious objections, cover the service you seek You missed open enrollment due to a temporary loss of eligibility for 60 days Other reasons per 42 CFR 438.56(d)(2), including, but not limited to: Poor quality of care Lack of access to services covered under the contract Inordinate or inappropriate changes of PCPs Service access impairments due to significant changes in the geographic location of services Lack of access to providers experienced in dealing with your health care needs Fraudulent enrollment Voluntary enrollees may disenroll from the plan at anytime
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Some Medicaid recipients can change health plans whenever they choose, for any reason. For example, people who are eligible for both Medicaid and Medicare benefits and children who receive SSI benefits can change plans at any time for any reason. To find out if you can change plans, call the Medicaid Options Hotline at 1-888-367-6554.
Reasons Why You Can Be Disenrolled from Amerigroup

There are several reasons you could be disenrolled from Amerigroup without asking to be disenrolled. Some of these are listed below. If you have done something that may lead to disenrollment, we will contact you. We will ask you to tell us what happened. You could be disenrolled from Amerigroup if you: Let someone else use your ID card Take part in disruptive or abusive behavior Continue to fail to follow a proposed plan of medical care Lose Medicaid eligibility Miss 3 appointments in a row within one 6-month period Move out of the approved service area Get admitted into a long-term care facility, hospice program, prison or correctional facility Get services through the Medicaid AIDS waiver (Project AIDS Care) program, the assisted living waiver program, a prescribed pediatric extended care center or Childrens Medical Services Have other creditable health care coverage If you have any questions about your enrollment, call Member Services.
If You Get a Bill

Always show your Amerigroup ID card and your Gold 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 to make sure you are not sent a bill for services covered by Amerigroup. If you do get a bill, send it to us with a letter saying you have been sent a bill. Send the letter to the address below: Claims Amerigroup Community Care P.O. Box 61010 Virginia Beach, VA 23462 You can also call Member Services for help.
Changes in Your Amerigroup Coverage

Sometimes Amerigroup may have to make changes in the way it works, its covered services or its network doctors and hospitals. We will mail you a letter when we make changes in the services that are covered. Your PCPs office may move, close or leave our network. If this happens, we will call or send you a letter to tell you about this.
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We can also help you pick a new doctor. You can call Member Services if you have any questions. Member Services can also send you a current list of our network doctors.
How to Tell Amerigroup about Changes You Think We Should Make

We want to know what you like and do not like about Amerigroup. Your ideas will help us make Amerigroup better. Please call Member Services to tell us your ideas. You can also send a letter to: Amerigroup Community Care P.O. Box 62509 Virginia Beach, VA 23462 Amerigroup has a group of members who meet quarterly to give us their ideas. These meetings are called Member Advisory Meetings. This is a chance for you to find out more about us, ask questions and give us suggestions for improvement. If you would like to be part of this group, call Member Services. We also send surveys to some members. The surveys ask questions about how you like Amerigroup Community Care. If we send you a survey, please fill it out and send it back. Our staff may also call to ask how you like Amerigroup. Please tell them what you think. Your ideas can help us make Amerigroup better.
How Amerigroup Pays Providers

Different providers in our network have agreed to be paid in different ways by us. This is known as a Physician Incentive Plan. Your provider may be paid each time he or she treats you (fee-for-service). Or, your provider may be paid a set fee each month for each member whether or not the member actually gets services (capitation). These kinds of pay may include ways to earn more money. This kind of pay is based on different things like member satisfaction, quality of care, accessibility and availability. You can contact Amerigroup to get any other information you want, including the structure and operation of Amerigroup and how we pay providers (the amount of these payments are confidential). Please call Member Services or write us at: Amerigroup Community Care P.O. Box 62509 Virginia Beach, VA 23462
SUMMARY OF THE FLORIDA PATIENTS BILL OF RIGHTS AND RESPONSIBILITIES

Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care providers or health care facilitys right to expect certain behavior on the part of members. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows.
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Rights
As a patient, you have the right to: Enrollees have the right to be treated with respect and with due consideration for his or her dignity and privacy A member has the right to a prompt and reasonable response to questions and requests A member has the right to know who is providing medical services and who is responsible for his or her care A member has the right to know what member support services are available, including whether an interpreter is available if he or she does not speak English A member has the right to know what rules and regulations apply to his or her conduct Enrollees have the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollees condition and ability to understand; members are given the opportunity to participate in decisions involving their health care, except when such participation is contraindicated for medical reasons Enrollees have the right to participate in decision regarding his or her health care, including the right to refuse treatment Enrollees have the right to be furnished health care services in accordance with federal and state regulations A member has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care A member who is eligible for Medicare has the right to know, upon request and in advance of treatment; whether the health care provider or health care facility accepts the Medicare assignment rate A member has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care A member has the right to receive a copy of a reasonably clear and understandable itemized bill and, upon request, to have the charges explained A member has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap or source of payment A member has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment A member has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research A member has the right to express grievances regarding any violation of his or her rights, as states in Florida law, through the grievance procedure to the health care provider or health care facility which served him or her and to the appropriate state licensing agency A member has the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation A member has the right to participate in decision regarding his or her health care, including the right to refuse treatment A member has the right to request and receive a copy of his or her medical records, and request that they be amended or corrected Additionally, the state must ensure that you are free to exercise your rights, and that the exercise of those rights does not adversely affect the way the health plan and its providers or the state agency treat you.
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Responsibilities
As a patient, you have the responsibility to: A member is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications (including over-the-counter products), dietary supplements, any allergies or sensitivities, and other matters relating to his or her health A member is responsible for reporting unexpected changes in his or her condition to the health care provider A member is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her A member is responsible for following the treatment plan recommended by the health care provider A member is responsible for keeping appointments and, when he or she is unable to do so for any reason, notifying the health care provider or health care facility A member is responsible for his or her actions if he or she refuses treatment or does not follow the health care providers instructions A member is responsible for informing his or her provider about any living will, medical power of attorney, or other directive that could affect his or her care A member is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible A member is responsible for following health care facility rules and regulations affecting member care and conduct A member is responsible for conducting him or herself in a manner that is respectful of all health care providers and staff, as well as of other members
HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID PROGRAM

If you know someone who is misusing (through fraud, abuse and/or overpayment) the Medicaid program, you can report him or her. To report doctors, clinics, hospitals, nursing homes or Medicaid enrollees, write or call Amerigroup at: Corporate Investigations Department Amerigroup Community Care 4425 Corporation Lane Virginia Beach, VA 23462 1-800-600-4441 Suspicions of fraud and abuse can be e-mailed directly to the Amerigroup Corporate Investigations Department at corpinvest@amerigroup.com. Online: Suspicions of fraud and abuse can also be sent to the Corporate Investigations Department through the Amerigroup web site at www.myamerigroup.com. There are fraud and abuse links on the web site to report details about a possible issue. This information is sent directly to the e-mail address above which is checked every day.
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The Bureau of Medicaid Program Integrity (BMPI) at the Agency for Health Care Administration audits and investigates providers suspected of overbilling or defrauding Floridas Medicaid program. The BMPI recovers overpayments, issues fines and refers cases of suspected fraud for criminal investigation. To report suspected fraud and abuse in Florida Medicaid, call the Consumer Hotline toll free at 1-888-419-3456. Or go online and complete a Medicaid Fraud and Abuse Complaint Form. The form is available at ahcaxnet.fdhc.state.fl.us/InspectorGeneral/fraud_complaintform.aspx.
WE HOPE THIS BOOK HAS ANSWERED MOST OF YOUR QUESTIONS ABOUT AMERIGROUP. FOR MORE INFORMATION, YOU CAN CALL OUR MEMBER SERVICES DEPARTMENT. This program is sponsored by the Agency for Health Care Administration and operated by Amerigroup Florida, Inc.
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LIVING WILL
(FLORIDA DECLARATION)
On this ________ day of __________________ , 20_____ I, _____________________________________________ ,

LAST NAME, FIRST NAME, MIDDLE INITIAL
of my own free will, make known my desire that my dying not to be artificially prolonged under any of the circumstances set out below, and I do hereby declare that: Should I develop a terminal condition, and if my attending physician determines that there can be no reasonable expectation of recovery from such a condition, and that my death is imminent, I hereby direct that life prolonging procedures be withheld or withdrawn when such procedures serve only to artificially prolong the process of my dying. Under such circumstances, it is my desire that I be permitted to die naturally, with only the administration of such medication or the performance of any such medical procedure judged necessary to provide me with comfort and to provide pain relief. Relating to the administration of nutrition and hydration (food and fluids), I do _____ , I do not _____ (check one) desire that such be withheld or withdrawn when such procedures serve to only prolong in an artificial way the process of my dying. It is my intent that, should I be unable to give directions regarding the use of life-prolonging procedures, that this represent the declaration of my intent that will be honored by my physicians, as well as by my family, as a valid representation of my legal right to refuse medical and/or surgical treatment and to accept the consequences as such. I fully understand the importance and consequences of this declaration. I am competent to make such declaration, and it is my desire to do so. I make this declaration without coercion and of my own free will. (If I am diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall not be in effect in the course of my pregnancy.) I do _____ , I do not _____ (check one) desire to donate my organs. Signature:
DECLARATION OF WITNESS:
The above is known to me, and it is my judgment that he/she is of sound mind and is making the above declaration of his/her free will.
Witness #1: Witness #2:
Relationship: Relationship:
Note: One witness should not be a spouse nor a blood relative of the declarant in and for compliance with Florida Statute 765 amended effective 10/1/90.
DESIGNATION OF HEALTH CARE SURROGATE

(POWER OF ATTORNEY FOR HEALTH CARE DECISIONS)
In the event that my physician determines that I am incompetent or so incapacitated as to provide expressed and informed consent for medical treatment, surgical intervention or diagnosis procedures, I, ________________________________________________________________________________________________
LAST NAME, FIRST NAME, MIDDLE INITIAL
wish to designate the following person to make those decisions for me.
DESIGNEE
Name: Address:
ALTERNATE DESIGNEE
Telephone: Relationship (if any):
If the person that I have named is unable to act on my behalf, I authorize the following person to act on my behalf: Name: Address: Telephone: Relationship (if any):
I fully understand that this document will permit the above identified designee to support, withhold or withdraw consent for intended treatment and to do so on my behalf. That individual may also apply for public benefits to defer the cost of health care and authorize for my transfer to or from a health care facility. I further reaffirm that this designation is not being made as a condition of treatment or admission to a health care facility. I understand, should my judgmental incapacitation or incompetence be reversed such that I am once again considered competent to make my own decisions, such decisions will once again be mine. I understand that I may rescind this declaration at any time so long as I am judged to be competent and capable to make such judgments. Additional Instructions:
DO YOU HAVE A LIVING WILL DECLARATION?
YES
NO
Signature: Witness #1: Witness #2: Relationship: Relationship:
Note: One witness should not be a spouse, blood relative, Heir to the Estate of the designee or responsible for paying health care costs for that individual.
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE IS IN EFFECT APRIL 14, 2003. What Is this Notice? This Notice tells you: How Amerigroup handles your protected health information. How Amerigroup uses and gives out your protected health information. Your rights about your protected health information. Amerigroup Community Care responsibilities in protecting your protected health information. This Notice follows what is known as the HIPAA Privacy Regulations. These regulations were given out by the federal government. The federal government requires companies such as Amerigroup to follow the terms of the regulations and of this Notice. This Notice is also available on the Amerigroup Community Care web site at www.myamerigroup.com. NOTE: You may also get a Notice of Privacy Practices from the state and other organizations. What Is Protected Health Information? Protected Health Information (PHI) The HIPAA Privacy Regulations define protected health information as: Information that identifies you or can be used to identify you Information that either comes from you or has been created or received by a health care provider, a health plan, your employer, or a health care clearinghouse Information that has to do with your physical or mental health or condition, providing health care to you, or paying for providing health care to you In this Notice, protected health information will be written as PHI. What Are the Amerigroup Responsibilities to You about Your Protected Health Information? Your and your familys PHI is private. We have rules to help keep it safe and private. These rules are meant to follow state and federal laws. Amerigroup must: Protect the privacy of the PHI that we have or keep about you through: Staff training Secure computer systems and offices Secure disposal of written material that includes PHI Other technical methods Provide you with this Notice about how we get and keep PHI about you Follow the terms of this Notice Follow state privacy laws that do not conflict with or are stricter than the HIPAA Privacy Regulations We will not use or give out your PHI without your consent, except as described in this Notice.
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How Do We Use Your Protected Health Information? The sections that follow tell some of the ways we can use and share PHI without your written authorization. FOR PAYMENT We may use PHI about you so that the treatment services you get may be looked at for payment. For example, a bill that your provider sends us may be paid using information that identifies you, your diagnosis, the procedures or tests, and supplies that were used. FOR HEALTH CARE OPERATIONS We may use PHI about you for health care operations. For example, we may use the information in your record to review the care and results in your case and other cases like it. This information will then be used to improve the quality and success of the health care you get. Another example of this is using information to help enroll you for health care coverage. We may use PHI about you to help provide coverage for medical treatment or services. For example, information we get from a provider (nurse, doctor or other member of a health care team) will be logged and used to help decide the coverage for the treatment you need. We may also use or share your PHI to: Send you information about one of our disease or case management programs Send reminder cards that let you know that it is time to make an appointment or get services like EPSDT or Child Health Checkup services Answer a customer service request from you Make decisions about claims requests and appeals for services you received Look into any fraud or abuse cases and make sure required rules are followed Other Uses of Protected Health Information BUSINESS ASSOCIATES We may contract with business associates that will provide services to Amerigroup using your PHI. Services our business associates may provide include dental services for members, a copy service that makes copies of your record and computer software vendors. They will use your PHI to do the job we have asked them to do. The business associate must sign a contract to agree to protect the privacy of your PHI. PEOPLE INVOLVED WITH YOUR CARE OR WITH PAYMENT FOR YOUR CARE We may make your PHI known to a family member, other relative, close friend or other personal representative that you choose. This will be based on how involved the person is in your care or payment that relates to your care. We may share information with parents or guardians, if allowed by law. LAW ENFORCEMENT We may share PHI if law enforcement officials ask us to. We will share PHI about you as required by law or in response to subpoenas, discovery requests, and other court or legal orders. OTHER COVERED ENTITIES We may use or share your PHI to help health care providers that relate to health care treatment, payment or operations. For example, we may share your PHI with a health care provider so that the provider can treat you. PUBLIC HEALTH ACTIVITIES We may use or share your PHI for public health activities allowed or required by law. For example, we may use or share information to help prevent or control disease, injury or disability. We also may share information with a public health authority allowed to get reports of child abuse, neglect or domestic violence.
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HEALTH OVERSIGHT ACTIVITIES We may share your PHI with a health oversight agency for activities approved by law, such as audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Oversight agencies include government agencies that look after the health care system; benefit programs including Medicaid, SCHIP or Healthy Kids; and other government regulation programs. RESEARCH We may share your PHI with researchers when an institutional review board or privacy board has followed the HIPAA information requirements. CORONERS, MEDICAL EXAMINERS, FUNERAL DIRECTORS AND ORGAN DONATION We may share your PHI to identify a deceased person, determine a cause of death, or to do other coroner or medical examiner duties allowed by law. We also may share information with funeral directors, as allowed by law. We may also share PHI with organizations that handle organ, eye, or tissue donation and transplants. TO PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY We may share your PHI if we feel it is needed to prevent or reduce a serious and likely threat to the health or safety of a person or the public. MILITARY ACTIVITY AND NATIONAL SECURITY Under certain conditions, we may share your PHI if you are, or were, in the Armed Forces. This may happen for activities believed necessary by appropriate military command authorities. DISCLOSURES TO THE SECRETARY OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES We are required to share your PHI with the Secretary of the U.S. Department of Health and Human Services. This happens when the secretary looks into or decides if we are in compliance with the HIPAA Privacy Regulations. What Are Your Rights Regarding Your Protected Health Information? We want you to know your rights about your PHI and your Amerigroup family members PHI. Right to Get the Amerigroup Notice of Privacy Practices Each head of case or head of household will receive a printed copy of this Notice in the new member welcome package. We have the right to change this Notice. Once the change happens, it will apply to PHI that we have at the time we make the change and to the PHI we had before we made the change. A new Notice that includes the changes and the dates they are in effect will be mailed to you at the address we have for you. The changes to our Notice will also be included on our web site. You may ask for a paper copy of the Notice of Privacy Practices at any time. Call Member Services toll-free at 1-800-600-4441. If you are hearing impaired and want to talk to Member Services, call the toll-free AT&T Relay Service at 1-800-855-2880. Right to Request a Personal Representative You have the right to request a personal representative to act on your behalf, and Amerigroup will treat that person as if that person were you. Unless you apply restrictions, your personal representative will have full access to all of your Amerigroup records. If you would like someone to act as your personal representative, Amerigroup requires your request in writing. A personal representative form must be filled out and mailed back to the Amerigroup Community Care Member Privacy Unit. To ask for a personal representative form,
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please contact Member Services. We will send you a form to complete. The address and phone number are at the end of this Notice. Right to Access You have the right to look at and get a copy of your enrollment, claims, payment and case management information on file with Amerigroup. This file of information is called a designated record set. We will provide the first copy to you in any 12-month period without charge. If you would like a copy of your PHI, you must send a written request to the Amerigroup Community Care Member Privacy Unit. The address is at the end of this Notice. We will answer your written request in 30 calendar days. We may ask for an extra 30 calendar days to process your request, if needed. We will let you know if we need the extra time. We do not keep complete copies of your medical records. If you would like a copy of your medical record, contact your doctor or other provider; follow the doctors or providers instructions to get a copy; your doctor or other provider may charge a fee for the cost of copying and/or mailing the record We have the right to keep you from having or seeing all or part of your PHI for certain reasons. For example, if the release of the information could cause harm to you or other persons; or, if the information was gathered or created for research or as part of a civil or criminal proceeding; we will tell you the reason in writing; we will also give you information about how you can file an appeal if you do not agree with us Right to Amend You have the right to request and receive a copy of your medical records and to request that they be amended or corrected. To ask for a change, send your request in writing to the Amerigroup Community Care Member Privacy Unit. We can send you a form to complete. You can also call Member Services to request a form. The address and phone number are at the end of this Notice. State the reason why you are asking for a change If the change you ask for is in your medical record, get in touch with the doctor who wrote the record; the doctor will tell you what you need to do to have the medical record changed We will answer your request within 30 days of when we receive it. We may ask for an extra 30 days to process your request, if needed. We will let you know if we need the extra time. We may deny the request for change. We will send you a written reason for the denial if: The information was not created or entered by Amerigroup The information is not kept by Amerigroup You are not allowed, by law, to see and copy that information The information is already correct and complete Right to an Accounting of Certain Disclosures of Your Protected Health Information You have the right to get an accounting of certain disclosures of your PHI. This is a list of times we shared your information when it was not part of payment and health care operations. Most disclosures of your PHI by our business associates or us will be for payment or health care operations.
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To ask for a list of disclosures, please send a request in writing to the Amerigroup Community Care Member Privacy Unit. We can send you a form to complete. For a copy of the form, contact Member Services. The address and phone number are at the end of this Notice. Your request must give a timeperiod that you want to know about. The time-period may not be longer than 6 years and may not include dates before April 14, 2003. Right to Request Restrictions You have the right to ask that your PHI not be used or shared. You do not have the right to ask for limits when we share your PHI if we are asked to do so by law enforcement officials, court officials, or state and federal agencies in keeping with the law. We have the right to deny a request for restriction of your PHI. To ask for a limit on the use of your PHI, send a written request to the Amerigroup Community Care Member Privacy Unit. We can send you a form to fill out. You can contact Member Services for a copy of the form. The address and phone number are at the end of this Notice. The request should include: The information you want to limit and why you want to restrict access Whether you want to limit when the information is used, when the information is given out or both The person or persons that you want the limits to apply to We will look at your request and decide if we will allow or deny the request within 30 days. If we deny the request, we will send you a letter and tell you why. Right to Cancel a Privacy Authorization for the Use or Disclosure of Protected Health Information We must have your written permission (authorization) to use or give out your PHI for any reason other than payment and health care operations or other uses and disclosures listed under Other Uses of Protected Health Information. If we need your authorization, we will send you an authorization form explaining the use for that information. You can cancel your authorization at any time by following the instructions below. Send your request in writing to the Amerigroup Community Care Member Privacy Unit. We can send you a form to complete. You can contact Member Services for a copy of the form. The address and phone number are at the end of this Notice. This cancellation will only apply to requests to use and share information asked for after we get your Notice. Right to Request Confidential Communications You have the right to ask that we communicate with you about your PHI in a certain way or in a certain location. For example, you may ask that we send mail to an address that is different from your home address. Requests to change how we communicate with you should be submitted in writing to the Amerigroup Community Care Member Privacy Unit. We can send you a form to complete. For a copy of the form, contact Member Services. The address and phone number are at the end of this Notice. Your request should state how and where you want us to contact you. What Should You Do If You Have a Complaint About the Way That Your Protected Health Information is Handled by Amerigroup or Our Business Associates?
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If you believe that your privacy rights have been violated, you may file a complaint with Amerigroup or with the Secretary of Health and Human Services. To file a complaint with Amerigroup or to appeal a decision about your PHI, send a written request to the Amerigroup Community Care Member Privacy Unit or call Member Services. The address and phone number are at the end of this Notice. To file a complaint with the Secretary of Health and Human Services, send your written request to: Office for Civil Rights U.S. Department of Health and Human Services Atlanta Federal Center 61 Forsyth Street, SW, Suite 3B70 Atlanta, GA 30303 You will not lose your Amerigroup membership or health care benefits if you file a complaint. Even if you file a complaint, you will still get health care coverage from Amerigroup as long as you are a member. Where Should You Call or Send Requests or Questions about Your Protected Health Information? You may call us toll-free at: 1-800-600-4441. Or, you may send questions or requests, such as the examples listed in this Notice, to the address below: Member Privacy Unit Amerigroup Community Care 4425 Corporation Lane Virginia Beach, VA 23462 Send your request to this address so that we can process it timely. Requests sent to persons, offices or addresses other than the address listed above might be delayed. If you are hearing impaired, you may call the toll-free AT&T Relay Service at 1-800-855-2880.
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Amerigroup Florida, Inc. Florida Medicaid/MediKids Program

William L. McHugh Chief Executive Officer Amerigroup Community Care

AMERITIPS: HEALTH TIPS THAT MAKE HEALTH HAPPEN

WHEN IS IT TIME FOR A WELLNESS VISIT?

WELLNESS CARE FOR CHILDREN, THE CHILD HEALTH CHECK-UP PROGRAM

WHAT IF I BECOME PREGNANT?

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

AMERIGROUP MEMBER HANDBOOK

WELCOME TO AMERIGROUP COMMUNITY CARE!

WELCOME TO AMERIGROUP COMMUNITY CARE! .............................................. 6

YOUR DOCTORS .................................................................................................. 8

GOING TO THE DOCTOR .................................................................................... 11

AMERIGROUP COVERED SERVICES .................................................................... 12

WELLNESS CARE FOR CHILDREN AND ADULTS ................................................... 20

WELLNESS CARE FOR ADULTS ........................................................................... 23

SPECIAL CARE FOR PREGNANT MEMBERS ......................................................... 24

STATEMENT OF ADVANCE DIRECTIVE OR LIVING WILLS .................................... 28

GRIEVANCES AND APPEALS............................................................................... 29

OTHER INFORMATION ...................................................................................... 34

SUMMARY OF THE FLORIDA PATIENTS BILL OF RIGHTS AND RESPONSIBILITIES37

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

WELCOME TO AMERIGROUP COMMUNITY CARE!

How to Get Help

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

Your Identification Cards (ID Cards)

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

Second Medical Opinion

If You Had a Different Doctor Before You Joined Amerigroup

If Your PCPs Office Moves, Closes or Leaves the Amerigroup Network

How to Change Your PCP

If Your PCP Asks for You to Be Changed to Another PCP

If You Want to Go to a Doctor Who Is Not Your PCP

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

GOING TO THE DOCTOR

How to Make an Appointment

Wait Times for Appointments

What to Bring When You Go for Your Appointment

How to Cancel an Appointment

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

How to Get to a Doctors Appointment or to the Hospital

Disability Access to Amerigroup Network Doctors and Hospitals

What Does Medically Necessary Mean?

AMERIGROUP COVERED SERVICES

Inpatient Hospital Stay (including Behavioral Health Care)

Emergency Medical Services and Care

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

Family Planning Services

Behavioral Health Care Services

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

Lab and X-ray Services

Home Health Care

EXTRA AMERIGROUP BENEFITS

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

DIFFERENT TYPES OF HEALTH CARE

What is an emergency medical condition?

B-FLMHB-0002-11 FL Medicaid 01.11 ENG

What is an emergency behavioral health condition?

How to Get Health Care When Your Doctors Office Is Closed

How to Get Health Care When You Are Out of Town

On this day of ________ , 20_ I, ___________________________________________ ,