Member Handbook Amerigroup Community Care 1-800-600-4441
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Member Handbook Amerigroup Community Care NJ-MHB-0014-15 01.16 OMHC #078-15-71 1-800-600-4441 ■ TTY 711 www.myamerigroup.com/nj www.myamerigroup.com Dear Member: Welcome to Amerigroup Community Care. We are happy you chose Amerigroup to arrange for health care services for you or your family as part of NJ FamilyCare. The member handbook explains how Amerigroup works and how to help keep your family healthy. It tells you how to receive health care or emergency care when you need it and gives you information about going to your primary care provider (PCP). Your PCP is the family doctor or provider that you will go to for most of your health care needs. Your handbook also tells you how to select a dentist and explains your extra Amerigroup benefits. You may have already received your Amerigroup ID card and additional information from us. Your ID card will tell you when your Amerigroup membership starts and the name of your PCP. Please check your ID card right away. If you have not received an ID card from us within one week of receiving this packet, or if the name of your PCP or any other information on the card is not correct and needs to be changed, please call us at 1‐800‐600‐4441 (TTY 711). We will send you a new ID card with the correct information right away. We want to hear from you. Call 1‐800‐600‐4441 (TTY 711). You can talk to a nurse on our 24‐hour Nurse HelpLine or you can talk to a Member Services representative about your benefits, Monday through Friday, 8 a.m. to 6 p.m. You can also search for network providers and learn more about your benefits online at www.myamerigroup.com/NJ. We are here to help you and your family receive the right care in your own community. If you 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. We will also try to help you find a doctor who speaks your language or shares your cultural beliefs. Call Member Services at 1‐800‐600‐4441 (TTY 711) for more information. Thank you again for choosing us as your family’s health plan. Sincerely, John Koehn President Amerigroup Community Care WELCOME TO AMERIGROUP COMMUNITY CARE! If you have any questions, need help or want to find out what services are available, you can: Call 1‐800‐600‐4441 (TTY 711) Talk to a nurse on our 24‐hour Nurse HelpLine Talk to a Member Services representative about your benefits, Monday through Friday, 8 a.m. to 6 p.m. If you would like to speak to someone in your language, ask for an interpreter. We can also provide an interpreter for your doctor’s appointment at no cost to you. Please let us know at least 24 hours before your appointment if you need an interpreter. In addition, we will try to help you find a doctor who speaks your language. We are here to help you and your family receive the right care in your community. We will be sending you bulletins and newsletters during the year to keep you informed of various health topics. You will find information on things we do to help you get access to quality care and service. Every year, we will send you a member bulletin with the results of our member satisfaction survey and information about our quality improvement program along with some of the plans we have for making improvements. To see the member bulletin, visit our website at www.myamerigroup.com/NJ. Or if you would like more information on our quality improvement program, please call 1‐800‐600‐4441 (TTY 711). 歡迎光臨 AMERIGROUP COMMUNITY CARE (關懷保健)！ 如有任何疑問，需要任何援助或欲了解可享用的服務： 請撥 1‐800‐600‐4441 (TTY 711) 與 24 小時護士熱線與護士交談 週一至週五的上午 8:00 至下午 6:00，與會員服務部代表討論您的福利事項。 如欲使用您的母語交談，可要求翻譯服務。 在您就診時，我們也可為您提供免費的翻譯服務。如您需要翻譯服務，請在預約至少 24 小時前知會我們。此外，我們會設法幫助您聯絡與您使用同一語言的醫師。 我們在社區內為您和您的家人提供滿意的醫療保健服務。我們會在本年度向您寄發單張和簡訊， 以知會您各種醫療主題。您將能瞭解我們所提供服務的相關資訊，以幫助您獲取優質的醫療保健 服務。我們每年都會向您寄發會員簡報，內含會員滿意度調查結果、有關品質改進計劃的資訊以 及我們的改善計劃。欲查看會員簡報，請造訪我們的網站www.myamerigroup.com/NJ；如欲瞭解 有關品質改進計劃的更多資訊，請撥1‐800‐600‐4441 (TTY 711) 即可。 BEM‐VINDO A AMERIGROUP COMMUNITY CARE! Se tiver alguma pergunta, precisar de ajuda ou quiser saber quais serviços estão disponíveis, você pode: Ligar para 1‐800‐600‐4441 (TTY 711) Falar com uma enfermeira na nossa Nurse HelpLine de 24 horas Falar com um representante de Serviços para Membros sobre seus benefícios, de segunda a sexta, de 8:00 às 18:00 hs. Se quiser falar com alguma pessoa no seu idioma, peça um intérprete. Também podemos fornecer a você um intérprete para sua consulta médica sem nenhum custo. Se precisar de um intérprete, avise‐nos pelo menos 24 horas antes da sua consulta. Além disso, tentaremos ajudá‐lo a encontrar um médico que fale o seu idioma. Estamos para ajudar a você e à sua família para que recebam o cuidado adequado na sua comunidade. Estaremos enviando a você boletins e folhetos informativos durante o ano para mantê‐lo informado sobre vários temas de saúde. Você encontrará informações sobre as coisas que fazemos para ajudá‐lo a ter acesso ao cuidado e serviço de qualidade. Todos os anos enviaremos um Boletim para Membros com os resultados da nossa pesquisa de satisfação do membro e informações sobre o nosso programa de melhoramento da qualidade, juntamente com alguns dos planos que temos para fazer melhoras. Para ver o Boletim para Membros, visite o nosso website em www.myamerigroup.com/NJ ou se quiser mais informações sobre o nosso programa de melhoramento da qualidade, ligue para 1‐800‐600‐4441 (TTY 711). अमेरीगर्प ु कम्यिनटी ू के यर मᱶआपका स्वागत ह!ै यिद आपके कु छ पर᳤् ह,ᱹ आपको मदद की ज़रूरत है या आप यह जानना चाहते ह ᱹ िक कौन सी सेवाएं उपलब्ध ह ᱹ तो आप: ᱹ 1‐800‐600‐4441 (TTY 711) पर फोन कर सकते ह हमारी 24‐घंटे की नसर् हल्पलाइन े पर एक नसर् से बात कर सकते ह ᱹ एक सदस्य सेवा पर्ितिनिध से आपको पर्ा᳙ होने वाले लाभᲂ के बारे म,ᱶ सोमवार से शुकर्वार, सबह ु 8:00 बजे से लेकर शाम 6:00 बजे तक बात कर सकते ह।ᱹ यिद आप िकसी ᳞िक्त से अपनी भाषा म ᱶ बात करना चाहते ह ᱹ तो एक दुभािषये के िलए पूछᱶ। हम आपको िबना िकसी कीमत के आपकी डॉक्टर के साथ अपाईटमᱶट के िलए भी एक दुभािषया पर्दान कर सकते ह।ᱹ यिद आपको कर।ᱶ साथ ही, हम एक ऐसे डॉक्टर को एक दुभािषये की ज़रूरत है तो कृ पया हम ᱶ अपने अपाईटमᱶट से कम से कम 24 घंटे पहले सिचत ू ढू ंढन े मᱶ आपकी मदद करगे ᱶ जो आपकी भाषा बोलता/बोलती ह।ᱹ पर्ा᳙ कर सकᱶ । हम हम यहां आपकी और आपके पिरवार की सहायता के िलए मौजूद ह ᱹ तािक आप अपने समुदाय म ᱶ सही देखभाल आपको पूरे साल के दौरान िविभ᳖ स्वास्थ्य िवषयᲂ के बारे म ᱶ जानकारी देने के िलए बुलेिटन और न्यूज़लैटर भेजते रहगे ᱶ । आपको और सवा उत्कृ ᳥ कोिट की दखभाल े े तक पहुच ं पर्दान करन े के िलए जो भी हम करते ह,ᱹ उसके बारे म ᱶ आपको जानकारी िमलती रहेगी। सधार हर साल हमारे सदस्यᲂ के संतुि᳥ सवक्षण ु योजनाᲐ के साथ हमारे गणवᱫा ु ु कायर्कर्म ᱷ के नतीजᲂ और सुधार लाने की हमारी कछ के बारे मᱶ जानकारी सिहत हम आपको एक सदस्य बुलिटन े भेजᱶगे। सदस्य बुलेिटन दखन े े के िलए, हमारी वेबसाइट www.myamerigroup.com/NJ पर िविज़ट करᱶ या यिद आप हमारे गुणवᱫा सुधार कायर्कर्म के बारे मᱶ और अिधक जानकारी चाहते ह ᱹ तो कृ पया 1‐800‐600‐4441 (TTY 711) पर फोन कर।ᱶ BYENVENI NAN AMERIGROUP KI BAY SWEN KOMINOTÈ! Oka w ta genyen nenpòt kesyon, oswa w bezwen yon koudmen pou jwenn ki sèvis ki disponib, w kapab: • Rele 1‐800‐600‐4441 (TTY –moun ki soud ak bèbè‐ 711) • Pale ak yon enfimyè ki nan Nurse Helpline (telefòn Enfimyè) ki la 24 trè sou 24 • Pale ak yon ajan Member Services (Sèvis pou moun ki se manm) konsènan benefis ou yo, dilendi jiska vandredi, de 8 tè dimaten rive 6 zè nan lapremidi. Si w ta renmen pale ak yon moun ki pale lang pa w’, mande yon entèprèt. Nou kapab bay yon entèprèt gratis pou pran randevou ak doktè ou a. Tanpri fè nou konnen si w’ ap bezwen yon entèprèt omwen 24 trèdtan alavans anvan randevou ou a. Anplis sila, nou pral chèche ede ou jwenn yon doktè ki pale lang pa w’. Nou la pou ede w ak fanmi ou resevwa swen ki kòrèk nan kominote ou a. Nou prale voye ou bilten ak bilten‐nouvèl pandan ane pou fè ou konnen latriye sijè sou lasante. W ap jwenn enfòmasyon sou bagay nou fè yo pou ede ou trouve bon kalite swen ak sèvis. Chak ane n ap voye ba ou yon bilten pou manm. Bilten sila ap genyen rezilta sondaj satisfaksyon manm nou yo ansanm ak enfòmasyon sou pwogram nou genyen pou rann bon kalite vini pi bon. Bilten sila prale bay kèk nan plan nou genyen yo pou pou fè amelyorasyon sila yo. Si ou vle wè bilten manm nan, vizite sit entènèt nou an nan www.myamerigroup.com/NJ oswa si w ta renmen plis enfòmasyon sou pwogram kalite amelyorasyon nou an, tanpri souple rele 1‐800‐600‐4441 (TTY 711). !للرعاية المجتمعية أمريجروب ً مرحبا بكم في مؤسسة : يمكنكم، أو أردتم التعرف على الخدمات المتاحة، أو كنتم في حاجة للمساعدة،إذا كانت لديكم أية أسئلة (711 )أو إرسال برقية على رقم1-800-600‐4441 االتصال برقم التحدث إلى إحدى الممرضات على خط المساعدات التمريضية على مدار 24ساعة ً أسبوعيا من 8 التحدث إلى أحد مندوبي خدمات األعضاء لالستفسار عن المزايا التي يمكنكم التمتع بھا ،من االثنين إلى الجمعة ً ً مساء . صباحا وحتى 6 إذا كنت تريد التحدث إلى أحد ما بلغتك يمكنك طلب مترجم فوري . ً مجانا ليصطحبك إلى الموعد المحدد للكشف عند الطبيب .وفي حالة الرغبة في اصطحاب مترجمُ ،يرجى كما يمكن توفير مترجم فوري إخطارنا قبل الموعد بـ 24ساعة على األقل .كما يمكننا أن نعينك في البحث عن طبيب يتحدث لغتك. كما أننا على أتم االستعداد لمساعدتك أنت وعائلتك في تلقي الرعاية الصحية المثلى في مجتمعك ،وسنداوم على إرسال مطبوعات ورسائل إخبارية على مدار العام إلبقائكم على اطالع على مختلف األمور المتعلقة بالرعاية الصحية ،وستجدون في ھذه المطبوعات ً سنويا النشرة المخصصة معلومات حول الخدمات التي نقدمھا لكي تحصلوا على أفضل رعاية وخدمة صحية .كما سنرسل لكم لألعضاء التي تتضمن نتائج االستطالع الخاص بمدى رضا عمالئنا إضافة إلى المعلومات المتعلقة ببرنامج تطوير جودة الخدمات التي نقدمھا ،ھذا فضالً عن بعض الخطط التي ننوي تطبيقھا في إطار عمليات تحسين الخدمات .لالطالع على النشرة الخاصة باألعضاء، يمكنكم زيارة موقعنا اإللكتروني /NJwww.myamerigroup.comأو في حالة الرغبة في الحصول على المزيد من المعلومات حول برنامج تطوير جودة الخدماتُ ،يرجى االتصال برقم ) 1-800-600‐4441أو إرسال برقية على رقم .(711 AMERIGROUP COMMUNITY CARE를 소개합니다! 질문이 있거나 도움이 필요하거나 이용 가능한 서비스를 알아보려는 경우 다음과 같이 문의할 수 있습니다. 1‐800‐600‐4441 (TTY 711)로 전화 문의 24시간 너스 헬프라인의 간호사에게 문의 월요일부터 금요일까지 오전 8:00부터 오후 6:00 사이에 회원 서비스 담당자에게 혜택 문의 영어가 아닌 모국어로 말하고 싶으면 통역자를 요청하십시오. 진료 예약에도 추가 비용 없이 통역자를 이용할 수 있습니다. 통역자가 필요한 경우 최소 예약 24 시간 전에 알려 주십시오. 또한 Amerigroup은 모국어를 사용하는 의사를 찾을 수 있도록 도와 드립니다. Amerigroup은 여러분과 여러분의 가족이 지역 사회에서 올바른 관리를 받을 수 있도록 지원합니다. 연중 소식지와 뉴스레터를 통해 건강과 관련된 다양한 주제에 대한 정보를 제공해 드립니다. 이러한 소식지/뉴스레터를 통해 양질의 건강 관리 및 서비스를 제공하기 위해 Amerigroup이 어떤 노력을 하고 있는지도 확인할 수 있습니다. 매년 Amerigroup은 회원들의 만족도 조사 결과, 개선을 위해 노력 중인 일부 보험에 대한 품질 개선 프로그램 정보 등이 담긴 회원 소식지를 보내 드립니다. 회원 소식지를 보려면 웹 사이트 www.myamerigroup.com/NJ 을 방문하시면 됩니다. 품질 개선 프로그램에 대한 자세한 내용을 알고 싶으면 1‐800‐600‐4441 (TTY 711)로 문의해 주십시오. AMERIGROUP COMMUNITY CARE માં આપȵંુ ƨવાગત છે ! જો આપને કોઈ પ્રĕો હોય, મદદની જĮર હોય અથવા કઈ કઈ સેવાઓ ઉપલƞધ છે તે જાણવા માંગતા હો તો, આપ : 4441‐600‐800‐1પર કૉલ કરી શકો )TTY 711( અમારી 24‐hour Nurse HelpLine (નસર્ હેƣપલાઇન( પર નસર્ સાથે વાત કરો. ુ આપના ફાયદાઓ િવષે અમારા સƟય સહાય પ્રિતિનિધ સાથે વાત કરો, સોમવારથી શક્રવાર સવારે 8:00 વાગ્યાથી ુ સાંȐ 6:00 વાગ્યા સધી. જો તમે કોઈની સાથે તમારી ભાષામાં વાત કરવા ઇƍછતા હો તો, અથર્ સમજાવનાર ƥયિક્ત િવષે પ ૂછો. ુ ૂ અમે વધારાના કોઈ જ ખચર્ વગર આપને આપની ડૉક્ટર સાથેની મલાકાત માટે પણ અથર્ સમજાવનાર ƥયિક્તની સહાય પરી પાડીએ છે 24 જો આપને અથર્ સમજાવનાર ƥયિક્તની જĮર હોય તો આપની અપોઈƛટમેƛટના . કલાક પહલા ે અમને જાણ કરવા ુ ., અમે આપને આપની જ ભાષામાં વાત કરતાં ડૉક્ટર મળે તેવો પ્રયાસ કરીશ.ું િવનંતીવધમાં અમે અહીંયા આપને અને આપના પિરવારને આપની કૉƠયુિનટીમા ં યોગ્ય સારવાર મળે તે માટે યોગ્ય મદદ કરવા માટે છીએ . ૂ આરોગ્યને લગતા િવિવધ મુĆાઓ િવષે આપને માિહતગાર રાખવા માટે અમે વષર્ દરિમયાન આપને બુલિટƛસ ે અને ƛયઝ લેટસર્ મોકલીશું તેમા ં .આપને સારી સંભાળ અને સુિવધા અપાવવા માટે અમે શંુ પ્રયƗનો કરીએ છીએ તે િવષે માિહતી મળશે . ુ ુ દર વષેર્, અમે આપને અમારા સƟય સતિƧટ ં ુ સવના ેર્ પિરણામો તમજ ે અમારા ગણવĂા સધારણા કાયક્રમની ર્ સાથે સાથે એ ું સુધારાઓ કરવા માટની ે અમારી કટલીક ે યોજનાઓ સિહતની સƟય પિત્રકા મોકલીશƟય પિત્રકા જોવા માટેઆ સ ., અમારી ુ ુ સધારણા કાયક્રમ િવષે વધુ માિહતી મેળવવા ઇƍછતા વેબસાઈટ www.myamerigroup.com/NJ. અથવા જો આપ ગણવĂા ર્ હો તો કૃપા કરી 1‐800‐600‐4441 પર કૉલ કરો )TTY 711). 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 Community Care members need to have regular wellness visits. This way, your primary care provider (PCP) can determine if you have a health problem that requires medical treatment or follow‐up. When you become an Amerigroup member, call your PCP and make the first appointment for you and your child before the end of 90 calendar days after you enroll. WELLNESS CARE FOR CHILDREN Children need more wellness visits than adults. Your child should get wellness visits at the ages listed below. Newborn 9 months Under 6 weeks 12 months 2 months 15 months 4 months 18 months 6 months 24 months After age 2, your children should keep going to your PCP every year through age 20 for well‐child visits. WHAT IF I BECOME PREGNANT? If you think you are pregnant, call your PCP or OB/GYN doctor right away. This can help you have a healthy baby and stay healthy yourself. If you have any questions or need help making an appointment with your PCP or OB/GYN, please call Amerigroup Member Services at 1‐800‐600‐4441 (TTY 711). IMPORTANT! Keep your health care coverage. Do not lose your health care benefits. Renew your eligibility for NJ FamilyCare benefits on time. See “Renew Your Eligibility for Your Medicaid, SSI or NJ FamilyCare Benefits on Time” for more details. WHEN CAN I EXPECT TO GET AN APPOINTMENT? You can get an appointment for the following types of care in these time frames. TYPE OF CARE AVAILABILITY Emergency Services Immediately Urgent Care Within 24 hours Acute Care Within 72 hours TYPE OF CARE Routine Care AVAILABILITY Within 28 days Specialist Referrals Within four weeks depending on the condition Urgent Specialty Care Within 24 hours of referral Adult Physicals for New Members Within 180 days of enrollment Child Physicals for New Members and New Adult DDD Clients Prenatal Care Within 90 days of enrollment Routine Physicals Lab and Radiology Services First Child Appointments Dental Appointments Behavioral Health Appointments Pregnant members should be seen within the following time frame: Three weeks of a positive pregnancy test (home or lab) Three days of being diagnosed as “high‐risk” Seven days of request in first and second trimester Three days of first request in third trimester Within four weeks for routine physicals needed for school, camp, work or any other reasons Three weeks for routine care 48 hours for urgent care Within three months of enrollment Emergency care no later than 48 hours Urgent care within three days of referral Routine care within 30 days of referral Emergency care immediately Urgent care within 24 hours of request Routine care within 10 days of request AMERIGROUP COMMUNITY CARE MEMBER HANDBOOK 101 Wood Ave. S., 8th Floor, Iselin, NJ 08830 1‐800‐600‐4441 ● (TTY 711) www.myamerigroup.com/NJ Welcome to Amerigroup Community Care! You will get most of your health care services covered through Amerigroup. This member handbook will tell you how to use Amerigroup to get the health care you need. Table of Contents FREQUENTLY ASKED QUESTIONS...................................................................................................................... 1 WELCOME TO AMERIGROUP COMMUNITY CARE ............................................................................................. 2 INFORMATION ABOUT YOUR NEW HEALTH PLAN ..................................................................................................2 HOW TO GET HELP...................................................................................................................................................3 AUTOMATED SELF‐SERVICE FEATURES .................................................................................................................4 MEMBER SERVICES DEPARTMENT ........................................................................................................................4 24‐HOUR NURSE HELPLINE ...................................................................................................................................5 IMPORTANT PHONE NUMBERS.............................................................................................................................5 ¿QUÉ HAGO SI NO HABLO INGLÉS? (WHAT IF I DO NOT SPEAK ENGLISH?) .........................................................5 YOUR AMERIGROUP MEMBER HANDBOOK ............................................................................................................5 YOUR AMERIGROUP IDENTIFICATION CARD ...........................................................................................................6 ENROLLMENT IN AMERIGROUP...............................................................................................................................7 INFORMATION ABOUT NJ FAMILYCARE ..................................................................................................................7 GOING TO THE DOCTOR ................................................................................................................................... 7 CHOOSING YOUR FAMILY DOCTOR .........................................................................................................................7 HOW TO GET A LIST OF AMERIGROUP PROVIDERS.................................................................................................8 AMERIGROUP PROVIDERS NEED TO KNOW YOUR HEALTH HISTORY AFTER YOU ENROLL.....................................8 SECOND OPINIONS...................................................................................................................................................8 CHANGING FAMILY DOCTORS OR DENTISTS ...........................................................................................................9 IF YOUR FAMILY DOCTOR OR DENTIST ASKS YOU TO CHANGE TO A NEW FAMILY DOCTOR OR DENTIST.............9 GETTING TO YOUR DOCTOR – TRANSPORTATION SERVICES ................................................................................10 CANCELING AN APPOINTMENT .............................................................................................................................10 AFTER‐HOURS CARE...............................................................................................................................................10 SPECIALISTS............................................................................................................................................................10 IF YOU WANT TO SEE A DOCTOR WHO IS NOT IN THE AMERIGROUP NETWORK ................................................11 CHOOSING A DENTIST............................................................................................................................................12 DISABILITY ACCESS TO AMERIGROUP NETWORK DOCTORS AND HOSPITALS ......................................................12 PREMIUMS FOR NJ FAMILYCARE D MEMBERS AND COPAYMENTS FOR NJ FAMILYCARE C AND D MEMBERS...13 PREMIUMS FOR NJ FAMILYCARE D MEMBERS ......................................................................................................13 COPAYMENTS FOR NJ FAMILYCARE C AND D MEMBERS ......................................................................................13 MEMBERS AGE 55 AND OVER................................................................................................................................13 AMERIGROUP COVERED SERVICES FOR MEDICAID AND NJ FAMILYCARE MEMBERS........................................13 EXTRA AMERIGROUP BENEFITS FOR NJ FAMILYCARE MEMBERS .....................................................................32 WE GIVE YOU THESE BENEFITS TO HELP KEEP YOU HEALTHY AND TO THANK YOU FOR CHOOSING AMERIGROUP AS YOUR HEALTH CARE PLAN. ..................................................................................................32 SERVICES PROVIDED UNDER FEE‐FOR‐SERVICE FOR NJ FAMILYCARE MEMBERS ..............................................32 SERVICES THAT DO NOT NEED REFERRALS…………………………………………………………………………………………………….35 SERVICES NOT COVERED BY AMERIGROUP OR FEE‐FOR‐SERVICE FOR NJ FAMILYCARE MEMBERS ...................36 DIFFERENT TYPES OF HEALTH CARE.................................................................................................................37 ROUTINE CARE .......................................................................................................................................................37 URGENT CARE ........................................................................................................................................................37 EMERGENCY CARE .................................................................................................................................................38 EMERGENCY DENTAL CARE....................................................................................................................................39 IF YOU NEED TO GO TO THE HOSPITAL..................................................................................................................40 OUT‐OF‐TOWN CARE .............................................................................................................................................40 NEW TYPES OF CARE..............................................................................................................................................40 WELLNESS VISITS: EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT SERVICES ........................40 WHY WELLNESS CARE IS IMPORTANT FOR CHILDREN ..........................................................................................40 MISSING WELLNESS VISITS ....................................................................................................................................42 SPECIAL KINDS OF HEALTH CARE .....................................................................................................................42 SPECIAL CARE FOR PREGNANT MEMBERS.............................................................................................................42 SPECIAL SERVICES FOR PREGNANT AND NURSING WOMEN.................................................................................44 WIC LOCAL AGENCIES AND SERVICE AREAS ..........................................................................................................44 MEDICINES .............................................................................................................................................................46 Prior Authorization (PA) Drugs………………………………………………………………………………………………………………………47 Prior Authorization (PA) Drugs for Behavioral Health‐Related Conditions………………………………………………………..47 Over‐the‐Counter (OTC) Drugs…………………………………………………………………………………………………………………………48 If You Are Unable to Leave Your Home…………………………………………………………………………………………………………….48 SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING ...................................................................................48 HEALTH INFORMATION..........................................................................................................................................48 HEALTH EDUCATION CLASSES................................................................................................................................48 CARE MANAGEMENT SERVICES/SERVICES FOR ENROLLEES WITH SPECIAL NEEDS ..............................................49 RESOURCES FOR CAREGIVERS ...............................................................................................................................50 DISEASE MANAGEMENT CENTRALIZED CARE UNIT...............................................................................................50 MINORS ..........................................................................................................................................................52 MAKING A LIVING WILL...................................................................................................................................52 COMPLAINTS, GRIEVANCES AND MEDICAL APPEALS .......................................................................................53 IF YOU HAVE A COMPLAINT...................................................................................................................................53 FILING A GRIEVANCE..............................................................................................................................................54 LEVEL 1 GRIEVANCE.............................................................................................................................................54 LEVEL 2 GRIEVANCE.............................................................................................................................................55 MEDICAID FAIR HEARING.......................................................................................................................................55 IF AMERIGROUP WILL NOT PAY FOR OR AUTHORIZE A SERVICE ..........................................................................56 HOW TO FILE A MEDICAL APPEAL..........................................................................................................................56 STAGE 1 APPEAL ..................................................................................................................................................57 STAGE 2 APPEAL ..................................................................................................................................................57 INDEPENDENT HEALTH CARE APPEALS PROGRAM ...............................................................................................58 IF YOUR DOCTOR FILES A CLAIM APPEAL ..............................................................................................................59 MEDICAID FAIR HEARING FOR APPEALS ................................................................................................................59 MEMBER EXPLANATION OF BENEFITS...................................................................................................................60 OTHER INFORMATION ....................................................................................................................................60 IF YOU MOVE .........................................................................................................................................................60 RENEW YOUR ELIGIBILITY FOR YOUR MEDICAID, SSI OR NJ FAMILYCARE BENEFITS ON TIME.............................60 LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES ..............................................................................................61 HOW TO DISENROLL FROM AMERIGROUP FOR AFDC/TANF OR ABD AND RELATED GROUPS.............................63 FOR NJ FAMILYCARE MEMBERS ..........................................................................................................................64 REASONS YOU CAN BE DISENROLLED FROM AMERIGROUP FOR AFDC/TANF OR ABD AND RELATED GROUPS ..64 FOR NJ FAMILYCARE MEMBERS ..........................................................................................................................65 YOU ASKED TO BE ENROLLED IN AMERIGROUP AND DID NOT GET ENROLLED....................................................66 IF YOU HAVE OTHER HEALTH INSURANCE.............................................................................................................66 WHAT YOU SHOULD DO IF YOU GET A BILL FOR A SERVICE..................................................................................67 CHANGES IN YOUR AMERIGROUP COVERAGE ......................................................................................................67 HOW TO TELL AMERIGROUP ABOUT CHANGES YOU THINK SHOULD BE MADE...................................................67 HOW AMERIGROUP PAYS PROVIDERS...................................................................................................................67 YOUR RIGHTS AND RESPONSIBILITIES .............................................................................................................68 HOW TO REPORT SOMEONE WHO IS MISUSING THE NJ FAMILYCARE PROGRAM ............................................71 HIPAA NOTICE OF PRIVACY PRACTICES.......................................................... ERROR! BOOKMARK NOT DEFINED. FREQUENTLY ASKED QUESTIONS As an Amerigroup Community Care member, we want you to be able to easily find information that best helps you use your Amerigroup benefits and services. We speak to thousands of members every day, and we often hear the same questions from them. So that you also get the benefit of those frequently asked questions, we have put together the most commonly asked questions (and our answers) for you: Q: Do I have dental benefits? Who is my dentist? A: Your dental coverage will be shown on your ID card. We contract with HealthPlex to manage your dental benefits. Please call HealthPlex toll free at 1‐800‐720‐5352 (TTY 1‐800‐662‐1220) to request a list of dentists in your area. Q: Do I have routine vision benefits? Who is my eye doctor? A: Your routine vision coverage will be shown on your ID card. We contract with Superior Vision to manage your routine vision benefits. Please call Superior Vision at 1‐800‐879‐6901 (TTY 1‐800‐735‐2258) to request a list of providers in your area. Q: What do I do if I need a ride to my doctor’s appointment? A: Rides to your providers are nonemergency transportation. This is covered by the state if you are eligible. Eligible members should call [LogistiCare] Medical Transportation at 1‐866‐527‐9933 (TTY 1‐866‐288‐3133). Transportation appointments must be scheduled at least three days in advance. Please have the following information when calling to schedule your transportation: Name of the doctor or medical provider Address Telephone Time of appointment Type of transportation needed (e.g., regular car, wheelchair‐accessible van) Q: I’m an MLTSS member and I need a ride to the grocery store. Is that covered? A: Nonmedical transport is a covered benefit for members who qualify for Managed Long Term Services and Supports (MLTSS). Call your Amerigroup care manager if you are an MLTSS member and need to arrange a ride somewhere like church, the grocery store, or for some other errand to see if this is covered for you and should be included in your plan of care. Q: How do I change my PCP? A: Please call our Member Services department at 1‐800‐600‐4441 (TTY 711), Monday‐Friday, 8 a.m.‐6 p.m. They will help you choose a new doctor. You will receive a new member ID card with the updated information. If you need to visit the doctor before you receive the new card, let Member Services know, and they will help you. Q: How do I give Amerigroup my new address and phone number? 1 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 A: You will need to contact the state first directly toll free at 1‐800‐701‐0710 (TTY 1‐800‐701‐0720). Please make sure they have a current address and phone number for you so we can contact you when necessary. This is very important. Q: How do I find out if Amerigroup covers my medications? What do I do if they are not covered? A: The pharmacist you go to will inform you if a medication is covered or not. If a medication is not covered, it might be because it needs prior authorization. This means that the provider who prescribed the medicine will have to contact Amerigroup first to request it for you. You or your pharmacist can call your provider to ask for a prior authorization or change the medicine to a similar one that is covered. Q: What is an Amerigroup care manager, and what do they do for me? A: Care managers are nurses and social workers who assist members with the coordination of medical services, provide information about additional supportive services, and provide education about medical conditions and preventive measures. Care managers can assist with locating specialists, scheduling appointments, and ensuring that members receive medical equipment and other supportive services at home or in the community. Q: What can I do for help after my provider’s office is closed? A: Your provider will have an on‐call service. Call your provider’s office to speak with someone from their on‐call service. You can also call our 24‐hour Nurse HelpLine at 1‐800‐600‐4441 (TTY 711). Q: How do I get another member handbook? A: Please call our Member Services department at 1‐800‐600‐4441 (TTY 711). Q: How do I get an Amerigroup member ID card? A: All members get a member ID card from us when they first enroll. If you need a new one, you can call Member Services at 1‐800‐600‐4441 (TTY 711). Q: How do I use the free glucometer program through Amerigroup? A: Your doctor can call NIPRO at 1‐855‐253‐2407 and request the True Test glucometer and starter supply kit. Q: What are the common phone numbers I should have on hand? Amerigroup Member Services: 1‐800‐600‐4441 (TTY 711) HealthPlex (dental): 1‐800‐720‐5352 (TTY 1‐800‐662‐1220) Superior Vision: 1‐800‐879‐6901 (TTY 1‐800‐735‐2258) NJ FamilyCare: 1‐800‐701‐0710 (TTY 1‐800‐701‐0720) Q: What should I do if I get a bill from my provider’s office? A: If you receive a bill from your doctor, please call Member Services at 1‐800‐600‐4441 (TTY 711), Monday‐ Friday, 8 a.m.‐6 p.m. A representative can let you know what to do. WELCOME TO AMERIGROUP COMMUNITY CARE Information About Your New Health Plan Welcome to Amerigroup New Jersey, Inc., doing business as Amerigroup Community Care. Amerigroup is a New Jersey health maintenance organization (HMO) committed to helping you get the care you need when you need 2 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 it. In Amerigroup, you and your family doctor work together to help keep you healthy and care for your health problems. Amerigroup gives you many ways to get quality health care. Our members include the following groups: Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families (TANF) Foster Care Children receiving title IV‐E foster care payments or with title IV‐E adoption assistance agreements AFDC/TANF‐Related, New Jersey Care – Special Medicaid Program for Pregnant Women and Children, including restricted alien pregnant women SSI‐Aged, Blind, Disabled 1619(b) – Disabled individuals whose earnings are too high to receive SSI cash Breast and Cervical Cancer – Uninsured low‐income women under the age of 65 who have been screened at a NJ cancer education and early detection site and need treatment; no Medicaid resource limit; Medicaid income limit of 250 percent Federal Poverty Level (FPL) New Jersey Care – Special Medicaid programs for Aged, Blind, and Disabled New Jersey Care Special Medicaid Programs for Poverty level pregnant women; poverty level infants; poverty level children age 1‐5; poverty level infants and children receiving inpatient services who lose eligibility because of age must be covered through an inpatient stay Special Home‐ and Community‐Based Services Group: Individuals who would be eligible in an institution but are living in the community and receive services through MLTSS Chafee Kids Individuals under 18 who would be mandatorily categorically eligible except for income and resources Pregnant women who would be categorically eligible except for income and resources – §1902(a)(10)(C)(ii)(II) Pregnant women who lose eligibility receive 60 days coverage for pregnancy‐related and postpartum services – §1902(a)(10)(C) §1905(e)(5) Division of Developmental Disabilities Clients including the Division of Developmental Disabilities Community Care Waiver (CCW) (acute care services only; CCW services are covered by FFS) Medicaid only or SSI‐related Aged, Blind, and Disabled Uninsured parents/caretakers and childless adults with income up to and including 133% FPL Children who are covered under NJ FamilyCare, including restricted alien children Children in DCP&P/DCF custody residing in resource families or residential treatment centers with a county of residence as 0‐21, and individuals under the New Jersey Chafee Plan Individuals in the Provider Lock‐in or Hospice programs Members enrolled in the Managed Long Term Services and Supports (MLTSS) program How to Get Help Amerigroup is here to help you. We want you to be happy with the care you get. If you have any questions, need help or want to find out what services are available, you can call 1‐800‐600‐4441 (TTY 711) Monday‐Friday, 8 a.m.‐6 p.m. When you call, you can access our automated self‐service features, speak with a Member Services representative or get in touch with a nurse on our 24‐hour Nurse HelpLine. We can also help you if you need help in another language. 3 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 If you have questions regarding an authorization or request for services, you can call Member Services at 1‐800‐600‐4441 (TTY 711). Automated Self‐Service Features You can take advantage of these services with our automated line 24 hours a day, 7 days a week. You can: Choose or find a primary care provider (PCP) in the Amerigroup network Change your PCP Request an ID card Update your address or phone number Request a member handbook or provider directory Member Services Department You can also contact Member Services to speak with a representative. Call 1‐800‐600‐4441 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m. Member Services can help answer questions about: This member handbook Member ID cards Getting services Doctor appointments Transportation Special needs Choosing your family doctor Choosing a dentist Changing family doctors Out‐of‐town care/out‐of‐state care Urgent care Finding an Amerigroup network pharmacy Healthy living Health education classes Authorization for out‐of‐network or out‐of‐state providers, if needed NJ Smiles, a dental program especially for children from 0‐6 years of age Please also contact Member Services if: You wish to request a copy of the Amerigroup Notice of Privacy Practices, which describes how medical information about you may be used and disclosed and how you can get access to this information You move; we will need to know your new address and telephone number You may also need to give your new address to other agencies. NJ FamilyCare members should call the state’s Health Benefits Coordinator at 1‐800‐701‐0710 (TTY 1‐800‐701‐0720). If you are an AFDC/TANF member with Medicaid, call the County Welfare Agency in your county (see the chart “LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES” on pages 61‐63 for a list of telephone numbers). SSI (Supplemental Security Income) members should call the Social Security Administration at 1‐800‐772‐1213. 4 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 24‐hour Nurse HelpLine You can speak with a nurse on our 24‐hour Nurse HelpLine anytime. Call 1‐800‐600‐4441 (TTY 711). Our nurses can help you know: How soon you need to get care when you are sick What kind of health care you need What you can do to take care of yourself until you see your doctor How you can get the care you need Important Phone Numbers For dental care, call HealthPlex at 1‐800‐720‐5352 For vision care, call Superior Vision at 1‐800‐879‐6901 (TTY 1‐800‐735‐2258) NJ FamilyCare, call 1‐800‐701‐0710 (TTY 1‐800‐701‐0720) Medicaid/NJ FamilyCare members who are not clients of the Division of Developmental Disabilities (DDD) and who are not in the Managed Long Term Services and Supports (MLTSS) program should contact their local Medical Assistance Customer Center (MACC) office for referrals to mental health services and for mental health appointments. If you are not sure where your MACC office is, call Amerigroup’s Member Services number, 1‐800‐600‐4441, (TTY 711), for assistance. Non‐MLTSS members who need substance use disorder treatment should call the NJ Addiction Services Hotline at 1‐844‐276‐2777. ¿Qué Hago Si No Hablo Inglés? (What If I Do Not Speak English?) Si no habla inglés, llame a Servicios para Miembros al 1‐800‐600‐4441 (TTY 711) de lunes a viernes, de 8 a.m. a 6 p.m. Nuestro personal de Servicios para Miembros habla diferentes idiomas. Nuestro departamento tratara de encontrarle un médico que hable su idioma o le ayudara á comunicarse con su doctor. Es muy importante que usted hable con su médico y entienda lo que le dice. 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 to assist you at your doctor’s appointment at least 24 hours before your appointment. We will also try to help you find a doctor who speaks your language. Call Member Services at 1‐800‐600‐4441 (TTY 711) for more information. For members who are deaf or hard of hearing, call 711. Amerigroup will set up and pay for you to have a person who knows sign language help you during your medical visits. Please let us know if you need an interpreter at least 24 hours before your appointment. Your Amerigroup member handbook This member handbook tells you about your Amerigroup health plan and benefits. If you have questions about the handbook or your benefits, call Member Services toll free at 1‐800‐600‐4441 (TTY 711). You may write to us at: Amerigroup Community Care 101 Wood Ave. South, 8th Floor Iselin, NJ 08830 5 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 We can help you in many languages. If you are deaf or hard of hearing, call 711. You can also get this handbook in other languages, large print, on audio tape or in Braille from Member Services if you need it. Call us at 1‐800‐600‐4441 (TTY 711).. Members in the Managed Long Term Services and Supports (MLTSS) program can find out more about their MLTSS benefits in the Managed Long Term Services and Supports Companion Guide sent to them when they joined the MLTSS program. If you are a MLTSS member and you did not receive this extra guide, please let your care manager know. He or she can get you a new one. Your Amerigroup Identification Card If you do not have your Amerigroup ID card yet, you will get it soon. Please carry it with you at all times. Show it to any doctor, dentist or hospital you visit. The card shows you arre a member of Amerigroup. You do not have to show your ID card before you get emergency care. Your ID card has the name and telephone number of your family doctor on it. Your effective enrollment date, or the date you became an Amerigroup member, is also shown. The ID card tells your doctor that he or she should not ask you to pay for your Amerigroup covered services. The only members who may have to pay anything are some NJ FamilyCare C and D members who have copayments for certain services. Members with AFDC/TANF and ABD‐related groups still have a Medicaid card for the services Amerigroup does not cover. Do not throw it away. Carry it with you in case you need those services. NJ FamiilyCare members get an ID card from the New Jersey Division of Medical Assistance and Health Services (DMAHS). This card is for services covered by DMAHS that are not covered by Amerigroup.. Below is an example of what your Am merigroup member ID card looks like.. If you have Medicare coverage, you will also have separate Medicare ID cards. Everyone who has Mediccare receives a carrd from the Centers for Medicare & Medicaid Services (CMS). This card from CMS is often referred to as the red, white and blue card. If you have Original Medicare,, you’ll use this card for your benefits. If you have Medicare coverage through a health plan, typically you’ll use the ID card from your health plan. So if you have Medicare coverage through Amerigroup, we’ll send you an ID card. Keep your CMS card in a safe place and use the ID card we send you to get your benefits. 6 Memberr Services • 1‐‐800‐600‐4441 • TTY 711 • Monday‐Friiday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Enrollment in Amerigroup Enrolling takes 30 to 45 days. This is from the time you first apply to your effective enrollment date when you start receiving Amerigroup benefits. During this time, you will continue to receive benefits through Medicaid fee‐for‐service or the health plan you are enrolled in, whichever applies. If your effective enrollment date changes during this time, we’ll tell you of the change. The New Jersey Division of Medical Assistance and Health Services (DMAHS) must approve your enrollment in Amerigroup. Any enrollee who is dissatisfied with a State agency determination that there is not good cause for disenrollment may request and receive a State Fair Hearing if the enrollee is in NJ FamilyCare A or ABP. When you enroll in Amerigroup, there is a 12‐month enrollment period for all NJ FamilyCare members. You can disenroll and choose another health plan for any reason during the first 90 days after your enrollment date or the date we tell you you’re enrolled, whichever is later. After this 90‐day period, if you remain in Amerigroup, you will be a member of our plan for the rest of the 12‐month enrollment period. This is known as the lock‐in period. During the lock‐in period, you can disenroll only for certain reasons. (See the section “How to Disenroll from Amerigroup for AFDC/TANF or ABD and Related Groups” for more about disenrollment.) The Annual Open Enrollment Period occurs from October 1 through November 15 each year. After every 12‐ month period, you will continue to be enrolled with Amerigroup as long as you are still eligible for NJ FamilyCare, or unless you choose a new health plan during the open enrollment period. Information About NJ FamilyCare NJ FamilyCare is a program for adults and children who meet certain state guidelines. There are five different plans: A, B, C, ABP and D – as well as traditional Fee‐for‐Service (FFS). The plan you are eligible for is based on your total family income and household size. If you have questions about NJ FamilyCare and would like to know how to enroll, you can call Amerigroup toll free at 1‐877‐453‐4080 (TTY 711). You must be enrolled in a health plan that has a contract with the Department of Human Services (DHS), Division of Medical Assistance and Health Services (DMAHS) in order to get services and benefits as a member of NJ FamilyCare. DMAHS approves your enrollment in NJ FamilyCare. GOING TO THE DOCTOR Choosing Your Family Doctor We offer you a variety of nearby family doctors to choose from. Family doctors can treat your entire family or be individual doctors for children or adults. Our network includes a choice of at least two family doctors within six miles of your home if you live in Atlantic, Bergen, Burlington, Camden, Cumberland, Essex, Gloucester, Hudson, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Somerset or Union counties. If you live in Cape May, Hunterdon, Sussex or Warren, we offer at least two family doctors within 15 miles of your home. All Amerigroup members must have a family doctor. This doctor is also called your primary care provider (PCP). Your relationship with your family doctor is a very important part of your Amerigroup plan. Your family doctor will provide all of the basic health services you need. Your doctor can also send you to other specialist doctors, hospitals and special care facilities for special care, when needed. You must choose your family doctor from the Amerigroup network. If you do not choose one within your county, Amerigroup will assign you to a family doctor within 10 days of your enrollment. Your Amerigroup ID 7 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 card has the name and telephone number of your family doctor. If you want a different doctor or need help choosing one, please call Member Services at 1‐800‐600‐4441 (TTY 711). You can have someone help you pick a family doctor or set up your first doctor visit. We will try to call you within one month from the time you join Amerigroup. We will help you set up an appointment to get to know your doctor. It is important for you to contact and have a checkup with your new doctor soon after you enroll. Your doctor and his/her office staff will help you find out more about your health. If you need help, don’t have a telephone or changed your telephone number not too long ago, you can call Member Services. Or you can write to us. (See page 5 for address.) You can also call your doctor yourself. Your doctor’s telephone number is on your Amerigroup ID card. Since you have benefits such as physical exams, well‐woman exams and well‐child care, you do not have to wait until you are sick to see your family doctor. You should also get a baseline medical and dental checkup with your new doctor. After you enroll, call to set up a visit within 90 days for children under age 21 and adult DDD members. Set up a visit within 180 days for all other adults age 21 and older. Your family doctor coordinates your care and will help you make decisions about your health care. Your family doctor’s staff may include nurse practitioners, physician assistants, registered nurses and licensed practical nurses employed by your doctor to help meet your health care needs. How to Get a List of Amerigroup Providers Names of doctors in the Amerigroup network are in our provider directory. You can request a copy of the provider directory by calling Member Services at 1‐800‐600‐4441 (TTY 711) or access the directory online at www.myamerigroup.com/NJ. Just click on Find a Doctor. If you need help choosing a new doctor, call Member Services at 1‐800‐600‐4441 (TTY 711). Amerigroup Providers Need to Know Your Health History After You Enroll When the state’s Health Benefits Coordinator (HBC) helped you choose Amerigroup, you signed a medical release form. Signing this form allows the release of your medical records. You also had to tell the HBC if you were currently seeing any doctors for care. Your Amerigroup network doctor will have to ask your past doctor(s) to send your medical records. Having those past medical records helps your family doctor give you the care you need. The HBC also asked you questions about your health on the Plan Selection Form. This form was sent to Amerigroup. Your signature or the signature of an authorized person you chose allows the release of your medical records. We will ask you questions about your health during your new member telephone call. You may say that you have a sickness that might need care right away. If so, an Amerigroup care manager or special needs coordinator will help you. Second Opinions You can ask your family doctor to send you to another Amerigroup network doctor for a second opinion. You can do this for several reasons, including: If you have a serious medical condition If you have chosen to have an elective surgery When a provider recommends a treatment you don’t think you need If you believe you have a condition that the provider did not diagnose 8 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Your family doctor will make this appointment for you. He or she will also make sure all of your records are shared with that doctor with your consent. Please follow up with your family doctor after you have your second opinion visit. You and your doctor can talk about what to do next. It could be that we do not have another doctor in our network who knows about your type of illness. If this is so, your family doctor will work with Amerigroup to find another doctor for you to see. We will still pay for this visit for services covered by Amerigroup. There may be times when we ask for you to have a second opinion. We will set up your appointment and pay for the visit. Changing Family Doctors or Dentists If you want to change your family doctor or dentist, you may pick another one in the Amerigroup medical network or HealthPlex dental network. You may want to change family doctors for the following reasons: You just joined Amerigroup and need to pick a family doctor You want a male or a female doctor You want a doctor who speaks your language You are unhappy with your doctor or his or her staff Your doctor is not an Amerigroup network doctor anymore You want a children’s dentist (pediatric dentist). Names of doctors in the Amerigroup network are in our provider directory. You can ask for a copy of the provider directory by calling Member Services at 1‐800‐600‐4441 (TTY 711). You can also access it online at www.myamerigroup.com/NJ. If you need help choosing a new doctor, call Member Services at 1‐800‐600‐4441 (TTY 711). If you decide to choose another family doctor, the change will take place the next day after you ask for it. If you want to change your dentist, you may contact HealthPlex Member Services at 1‐800‐720‐5352, Monday through Friday, 8 a.m. to 6 p.m. EST (TTY 1‐800‐662‐1220). Names of dentists in the HealthPlex network can also be accessed online at www.healthplex.com. If you want a listing of NJ FamilyCare dentists who will treat children, this may be found at www.insurekidsnow.gov. You may not be able to change to a new family doctor or dentist for the following reasons: The doctor is not an Amerigroup network doctor The doctor is not accepting new patients at the time The doctor is a specialist If Your Family Doctor or Dentist Asks You to Change to a New Family Doctor or Dentist It is important for you to have a good relationship with your doctor. This will help you get the health care you need. Your family doctor may ask us to change you to another doctor if you do the following things: You or a family member hurts a doctor or other provider You or a family member uses very bad language to a doctor or other provider You or a family member damages an office You miss appointments over and over again You often do not follow your doctor’s advice 9 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 We ask our doctors to tell us if our members are doing things that might cause the doctor to ask to have a member changed to another doctor. If your doctor talks to us about you, we will let you know what you are doing that might cause you to have to change doctors. If your doctor decides that you need to change doctors, he or she will send Amerigroup a letter. This letter will tell Amerigroup why you need to change to a new doctor. Amerigroup will send a copy of this letter to you. We will also call you to help you pick a new doctor. If you do not pick a new doctor, we will pick one for you. You will get a new ID card with the new doctor’s name and telephone number on it. Getting to Your Doctor – Transportation Services Amerigroup covers ground transportation for members in cases of emergency only. Members receive all other transportation services through fee‐for‐service (except MLTSS members, who get nonmedical transportation through Amerigroup. If you’re an MLTSS member and need a ride to go to church or for shopping or other reasons, call your care manager.) To find out more about getting a ride to your nonemergency medical doctor visits, call [LogistiCare] at 1‐866‐527‐9933 (TTY 1‐866‐288‐3133) (see page 1 for more details). If you have any problems with the service you receive, you can call the [LogistiCare] Complaint Hotline at 1‐866‐333‐1735. If you need emergency care and have no way to get to the hospital, call 911 for an ambulance. Canceling an Appointment If you make an appointment and then can’t go, call your provider’s office. Try to call at least 24 hours before your appointment. Tell them to cancel the appointment. If you want us to cancel the appointment, just call Member Services at 1‐800‐600‐4441 (TTY 711). After‐hours Care You never know when you will need medical care. Amerigroup requires our providers to have an after‐hours service you can call for help. If you call your PCP when the office is closed, leave a message with your name and a telephone number where you can be reached. Your PCP should call you back: The same day if you are not sick (nonsymptomatic) Within 30‐45 minutes if you are sick (symptomatic) and it’s not an emergency Within 15 minutes for crisis/emergency situations If you are not able to reach your doctor, you may also call our 24‐hour Nurse HelpLine at 1‐800‐600‐4441 (TTY 711) 24 hours a day, 7 days a week for help. Specialists Your family doctor can take care of many of your health care needs, but you may also need care from some other kind of doctor. Your family doctor can refer you to specialists if you need special care. You can also ask your family doctor about going to a specialist. Specialists are doctors, such as surgeons, OB/GYNs or podiatrists, who focus on a certain illness or part of the body. The specialist will treat you and tell your family doctor about your medical condition. Amerigroup has contracted with many types of doctors and other health care providers. This includes specialists. Your family doctor will refer you to the health care provider you need. Your doctor will tell you who the provider is, where the provider is and the provider’s telephone number. 10 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 If your family doctor refers you to another doctor, it is very important that you go to that doctor. Tell your doctor or Member Services if you think you might not go to the other doctor because getting there is too hard. Amerigroup can help you get to the doctor’s office to get the care you need. If you do not see the doctor you were referred to, you may become sicker. Amerigroup recommends that you get a referral from your family doctor to go to a specialist and get most other services. A referral is the approval from your family doctor to see another doctor who specializes in treating a certain kind of illness. These other services may include the following: Another doctor, for example, a specialist Chiropractors Podiatrists Hospital care, except in emergencies or emergency admissions Sometimes you may have an illness for which you may need to see a specialist for a long time. Such illnesses could include cancer, HIV or sickle cell. If you have one of these illnesses, your family doctor may give you or you may ask for a referral that will let you keep going to the specialist for a longer time. This will let you keep going without having to go back to your family doctor. This is called a standing referral. The standing referral will say how long you can keep going to the specialist until your family doctor has to give you another referral. Call Member Services at 1‐800‐600‐4441 (TTY 711) to talk to a care manager. Sometimes a specialist can be your family doctor. This may happen when you have a special health care need that is being taken care of mostly by a specialist or specialty care center. If one of our care managers has already talked with you about your special needs, he or she can help you make this change if it is best for your care and the specialist agrees. You can also request that a specialist be your family doctor. If you have special needs and you have not talked with one of our care managers yet, call Member Services. Referrals make sure that your family doctor knows about all the care you get. It also helps your family doctor get you all the care you need. It makes sure you go to a specialist in the Amerigroup plan. It also helps to make sure that you do not get a bill for the visit unless you are a NJ FamilyCare member who has a copayment. For some types of services, you don’t need a referral from your doctor. You can self‐refer. See the section “Services Provided Under Fee‐For‐Service for NJ FamilyCare Members” for a list of these services. For some services, a prior authorization may be required. Your doctor will coordinate this for you with Amerigroup. If you have questions regarding an authorization, a request for services or a utilization management question, you can call Member Services. You may also call our 24‐hour Nurse HelpLine at 1‐800‐600‐4441 (TTY 711) 24 hours a day, 7 days a week for help. If You Want to See a Doctor Who Is Not in the Amerigroup Network For all covered nonemergency services, you must see your network family doctor. Or you can see a doctor in the Amerigroup network. Your family doctor may also refer you to a health care provider out of the Amerigroup plan. He or she will do this if a plan provider is not available to meet your medical needs. Your doctor must get approval from Amerigroup to do this before you can see a doctor out of the Amerigroup plan. If you want to go to a doctor who is not in our plan, and your network family doctor has not sent you, you must call us first. You will need to get an authorization. Amerigroup will look at your health care needs to see if this would be the right doctor for you. 11 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Choosing a Dentist Like the relationship with your family doctor, the relationship with your family dentist is important, too. Your family dentist, also known as your primary care dentist (PCD), takes care of all your general dental needs. This includes checkups, cleanings, and routine fillings and extractions. It is important to have a checkup with a dentist soon after you enroll. This is very important if it has been more than six months since you last saw a dentist. To make an appointment, all you have to do is call your PCD. If you have special dental needs, your PCD can refer you to a dental specialist. Your dental benefits are provided through HealthPlex. Members with dental benefits can choose a PCD from the HealthPlex network of dentists. A list of network dentists can be found in the Healthplex online directory at www.healthplex.com including dentists that treat children under 6 years old. If you need help choosing a dentist, making an appointment or help with using the online directory, you can call HealthPlex at 1‐800‐720‐5352 (TTY 1‐800‐662‐1220). Sometimes, you may need dental care that includes medical services. In these cases, services performed by a dentist will be dental. Services that are most often taken care of by a medical doctor will be medical. There may be times when the type of dental care you need is severe or life threatening, such as the treatment of jaw fractures or the removal of tumors. Or you could have a condition, such as heart disease, that may require you to receive certain dental care in a hospital setting. If so, Amerigroup will decide which services are medical. If a change in enrollment occurs, approved dental services with a prior authorization will be honored. New enrollees must get a new prior authorization for the services even if your treatment plan has not started. This prior authorization shall be honored for at least 6 months or until it expires (whichever time period is longer.) If the prior authorization has expired, you must get a new prior authorization. See the section “Amerigroup Covered Services for Medicaid and NJ FamilyCare Members” to learn more about your dental benefits. Information About NJ Smiles Our network includes family doctors who have been certified to screen children less than six years of age. These NJ Smiles doctors provide dental risk assessments, fluoride varnish application and a referral to a primary care dentist for a comprehensive examination and treatment. For more information about NJ Smiles or for help finding a certified doctor, visit our website at www.myamerigroup.com/NJ or call Member Services at 1‐800‐600‐4441 (TTY 711). Disability Access to Amerigroup Network Doctors and Hospitals All Amerigroup network doctors and hospitals will 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 will need a ramp or other help, make sure your doctor’s office knows before you get there. This way, the staff will be ready to help you. If you want help in talking to your doctor about your disability needs, call Member Services at 1‐800‐600‐4441 (TTY 711). We will have a care manager get in touch with you to make sure you get the care you need. Amerigroup can help you if you have trouble hearing. We will set up and pay for you to have a person who knows sign language to help you during your doctor’s visits. To use a TTY relay service, call 711, and we can help set this up for you. 12 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 PREMIUMS FOR NJ FAMILYCARE D MEMBERS AND COPAYMENTS FOR NJ FAMILYCARE C AND D MEMBERS Premiums for NJ FamilyCare D members A premium is a monthly payment you pay to get health care coverage. Only certain NJ FamilyCare D members make these payments. The state’s Health Benefits Coordinator (HBC) tells you if you have to pay. Eskimos and Native American Indians under the age of 19 do not have to make monthly payments. This payment will go toward your family cost‐share that is computed once every 12 months. Your family cost‐ share is based upon your total family income. Remember, if you have a monthly payment and do not pay it, you will be disenrolled. Copayments for NJ FamilyCare C and D Members A copayment (or copay) is the amount you need to pay for a covered service. Only certain NJ FamilyCare C and D members have copays. The amount of the copay is on your ID card. Eskimos and Native American Indians under the age of 19 do not have copays. After you exceed your family cost‐share, you will not have to pay a copay when you get more services. You will also get a new member ID card from Amerigroup after your family cost‐share is met. Remember, your family cost‐share with your copay should not be more than five percent of your total family income. You should always ask for a receipt when you pay a copay. Keep track of what you spend on copays as well as your premiums. Once you exceed your five percent cost‐share amount, call the HBC at 1‐800‐701‐0710 (TTY 1‐800‐701‐0720) for help. Members Age 55 and Over Medicaid benefits received after age 55 may be paid back to the state of New Jersey from your estate. This may include premium payments made on your behalf to Amerigroup. AMERIGROUP COVERED SERVICES FOR MEDICAID AND NJ FAMILYCARE MEMBERS These services are the ones Amerigroup will arrange for you when you need them (except where otherwise noted). For all of these covered nonemergency services, you must see your family doctor or a doctor in the Amerigroup network. For emergency care (24 hours a day, 7 days a week), go to the nearest hospital emergency room or call 911. For most other services, you must go to your family doctor first. There are some services you can get without seeing your family doctor first. See the section “Services That Do Not Need Referrals” to learn more about these benefits. Your family doctor will help you get the following services as you need them. The boxes below show the copay amounts for services that have copays. Copays are for NJ FamilyCare C and D members who have copays. 13 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP Audiology Services Include: Diagnostic services Screening services Preventive services Corrective services Needed supplies and equipment No copay No copay No copay Covered for age 15 and younger Limited to $1,000 per ear every 24 months Requires referral from physician or other licensed medical practitioner Behavioral Health (includes Mental Health and Substance Abuse Services) Includes: Intake evaluation Off‐site crisis intervention Family therapy Family meetings Psychological testing Medication management Services for conditions that alter mental states that are of an organic nature covered by Amerigroup Partial hospitalization and partial care covered by Amerigroup for MLTSS members and under the FFS No copay No copay No copay $5 per visit Covered by Covered by FFS Amerigroup for Medicaid* members who are clients of Division of Developmental Disabilities (DDD & DDD/CCW) and MLTSS members Covered by FFS Covered by FFS Medicaid* Medicaid* *See the section “Services Provided Under Fee‐For‐Service for NJ FamilyCare Members” for more information, limits and exclusions Behavioral health day care programs at Adult Partial Care Centers covered by Amerigroup for MLTSS members and by FFS for all other members Covered by FFS for all other members* 14 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP Medicaid program for clients of Division of Developmental Disabilities (DDD & DDD/CCW) Chiropractor Services Includes manual manipulation of the spine No copay No copay $5 per visit Not covered Dental Services No copay Diagnostic and preventive dental services (exams, cleanings, space maintainers, sealants and fluoride): Every 6 months for all age groups. Fluoride is covered every 6 months for all age groups Sealants: Once every three years for those under age 17 Not covered for those age 17 or older Restorative (fillings and crowns): Silver and tooth colored fillings are covered Endodontic (root canals and related services) – Implants associated with retaining complete No copay $5 per visit (no copay for diagnostic and preventive care) $5 per visit (no copay for diagnostic and preventive care) 15 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP dentures: Need prior authorization Periodontics treatment of the gums and bone supporting the teeth, periodontal scaling and root planing: Need prior authorization Prosthodontic (removable dentures) – Fixed bridges in special cases when medically necessary: Need prior authorization Oral and maxillofacial surgery (extractions and oral surgery): For oral surgery, prior authorization is required for inpatient and outpatient facilities. Orthodontic – Limited to children under age 19 when medically necessary: Need prior authorization For children with one or more of the following: Severe functional difficulties Developmental 16 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP anomalies of facial bones and/or oral structures Facial trauma resulting in severe functional difficulties Demonstration that long‐term psychological health requires orthodontic correction Orthodontic‐ Orthognathic Surgical: Limited to children age 15 years and older Fee‐for‐Service (FFS) Medicaid to provide and pay for certain approved dental services requiring multiple visits by a Medicaid non‐ Amerigroup provider that are started 60‐ 120 days prior to a member’s enrollment in managed care No copay Durable Medical Equipment (DME) and Supplies Includes: Assistive technology devices, artificial aids, surgical implants, No copay No copay Limited coverage 17 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP wheelchairs, beds Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services Includes: Medical exams Dental services Vision services Hearing services Lead screening Health care and treatment to correct or help improve any defects or conditions found in screenings Includes the following when indicated as a result of an EPSDT screening: Nonlegend drugs Ventilator services in the home Private duty nursing (provided by a registered nurse or licensed practical nurse under the guidance of the member’s physician in the member’s home) No copay No copay No copay No copay Private duty nursing included only if approved by Amerigroup Coverage limited to screening and diagnosis Coverage limited to screening and diagnosis Coverage limited to well‐child visits, including immunizations, lead screening and treatments only. Treatment services limited to those: Included in Amerigroup benefits, or Specified through FFS Medicaid Private duty nursing included only if approved by Amerigroup Treatment services limited to those: Included in Amerigroup benefits, or Specified through FFS Medicaid Private duty nursing included only if approved by Amerigroup Private duty nursing included only if approved by Amerigroup Screening services are provided periodically: Neonatal exam 18 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP Under 6 weeks 2 months 4 months 6 months 9 months 12 months 15 months 18 months 24 months Annually through age 20 Dental services are as follows: First visit to a dentist at 1 year of age or soon after the eruption of the first primary tooth After first visit, preventive dental visits twice a year or every 6 months until age 20 All covered dental services are available Emergency Medical Care 24 hours a day, 7 days a week Family Planning Services Includes: Services needed to delay or prevent pregnancy Pregnancy testing Genetic testing and counseling No copay No copay $10 per visit $35 (no copay required if member is referred to ER by PCP for services normally rendered in PCP office or if admitted to the hospital) $5 per visit (no copay for Pap smears or preventive care services) $5 per visit (no copay for preventive care services) No copay No copay May use Amerigroup network providers or Medicaid approved family May use Amerigroup network providers or Medicaid May use approved family Amerigroup planning network NJ FamilyCare D members must use Amerigroup network providers. Call Member Services to learn 19 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES Contraceptives (including oral contraceptives) Follow‐up care for complications linked with contraceptive methods issued by the FP provider Sterilizations NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP planning providers providers providers or more. Medicaid approved family planning providers No copay No copay No copay Abortions (and related services) are covered under the FFS Medicaid program, including certain related office, laboratory, drugs, radiological and diagnostic services and surgical procedures Infertility and sterilization reversals are not covered. Hearing Aid Services Include: Hearing aids and accessories Ear mold impressions Routine follow‐up and adjustments Repairs Covered up to age 16 Limited to $1,000 per ear every 24 months Requires hearing screening, resulting in prescription for hearing aid services Home Health Agency No copay Services No copay No copay No copay Coverage provided by 20 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP Include: Services given at member’s home (excludes a hospital, nursing facility or intermediate care facility) Nursing services by a registered nurse or licensed practical nurse Medical social services Home health aide services Medical supplies and equipment Appliances Audiology services Amerigroup limited to skilled nursing provided or supervised by a registered nurse, home health aides for skilled care and medical social services that are medically necessary No copay No copay No copay No copay Palliative and curative care covered for children under age 21 Palliative and curative care covered for children under age 21 Palliative and curative care covered for children under age 21 Palliative and curative care covered No copay No copay No copay No copay Services must be ordered by member’s physician Hospice Agency Services Hospice services covered in community and institutional settings for all ages Room and board services covered only when services are delivered in an institutional (nonprivate residence) setting Inpatient Hospital (includes 21 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP rehabilitation hospitals and special hospitals) Includes services normally given in a hospital that are under the guidance of a physician An acute psychiatric hospital admission, coverage provided by traditional Medicaid for members when primary diagnosis is behavioral health‐ related The plan covers all hospital admissions (except partial care and partial hospitalization services) for DDD/MLTSS members Requires prior authorization for nonemergency care and care following stabilization of an emergency condition Not covered: Cosmetic surgery Rest cures Personal comfort and convenience items Services and supplies not directly related to 22 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP the care of the patient Telephone charges Take‐home supplies Laboratory Services Must be ordered by a physician or other licensed practitioner No copay No copay No copay No copay No copay No copay for prenatal care visits $5 per visit for each visit that is not part of an office visit Members will be notified of results within 24 hours for urgent and emergent cases and within 10 business days for routine cases Maternity and Related Newborn Care $5 copay for first prenatal visit No copay for preventive services or newborns covered under FFS Medicaid $10 copay for services rendered during nonoffice hours and for home visits Medical Day Care Services No copay Not covered Not covered Not covered Medical Supplies Includes diagnosis‐ specific disposable medical supplies No copay No copay No copay No copay Managed Long Term Services and Supports Limited coverage 23 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP Nursing Facility Services Covered from the date of admission to the date of discharge. Optical Appliances (artificial eyes, eyeglasses, contact lenses and other visual aids prescribed) No copay Not covered Not covered Inpatient Rehabilitation service or inpatient hospice benefit for NJ FamilyCare B members may be provided in this setting, when appropriate. Not covered Inpatient Inpatient Rehabilitation service Rehabilitation or inpatient hospice benefit for service or NJ FamilyCare D members may inpatient be provided in this setting, when hospice benefit appropriate, except for for NJ Rehabilitative Services for FamilyCare C Substance Abuse (not covered) members may be provided in this setting, when appropriate. No copay No copay Optical appliances must be prescribed by a participating ophthalmologist or optometrist No copay Limited to one pair of glasses (or contact lenses) per 24‐month period or as medically necessary For members age 0‐ 18 and age 60 or older: Members can get one pair of frames and eyeglass lenses chosen from Medicaid‐approved materials once every year, or sooner in some cases, when meeting Medicaid‐ approved criteria for changes in prescription 24 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP For members age 19‐ 59: Members can get one pair of frames and eyeglass lenses chosen from Medicaid‐approved materials once every two years, or sooner in some cases, when meeting Medicaid‐ approved criteria for changes in prescription Talk to your vision provider to see if you need a new eyeglass prescription. Members have a choice of covered frames. Contact lenses may be covered for members: With certain ocular pathological conditions Whose vision cannot be improved to at least 20/70 with regular lenses but can be improved to 20/70 or better with contact lenses Contact lenses may be replaced once every two years, or more often, if there 25 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP is a significant change in a member’s prescription. If members do not meet any of the above medical necessity criteria, but choose contact lenses anyway, up to a $100 credit may be given toward the cost of the contact lenses. Optometrist Services No copay No copay $5 per visit $5 per visit One routine eye exam covered every 12 months Organ Transplants No copay Includes liver, lung, heart, heart‐lung, pancreas, kidney, cornea, intestine and bone marrow, including autologous bone marrow transplants No copay No copay No copay No copay $5 for each $5 for each outpatient visit outpatient visit (no copay for preventive care) (no copay for preventive care) Donor and recipient costs covered by Amerigroup. Outpatient Hospital Services Include: Preventive services Diagnostic services Therapeutic services Palliative services No copay 26 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP May require prior authorization for nonemergency care and physician referral Behavioral health visits covered by FFS Medicaid with the exception of the DD population (see the section “Services Provided Under Fee‐ For‐Service for NJ FamilyCare Members” for details) Outpatient Rehabilitation Includes: Physical therapy Occupational therapy Speech pathology services Cognitive rehabilitation therapy Covered Personal Care Assistant Services If a member chooses and is approved to self‐direct his/her PCA services, Amerigroup will provide Personal No copay Limited according to state regulations Therapy limited to 60 visits per incident per therapy per calendar year Not covered $5 copay $5 copay Therapy limited to 60 visits per incident per therapy per calendar year Therapy for nonchronic conditions, acute illnesses and injuries limited to 60 visits per incident per therapy per calendar year Not covered Speech pathology services for treatment of speech development delays are not covered unless the delays are a result of disease, injury or congenital defects Not covered 27 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP Preference Program services Podiatrist Services Excludes routine hygienic care of the feet, such as treatment of corns, calluses, nail trimming, foot soaking or other services, in the absence of a pathological condition Prescription Drugs May require prior authorization for selected drugs Amerigroup uses a formulary: a list of drugs your doctor can choose from to treat your illnesses; prior authorization is required for consideration of drugs outside the formulary when medically necessary except in the case of certain prescriptions or pharmacy services ordered by behavioral health providers for behavioral health‐ related conditions (see the section No copay No copay $5 per visit $5 per visit $1 copay for generic, $5 copay for brand‐name drugs $5 copay – if greater than 34‐day supply, then $10 copay No copay No copay Over‐the‐ counter drugs covered for children under the age of 21 and limited to $15 per quarter for members 21 and older* Over‐the‐ counter drugs covered for children under the age of 21 and limited to $15 per quarter for members 21 and older* Over‐the‐ counter drugs covered for children under the age of 21 and limited to $15 per quarter for members 21 and older* Over‐the‐counter drugs are not covered. *See “Extra Amerigroup Benefits for NJ FamilyCare Members” for more info on over‐the‐counter drugs 28 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP “Prior Authorization (PA) Drugs for Behavioral Health‐ Related Conditions” for more details) Legend (prescription) drugs and non‐ legend drugs approved by the Medicaid program are covered No copay Preventive Health Care, Counseling and Health Promotion Includes referrals to WIC programs No copay No copay No copay No copay $5 per visit No copay for $5 per visit during normal office hours For all female members: If your PCP is not a women’s health specialist, covered services include direct access to an Amerigroup network woman’s health specialist for covered care that is needed to provide women’s routine and preventive health care services, such as annual gynecological exams, mammograms Primary Care and Physician Services (24 hours a day, 7 No copay 29 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP days a week) Include: Primary and specialty care Certified nurse‐ midwives Certified nurse practitioners Clinical nurse specialists Physician assistant services Independent clinic services (includes preventive, diagnostic, therapeutic, rehabilitative or palliative services) wellness visits, lead screenings and treatments, age‐ appropriate immunizations, prenatal care and Pap smears, when needed $10 per visit for non‐office hours and home visits $5 for first prenatal care visit only – no copay thereafter No copay No copay No copay for preventive wellness visits, lead screenings and treatments, age‐appropriate immunizations, and Pap smears, when needed Services provided by nonparticipating providers require prior authorization. Prosthetic and Orthotic Devices (includes certified shoe provider) Prosthetic devices include corrective or supportive devices that: Replace a missing part of the body Prevent or correct physical deformity or malfunction Support a weak or deformed part of No copay No copay Limited to the initial provision of a prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease, injury or congenital defect Replacement or repair covered when due to natural growth. Orthotic devices are not covered. 30 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP the body Orthotic devices include devices or braces that provide support, more function and help to overcome physical impairment or defects; prosthetic and orthotic devices must be prescribed by a physician or other licensed practitioner Radiology Services No copay (X‐rays) Diagnostic and therapeutic services mean professional and technical radiology services. No copay No copay $5 per visit for each visit not part of an office visit No copay No copay No copay Members will be notified of results within 24 hours for urgent and emergent cases and within 10 business days for routine cases. Transportation Services Ground transportation covered for emergencies only No copay See the section “Services Provided Under Fee‐For‐ 31 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COVERED SERVICES NJ MEDICAID NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D AND NJ FAMILYCARE A AND ABP Service for NJ FamilyCare Members” for more transportation benefits EXTRA AMERIGROUP BENEFITS FOR NJ FAMILYCARE MEMBERS Amerigroup gives you special benefits you cannot get from regular NJ FamilyCare. They include the following: Members 21 or over may get up to $15 worth of certain over‐the‐counter drugs like cough medicine and aspirin. Amerigroup will pay up to $15 for each member 21 or over each quarter. Quarters start on the first day of January, April, July and October. This requires a prescription from your Amerigroup network family doctor. For members under age 21, the over‐the‐counter drug benefit for certain over‐the‐counter drugs like cough medicine and aspirin is unlimited. This requires a prescription from your Amerigroup network family doctor. For NJ FamilyCare D members, over‐the‐counter drugs are not covered. A gift for pregnant members who get all required prenatal care visits or go to approved prenatal care classes. See the section “Special Care for Pregnant Members” 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 PROVIDED UNDER FEE‐FOR‐SERVICE FOR NJ FAMILYCARE MEMBERS You can get the following services through fee‐for‐service. (This means that it is covered by the state.) Amerigroup does not pay for these services, but NJ FamilyCare does. You must tell Amerigroup when you need these services. You may get these services through the provider of your choice according to Medicaid regulations. Amerigroup or your family doctor can help you find a provider for these services. If you need these services, please call your family doctor or Member Services for help. BEHAVIORAL HEALTH NJ FAMILYCARE A NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D SERVICES AND ABP Targeted Case Management Community Support Services Covered Covered Covered Covered Behavioral Health 32 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 BEHAVIORAL HEALTH SERVICES NJ FAMILYCARE A NJ FAMILYCARE B NJ FAMILYCARE C AND ABP NJ FAMILYCARE D Behavioral Health Services Partial hospitalization Partial care Covered Covered Covered Covered DCP&P Residential Treatment Center Care Covered through fee‐for‐service Covered through fee‐for‐service Covered through fee‐for‐service Not covered Home (Bergen and Mercer Counties) Psychiatric Emergency Rehabilitation Services/Affiliated Emergency Services Mental Health Outpatient Substance Use Disorder Outpatient (for ABP members only) Adult Mental Health Rehabilitation (group homes) Inpatient Psychiatric Services Opioid Treatment Services Psychiatrist, Psychologist or Advanced Practice Nurse Partial Care/Hospitalization Program of Assertive Community Treatment (PACT) Treatment centers to provide medical and social services to ensure the safety and well‐being of children who may be 33 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 BEHAVIORAL HEALTH SERVICES NJ FAMILYCARE A NJ FAMILYCARE B NJ FAMILYCARE C AND ABP NJ FAMILYCARE D Covered abused or neglected; includes critical diagnostic and treatment services, and timely and needed access to all covered benefits Elective, Induced Abortions and Related Services Covered Covered Covered Family Planning Services Can be covered through any Amerigroup provider or any state‐approved fee‐for‐service provider Can be covered through any Amerigroup provider or any state‐approved fee‐for‐service provider Can be covered through any Amerigroup provider or any state‐approved fee‐for‐service provider Can be covered through any Amerigroup provider. Obtaining family planning services outside Amerigroup’s provider network is not available to NJ FamilyCare D members. Inpatient and Outpatient Covered Mental Health Services Covered Covered $5 per visit; Limited benefit Inpatient Psychiatric Hospital Services Covered for members under 22 or 65 and over Covered for members under 22 or 65 and over Covered for members under 22 or 65 and over Covered for members under 22 or 65 and over Intermediate Care Facilities/Intellectual Disability Covered; Member is disenrolled from Amerigroup on date of admission Not covered Not covered Not covered Sex Abuse Exams and Related Diagnostic Testing (at DCP&P‐contracted Child Abuse Regional Diagnostic Centers or by DCP&P‐contracted Covered Covered Covered Covered 34 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 BEHAVIORAL HEALTH SERVICES NJ FAMILYCARE A NJ FAMILYCARE B NJ FAMILYCARE C AND ABP NJ FAMILYCARE D Substance Abuse Services Includes: Diagnosis, treatment and detoxification services Methadone and its administration Covered ABP members have enhanced services Covered $5 per visit Transportation Services – Nonemergency ambulance, Mobile Intensive Care Units (MICUs) and invalid coach services Covered Covered Covered Not covered Transportation Services – Livery (taxi, bus, train, car service, and reimbursement for mileage, etc.) transportation for travel to medical providers Covered See transportation Broker [(LogistiCare)] for more information See transportation Broker [(LogistiCare)] for more information Not covered physicians) Covered SERVICES THAT DO NOT NEED REFERRALS It is always best to ask your family doctor for a referral for any of the Amerigroup services. But you can get the following services without your family doctor’s referral: Emergency care Yearly exams from an Amerigroup network obstetrician/gynecologist Care provided by your Amerigroup network PCP’s nurse or physician assistant Dental care from a HealthPlex network family dentist Family planning from any Amerigroup network or approved Medicaid family planning provider Medicaid services Amerigroup does not cover Prenatal care from an Amerigroup network obstetrician or certified nurse‐midwife Screening or testing for sexually transmitted diseases, including HIV, from your Amerigroup network doctor or state‐approved Medicaid provider you choose Vision care from a Superior Vision provider EPSDT services from an Amerigroup participating provider. See the section “Amerigroup Covered Services for Medicaid and NJ FamilyCare Members” for details. 35 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 SERVICES NOT COVERED BY AMERIGROUP OR FEE‐FOR‐SERVICE FOR NJ FAMILYCARE MEMBERS There are other services that are not part of your Amerigroup benefits. These services are not covered by Medicaid, either. These services are listed below: All services your family doctor or Amerigroup says are not medically necessary Cosmetic surgery, except when medically necessary and with prior approval Experimental organ transplants Infertility diagnosis and treatment services, including sterilization reversals and related office (medical or clinic), drugs, lab, radiological and diagnostic services, and surgical procedures Rest cures, personal comfort and convenience items, services, and supplies not directly related to the care of the patient, including guest meals and lodging, telephone charges, travel expenses, take‐home supplies and similar costs Respite care (except for MLTSS and DDD members) Services that involve the use of equipment in facilities when the purchase, rental or construction of the equipment has not been approved by New Jersey law All claims that come directly from services provided by or in federal institutions Services provided in an inpatient psychiatric institution that is not an acute‐care hospital to members under 65 and over 21 years old Free services provided by public programs or voluntary agencies (should be used when possible) Services or items furnished for any sickness or injury that occurs while the covered member is on active duty in the military Payments for services provided outside of the United States and territories (pursuant to N.J.S.A. 52:34‐13.2 and section 6505 of the Affordable Care Act of 2010, which amends section 1902(a) of the Social Security Act) Services or items furnished for any condition or accidental injury that arises out of and during employment where benefits are available (workers’ compensation law, temporary disability benefits law, occupational disease law or similar laws); this applies whether or not the member claims or receives benefits and whether or not a third party gets a recovery for resulting damages Any benefit that is covered or payable under any health, accident or other insurance policy Any services or items furnished that the provider normally provides for free Services furnished by an immediate relative or member of the Medicaid beneficiary’s household (except for members in the Personal Preference Program) Services billed when the health care records do not correctly reflect the provider’s procedure code Services or items reimbursed based on a cost study or other evidence acceptable to the state of New Jersey For NJ FamilyCare D members, these additional services are not included: Intermediate Care Facilities/Intellectual Disability Private duty nursing, unless authorized by Amerigroup Personal care assistant services Medical daycare services Chiropractic services Orthotic devices Residential treatment center psychiatric programs Religious nonmedical institutions care and services EPSDT (except for well‐child care, including immunizations and lead screening and treatments) 36 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Transportation services, including nonemergency ambulance, invalid coach and livery transportation such as taxi or bus Hearing aid services, except for children up to age 16 Blood and blood plasma (except administration of blood, processing of blood, processing fees and fees related to autologous blood donations are covered) Cosmetic surgery (except when medically necessary and with prior approval) Custodial care Special remedial and educational services Experimental and investigational services Rehabilitative services for substance abuse Weight reduction programs or dietary supplements (except surgical operations, procedures or treatment of obesity when approved by the contractor) Acupuncture and acupuncture therapy (except when performed as a form of anesthesia in connection with covered surgery) Recreational therapy Sleep therapy Court‐ordered services Thermograms and thermography Biofeedback Radial keratotomy Nursing facility services, except when the admission is for rehabilitative services Audiology services, except for children up to age 16 Managed long‐term services and supports not otherwise listed above DIFFERENT TYPES OF HEALTH CARE 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. You should be able to see your primary care provider (PCP) within 28 days for a routine appointment; you should be able to see your primary care dentist (PCD) for dental care within 30 days; and for behavioral health care, within 10 days. Your PCP is someone you see when you are not feeling well, but that is only part of your PCP’s job. Your PCP also takes care of you before you get sick. This is called wellness care. Urgent Care The second type of care is urgent care. There are some injuries and illnesses that are not emergencies but can turn into an emergency if they are not treated within 24 hours. Some examples are: Throwing up Minor burns or cuts Earaches Headaches Sore throat Fever over 101 degrees Fahrenheit Muscle sprains/strains 37 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Controllable bleeding/sore gums Toothache/pain Lost filling/crown 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 PCP’s instructions. In some cases, your PCP may tell you to go to the emergency room at a hospital for care. See the next section about emergency care for more information. If you are unable to contact your PCP, you can also call our 24‐hour Nurse HelpLine at 1‐800‐600‐4441 (TTY 711) for advice about urgent care. You should be able to see your PCP or an urgent care provider within 24 hours for an urgent care appointment (for dental care, within three days and for behavioral health care, within 24 hours). 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 (TTY 711). The most important thing is to get medical care as soon as possible. You should be able to see a physician right away for emergency care (for dental care, within 48 hours and for behavioral health care, right away). What is an emergency? An emergency is when not seeing a doctor right away to get care could result in death or very serious bodily harm. The problem is so severe that someone with an average knowledge of health can tell the problem may be life‐threatening or cause serious damage to your body. This is known as an emergency medical condition. Here are some examples of problems that are most likely emergency medical conditions: Very bad bleeding that does not stop Severe pain Chest pains/facial paralysis Very bad burns Passing out Shakes called convulsions or seizures Trouble breathing Miscarriage Broken bones Throwing up blood Suspected drug overdose or poisoning Rape/sexual assault 38 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 If you think you need emergency care, Amerigroup will pay for your exam under the prudent layperson standard at any hospital emergency room. The emergency department doctor will check you to see if you need emergency care. Amerigroup will also provide coverage for your medically necessary post‐stabilization care services. These are services you receive after emergency medical care. You get these services to help keep your condition stable. If you do not need emergency care, the hospital may call your PCP to see if the hospital should treat you. Or the hospital may tell you to go to your family doctor for care. Amerigroup will pay for the emergency care, including screenings, when your condition seems to fit the meaning of an emergency to a prudent layperson. We’ll pay even if it is later found not to be an emergency. A prudent layperson is a person who: Knows what the average person knows about health and medicine Could expect that the health of the person would be in serious trouble if he or she did not get medical care right away Not getting medical care right away could cause bodily functions to not work right or not work at all. This is the same if the person is a pregnant woman where the health of the woman or her unborn child would be in serious trouble. You do not need permission from your PCP or Amerigroup to receive emergency services. If you get emergency services: You do not need to show your Amerigroup ID card before you get emergency care You do not need to get a referral or precertification You need to call your family doctor within 24 hours, or you can have someone else call for you You need to call your PCP for a referral if the hospital wants you to get follow‐up care Emergency Dental Care Amerigroup will pay for emergency dental care including if there is the presence of an infection. See the section “Choosing a Dentist” for more details. You can get covered emergency care 24 hours a day, seven days a week, for dental problems such as the examples listed below: A broken or dislocated jaw Heavy or uncontrolled bleeding from mouth A permanent tooth is knocked out Very bad pain in the gum around a tooth, with or without a fever Trauma to face or mouth Facial swelling If you need emergency dental care, please call your dentist right away. If you are unable to reach your dentist, you can call HealthPlex at 1‐800‐720‐5352 (TTY 1‐800‐662‐1220). You can call Monday through Friday from 8 a.m. to 6 p.m. for help in getting emergency dental care. You can also speak with a HealthPlex representative if you call after hours between 6 p.m. and 8 a.m. or on weekends. You can see a HealthPlex dentist. You can also see a dentist who is not part of the Amerigroup network, visit a clinic or use an emergency department in a hospital for emergency dental care. If you are out of town and need emergency dental care, you can go to any dentist, clinic or emergency room for care, or you can call HealthPlex at 1‐800‐720‐5352 (TTY 1‐800‐662‐1220) Monday through Friday from 8 a.m. to 6 p.m. for help in finding a dentist. 39 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 If You Need to Go to the Hospital You must use hospitals in the Amerigroup network unless you have an emergency, or you need a service you can only get somewhere else. These hospitals are listed in the provider directory. You can request a copy of the provider directory by calling Member Services at 1‐800‐600‐4441 (TTY 711). You can also access the directory online at www.myamerigroup.com/NJ. Since your doctor coordinates your care, he or she will get approval from Amerigroup if you need to go to the hospital, unless it is an emergency. Your doctor will get a referral and will take care of getting you admitted. Out‐of‐Town Care If you need urgent or emergency care when you are out of town, go to the nearest hospital emergency room or call 911. See the sections above for more information regarding urgent and emergency care. You can also call our 24‐hour Nurse HelpLine at 1‐800‐600‐4441 (TTY 711). If you need routine care like a checkup or prescription refill when you are out of town, call your family doctor or our 24‐hour Nurse HelpLine. If you are out of town and need emergency dental care, you can go to any dentist for care. Call Member Services at 1‐800‐600‐4441 (TTY 711) to let them know you got care from a dentist out of town. If you need to have a prescription filled when you are away from your home service area, be sure to bring your prescription or refill, and your Amerigroup ID card with you. You can go to any network pharmacy in New Jersey, New York, Pennsylvania and Delaware to have your prescription filled. Use the online Provider Search tool at www.myamerigroup.com/NJ or call Member Services at 1‐800‐600‐4441 (TTY 711) to find a network pharmacy. The pharmacy will process your prescription using the member and benefit information shown on your Amerigroup ID card. If you are traveling outside of New Jersey, New York, Pennsylvania and Delaware, you will need to obtain approval from Amerigroup prior to obtaining the medication. New Types of Care Amerigroup medical directors and network doctors are always looking at new medical advances and medical studies. They do this to see if: These advances should be covered benefits The government has agreed the treatment is safe and effective The new advance results are as good as or better than covered benefit treatments in effect now WELLNESS VISITS: EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT SERVICES Why Wellness Care Is Important for Children We all need to see a family doctor sometimes, even when we are feeling well. Wellness visits are an important part of staying healthy. When you become an Amerigroup member, call your doctor and make your first appointment within 90 calendar days of when you enroll. To make sure you’re as healthy as can be, you and your family should make regular use of preventive medical and dental services. Babies, children and pregnant women need more care so children can get a good start in life. Here is a list of the well‐child visits your children should get at each age: Birth to Age 1 40 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Babies need to see a doctor at least seven times in their first year and more times if they get sick. At the seven well‐child visits, your doctor will: Make sure your baby is growing well Check your baby’s vision and hearing Tell you ways to care for your baby Tell you what to feed your baby Tell you how to help your baby go to sleep Answer any questions you have about your baby Look for problems that may need more medical attention Give your baby shots (immunizations) that will protect him or her from bad sicknesses like whooping cough, polio, tetanus and other illnesses Refer your baby for a first dental visit soon after his or her first tooth comes in. Your baby should see a dentist by the time he or she turns one. The first visit of the seven well‐child visits will take place in the hospital right after the baby is born. For the next six visits, you must take your baby to your baby’s family doctor. Amerigroup will try to help you choose a family doctor for your baby before the baby is born. If your baby does not have an Amerigroup network family doctor, call Member Services to get one. Call 1‐800‐600‐4441 (TTY 711). You must set up well‐child visits with the baby’s family doctor when the baby is at these ages: Newborn Under 6 weeks 2 months 4 months 6 months 9 months 12 months Age 1 to 2 In a baby’s second year, the baby must go to the dentist two times per year or more often if your dentist recommends any follow‐up care. Your baby must also see a doctor three more times for well‐child visits. If your baby gets sick, your baby should see the doctor more often. You must take your baby to the doctor at these ages: 15 months 18 months 24 months Age 2 to 20 You and your children should keep going to your family doctor for wellness visits every year through age 20. You and your children should also see your family dentist twice a year for exams and cleanings as well as completion of any treatment your dentist recommends. These visits will help you and your children stay healthy. They also help doctors find health problems early. This is when it is easiest to take care of them. Blood Lead Screening Your Amerigroup network doctor will check your child’s blood levels: Between 9 and 18 months (prefer at 12 months) 41 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Between 18 and 26 months (prefer at 24 months) Between 27‐72 months if his or her blood levels have never been checked Here is an example of how wellness visits can help prevent sickness. Older houses and apartments (built before 1978) were painted with lead‐based paint. Over time, lead‐based paint peels and flakes from walls. Lead‐based paints taste sweet and can be eaten by children. Also, small flakes and paint dust can be inhaled. Too much lead in children’s blood can cause permanent brain damage and will make it hard for them to do well in school later. During a well‐child visit, your doctor will test your child’s blood for lead and other problems. Or your doctor may refer you to another office to have a lead blood test. By finding and correcting a lead problem early, your doctor can help keep more serious problems from happening later. Missing Wellness Visits It is important to see your doctor for wellness visits, not just when you are sick. If you are not sure when you should get a wellness visit, call your doctor or our 24‐hour Nurse HelpLine at 1‐800‐600‐4441 (TTY 711).Getting wellness visits on time is important. If you miss a wellness visit, make sure that you and your children go to the doctor as soon as you can. If you need help getting the visit set up, call Amerigroup Member Services. If you have not visited the doctor on time, Amerigroup will try to contact you to see if you need help. SPECIAL KINDS OF HEALTH CARE Special Care for Pregnant Members Taking Care of Baby and Me® is an Amerigroup program for all pregnant members. It’s very important to see your primary care provider (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 baby gifts for getting prenatal care and postpartum care. Our program also helps pregnant members with complex health care needs. Nurse case managers work closely with these members to help teach them about these needs. They also give emotional support and help members to follow their doctors’ care plan. Our nurses also work with doctors. They help with other services members may need. The goal is to promote better health for members and the birth of healthy babies. 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 14 days. We can help you find an OB/GYN in the Amerigroup network, if needed. You must also call Amerigroup Member Services when you find out you are pregnant. Call 1‐800‐600‐4441 (TTY 711). This will help you make sure you choose a doctor for your baby. If you are a new Amerigroup member who is pregnant and have been seen by a non‐Amerigroup provider for at least one complete prenatal checkup before you joined Amerigroup, then you may be able to keep seeing that provider with approval from Amerigroup throughout your pregnancy, during delivery and up to two months after your baby is born. 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 Self‐care book 42 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Taking Care of Baby and Me® reward program brochure Nurse HelpLine Ameritips 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. When you are pregnant, you must go to your PCP or OB/GYN at least: Every four weeks for the first six months Every two weeks for the seventh and eighth months Every week during the last month Your PCP or OB/GYN may want you to visit more than this based on your health needs. 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). See the section “WIC Local Agencies and Service Areas” on pages 44‐46 to get the telephone number for the WIC program close to you. You also need to get dental care while you’re pregnant and after you have your baby. This will help make sure you have a healthy baby. See the section “Choosing a Dentist” for more details. When You Have a New Baby When you deliver your baby, you and your baby may stay in the hospital at least: Two days (not including the day of delivery) after a vaginal delivery Four days (not including the day of delivery) after a cesarean section (C‐section) You may stay in the hospital less time if your PCP or OB/GYN and the baby’s doctor see that you and your baby are doing well. You and your baby should stay in the hospital until your doctor says you can leave. You and your baby can leave the hospital before your doctor releases you, but it is best not to do this. If you and your baby leave the hospital early, the doctor may ask you to have an office or in‐home nurse visit within 48 hours. Please call your County Welfare Agency office after you have your baby. (See the chart “LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES” on pages 61‐63 for telephone numbers.) This way, you can arrange to have your baby covered by Medicaid. You must also call Amerigroup Member Services as soon as you can to let us know you had your baby. We will need to get information about your baby. 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. 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 Baby‐care book Taking Care of Baby and Me® reward program brochure about going to your postpartum visit Brochure about postpartum depression Nurse HelpLine Ameritips fact sheet 43 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 You can use the baby‐care book to write down things that happen during your baby’s first year. This book will give you information about your baby’s growth. Special Services for Pregnant and Nursing Women Pregnant women and children may be eligible to receive additional help through the Women, Infants, and Children (WIC) program. The WIC program provides members with vouchers to buy certain healthy foods. The following members may qualify for this program: Babies under 12 months old Children under 5 years old Pregnant women Women breastfeeding babies under 12 months old Women who are not breastfeeding with babies under 6 months old WIC Local Agencies and Service Areas WIC Programs ‐ North Region St. Joseph’s WIC Program 185 6th Ave. Paterson, NJ 07524 (973) 754‐4575 wic@sjhmc.org Passaic WIC Program 333 Passaic St. Passaic, NJ 07055 (973) 365‐5620 passaicwic@cityofpassaicnj.gov Service Areas: BERGEN and MORRIS COUNTIES; PASSAIC COUNTY except for Service Areas: City of Passaic the City of Passaic (See Passaic WIC Program.) North Hudson WIC Program 407 39th St. Union City, NJ 07087 (201) 866‐4700 KLazarowitz@nhcac.org rlavagnino@nhcac.org Jersey City WIC Program 199 Summit Ave. Suite A2, Jersey City, NJ 07304 (201) 547‐6842 Help@JCWIC.org Service Areas: HUDSON COUNTY except for Bayonne and Jersey City (See Service Areas: Bayonne and Jersey City Jersey City WIC Program.) East Orange WIC Program 185 Central Ave. Suites 505 & 507 East Orange, NJ 07018 (973) 395‐8960 monica@ci.east‐orange.nj.us Newark WIC Program 110 Williams St. Newark, NJ 07102 (973) 733‐7628 reynoldsc@ci.newark.nj.us 44 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Service Areas: ESSEX COUNTY: Service Areas: ESSEX COUNTY: Newark, Irvington, Orange, Maplewood, South Orange, Fairfield, Verona, West Caldwell, Essex Falls, Cedar Grove, East Orange, Bloomfield, Belleville Glen Ridge, North Caldwell, Caldwell, Montclair, Orange, East Orange, West Orange, South Orange, Bloomfield, Belleville, Nutley, Millburn, Livingston, Roseland Rutgers ‐ NJMS WIC Program Stanley Bergen Blvd. (GA‐06) 65 Bergen Ave. Newark, NJ 07107 (973) 972‐3416 Service Areas: ESSEX COUNTY WIC Programs ‐ Central Region Trinitas WIC Program 40 Parker Road Elizabeth, NJ 07208 (908) 994‐5141 aotokiti@trinitas.org Plainfield WIC Program 510 Watchung Ave. Plainfield, NJ 07060 (908) 753‐3397 prema.achari@plainfieldnj.gov Service Areas: UNION COUNTY except for Plainfield City (See Plainfield WIC Program.) Service Areas: City of Plainfield NORWESCAP WIC Program 350 Marshall St. Phillipsburg, NJ 08865 (908) 454‐1210 (800) 527‐0125 quinnn@norwescap.org VNA of Central Jersey WIC Program 888 Main St. Belford, NJ 07718 (732) 471‐9301 rmcrober@vnacj.org Service Areas: MONMOUTH and MIDDLESEX COUNTIES; Franklin Township in SOMERSET COUNTY Service Areas: HUNTERDON, SUSSEX and WARREN COUNTIES; SOMERSET COUNTY except for Franklin Township (See VNA WIC Program.) 45 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 The Children’s Home Society of NJ’s Mercer WIC Program 416 Bellevue Ave. Trenton, NJ 08618 (609) 498‐7755 www.chsofnj.org Service Areas: MERCER COUNTY jmartin@chsofnj.org WIC Programs ‐ South Region Atlantic City WIC Program City Hall, 1st Floor 1301 Bacharach Blvd. Atlantic City, NJ 08401 (609) 347‐5656 ttrotman@cityofatlanticcity.org Service Areas: ATLANTIC COUNTY Gateway CAP 10 Washington St. Bridgeton, NJ 08302 (856) 451‐5600 Tricounty_WIC@gatewaycap.org Service Areas: CAMDEN, CUMBERLAND, CAPE MAY and SALEM COUNTIES Ocean County WIC Program 175 Sunset Ave. P.O. Box 2191 Toms River, NJ 08754 (732) 341‐9700, Ext. 7520 (800) 342‐9738 megmccarthy@ochd.org Service Areas: OCEAN COUNTY Burlington County WIC Program Raphael Meadow Health Center 15 Pioneer Blvd. P.O. Box 6000 Westampton, NJ 08060 (609) 267‐4304 ddas@co.burlington.nj.us Service Areas: BURLINGTON COUNTY Gloucester County WIC Program 204 East Holly Ave. Sewell, NJ 08080 (856) 218‐4116 kmahmoud@co.gloucester.nj.us Service Areas: GLOUCESTER COUNTY Medicines You can get prescriptions at pharmacies that take Amerigroup. All members except NJ FamilyCare D members can get over‐the‐counter medications, too. If you are not sure if the pharmacy takes Amerigroup, just ask the pharmacist. If you need help finding a store that accepts Amerigroup prescriptions, call Member Services at 1‐800‐600‐4441 (TTY 711). When you are prescribed a medication, discuss with your health care provider if the medication is part of Amerigroup’s formulary. Members who have severe illnesses, see different doctors and take different kinds of medicine may be put into the Provider Lock‐in Program. In the Provider Lock‐in Program, the member will be able to fill their prescriptions at only one pharmacy. By using one pharmacy, the staff will get to know the member’s health status. The staff 46 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 will also be better prepared to help the member with his or her health care needs. The pharmacist can also look at past prescription history and work with the member’s doctor if problems with medications occur. A member may also be put into the Provider Lock‐in Program if he or she is not using prescriptions the right way. Amerigroup will work with the member and the member’s doctor to inform the member about proper use of prescriptions. Members who are put in the Provider Lock‐in Program will only be able to get a 72‐hour supply of medicine from a different pharmacy if their chosen pharmacy does not have that medicine on hand or there is an emergency. If you are put in the lock‐in program, you will receive a letter to let you know. If you do not agree with our decision to assign you to just one pharmacy or one provider, you can appeal it over the phone or in writing. We recommend that you follow up your phone call request with a written request for an appeal, but it is not required. If you ask for an expedited resolution over the phone, you do not need to follow up in writing. Written appeals must be received by us within 90 days of the date when you get this letter. Send written appeals to: Appeals Department Amerigroup Community Care 101 Wood Ave. South, 8th Floor Iselin, NJ 08830 Prior Authorization (PA) Drugs You may also be able to get prescriptions (if you have this benefit) for medications that are not on the Amerigroup list of authorized medications (Preferred Drug List, or PDL) or for brand‐name drugs instead of the available generic versions. You may be able to get these medications if your doctor says they are medically necessary to treat your condition or keep you in good health. To get these types of medications, your doctor will need to get a prior authorization. This means that he or she will have to contact Amerigroup first to request the medicine for you. Decisions are based on medical necessity and are determined according to certain established medical criteria. We will make a decision on this within 24 hours of your provider’s request. We will also provide you with a 72‐hour supply of medications not on our PDL during that time. Prior Authorization (PA) Drugs for Behavioral Health‐Related Conditions All pharmacy services are covered by Amerigroup (except Methadone and its administration when prescribed for substance abuse treatment), including drugs prescribed by BH providers Atypical antipsychotic and anticonvulsant drugs ordered by a nonparticipating or participating Amerigroup provider will always be covered regardless of the treatment plan established by Amerigroup Amerigroup PDL and prior authorization (PA) requirements will apply only when the initial medication treatment plan is changed Amerigroup will restrict coverage of or require PA for drugs or pharmacy services prescribed by BH providers if one of the following exceptions is demonstrated: ‐ The drug prescribed is not related to the treatment of substance abuse/dependency/addiction or mental illness or to any side effects of the psychopharmacological agents – these drugs are to be prescribed by Amerigroup primary care providers (PCPs) or specialists in the Amerigroup network 47 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 ‐ The prescribed drug exceeds benefit plan coverage parameters as defined and approved by New Jersey Division of Medical Assistance and Health Services (NJ DMAHS) – i.e., does not conform to standard rules of the Amerigroup pharmacy plan Over‐the‐Counter (OTC) Drugs Members 21 or over (except NJ FamilyCare D members) may get up to $15 worth of certain over‐the‐counter medicines. These include cough medicine and aspirin. Amerigroup will pay up to $15 for each member 21 or over each calendar quarter. Calendar quarters start on the first day of January, April, July and October. This requires a prescription from your Amerigroup network doctor. For members under age 21, the over‐the‐counter drug benefit for certain over‐the‐counter drugs like cough medicine and aspirin is unlimited. This requires a prescription from your Amerigroup network family doctor. For NJ FamilyCare D members, over‐the‐counter drugs are not covered. If You Are Unable to Leave Your Home Amerigroup can help take care of you even if you cannot leave your home. Call Member Services at 1‐800‐600‐4441 (TTY 711) right away if you are homebound. We will have a care manager get in touch with you to make sure you get the care you need. SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING Health Information You can learn more about healthy living for you and your family through our health information programs. One way to get health information is to ask your family doctor. Another way is to call the 24‐hour Nurse HelpLine at 1‐800‐600‐4441 (TTY 711). Our 24‐hour Nurse HelpLine nurses can answer your health questions 24 hours a day, 7 days a week. 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 or your child may have. Learning about your health should be fun, too! Amerigroup sponsors 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. You can go to our website at www.myamerigroup.com/NJ to find out more about where and when events take place. Some of the larger medical sites (such as clinics) in our network will show health videos. These videos talk about shots, prenatal care and other important health topics. If your doctor’s office shows these kinds of videos, we hope they will make your time at your doctor’s office more comfortable. We will also mail a member newsletter to you once a year. This newsletter gives you health information about wellness care, managing your illness, parenting and many other topics. Health Education Classes We offer health education programs to help you and your family stay healthy. We can help you find classes near your home. You can call Member Services or visit our website at www.myamerigroup.com/NJ to find out where and when health education events or classes are held. We have classes about: 48 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Amerigroup services and how to get them Pregnancy Lead poisoning prevention Nutrition Managing stress Injury prevention Women’s health Men’s health Cultural awareness Immunizations and well‐child health Asthma Food safety Dental health Flu and germ prevention Creating a healthy, safe home Sun safety Diabetes and heart health Autism Care Management Services/Services for Enrollees with Special Needs We can help all Amerigroup members get services and make medical and dental appointments. We will help members with hearing problems communicate with their doctors through trained interpreters that know sign language. Amerigroup will help set up and pay for this service. Some members have special needs and need extra help with their health care. We may call you or your representative, if you let us, and try to help you get the care you need. We can also tell you about other medical, social or support services that can help you. Upon enrolling with Amerigroup, you or your representative will be asked to complete an initial health screening (IHS). This will help us see if you have any special health care needs. If the answers from the IHS, or other medical information Amerigroup gathered from your doctors, or from the State, or your present services, indicate that you may have special needs, you will be asked to complete a CNA (Comprehensive Needs Assessment) to determine if you need special services and care management. We will attempt to contact members within 45 days of enrollment to complete the IHS and/or CNA and coordinate needed services, which include a visit to your PCP or specialist. If you have this assessment, we can put together an individual health care plan just for you. You, your representative and your doctor must agree before we do this. It is good to include your doctor and others you want to be included when planning your care. We will ask you if you want to include others. We can have you, your representative, your doctor, your Amerigroup care manager and a case manager from the Division of Developmental Disabilities or the Division of Child Protection and Permanency (if appropriate) set up a mutually agreeable time to develop your individual health care plan. A care plan will be developed for members with special needs no later than 30 days after being identified for care management. Your family doctor may give you or you may ask for a referral that will let you keep going to a specialist for a long time. This will let you keep going without having to go back to your family doctor. This is called a standing referral. Or sometimes a specialist can be your family doctor. This may happen when you have a special health care need that is being taken care of by a specialist. This special health care need could be a life‐ threatening condition or a degenerative and/or disabling condition, which requires specialized medical care over a prolonged period of time. If one of our care managers has already talked with you about your special needs, he or she can help you make this change if the specialist agrees. If you have special needs and you have not talked with one of our care managers yet, call Member Services at 1‐800‐600‐4441 (TTY 711). Ask to be transferred to a care manager. You may call our Care Management department at 1‐800‐452‐7101 (TTY 711), ext. 66050, Monday through Friday from 8 a.m. to 5 p.m. Eastern time. Our address is: 49 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Care Management Department Amerigroup Community Care 101 Wood Ave. South, 8th Floor Iselin, NJ 08830 For children with special needs, your care manager can help arrange the health care your child needs. This includes well‐child visits, immunizations, disease management, comprehensive dental and specialty care. If you have a crisis or emergency situation, please call 911 or go to the nearest hospital emergency room as soon as possible. An emergency could be one of the following: Very bad bleeding that does not stop Severe pain Chest pains/facial paralysis Very bad burns Passing out Shakes called convulsions or seizures Trouble breathing Miscarriage or a woman in labor Broken bones Throwing up blood Suspected drug overdose or poisoning Rape/sexual assault Thoughts of suicide or hurting yourself For nonemergency care, you should call your primary care provider (PCP) who will tell you what to do. You can also call our 24‐hour Nurse HelpLine at 1‐800‐600‐4441 (TTY 711). If you have been receiving care from a doctor who is not in our plan and would like to keep receiving care from this doctor, you must have this doctor or your primary care doctor call us first for authorization. Amerigroup will look at your health care needs to see if it is medically necessary for you to keep seeing this doctor. Resources for Caregivers At Amerigroup, we understand providing care requires a lot. The person you care for is depending on you, so it may be harder to take the time to think about yourself. It is important to understand your needs so that you can stay healthy and continue to be the best possible caregiver. You can find more information at: www.nia.nih.gov caregiveraction.org www.acl.gov If you have any questions or need assistance, call Member Services at 1‐800‐600‐4441 (TTY 711). Disease Management Centralized Care Unit Amerigroup has a Disease Management Centralized Care Unit (DMCCU) program. A team of licensed nurses and social workers, called DMCCU case managers, educate you about your condition and help you learn how to 50 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 manage your care. Your primary care provider (PCP) and our team of DMCCU case managers will assist you with your health care needs. DMCCU case managers provide support over the phone for members with: Diabetes Behavioral health conditions ‐ Bipolar disorder HIV/AIDS ‐ Major depressive disorder Heart conditions ‐ Schizophrenia ‐ Coronary artery disease ‐ Substance use disorder ‐ Congestive heart failure ‐ Hypertension Lung conditions ‐ Asthma ‐ Chronic obstructive pulmonary disease DMCCU case managers work with you to create health goals and help you develop a plan to reach them. As a member in the program, you will benefit from having a case manager who: Listens to you and takes the time to understand your specific needs Helps you create a care plan to reach your health care goals Gives you the tools, support and community resources that can help you improve your quality of life Provides health information that can help you make better choices Assists you in coordinating care with your providers As an Amerigroup member enrolled in the DMCCU, you have certain rights and responsibilities. You have the right to: Have information about Amerigroup, including all Amerigroup programs and services as well as our staff’s education and work experience; it also includes contracts we have with other businesses or agencies Refuse to take part in or disenroll from programs and services we offer Know which staff members arrange your health care services and who to ask for a change Have Amerigroup help you to make choices with your doctors about your health care Learn about all DMCCU‐related treatments, including 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 keep it private and confidential Be treated with courtesy and respect by Amerigroup staff File a complaint with Amerigroup and be told how to make a complaint, including knowing about Amerigroup standards of timely response to complaints and resolving issues of quality Get information that you can understand Have Amerigroup act as an advocate for you if needed You are encouraged 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 DMCCU program 51 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 If you have one of these conditions or would like to know more about our DMCCU, please call 1‐888‐830‐4300 (TTY 711), Monday through Friday, 8:30 a.m. to 5:30 p.m. Eastern time. Ask to speak with a DMCCU case manager. You can also visit our website at www.myamerigroup.com/NJ. MINORS The Amerigroup network of doctors and hospitals cannot give you care without your parent’s or legal guardian’s consent. This is true for most Amerigroup members under age 18. This is not true if emergency care is needed. Your parents or legal guardians can find out what is in your medical records. You can ask your doctor not to tell your parents what is in your medical records, but if they ask, the doctor must show your medical records to your parents. These rules do not apply to emancipated minors under age 18 who: Are married Are pregnant Have a child Are being treated for sexually transmitted diseases (STDs) Are getting family planning services Emancipated minors may decide about their own medical care and the medical care of their children. Parents do not have the right to see the medical records of emancipated minors. MAKING A LIVING WILL To the extent of the law, you may refuse care your doctor wants to give you. Here’s how a living will or advance directive works. Sometimes people are very sick or hurt. Their doctor may tell them or their families that death or something like a permanent coma may happen. By giving you some kinds of care, they can keep you living longer, but it will probably not improve your health. This care may include using machines that replace breathing or eating. Some people do not want to get that kind of care. But they know that they may be too sick to refuse care. To make sure they get only the kind of care they want, they sign a living will. This is a paper that says what kinds of care they want to refuse if death or something like a permanent coma happens. You can sign a living will for yourself or your children. It will tell your doctor what kinds of care you do not want if this happens to you. If you need help getting a living will, call Amerigroup Member Services at 1‐800‐600‐4441 (TTY 711) or you can access it from www.caringinfo.org and download your state‐specific advance directive form. You and your family doctor must work together to complete your living will. Give your living will to your family doctor. Your family doctor will make sure it is in your medical record. Then, he or she will know how you want to be cared for if you are very sick or hurt very badly and cannot say what care you want. You can change your mind after you have signed a living will. Call your Amerigroup network family doctor. He or she will help you take the living will out of your medical record. You can also make changes in the living will by filling out, signing and dating a new one. 52 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 COMPLAINTS, GRIEVANCES AND MEDICAL APPEALS If You Have a Complaint If you have a problem with your health care or Amerigroup services, you can call Member Services or write to the address below. You can also ask your doctor and/or an authorized person to call or write to us for you. Quality Management Department Amerigroup Community Care 101 Wood Ave. South, 8th Floor Iselin, NJ 08830 Telephone: 1‐800‐600‐4441 (TTY 711) Fax: 1‐877‐271‐2409 A Member Services representative will work with you to try to help fix your problem. If your problem is not resolved right away, we will send you a letter or call you for more information. We will try to resolve your complaint within five business days of when we got your call or letter. If we can’t resolve it in five days, then your complaint is considered a grievance. If you are not satisfied with our answer to your problem, you can file a grievance. You have the right to file a grievance in your language. Upon request, we’ll notify you in your primary language of your rights to file complaints, grievances and appeals and will provide the decision in your primary language. If you need help filing a grievance in your language, call Member Services at 1‐800‐600‐4441 (TTY 711). New Jersey Medicaid, NJ FamilyCare A and NJ FamilyCare ABP members can ask for a Medicaid fair hearing. You can ask for a Medicaid fair hearing at any time, as long as it is within 20 calendar days from the date of the notice of the decision about your complaint. According to state rules, NJ FamilyCare B, C and D members do not have the right to a Medicaid fair hearing. See the section “Medicaid Fair Hearing” for more information. More information about grievances and fair hearings is given below. If your complaint is an emergency, we will give you an answer within 24 hours of when we get it. If it is urgent, it will be answered within 48 hours. If you make a complaint, Amerigroup will not hold it against you. We will still be here to help you get quality health care. You or your doctor can also ask the state for help with a complaint. They will also send Amerigroup a copy so that Amerigroup can answer the complaint. Contact the state at the address and telephone number below: NJ FamilyCare P.O. Box 712 Trenton, NJ 08625‐0712 Telephone: 1‐800‐701‐0710 (TTY 1‐800‐701‐0720) 53 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Filing a Grievance Level 1 Grievance If you are unhappy with the answer you got about your complaint, you, your doctor or an authorized representative (with your written consent) have 90 days from the date of our response to file a special complaint. This is called a Level 1 grievance. To file a grievance, you or your doctor can call us, write to us or send us a fax. Tell us the problem, when it happened and the people involved. Contact us at the address and telephone numbers below: Quality Management Department Amerigroup Community Care 101 Wood Ave. South, 8th Floor Iselin, NJ 08830 Telephone: 1‐800‐600‐4441 (TTY 711) Fax: 1‐877‐271‐2409 Once we get your grievance, we will send you (and your doctor, if he or she made the request) a letter within five business days to let you know we have your grievance. We will ask you for more information, if needed. We will try to solve the problem so that you are satisfied. We will then send you (and your doctor, if he or she made the request) a letter within 30 calendar days from when you contacted us about your grievance. This letter will give you our answer to your grievance. It will tell you that you can file another grievance with us about this problem if you are still not pleased. New Jersey Medicaid, NJ FamilyCare A and NJ FamilyCare ABP members can also ask for a Medicaid fair hearing within 20 calendar days from the date of the notice of the decision. According to state rules, NJ FamilyCare B, C and D members do not have the right to a Medicaid fair hearing. See the section “Medicaid Fair Hearing” for more information. More information about Level 2 grievances and fair hearings is given below. If your grievance is an emergency, we will take care of it within 24 hours of when we get it. If it is urgent, it will be taken care of within 48 hours. If you file a Level 1 grievance, Amerigroup will not hold it against you. We will still be here to help you get quality health care. You or your doctor can also ask the state for help with a grievance. They will also send a copy to Amerigroup so we can resolve it. Contact the state at the address and telephone number below: NJ FamilyCare P.O. Box 712 Trenton, NJ 08625‐0712 Telephone: 1‐800‐701‐0710 TTY 1‐800‐701‐0720 54 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Level 2 Grievance If you are still unsatisfied with the answer you got about your Level 1 grievance, you or your doctor have 90 days from the date of our response to file a Level 2 grievance. To file a Level 2 grievance, you or your doctor can call us, write to us or send us a fax. Tell us the problem, when it happened and the people involved. Contact us at the address and telephone numbers below: Quality Management Department Amerigroup Community Care 101 Wood Ave. South, 8th Floor Iselin, NJ 08830 Telephone: 1‐800‐600‐4441 (TTY 711) Fax: 732‐906‐8327 We will send you a letter within 30 calendar days of when we got your Level 2 grievance. This letter will tell you the final decision. Medicaid, NJ FamilyCare A and NJ FamilyCare ABP members can also ask for a Medicaid fair hearing within 20 calendar days from the date of the notice of the decision. According to state rules, NJ FamilyCare B, C and D members do not have the right to a Medicaid fair hearing. See the section “Medicaid Fair Hearing” for more information. More information about fair hearings is below. If your grievance is an emergency, we will take care of it within 24 hours of when we get it. If it is urgent, it will be taken care of within 48 hours. If you file a Level 2 grievance, Amerigroup will not hold it against you. We will still be here to help you get quality health care. Medicaid Fair Hearing For Complaints and Grievances If you are not pleased with the way Amerigroup has answered your complaint or grievance, all Medicaid enrollees, NJ FamilyCare A and NJ FamilyCare ABP members can ask for a Medicaid fair hearing. You can write to ask for a fair hearing within 20 calendar days from the date of the notice of the decision regarding your complaint or grievance. You can ask for a Medicaid fair hearing by writing to: Department of Human Services Division of Medical Assistance and Health Services Fair Hearing Section P.O. Box 712 Trenton, NJ 08625‐0712 Please include with your request a copy of the denial letter you received. You can call Member Services to get help writing this letter. According to state rules, NJ FamilyCare B, C and D members do not have the right to a Medicaid fair hearing. If you are not sure if you have the right to a fair hearing, you can call Member Services at 1‐800‐600‐4441 (TTY 711). 55 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 If Amerigroup Will Not Pay for or Authorize a Service There may be times when we say we will not pay for or authorize care that has been requested. For example, if you or your doctor asks for a service that is not medically necessary, or your doctor tells you that a service is not covered and you agree to pay for it before you get care, we may not pay for it. If we do not pay for or authorize the services requested, you can file an appeal. You may also give your doctor, a lawyer, a friend or other person your written permission to appeal on your behalf. An 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 may also request a copy of the records related to the appeal free of charge. You have the right to file an appeal in your language. If you need help filing an appeal in your language, call Member Services at 1‐800‐600‐4441 (TTY 711). If your doctor, lawyer, friend or other authorized person appeals on your behalf, you must provide your written consent. You will still be covered for the service by Amerigroup while an appeal is being reviewed if: The appeal is filed on time The appeal involves a course of treatment that was authorized The services were ordered by an Amerigroup authorized provider For those who are eligible and request a Medicaid Fair Hearing, your written request to continue services is received within 20 calendar days of the most recent denial notice. If you request a continuation of benefits under the Medicaid appeal process and your appeal is denied, you may be required to pay for the cost of these services. How to File a Medical Appeal Amerigroup has two stages of appeal: 1. At Stage 1, you or your doctor, lawyer, friend or other authorized person (with your written consent) can ask for an appeal. A different doctor, who was not involved in the first decision, will review your appeal and decide what we should do. 2. If the medical director who looks at your case decides that the service is not medically necessary, you or your doctor (with your written consent) can ask for a Stage 2 appeal. A panel of doctors, nurses and/or other health care professionals who have not seen your case before will review it and decide what we should do. If the care your doctor says you need is an emergency, we will answer your appeal within 24 hours of when we get it. If the care your doctor says you need is urgent, we will answer your appeal within 48 hours. All other Stage 1 appeals will be concluded in 10 calendar days. If you are not satisfied with any denial decision, you or your doctor (with your consent) can talk to the same medical director who made the denial determination. During any stage of the appeal process, you will still be covered for the service by Amerigroup while an appeal is being reviewed if: The appeal is filed on time The appeal involves a course of treatment that was authorized The services were ordered by an Amerigroup authorized provider For those who are eligible and request a Medicaid Fair Hearing, you must request this in writing within 20 days of the date of our most recent denial letter to receive continuation of the services. If you request a 56 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 continuation of benefits under the Medicaid appeal process and your appeal is denied, you may be required to pay for the cost of these services. Stage 1 Appeal To ask for a Stage 1 appeal, you can write us a letter or call us to ask for an appeal. You must ask for this appeal within 90 calendar days from the date of the letter that told you we still will not pay for the service. You can call Member Services at 1‐800‐600‐4441 (TTY 711) or mail your letter and all of your medical information about the service to: Appeals Department Amerigroup Community Care 101 Wood Ave. South, 8th Floor Iselin, NJ 08830 Your doctor, lawyer, friend or other person (with your written consent) can appeal on your behalf. If we need more medical information to look at your case, we will ask you or your doctor for the information we need. We will let you know what we decide within 10 calendar days of when we get this information and give you the reason for our decision. If the care your doctor says you need is an emergency, we will answer your appeal within 24 hours of when we get it. If the care your doctor says you need is urgent, we will answer your appeal within two calendar days. If Amerigroup will still not pay for or authorize the service, a Stage 2 appeal can be requested. During any stage of the appeal process, you will still be covered for the service by Amerigroup while an appeal is being reviewed if: The appeal is filed on time The appeal involves a course of treatment that was authorized The services were ordered by an Amerigroup authorized provider For those who are eligible and request a Medicaid Fair Hearing, your written request to continue services is received within 20 calendar days of the most recent denial notice. If you request a continuation of benefits under the Medicaid appeal process and your appeal is denied, you may be required to pay for the cost of these services. Stage 2 Appeal If Amerigroup will still not pay for the service, you or your doctor, lawyer, friend or other authorized person (with your written consent) can ask for a Stage 2 appeal. The Stage 2 appeal can be requested orally or in writing within 90 calendar days from the date of the Stage 1 appeal letter that told you we would not pay for the service. If you call, we recommend that you follow your call with a written request, although this is not required. You can call us at 1‐800‐600‐4441 (TTY 711). And mail your letter and any additional information to the address above. When we get your call or the letter requesting the Stage 2 appeal, we will send you a letter within 10 calendar days that will let you know that we got your appeal. Amerigroup will choose doctors, nurses and other health care professionals to be on your appeal panel who have not seen your case before. At least one of those doctors will specialize in the care you are asking for. You have the right to speak to the appeal panel in person or on the telephone. We will send you a letter with an 57 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 answer within 20 business days from when you or your doctor asks to appeal and give you a reason for our decision. If the care your doctor says you need is an emergency, we will tell you what we decide about your appeal within 24 hours of when we get it. If the care your doctor says you need is urgent, we will tell you what we decide about your appeal within two days. During any stage of the appeal process, you will still be covered for the service by Amerigroup while an appeal is being reviewed if: The appeal is filed on time The appeal involves a course of treatment that was authorized The services were ordered by an Amerigroup authorized provider For those who are eligible and request a Medicaid Fair Hearing, you must request this in writing within 20 days of the date of our most recent denial letter to receive continuation of the services. If you request a continuation of benefits under the Medicaid appeal process and your appeal is denied, you may be required to pay for the cost of these services. Independent Health Care Appeals Program You also have the right to a Stage 3 appeal. This appeal does not apply to services related to Personal Care Assistance (PCA). The appeal is sent to the Independent Health Care Appeals Program (IHCAP), which is run by the New Jersey Department of Banking and Insurance (DOBI). Just like for the first two stages of appeals, you also have the right to consent to have your doctor or provider appeal on your behalf. Through IHCAP, your appeal will be reviewed by an Independent Utilization Review Organization (IURO). If your appeal involves the denial of Personal Care Assistant (PCA) services, you cannot proceed to a Stage 3 appeal with the IURO. If you choose to continue to appeal a denial of PCA services after Stage 2, you must proceed to a Medicaid Fair Hearing. See the section on “Medicaid Fair Hearing for Appeals.” You or your doctor, lawyer, friend or other authorized person (with your written consent) can file this appeal if the Stage 2 appeal panel decides that we should not pay for or authorize the services, if Amerigroup does not complete your appeal on time, or if Amerigroup gives up its right to review your appeal. If we send you a Stage 2 denial letter, we will also send you a form to apply for an appeal to IHCAP. An appeal to IHCAP must be made within four months of the date of the Stage 2 appeal letter. Send the signed application, a copy of the Stage 2 appeal letter and copies of any related medical records to: Department of Banking and Insurance Office of Managed Care P.O. Box 329 Trenton, NJ 08625‐0329 The IURO assigned by IHCAP will let you know right away if they will review your case. If they do, a decision will be made within 45 calendar days. In emergency/urgent care cases, the IURO will complete its review within 48 hours of when it received the appeal. Amerigroup will do what the IURO decides. If the IURO decides you were denied services that are medically necessary, it will let you know the proper covered services you should receive. The IURO will also tell 58 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Amerigroup what services you should receive. Amerigroup will provide coverage for the services the IURO says are medically necessary. To get IHCAP application forms and consent forms online, go to the DOBI home page at www.state.nj.us/dobi. If you have any questions about IHCAP, call Member Services at 1‐800‐600‐4441 (TTY 711). Or call DOBI at 609‐292‐5316, ext. 50998, or toll free at 1‐888‐393‐1062. If Your Doctor Files a Claim Appeal Your doctor, a hospital where you were treated or other providers have the right to appeal a claim denial and go to arbitration on their own behalf. To do this, they will need your consent to release your personal health information. If you have not already signed the consent form, they might ask you to sign the form for this appeal. The outcome of this appeal does not affect your coverage with Amerigroup. If you have any questions, call Member Services. Medicaid Fair Hearing for Appeals Medicaid, NJ FamilyCare A and NJ FamilyCare ABP members also have the right to ask for a Medicaid fair hearing. You can write to ask for a fair hearing anytime during the appeal process. But you must ask for a fair hearing no later than 20 calendar days from the date of our denial letter about the appeal. You have the right to appear at the fair hearing. You can have a lawyer, friend or someone else speak for you at the hearing. Amerigroup will follow the fair hearing decision. To ask for a fair hearing, send a letter and a copy of the denial letter to: Division of Medical Assistance and Health Services Fair Hearing Section P.O. Box 712 Trenton, NJ 08625‐0712 If you decide to request a Medicaid fair hearing at this time and wish to request a continuation of benefits, you must do so in writing within 20 calendar days of the date of the most recent denial letter. If you request a continuation of benefits under the Medicaid fair hearing process and your appeal is denied, you may be required to pay for the costs of these services. During any stage of the appeal process or the Medicaid fair hearing process, you will still be covered for the service by Amerigroup while an appeal is being reviewed if: The appeal is filed on time The appeal involves a course of treatment that was authorized The services were ordered by an Amerigroup authorized provider For the Medicaid Fair Hearing process only, your written request to continue services is received within 20 calendar days of the date on the most recent denial letter. If you request a continuation of benefits under the Medicaid appeal process and your appeal is denied, you may be required to pay for the cost of these services. If you file a fair hearing, Amerigroup will not hold it against you. We will still be here to help you get quality health care. If you have any questions about our appeal process, the IURO or the Medicaid fair hearing, please call Member Services. 59 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Member Explanation of Benefits If you receive a service from a provider, and Amerigroup does not pay for that service, you may receive a notice from Amerigroup. This notice is 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 can’t pay for it. 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 have to do anything at that time, unless you or your provider wants to appeal the decision. An appeal is when you ask Amerigroup to look again at the service we said we would not pay for. You must ask for an appeal within 90 calendar days of receiving the EOB. To appeal, you or your doctor can call Member Services or mail your request and medical information for the service to: Medical Appeals Amerigroup Community Care P.O. Box 62429 Virginia Beach, VA 23466‐2429 Amerigroup can accept your appeal by telephone. Medicaid, NJ FamilyCare A and NJ FamilyCare ABP members have the right to ask for a Medicaid fair hearing. You can request a fair hearing by sending a letter and a copy of the denial letter to: Division of Medical Assistance and Health Services Fair Hearing Section P.O. Box 712 Trenton, NJ 08625‐0712 You must ask for a fair hearing within 20 calendar days from the date you receive the EOB. If you have any questions about your rights to appeal or request a fair hearing, call Member Services at 1‐800‐600‐4441 (TTY 711). OTHER INFORMATION If You Move If you move to another county in New Jersey, you may need to disenroll from Amerigroup. ABD, DDD and DDD/CCW members may stay in Amerigroup even if they move out of the service area. But they must keep seeing an Amerigroup network doctor. All Amerigroup members should call the Health Benefits Coordinator at 1‐800‐701‐0710 (TTY 1‐800‐701‐0720) if they are moving or planning to move. You can visit your County Welfare Agency if you are planning to move, too. If you are a NJ FamilyCare member, please call NJ FamilyCare at 1‐800‐701‐0710 (TTY 1‐800‐701‐0720) to report your new address. You may also call Amerigroup Member Services at 1‐800‐600‐4441 (TTY 711). Renew Your Eligibility for Your Medicaid, SSI or NJ FamilyCare Benefits on Time Keep your health care coverage. Do not lose your health care benefits. You could lose your benefits even if you still qualify. Every year, the County Welfare Agency (CWA) will send you a form. This form tells you it is time to renew your Medicaid, SSI or NJ FamilyCare benefits. Be sure to look at the due date on your form. You need to renew your eligibility on time. If your eligibility has ended, you will no longer be enrolled in Amerigroup. Be sure to follow 60 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 the CWA rules about filling out the form. Turn it in before the date on your form. Your state case manager can help you fill out the form. If you have any questions, you can also call or go to the CWA office in your area. These offices are listed below. NJ FamilyCare members should call NJ FamilyCare at 1‐800‐701‐0710 (TTY 1‐800‐701‐0720) with any questions about renewing their eligibility. We want to help you keep getting your health care benefits from us if you still qualify. Helping you stay well is very important to us. LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES Atlantic County Department of Family and Community Development 1333 Atlantic Ave. Atlantic City, NJ 08401 609‐348‐3001 Fax: 609‐343‐2374 Hours: 8:00 a.m. ‐ 5:00 p.m. Bergen County Bergen County Board of Social Services 218 Route 17 North 17 Park Office Center ‐ Building A Rochelle Park, NJ 07662 201‐368‐4200 Fax: 201‐368‐8710 Hours: 7:45 a.m.‐ 4:45 p.m. Tues.: 7:45 a.m. ‐ 8:00 p.m. Burlington County Burlington County Board of Social Services Human Services Facility 795 Woodlane Road Mount Holly, NJ 08060 609‐261‐1000 Fax: 609‐261‐0463 Hours: 8:00 a.m. ‐ 5:00 p.m. Camden County Camden County Board of Social Service Althea R. Wright Administration Building 600 Market St. Camden, NJ 08102‐1255 856‐225‐8800 Fax: 856‐225‐7797 Hours: 8:30 a.m. ‐ 4:30 p.m. Cape May County Cape May County Board of Social Services 4005 Route 9 South Rio Grande, NJ 08242 South Rio Grande, NJ 08242 609‐886‐6200 Fax: 609‐889‐9332 Hours: 8:30 a.m. ‐ 4:30 p.m. Cumberland County Cumberland County Board of Social Services 275 North Delsea Dr. Vineland, NJ 08360‐3607 856‐691‐4600 Fax: 856‐692‐7635 Hours: 8:30 a.m. ‐ 4:30 p.m. Essex County Essex County Dept of Citizen Services Division of Welfare 18 Rec‐r St. ‐ 9th Floor Newark, NJ 07102 973‐733‐3000 Fax: 973‐643‐3985 Hours: 7:30 a.m. ‐ 4:00 p.m. Weds. by appointment only: 7:30 a.m. ‐ 7:30 p.m. Gloucester County Gloucester County Division of Social Services 400 Hollydell Drive Sewell, NJ 08080 856‐582‐9200 Fax: 856‐582‐6587 Hours: 8:30 a.m. ‐ 4:30 p.m. Every 1st & 3rd Tues.: 8:30 a.m. ‐ 6:30 p.m. 61 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES Hudson County Hudson County Dept of Family Services Division of Welfare 257 Cornelison Ave. Jersey City, NJ 07302 201‐420‐3000 Fax: 201‐420‐0343 Hours: 8:00 a.m. ‐ 4:15 p.m. Hunterdon Hunterdon County Department of Human Services Division of Social Services P.O. Box 2900 6 Gauntt Place Flemington, NJ 08822‐2900 908‐788‐1300 Fax: 908‐806‐4588 Hours: 8:30 a.m. ‐ 4:30 p.m. Mercer Mercer County Board of Social Services 200 Woolverton St. Trenton, NJ 08650‐2099 609‐989‐4320 Fax: 609‐989‐0405 Hours: 8:30 a.m. ‐ 4:30 p.m. Tues.: 8:30 a.m. ‐ 8:30 p.m. Middlesex Middlesex County Board of Social Services 181 How Lane P.O. Box 509 New Brunswick, NJ 08903 732‐745‐3500 Fax: 732‐745‐4558 Hours: 8:30 a.m. ‐ 4:15 p.m. Monmouth Monmouth County Division of Social Services 3000 Kozloski Road P.O. Box 3000 Freehold, NJ 07728 Fax: 732‐431‐6017 Freehold Hours: 8:30 a.m. ‐ 4:40 p.m. Thurs.: 8:30 a.m. ‐ 8:00 p.m. Ocean Field Office: 8:30 a.m. ‐ 4:30 p.m. Tues. & Weds.: 8:30 a.m. ‐ 8:00 p.m. Morris Morris County Office of Temporary Assistance 340 W. Hanover Ave. P.O. Box 900 Morristown, NJ 07963‐0900 973‐326‐7800 Fax: 973‐326‐7875 Hours: 8:30 a.m. ‐ 4:30 p.m. Every Other Tues.: 8:30 a.m. ‐ 7:30 p.m. Ocean Ocean County Board of Social Services 1027 Hooper Ave. P.O. Box 547 MS River, NJ 08753‐0547 732‐349‐1500 Fax: 732‐244‐8075 Hours: 8:30 a.m. ‐ 4:30 p.m. Tues.: 8:30 a.m. ‐ 6:00 p.m. Passaic Passaic County Board of Social Services 80 Hamilton St. Paterson, NJ 07505‐2060 973‐881‐0100 Fax: 973‐881‐3232 Hours: 7:30 a.m. ‐ 4:30 p.m. 62 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES Salem Salem County Board of Social Services 147 South Virginia Ave. Penns Grove, NJ 08069‐1797 856‐299‐7200 Fax: 856‐299‐3245 Hours: 8:00 a.m. ‐ 4:00 p.m. Somerset Somerset County Board of Social Services P.O. Box 936 73 East High St. Somerville, NJ 08876‐0936 908‐526‐8800 Fax: 908‐231‐9010 Hours: 8:15 a.m. ‐ 6:00 p.m. Field Office Hours: 8:30 a.m. ‐ 4:30 p.m. Sussex Sussex County Division of Social Services 83 Spring St., Suite 203 P.O. Box 218 Newton, NJ 07860‐0218 973‐383‐3600 Fax: 973‐579‐9894 Hours: 8:30 a.m. ‐ 4:30 p.m. Union Union County Division of Social Services 342 Westminster Ave. Elizabeth, NJ 07208‐3290 908‐965‐2700 Fax: 908‐965‐2752 Hours: 8:30 a.m. ‐ 4:30 p.m. Warren Warren County Division of Temporary Assistance and Social Services 1 Shotwell Drive Belvidere, NJ 07823 908‐475‐6301 Fax: 908‐475‐1533 Hours: 8:30 a.m. ‐ 4:30 p.m. How to Disenroll from Amerigroup for AFDC/TANF or ABD and Related Groups If you do not like something about Amerigroup, please call Member Services at 1‐800‐600‐4441 (TTY 711). Or call the state’s Health Benefits Coordinator at 1‐800‐701‐0710 (TTY 1‐800‐701‐0720). We want to keep you as a member. We will try to work with you to fix the problem. If you are an AFDC/TANF member, you can disenroll without a reason during the first 90 calendar days. Or you can disenroll after your enrollment date. You can also disenroll during the first 90 calendar days after the date you were told you were enrolled, whichever is later. AFDC/TANF members may not disenroll without a reason for the rest of their 12‐month enrollment period after the first 90 calendar days. You can only disenroll if you have a good reason. After this period, you can choose to disenroll during the annual open enrollment period without cause. The annual open enrollment period is October 1 through November 15. Otherwise, enrollment with Amerigroup will continue as long as you are still eligible for benefits. Individuals who are eligible through the Division of Child Protection and Permanency can disenroll and transfer to another health plan at any time. 63 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 To disenroll from Amerigroup, you must call the Health Benefits Coordinator at 1‐800‐701‐0710 (TTY 1‐800‐701‐0720). The Health Benefits Coordinator is with the Department of Human Services (DHS). DHS must approve your disenrollment. If you disenroll on your own for good cause, during the first 90 calendar days or open enrollment, you can write a letter that tells the reasons why you are disenrolling. You do not have to write a letter if you do not want to. As soon as you disenroll, you must return your Amerigroup ID card to Amerigroup (see page 5 for address). If you have any questions about this, please call Member Services at 1‐800‐600‐4441 (TTY 711). If you get AFDC/TANF through Medicaid and you disenroll, you must enroll with another plan to keep getting Medicaid. SSI, DDD and DDD/CCW members (Medicaid only/without Medicare coverage) also must join another health plan if they disenroll. SSI, DDD and DDD/CCW members with Medicaid and Medicare coverage do not have to enroll in another health plan if they disenroll. If you have Medicaid and Medicare coverage, you do not have to enroll with another plan and may keep getting Medicaid services through the regular Medicaid program. You may disenroll at any time with good reason. Disenrolling will take 30 to 45 calendar days. During this time, Amerigroup will keep providing for your care until you are disenrolled. If you disenroll from Amerigroup, you can change your mind. To switch back to Amerigroup, you must ask the Health Benefits Coordinator to re‐enroll you. Call 1‐800‐701‐0710 (TTY 1‐800‐701‐0720). Enrolling again takes 30 to 45 calendar days. During this time, you would not be covered by Amerigroup. You would continue to be covered by your current fee‐for‐service Medicaid or HMO, if applicable. For NJ FamilyCare Members You can disenroll without a reason during the first 90 calendar days after your enrollment date. You can also disenroll during the first 90 days after the date you were told you were enrolled, whichever is later. You may not disenroll without a reason for the rest of the 12‐month enrollment period. You must have a good reason to disenroll or transfer from Amerigroup. After this time, you can choose to disenroll without cause during the annual open enrollment period. The annual open enrollment period is October 1 through November 15. Otherwise, you will always be enrolled every 12 months with Amerigroup as long as you are still eligible for benefits, or unless you choose a different HMO. If you disenroll on your own for good cause, during the first 90 calendar days or open enrollment, you can write a letter that tells the reasons why you are disenrolling. You do not have to write a letter if you do not want to. As soon as you disenroll, you must return your Amerigroup ID card to Amerigroup (See page 5 for address). If you have any questions about when you became a member of Amerigroup, please call Member Services at 1‐800‐600‐4441 (TTY 711). You may disenroll at any time with good reason. If you choose to disenroll from Amerigroup, you must enroll with another plan to keep your coverage under NJ FamilyCare. DMAHS must approve your disenrollment. Please call the state’s Health Benefits Coordinator at 1‐800‐701‐0710 (TTY 1‐800‐701‐0720). Reasons You Can Be Disenrolled from Amerigroup for AFDC/TANF or ABD and Related Groups There are several ways you could be disenrolled without asking to be disenrolled. 64 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 The state will disenroll you from Amerigroup if you are no longer eligible for Fee‐for‐Service (FFS). If you are eligible for FFS again within the next two months, the state will re‐enroll you in Amerigroup. The state will disenroll you from Amerigroup if you are changed to certain eligibility groups or programs or types of care. You may not be in Amerigroup if you are in: An intermediate care facility for persons with developmental disabilities, or some other residential treatment setting (under some circumstances your care may be authorized by Amerigroup) The medically needy Medicaid eligibility group The presumptive eligibility group A Program of All‐Inclusive Care for the Elderly (PACE) program Others who may not be in Amerigroup include: Infants of inmates of a public institution living in a prison nursery Individuals in out‐of‐state placements unless approved by Amerigoup Full‐time students attending school and residing out of the country You can be disenrolled for the following reasons: Amerigroup stops providing services for the NJ FamilyCare program You are no longer eligible You move outside of the enrollment area covered by the contract DMAHS and you decide that disenrollment would be best for you You are an MLTSS member with a payment liability you have not paid You are institutionalized in a facility other than a nursing facility/special care nursing facility You willfully act in a way that hurts the purpose of our plan such as: ‐ You do not follow the rules in this handbook ‐ You let another person use your Amerigroup ID card, or you are involved in any other type of fraud ‐ You will not work with your doctor on getting and keeping appointments Before we ask DMAHS to disenroll you for any of these reasons, we will try to contact you at least three times. We will do this to explain to you why you could be disenrolled. We will try to help you stay in our plan. Being sick or needing a lot of health care is not a reason for us to ask the state to disenroll you. For NJ FamilyCare Members There are several ways you could be disenrolled without asking to be disenrolled: Amerigroup stops providing services for NJ FamilyCare Your family is no longer eligible You do not pay your premium (NJ FamilyCare D members only) You move outside of the enrollment area covered by the contract (this does not apply to covered full‐time students) You willfully act in a way that hurts the purpose of our plan such as: ‐ You do not follow the rules in this handbook ‐ You let another person use your Amerigroup ID card, or you are involved in any other type of fraud ‐ You will not work with your doctor on getting and keeping appointments 65 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Before we ask NJ FamilyCare to disenroll you for these reasons, we will try to contact you at least three times. We will do this to explain why you could be disenrolled. We will try to help you stay in our plan. Being sick or needing a lot of health care is not a reason for us to ask the state to disenroll you. You Asked to Be Enrolled in Amerigroup and Did Not Get Enrolled The state makes sure you can enroll in Amerigroup if you want. The Health Benefits Coordinator, as an agent of the state, processes your enrollment form. They may decide you cannot be in Amerigroup. This is usually for the reasons listed in the section Reasons You Can Be Disenrolled from Amerigroup. We hope you will choose Amerigroup again if you get a chance. It takes 30 to 45 calendar days for the state to enroll you in Amerigroup. So if you are not enrolled in Amerigroup yet, you may get enrolled next month. You will get health care benefits from fee‐for‐service Medicaid or your current health plan until your enrollment starts with Amerigroup. Your Amerigroup ID card tells you the date your enrollment starts. If you did not pick a health plan, the state will choose one for you. This is known as an auto‐assignment. If You Have Other Health Insurance Each type of health insurance coverage you have is called a payer. When there is more than one payer, there are certain rules to decide how payments are made and how much each payer gets. Other payers may be Medicare, another health insurance company or fee‐for‐service Medicaid. Certain payers pay for some services before others. Your NJ FamilyCare health plan pays for covered services last. Always show all of your insurance cards when getting services. The providers for your Medicare or other health care plan don’t have to be in the Amerigroup network. Also, if your provider through Medicare or other health care refers you to a specialist for services covered by Medicare or the other health care plan, you don’t need a referral from Amerigroup. You can find out more about the rules on having other health insurance by going online to www.state.nj.us/humanservices/dmahs/home/Medicaid_TPL_Coverage_Guide.pdf. The guide, When You Have Medicaid and Other Insurance, is provided by the state of New Jersey. It can help you understand how service payments work. The guide contains helpful reference. The charts are called When You Have Both Medicare and Medicaid and When You Have Both Other Health Insurance and Medicaid. They can help you decide which providers to choose and which company is the payer. Please call Amerigroup Member Services at 1‐800‐600‐4441 (TTY 711) if you or your children have other insurance. Your other insurance plan may need to be billed for your health care services before Amerigroup can be billed. Amerigroup will work with other insurance plans on payment for these services. 66 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 What You Should Do If You Get a Bill for a Service ABD, DDD, NJ FamilyCare A, ABP and B members do not pay for Amerigroup covered services. Certain NJ FamilyCare C and D members do pay a copayment for some services. The copayments are listed in the section “Amerigroup Covered Services for Medicaid and NJ FamilyCare Members.” Your doctor must tell you if any services are not covered and that you will be billed if you get any of these services. Also, if you want a noncovered service, you must agree in writing to pay for the service before you get care. If you go to a doctor who is not in the Amerigroup plan or is not a doctor your Amerigroup network doctor has sent you to, you will have to pay for your care unless it is an emergency or a self‐referral service. See the sections “Emergency Care” and “Services That Do Not Need Referrals” for more information. If you get a bill from a doctor by mistake, please call Amerigroup Member Services. We will work with the doctor to try to fix this. You may be responsible to pay for a service if you do not follow Amerigroup rules. If you go to a doctor who is not an Amerigroup provider and to whom your network PCP has not referred you, you must pay the doctor for this care. If you decide to get care that is not covered by Amerigroup or fee‐for‐service Medicaid, you will have to pay for this care. Changes in Your Amerigroup Coverage Amerigroup may have to make changes in the way it works, its covered services, or its network of doctors and hospitals. The Amerigroup member newsletter will tell you about any changes. Please read it when it comes. The member handbook we send you each year will also talk about any changes. Sometimes providers will leave Amerigroup or move. If we have to change one of your Amerigroup network providers, we will call or write you a letter. You have the right to get up to 120 calendar days coverage or more (if medically necessary) from your doctor if he or she leaves the Amerigroup network. (Note: If your doctor can’t take part in Medicaid or Medicare or is terminated for losing his/her license, your doctor can’t provide this care.) Member Services will help you find a new provider or your provider’s new office. How to Tell Amerigroup About Changes You Think Should Be Made We want to know what you like and do not like about Amerigroup. Your ideas will help us make Amerigroup better. You can call Member Services to tell us your ideas. Amerigroup has a group of members who meet quarterly to give us their ideas. If you would like to be a part of this group, call Member Services. Amerigroup also sends some members surveys. The surveys ask questions about how you like Amerigroup. If we send you a survey, please fill it out and send it back. Member Services staff may also call to ask how you like Amerigroup. Please tell them what you think. Your ideas can help make Amerigroup better. How Amerigroup Pays Providers Different providers in our network have agreed to be paid in different ways by us. 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). You can request more information about: How our PCPs or any other providers in our network are paid If your PCP qualifies for an incentive plan for EPSDT lead screening Whether stop‐loss protection is offered 67 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 The results of the member satisfaction surveys and quality testing done by the Department of Human Services If you want to request this information, please call Amerigroup Member Services at 1‐800‐600‐4441 (TTY 711). Or write to us at: Amerigroup Community Care 101 Wood Ave. South, 8th Floor Iselin, NJ 08830 Some providers may have a financial interest in another health care provider or facility. If this is the case and your provider sends you to one of these providers or facilities for care, he or she must tell you about this financial interest. You can ask your provider more about this. If you are unable to get this information from your provider, you can call: The Division of Consumer Affairs New Jersey Department of Law and Public Safety 973‐504‐6200 or 1‐800‐242‐5846 Amerigroup models its programs on the quality standards set by the National Committee for Quality Assurance. All Utilization Management (UM) decisions are based solely on a member’s medical needs and benefits. UM decision‐makers do not get any financial reward if members don’t use all of the available services. Practitioners and others involved in UM decisions do not receive any type of reward for denial of care or coverage. YOUR RIGHTS AND RESPONSIBILITIES Your Rights As an Amerigroup member, you have the right to: Get a current directory of doctors within the Amerigroup network that includes addresses, telephone numbers and a list of providers that accept members who speak languages other than English Choose any of our Amerigroup network specialists. You need to get a referral from your primary care provider (PCP) first. The referral is based on whether the specialist can take new patients. Some services do not need a referral. (See the section “Services That Do Not Need Referrals.”) Be referred by your PCP to get care from a specialist who has treated chronic disabilities Be able to get in touch with your PCP or a backup PCP 24 hours a day, 365 days a year for urgent care. This information is on your member ID card. Call 911 without getting an OK from Amerigroup if you have an emergency medical condition. This information is on your member ID card. Talk with your doctors about all medical treatments you can have, even if they are not covered. You can also get information on treatment you can have or other care options. This includes anything listed in the clinical guidelines. You can ask for a copy. Call Member Services at 1‐800‐600‐4441 (TTY 711). File a complaint or appeal with Amerigroup or the state and not be penalized. Please refer to the “Complaints, Grievances and Medical Appeals” section of the handbook for more information. Be treated with respect and dignity 68 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 Have information about Amerigroup, our services, policies and procedures, network providers, member rights and responsibilities, and any changes made Refuse treatment to the extent of the law and be aware of the results. This includes the right to refuse to be a part of research. Have an advance directive in effect. Expect that your records and communications will be kept confidential. They will not be given to anyone unless you allow it. Choose your own PCP in the Amerigroup network, choose a new network PCP and have privacy when seeing your providers Have a choice of specialists and get information on how to get a referral to a specialist or other provider, like an eye doctor Have your medical information given to a person you choose or have it given to a person who is legally authorized when concern for your health makes it inadvisable to give such information to you Get help from someone who speaks your language or through a TTY line Be free from being billed by providers for covered services that are medically necessary and were authorized by Amerigroup unless there is a copayment Offer suggestions for changes in the way Amerigroup does business Be free of hazardous procedures Be fully informed by your PCP, care manager or other Amerigroup network provider and help make decisions about your health care Take part in developing and implementing a plan of care that promotes the best results for you and encourages independence Have services that promote quality of life and independence. Amerigroup wants to help keep and encourage your natural support systems. Have a doctor be the one to decide if your coverage is to be denied or limited Voice complaints about Amerigroup or the care provided and recommend changes to policies and services to Amerigroup staff, providers and outside representatives of your choice free of limits, interference, force, discrimination or attack by Amerigroup or our providers Right to refuse care from specific providers Have access to your medical records in accordance with federal and state laws Be free from harm, including unnecessary physical restraints or isolation, excessive medication, physical or mental abuse, or neglect Make recommendations regarding the member rights and responsibilities policy Receive a second opinion You have the right to get information each year on: Member rights and responsibilities Amerigroup benefits and services and how to get these benefits and services Provisions for after‐hours and emergency coverage Charges to members, if charges apply, including: ‐ How to pay charges ‐ Copayments and fees ‐ What to do if you get a bill for services Termination of or changes in benefits, services, health care facilities or providers How to appeal decisions that affect your coverage, benefits or relationship with Amerigroup 69 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 How to change PCPs How to disenroll from Amerigroup for good cause How to file a complaint or grievance and how to recommend changes you think Amerigroup should make The percentage of Amerigroup network providers who are board‐certified A description of: ‐ How to get services, including authorization requirements ‐ Any special benefit rules that may apply to services you get outside of the Amerigroup network ‐ How to get services covered by fee‐for‐service Medicaid ‐ How to get out‐of‐area coverage ‐ Policies on referrals for specialty and ancillary care Your Responsibilities As an Amerigroup member, you have the responsibility to: Let your family doctor know as soon as possible after you get emergency treatment Treat your doctors, their staffs and Amerigroup employees with respect and dignity Get information and consider treatments before they are done Discuss any problems about following your doctor’s directions Know what refusing treatment recommended by a doctor can mean Help your family doctor get your medical records from the doctor you had before; you should help your doctor fill out your new record, as well Get permission from your family doctor or the doctor’s associates before seeing a consultant or specialist; you should also get permission from your doctor before going to the emergency room unless you have an emergency Call Amerigroup and change your doctor before seeing a new doctor Keep following Amerigroup policies and procedures until you are disenrolled Make and keep appointments and be on time; always call if you need to cancel an appointment or if you will be late State your complaints, concerns and opinions in an appropriate and courteous way Learn and follow the policies and procedures outlined in this handbook Tell your doctor who you want to be told about your health Become involved in your health care. You should work with your doctor about recommended treatment. You must then follow the plans and instructions for care that you have agreed upon with your provider. Carry your Medicaid and Amerigroup ID card at all times. You should report any lost or stolen cards to Amerigroup as soon as you can. Also, contact Amerigroup if information on your card is wrong or if you have changes in name or address. Provide, to the extent possible, information needed by Amerigroup, your doctor and professional staff in caring for you including the names of any doctors you are currently seeing Understand your health problems and take part in developing mutually agreed‐upon treatment goals, to the degree possible And remember, it’s your responsibility to keep your address and phone number current so we may send you updated information or contact you. 70 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 HOW TO REPORT SOMEONE WHO IS MISUSING THE NJ FAMILYCARE PROGRAM If you know someone who is misusing (through fraud, waste, abuse and/or overpayment) the NJ FamilyCare program, you can report him or her. To report doctors, clinics, hospitals, nursing homes or NJ FamilyCare enrollees, write or call Amerigroup at: Medicaid Special Investigations Unit Amerigroup Community Care 4425 Corporation Lane Virginia Beach, VA 23462 1‐800‐600‐4441 (TTY 711) Suspicions of fraud, waste and abuse can be emailed directly to the Amerigroup Medicaid Special Investigations Unit at corpinvest@amerigroup.com. Or go online at www.myamerigroup.com. Click the link for Report Waste, Fraud or Abuse to report details about a possible issue. This information is sent directly to the email address above, which is checked every business day. You can also make a report directly to the state of New Jersey. If you suspect Medicaid fraud, waste or abuse, call 1‐888‐937‐2835 toll free. WE HOPE THIS BOOK HAS ANSWERED MOST OF YOUR QUESTIONS ABOUT AMERIGROUP. FOR MORE INFORMATION, YOU CAN CALL THE AMERIGROUP MEMBER SERVICES DEPARTMENT AT 1‐800‐600‐4441 (TTY 711). 71 Member Services • 1‐800‐600‐4441 • TTY 711 • Monday‐Friday 8 a.m.‐6 p.m. NJ‐MHB‐0014‐15 OMHC #078‐15‐71 NJ MHB ENG 01/16 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION WITH REGARD TO YOUR HEALTH BENEFITS. PLEASE REVIEW IT CAREFULLY. HIPAA Notice of Privacy Practices The original effective date of this notice was April 14, 2003. The most recent revision date is shown at the end of this notice. Please read this notice carefully. This tells you who can see your protected health information (PHI). It tells you when we have to ask for your OK before we share it. It tells you when we can share it without your OK. It also tells you what rights you have to see and change your information. Information about your health and money is private. The law says we must keep this kind of information, called PHI, safe for our members. That means if you’re a member right now or if you used to be, your information is safe. We get information about you from state agencies for Medicaid and the Children’s Health Insurance Program after you become eligible and sign up for our health plan. We also get it from your doctors, clinics, labs and hospitals so we can OK and pay for your health care. Federal law says we must tell you what the law says we have to do to protect PHI that’s told to us, in writing or saved on a computer. We also have to tell you how we keep it safe. To protect PHI: On paper (called physical), we: – Lock our offices and files – Destroy paper with health information so others can’t get it Saved on a computer (called technical), we: – Use passwords so only the right people can get in – Use special programs to watch our systems Used or shared by people who work for us, doctors or the state, we: – Make rules for keeping information safe (called policies and procedures) – Teach people who work for us to follow the rules When is it OK for us to use and share your PHI? We can share your PHI with your family or a person you choose who helps with or pays for your health care if you tell us it’s OK. Sometimes, we can use and share it without your OK: For your medical care – To help doctors, hospitals and others get you the care you need For payment, health care operations and treatment – To share information with the doctors, clinics and others who bill us for your care – When we say we’ll pay for health care or services before you get them – To find ways to make our programs better, as well as giving your PHI to health information exchanges for payment, health care operations and treatment. If you don’t want this, please visit www.myamerigroup.com/pages/privacy.aspx for more information. For health care business reasons – To help with audits, fraud and abuse prevention programs, planning, and everyday work – To find ways to make our programs better For public health reasons – To help public health officials keep people from getting sick or hurt With others who help with or pay for your care – With your family or a person you choose who helps with or pays for your health care, if you tell us it’s OK – With someone who helps with or pays for your health care, if you can’t speak for yourself and it’s best for you 72 We must get your OK in writing before we use or share your PHI for all but your care, payment, everyday business, research or other things listed below. We have to get your written OK before we share psychotherapy notes from your doctor about you. You may tell us in writing that you want to take back your written OK. We can’t take back what we used or shared when we had your OK. But we will stop using or sharing your PHI in the future. Other ways we can — or the law says we have to — use your PHI: To help the police and other people who make sure others follow laws To report abuse and neglect To help the court when we’re asked To answer legal documents To give information to health oversight agencies for things like audits or exams To help coroners, medical examiners or funeral directors find out your name and cause of death To help when you’ve asked to give your body parts to science For research To keep you or others from getting sick or badly hurt To help people who work for the government with certain jobs To give information to workers’ compensation if you get sick or hurt at work What are your rights? You can ask to look at your PHI and get a copy of it. We don’t have your whole medical record, though. If you want a copy of your whole medical record, ask your doctor or health clinic. You can ask us to change the medical record we have for you if you think something is wrong or missing. Sometimes, you can ask us not to share your PHI. But we don’t have to agree to your request. You can ask us to send PHI to a different address than the one we have for you or in some other way. We can do this if sending it to the address we have for you may put you in danger. You can ask us to tell you all the times over the past six years we’ve shared your PHI with someone else. This won’t list the times we’ve shared it because of health care, payment, everyday health care business or some other reasons we didn’t list here. You can ask for a paper copy of this notice at any time, even if you asked for this one by email. If you pay the whole bill for a service, you can ask your doctor not to share the information about that service with us. What do we have to do? The law says we must keep your PHI private except as we’ve said in this notice. We must tell you what the law says we have to do about privacy. We must do what we say we’ll do in this notice. We must send your PHI to some other address or in a way other than regular mail if you ask for reasons that make sense, like if you’re in danger. We must tell you if we have to share your PHI after you’ve asked us not to. If state laws say we have to do more than what we’ve said here, we’ll follow those laws. We have to let you know if we think your PHI has been breached. We may contact you You agree that we, along with our affiliates and/or vendors, may call or text any phone numbers you give us, including a wireless phone number, using an automatic telephone dialing system and/or a pre‐ recorded message. Without limit, these calls or texts may be about treatment options, other health‐ related benefits and services, enrollment, payment, or billing. What if you have questions? 73 If you have questions about our privacy rules or want to use your rights, please call Member Services at 1‐800‐600‐4441. If you’re deaf or hard of hearing, call TTY 711. What if you have a complaint? We’re here to help. If you feel your PHI hasn’t been kept safe, you may call Member Services or contact the U.S. Department of Health and Human Services (DHHS) at 1‐800‐368‐1019. Nothing bad will happen to you if you complain. Write to or call the U.S. Department of Health and Human Services: Office for Civil Rights U.S. Department of Health and Human Services Jacob Javits Federal Building 26 Federal Plaza, Suite 3312 New York, NY 10278 Phone: 1‐800‐368‐1019 TDD: 1‐800‐537‐7697 Fax: 212‐264‐3039 We reserve the right to change this Health Insurance Portability and Accountability Act (HIPAA) notice and the ways we keep your PHI safe. If that happens, we’ll tell you about the changes in a newsletter. We’ll also post them on the Web at www.myamerigroup.com/pages/privacy.aspx. Race, ethnicity and language We receive race, ethnicity and language information about you from the state Medicaid agency and the Children’s Health Insurance Program. We protect this information as described in this notice. We use this information to: Make sure you get the care you need Create programs to improve health outcomes Develop and send health education information Let doctors know about your language needs Provide translator services We do not use this information to: Issue health insurance Decide how much to charge for services Determine benefits Disclose to unapproved users Your personal information We may ask for, use and share personal information (PI) as we talked about in this notice. Your PI is not public and tells us who you are. It’s often taken for insurance reasons. We may use your PI to make decisions about your: – Health – Habits – Hobbies We may get PI about you from other people or groups like: – Doctors – Hospitals – Other insurance companies We may share PI with people or groups outside of our company without your OK in some cases. We’ll let you know before we do anything where we have to give you a chance to say no. 74 We’ll tell you how to let us know if you don’t want us to use or share your PI. You have the right to see and change your PI. We make sure your PI is kept safe. Revised January 21, 2016 NJ‐MEM‐0461‐16 OMHC #078‐16‐06 75
