Member
Handbook
NJ-MHB-0017-15 01.16 OMHC #078-15-72
Managed Long Term Services
& Supports Companion Guide
1-800-600-4441 ■ TTY 711
www.myamerigroup.com/nj
www.myamerigroup.com Dear Member: Welcome to our Managed Long Term Services and Supports (MLTSS) program! Thank you for trusting Amerigroup Community Care to manage your MLTSS health care services for you as part of your NJ FamilyCare benefits. This handbook companion guide explains how our MLTSS program works and how it can help keep you healthy. It tells you what your MLTSS coverage is and what limits apply to your MLTSS benefits. For a complete listing of all your Amerigroup benefits and services, please see your Amerigroup member handbook. You may have already received your Amerigroup MLTSS ID card and other information from us. Your ID card will tell you when your Amerigroup membership starts and the name of your primary care provider (PCP). It will also tell you how to contact our MLTSS Care Management program with any questions or concerns. Please check your ID card right away. If you have not received an MLTSS 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. By calling 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 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. And, as our MLTSS member, you can call your care manager anytime. You can reach our MLTSS Team by calling 1‐855‐661‐1996 (TTY 711). We are here to help you receive the right care in your own home or 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 health plan. We are committed to providing you the best possible care. Sincerely, John Koehn President Amerigroup Community Care AMERIGROUP MEMBER HANDBOOK COMPANION GUIDE MANAGED LONG TERM SERVICES AND SUPPORTS PROGRAM 101 Wood Ave. South, 8th Floor ● Iselin, NJ 08830 1‐855‐661‐1996 ● (TTY 711) www.myamerigroup.com/NJ Welcome to Amerigroup Community Care! You will get most of your health care services covered through Amerigroup. This companion guide will tell you how to get the long‐term services you need. Table of Contents
1
Your Introduction to Managed Long Term Services and Supports...............................................................
1
Who is eligible for the MLTSS program?...................................................................................................
What long‐term care services are covered in MLTSS? ............................................................................. 1
Care Coordination and Role of the MLTSS Care Manager ............................................................................ 2
Independence, Dignity and Choice ........................................................................................................... 4
Changing Care Managers .......................................................................................................................... 4
Your MLTSS Member Representative ........................................................................................................... 6
How to Get Free Language Help ................................................................................................................... 6
Questions about your Amerigroup Community Care health plan? .............................................................. 6
6
MLTSS Covered Services and Coverage Limits..............................................................................................
11
Abuse, Neglect and Exploitation.................................................................................................................
12
Critical Incidents......................................................................................................................................
13
YOUR MEMBER RIGHTS AND RESPONSIBILITIES.........................................................................................
15 Renew Your NJ FamilyCare and SSI Benefits on Time .............................................................................
LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES ............................................................................... 15
How to Disenroll from Amerigroup ........................................................................................................ 18
COMPLAINTS, GRIEVANCES AND MEDICAL APPEALS ................................................................................. 19
If You Have a Complaint..........................................................................................................................
19
Filing a Grievance .................................................................................................................................... 20
Level 1 Grievance ................................................................................................................................ 20
Level 2 Grievance ................................................................................................................................ 22
Medicaid Fair Hearing ............................................................................................................................. 23
If Amerigroup Will Not Pay for or Authorize a Service ........................................................................... 23
How to File a Medical Appeal ................................................................................................................. 24
Stage 1 Appeal .................................................................................................................................... 25
Stage 2 Appeal .................................................................................................................................... 25
Independent Health Care Appeals Program ........................................................................................... 26
If Your Doctor Files a Claim Appeal.........................................................................................................
27
Medicaid Fair Hearing for Appeals..........................................................................................................
28
Member Explanation of Benefits ............................................................................................................ 28
MLTSS Patient Pay Liability ......................................................................................................................... 29
Collection of Patient Pay Liability ........................................................................................................... 29
Nonpayment of Patient Pay Liability ...................................................................................................... 29
MLTSS Nursing Facility Transitions ............................................................................................................. 30
How to Contact Us ...................................................................................................................................... 30
Behavioral Health Services..........................................................................................................................
31
MEDICAL ASSISTANCE CUSTOMER CENTERS .............................................................................................. 32
Your Introduction to Managed Long Term Services and Supports Now that you are a member of the NJ FamilyCare MLTSS program, we want to give you a quick introduction to your new program. Below are some answers to frequently asked questions about MLTSS and some basic details about the program we think will be of help to you. What is the Managed Long Term Services and Supports program? Managed Long Term Services and Supports (MLTSS) is a program for managing long‐term care services. Long‐term care includes help doing everyday tasks that you may no longer be able to do for yourself as you grow older or if you have a disability. These include bathing, dressing, getting around your home, preparing meals or doing household chores. Long‐term care also includes care in your own home or in the community that may keep you from having to go to a nursing home for as long as possible. These are called home‐ and community‐based services, or HCBS. Long‐term care services also include care in a nursing home. Who is eligible for the MLTSS program? You can be an Amerigroup MLTSS member if you:  Live in the Amerigroup service area  Meet the clinical eligibility requirements for nursing facility care; for example, you need help with daily living like bathing, dressing, eating or walking, or you have a chronic condition requiring nursing services  Meet Medicaid financial eligibility requirements What long‐term care services are covered in MLTSS? The covered long‐term care services you can receive in MLTSS are nursing home care or home‐ and community‐based services (HCBS) instead of nursing home care. The kind and amount of care you get depends on your needs. Here are the kinds of home care covered in MLTSS (some of these services may have limits):  Home‐based supportive care – Help with your household chores or errands like doing laundry, preparing meals, light housekeeping or grocery shopping  Home‐delivered meals – Nutritionally balanced meals delivered to your home  Personal emergency response system – A call button so you can get help in an emergency when your caregiver is not around  In‐home respite care – Services provided to members unable to care for themselves that are furnished on a short‐term basis because of the absence or need for relief of an unpaid, informal caregiver  Inpatient respite care – A short stay in a nursing home or assisted care living facility so your caregiver can get a break or attend to their personal business 1 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72  Home modifications – Certain modifications or changes to your home that will help you get around easier and safer in your home, like grab bars or a wheelchair ramp (up to $5,000 per project or per calendar year, and $10,000 per lifetime)  Vehicle modifications – Medically needed vehicle modification (such as electronic monitoring systems to enhance personal safety, mechanical lifts to make access possible) to your vehicle or a family vehicle  Assisted care living facility – A coordinated group of supportive personal and health services, chore services, medication administration, intermittent skilled nursing services, available 24 hours per day, to you if you are enrolled in the MLTSS program  Assisted living program – The provision of assisted living services if you live in qualified publicly subsidized housing buildings  Adult family care – Enables up to three unrelated individuals to live in the community in the primary residence of a trained caregiver who provides support and health services for members This doesn’t mean that you will receive services up to the cost of nursing home care. MLTSS won’t pay for more services than you must have to safely meet your needs at home. Remember, MLTSS only pays for services to meet long‐term care needs that can’t be met in other ways. MLTSS services provided to you in your home or in the community will not take the place of care you get from family and friends or services you already receive. If you get help from community programs, services paid for by Medicare or other insurance, or have a family member who takes care of you, these services will not be replaced by paid care through MLTSS. Instead, the home care you receive through MLTSS will work together with the help you already receive to help you stay in your home and community longer. Care in MLTSS will be provided as cost‐effectively as possible. This way, more people who need care will be able to get help. Care Coordination and Role of the MLTSS Care Manager As an MLTSS program member, you will have all of your physical health, behavioral health and long‐term care needs and services managed by Amerigroup. This is called care coordination. These functions are done by a care manager. Your care manager will play a vital role. Your care manager is your main contact person. He or she is the first person you should go to if you have any questions about your services. Amerigroup will tell you who your care manager is. And we’ll tell you how to reach them. Be sure to keep this companion guide in a place that’s easy to find. Write your care manager’s name and contact number below. My care manager is: __________________________________________________ I can reach my care manager at: ______________________________________ 2 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Your care manager will:  Provide information about MLTSS program requirements when you are newly enrolled and will discuss these on an ongoing basis, while updating your care plan  Work with you to ensure that you have all the information you need to make good choices about your health care  Help you get the right kind of long‐term care services in the right setting for you to address your needs  Coordinate all of your physical health, behavioral health, oral health and long‐term care needs  Help to solve issues that you have about your care  Make sure your plan of care is carried out and is working the way that it needs to  Be aware of your needs as they change, update your plan of care when needed (at least once a year), and make sure that the services you get are appropriate for your changing needs  Check at least twice a year to make sure that you continue to need the level of care provided in a nursing home  Communicate with your providers to make sure they know what’s happening with your health care and to coordinate your service delivery  Keep a record of all communications and discussions with you in your care management record Other tasks done by the care manager can vary. This will depend on the types of care you need or receive. If you receive nursing home care, your care manager will:  Be part of the care planning process with the nursing home where you live  Talk with you on an ongoing basis throughout the care planning process  Perform any additional needs assessments that may be helpful in managing your health and long‐
term care needs  Supplement (or add to) the nursing home’s plan of care if there are things Amerigroup can do to help manage health problems or coordinate other kinds of physical and behavioral health care you need  Conduct face‐to‐face visits at least every six months  Coordinate with the nursing home when you need services the nursing home isn’t responsible for providing  Determine if you’re interested and able to move from the nursing home to the community and if so, help make sure this happens timely If you receive home care, your care manager will:  Work with you to do a comprehensive, individual assessment of your health and long‐term care needs and determine the services most appropriate to meet those needs  Work with you to develop your individualized plan of care  Make sure the right health care professionals are consulted during your plan of care process  Give you information to help you choose long‐term care providers contracted with Amerigroup  Contact you by telephone and visit you in person at least once every three months  Make sure your plan of care is carried out and working the way that it needs to  Monitor to make sure you are getting what you need and that gaps in care are addressed right away 3 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 
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Give you information about community resources that might be helpful to you Make sure the home care services you receive are based on your needs and do not cost more than nursing home care Getting to know your care manager (and helping them get to know you) is one of the best ways to make sure you get the coordinated care you need. Please reach out to them with any questions or concerns. They are dedicated to you and your health. Independence, Dignity and Choice In MLTSS, if you qualify for nursing home care, you have the right to choose to get care:
 In your home
 Or in another place in the community (like an assisted living or adult family care program)
 Or in a nursing home
To get care in your home or in the community, you must qualify for MLTSS. And your care manager must
conclude that your needs can safely be met in that setting. The actual kind and amount of care you will
receive depends on your needs.
If you’re in a nursing home, you may be able to move from your nursing home to your own home and
receive services if you want to. If you’d like to move out of the nursing home into the community, talk
with your care manager.
What if you don’t want to leave the nursing home and move to the community? Then, Amerigroup or
your care manager won’t require you to do that, even if we think care in the community would cost less.
As long as you qualify for nursing home care, you can choose it. And you can change your choice at any
time. As long as you qualify, you can enroll in the setting you choose.
In MLTSS, you can also help choose the providers who will give your care. This could be an assisted living
or nursing home. Or it could be the agency who will give your care at home. You may also be able to hire
your own workers for some kinds of care. (This is called Self Direction).
The provider you choose must be willing and able to give your care. Also, the provider must be
contracted with Amerigroup to provide the kind of care you need. Your care manager will try to help you
get the provider you pick.
Changing Care Managers If you’re unhappy with your care manager and would like a different one, you can ask us about making a change. That doesn’t mean you can pick whoever you want to be your care manager. Amerigroup must be able to meet the needs of all its MLTSS members and assign staff in a way that allows us to do that. To ask for a different care manager, call Amerigroup at 1‐855‐661‐1996 (TTY 711). Tell us why you want to change care managers. If we can’t give you a new care manager, we’ll tell you why. We’ll help to address any problems or concerns you have with your current care manager. 4 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 There may be times when Amerigroup will have to change your care manager. This may happen if your care manager:  Is no longer with Amerigroup  Is temporarily not working, or  Has too many members to give them the attention they need If this happens, Amerigroup will send you a letter that says who your new care manager will be. We’ll also tell you how to contact your new care manager. If your assigned care manager is unavailable, you can call the MLTSS team at 1‐855‐661‐1996 (TTY 711). The manager will assign a backup care manager to assist you and follow up on the established care plan. As a member of our MLTSS program, you can contact your care manager any time you have a question or concern about your health care. You do not need to wait until a home visit or a phone call. You should contact your care manager any time you have a change in your health condition or other things that may affect the kind or amount of care you need. If you need help after normal business hours that won’t wait until the next day, you can call Amerigroup at 1‐800‐600‐4441 (TTY 711). As always, if you have a behavioral health crisis (including mental health and substance abuse), please call us at 1‐855‐661‐1996 (TTY 711) 24 hours a day, 7 days a week. Amerigroup has a Behavioral Health Specialized Call Center to manage behavioral health (BH) calls from you and providers. During normal business hours, these calls are answered by Behavioral Health Care Services Technicians (CSTs). They are trained to screen all calls for BH emergencies. When the CST recognizes a likely BH emergency, the call is “warm‐transferred” to a BH utilization management (UM) clinician. In a potential emergency, you are never placed on hold. Our staff will work with you to take care of the emergency. This may include calling 911 or other emergency responders in your community. We’ll remain on the call with you until we know you’re safe. In less extreme cases, we will work with you to make a plan to resolve the emergency. This may involve family members or caregivers, as needed, to be sure the crisis is safely resolved. We make sure to notify BH Care Management as soon as we can to follow up with you. We want to ensure that needed services were received. The BH case manager will also try to conduct a further assessment of your needs and engage them in case management as needed. The BH case manager will help you get appointments. They will also help coordinate care for you when there are many providers. After normal business hours, BH emergency calls are managed by the Nurse HelpLine, 1‐855‐661‐1996 (TTY 711). The 24‐hour Nurse HelpLine staff member will work with you and your family/caregivers, or with emergency responders, as needed, to resolve the emergency. Any emergency behavioral calls after hours are also referred to Care Management for follow‐up. 5 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Your MLTSS Member Representative In addition to your care manager, there is another person at Amerigroup to help you. This person is the MLTSS Member Representative. The MLTSS Member Representative can help you understand the Amerigroup MLTSS program by:  Helping MLTSS members understand and use the MLTSS program  Being a resource for MLTSS members for complaints, appeals and grievances  Providing MLTSS program information to members and their representatives, and  Facilitating resolution of any member issues To reach the MLTSS Member Representative, call 1‐855‐661‐1996 (TTY 711). Ask to speak with the MLTSS Member Representative. How to Get Free Language Help If English is not your first language, you can ask for help in another language. This is a free service. To get help in another language, call Amerigroup at 1‐800‐600‐4441 (TTY 711). Questions about your Amerigroup Community Care health plan? Please review your NJ member handbook. It will tell you how to get the health care you need. You can view your handbook online at www.myamerigroup.com/NJ. Or call our Member Services department at 1‐800‐600‐4441 or the New Jersey MLTSS department at 1‐855‐661‐1996 to request a copy. TTY users can call 711. MLTSS Covered Services and Coverage Limits As our MLTSS member, you receive all the benefits of NJ FamilyCare. You also get your MLTSS coverage and services. Below is a brief description of these services and their coverage limits. If you have any questions about MLTSS services or limits, please call your care manager. Covered Service Coverage Limits Adult Family Care (AFC) Members with AFC do not receive: Enables up to three unrelated individuals to live in  Personal Care Assistant (PCA) the community in the primary residence of a  Chore service trained caregiver who provides support and  Home‐delivered meals health services for the resident  Home‐based Supportive Care  Caregiver/Participant Training  Assisted Living or Assisted Living Program
6 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Covered Service Assisted Living Services (ALS) Coordinated group of supportive personal and health services, medication administration, intermittent skilled nursing services, available 24 hours per day, to residents enrolled in the MLTSS program Includes Assisted Living Residences (ALR) and Comprehensive Personal Care Homes (CPCH) Coverage Limits Members with ALS do not receive:  Personal Care Assistant (PCA)  Adult Day Health Services (ADHS)  Adult Family Care  Assisted Living Program  Environmental Accessibility Adaptations  Chore services  Personal Emergency Response Services  Home‐delivered meals  Caregiver/Participant Training  Social Adult Day Care  Attendant Care  Home‐based Supportive Care  Respite Care
Assisted Living Program (ALP) Members with ALP do not receive: Means the provision of assisted living services to  Personal Care Assistant (PCA) the tenants/residents of qualified publicly  Chore service subsidized housing buildings  Home‐Based Supportive Care  Caregiver/Participant Training Not available in all subsidized senior housing  Assisted Living buildings  Adult Family Care
Entry to this service is based on medical necessity TBI Behavioral Management (group and criteria, and the member must: individual) Daily program provided by, and under the  Have a diagnosis of acquired, nondegenerative, supervision of, a licensed psychologist or board‐
or traumatic brain injury (TBI) or certified/board‐eligible psychiatrist and by trained  Formerly be a TBI waiver member who behavioral aides designed to service recipients transitions into MLTSS who display severe maladaptive or aggressive behavior that is potentially destructive to self or others Caregiver/Participant Training Caregiver/Participant Training is not available to Instruction provided to a member and/or members who have chosen: caregiver in either a one‐to‐one or group situation  Assisted Living Services to teach a variety of skills necessary for  Assisted Living Program or independent living, including but not limited to:  Adult Family Care  Coping skills to assist the member in dealing with disability Does not duplicate the training that is part of the  Coping skills for the caretaker to deal with therapist’s scope of practice on teaching the use of supporting someone with long‐term care needs adaptive equipment  Skills to deal with care providers and attendants Limited to one visit a day. 7 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Covered Service Chore Services Services needed to maintain the home in a clean, sanitary and safe environment Noncontinuous, nonroutine heavy household maintenance tasks intended to increase the safety of the member Coverage Limits Chore services are not available to those with:  Assisted Living Services  Assisted Living Program  Adult Family Care Chore services are authorized only when: Neither the member nor anyone else in the household can perform or pay for the chore. No relative, caregiver, landlord, community agency, volunteer, or third party payer can complete the chore Does not include normal, everyday housekeeping tasks such as dusting, vacuuming, changing bed linens, washing dishes, cleaning the bathroom Cognitive Therapy (group and individual) The member must: Therapeutic interventions for maintenance and  Have a diagnosis of acquired, nondegenerative, prevention of deterioration, including direct or traumatic brain injury or retraining, use of compensatory strategies, use of  Formerly be a TBI waiver participant who cognitive orthotics and prostheses transitions to MLTSS
Community Residential Services (CRS) The member must: A package of services provided to a member living  Have a diagnosis of acquired, nondegenerative, in the community, residence‐owned, rented or or traumatic brain injury or supervised by a CRS provider  Formerly be a TBI waiver participant Community Transition Services Community Transition Services are furnished only Those goods and services provided to a member when they are: that may aid in the transitioning from institutional  Reasonable and necessary as determined settings to his/her own home in the community through the service plan development process through coverage of nonrecurring, one‐time  Clearly identified in the service plan; and the transitional expenses person is unable to meet such expense when the services are not available from other sources These services have a lifetime limit of $5,000. Home‐based Supportive Care (HBSC) HBSC is not available for those who have chosen Designed to assist MLTSS members with their Assisted Living (ALR, CPCH & ALP). Since the PCA Instrumental Activities of Daily Living (IADL) needs State Plan Service can assist with IADLs, HBSC is and are available to members whose Activities of offered only when Activities of Daily Living‐related Daily Living (ADL) needs are provided by nonpaid tasks are provided by a caregiver or another non‐
caregivers such as a family member or as a wrap‐
Medicaid program. around service to non‐Medicaid programs 8 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Covered Service Home‐delivered Meals Nutritionally balanced meals delivered to the member’s home when more cost‐effective than having a personal care provider prepare the meals Medication Dispensing Device Allows for a set amount of medications to be dispensed per the dosage instructions Nursing Facility Services Custodial services that are provided in a licensed facility that provide health care under medical supervision and continuous nursing care for 24 or more consecutive hours Therapy Occupational, physical, speech, hearing and language therapies available to members for the purpose of habilitation and the prevention of loss of function Personal Emergency Response System (PERS) Set up and monthly monitoring using an electronic device that enables members at high risk of institutionalization to secure help in an emergency Private Duty Nursing (PDN) Supplements any other source of care up to a maximum of 16 hours per day, including services provided or paid for by the other sources, if medically necessary, and if cost of service provided is less than institutional care Coverage Limits Home‐delivered meals are provided to a member residing in an unlicensed residence, only when:  The member can’t prepare the meal  The member can’t leave the home independently  There is no other caregiver, paid or unpaid, to prepare the meal No more than one meal per day will be provided through the MLTSS benefit. This device is for a member who lives alone or who is alone for significant amounts of time per the plan of care. Members might not have a regular caregiver for extended periods of time. Or they might need much routine supervision. Provided to members who do not require the degree of care and treatment that a hospital provides and who, because of their physical or mental condition, require continuous nursing care and services above the level of room and board Available only after rehabilitation therapy is no longer available or viable, and authorization will be based on medical necessity Approval of PERS is based on medical necessity for a member who lives alone or who is alone for significant amounts of time – not for members receiving Assisted Living Services or residing in a nursing facility Adult PDN services are provided in the community only (the home or other community setting of the member), and not in hospital inpatient or nursing facility settings. PDN services are a State Plan benefit for children under the age of 21. 9 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Covered Service Residential Modifications Those physical modifications/adaptations to a member's private primary residence which: Are required by his/her plan of care to ensure the health, welfare and safety of the member. Help the member function with greater independence in the home or community and without which the member would need to be in an institution. Respite Services provided to members unable to care for themselves that are furnished on a short‐term basis because of the absence or need for relief of an unpaid, informal caregiver (those persons who normally provide unpaid care) for the member Social Adult Day Care (SADC) A community‐based group program designed to meet the nonmedical needs of adults with functional impairments through a structured comprehensive program that provides a variety of health, social and related support services in a protective setting during any part of a day, but less than 24‐hour care Structured Day Program Program of productive supervised activities, for the development and maintenance of independent and community living skills, provided in a setting separate from the home in which the member lives Supported Day Services Program of member activities for the development of productive activity patterns, requiring initial and periodic oversight, at least monthly and intended to be a home‐ and community‐based service, not provided in an outpatient setting or within a Community Residential Service Vehicle Modifications Vehicle Modifications to a member’s or family vehicle as defined in an approved plan of care Coverage Limits Residential Modifications are limited to $5,000 per calendar year, $10,000 lifetime. Members living in licensed residences (ALR, CPCH, ALP, and Class B & C Boarding Homes) are not eligible to receive Residential Modifications. Adaptations to rented housing units must have the prior written approval of the landlord. Members must live in the residence at least one year for approval of the request. Respite is limited to up to 30 days per member per calendar year. Respite will not be paid back for members who reside permanently in a:  Community Residential Service setting (CRS)  Assisted Living Residence  Comprehensive Personal Care Home or for members admitted to the Nursing Facility
Not available to those receiving Assisted Living Services (ALR & CPCH); cannot be combined with Adult Day Health Services The member must have a diagnosis of acquired, nondegenerative, or traumatic brain injury or formerly be a TBI waiver participant. Structured Day Program cannot be combined with Adult Day Health Services. The member must have a diagnosis of acquired, nondegenerative, or traumatic brain injury or formerly be a TBI waiver participant. Supported Day Services are provided as an alternative to Structured Day Program when the member does not require continual supervision and are not to be provided in a setting where the setting itself is already paid to supervise the member. Vehicle Modifications must be needed to ensure the health, welfare and safety of a participant or which enable the individual to function more independently in the home or community. All services shall be provided in accordance with applicable state motor vehicle codes. 10 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Abuse, Neglect and Exploitation Like all Amerigroup members, our MLTSS members have the right to be free from abuse, neglect and exploitation. It’s important that you understand how to identify abuse, neglect and exploitation and how to report it. Abuse can be:  Physical abuse  Emotional abuse or  Sexual abuse It includes:  Inflicting pain, injury or mental anguish  Unreasonable confinement  Other cruel treatment Neglect can occur when:  An adult is unable to care for himself/herself or to obtain needed care, placing his or her health or life at risk – this is “self‐neglect.”  The basic needs of a child or an adult who is dependent on others are not met by a caregiver, resulting in harm or risk of harm to health or safety. The neglect may be unintended, resulting from the caregiver's lack of ability to provide or arrange for the care or services the person requires. Neglect also may be due to the purposeful failure of the caregiver to meet the person’s needs. Exploitation can include:  Fraud or coercion  Forgery or  Unauthorized use of banking accounts or credit cards Financial exploitation occurs when a caregiver improperly uses funds intended for the care or use of an adult. These are funds paid to the adult or to the caregiver by a governmental agency. If you think you or any other MLTSS member is a victim of abuse, neglect or exploitation, please tell your care manager. All suspected incidents of abuse, neglect or exploitation of an adult should be reported to Adult Protective Services (APS) program at 1‐800‐792‐8820. All reports of abuse or neglect of a child should be reported to 1‐877‐NJ‐ABUSE (1‐877‐652‐2873). At Amerigroup, we do not allow unfair treatment. No one is treated in a different way because of race, beliefs, language, birthplace, disability, religion, sex, color or age. Read more about your right to fair treatment in your Amerigroup NJ member handbook. 11 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Critical Incidents As a member of the Amerigroup MLTSS program, you have a right to enjoy a quality of life that is free of abuse, neglect and exploitation. Members, guardians and legal representatives receive information on Critical Incidents from your assigned care manager during your face‐to‐face visit. If you report a Critical Incident in good faith, or make allegations of abuse, neglect or exploitation, you have a right to be free from any form of retaliation. A Critical Incident Report applies to: 
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Members living in the community, community alternative residential settings, living in an assisted living or nursing facility/SCNF, inpatient behavioral health facility, or attending a program. All Amerigroup associates All MLTSS providers All members enrolled in the Personal Preference Program (PPP) Critical Incidents 
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Unexpected death of a member Missing person or Unable to Contact status Inaccessible for initial on‐site meeting Theft with law enforcement involvement Severe injury or fall resulting in the need for medical treatment Medical or psychiatric emergency, including suicide attempt Medication error resulting in serious consequences Inappropriate or unprofessional conduct by a provider/agency involving the member Suspected or evidenced physical or mental abuse (including seclusion and restraints, both physical and chemical) Sexual abuse and/or suspected sexual abuse Neglect/mistreatment, including self‐neglect, caregiver overwhelmed, and environmental Exploitation, including financial, destruction of property, and theft Failure of a member’s back‐up plan Elopement or wandering from home or facility Eviction/loss of home Facility closure with direct impact to the member’s health and welfare Media involvement or potential for media involvement Cancellation of utilities Natural disaster with direct impact to the member’s health and welfare Other, including if a home health aide does not show up and the backup plan does not work, or there is no backup plan in place 12 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 How to report a Critical Incident:  Members, MLTSS providers, and any Amerigroup associate can contact the member’s assigned care manager to make the report.  Call the NJ MLTSS Team at 1‐855‐661‐1996 (TTY 711), request to speak to a manager, and mention that you are calling to report a Critical Incident. We have designated staff that receive the Critical Incident report, submit the report to the State within 48 hours of the initial report and complete an investigation within 30 days of the initial report. The staff analyzes the information to identify and address potential or actual quality of care and/or health and safety issues. Once the Critical Incident is reported, Amerigroup and the MLTSS provider must take steps to ensure no further harm to the member. YOUR MEMBER RIGHTS AND RESPONSIBILITIES At Amerigroup, we are committed to treating our members in a manner that confirms their rights and responsibilities. We have a written policy that complies with federal and state laws affecting the rights of enrollees. As a member, you have a right to:  Be treated with respect, dignity and need for privacy  Be provided with information about the organization, its services, the practitioners providing care, and member rights and responsibilities and to be able to communicate and be understood with the assistance of a translator if needed  Be able to choose primary care practitioners, within the limits of the plan network, including the right to refuse care from specific practitioners  Participate in decision‐making regarding their health care, to be fully informed by the primary care practitioner, other health care provider or care manager of health and functional status, and to participate in the development and implementation of a plan of care designed to promote functional ability to the optimal level and to encourage independence  Voice grievances about the organization or care provided and recommend changes in policies and services to plan staff, providers and outside representatives of the enrollee's choice, free of restraint, interference, coercion, discrimination or reprisal by the plan or its providers  Formulate advance directives  Have access to his/her medical records in accordance with applicable federal and state laws  Be free from harm, including unnecessary physical restraints or isolation, excessive medication, physical, or mental abuse or neglect  Be free of hazardous procedures  Receive information on available treatment options or alternative courses of care  Refuse treatment and be informed of the consequences of such refusal  Have services provided that promote a meaningful quality of life and autonomy for members, independent living in members’ homes and other community settings as long as medically and socially feasible, and preservation and support of members’ natural support systems 13 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 We also have a written policy that recognizes the rights below. As our MLTSS member, you also have the right to:  Request and receive information on choice of services available  Have access to and choice of qualified service providers  Be informed of your rights prior to receiving chosen and approved services  Receive services without regard to race, religion, color, creed, gender, national origin, political beliefs, sexual orientation, marital status or disability  Have access to appropriate services that support your health and welfare  Assume risk after being fully informed and able to understand the risks and consequences of the decisions made  Make decisions concerning your care needs  Participate in the development of and changes to the plan of care  Request changes in services at any time, including adding, increasing, decreasing or stopping services  Request and receive from your care manager a list of names and duties of any person(s) assigned to provide services to you under the plan of care  Receive support and direction from your care manager to resolve concerns about your care needs and/or complaints about services or providers  Be informed of and receive in writing facility‐specific resident rights upon admission to an institutional or residential setting  Be informed of all the covered/required services you are entitled to, required by and/or offered by the institutional or residential setting, and any charges not covered by the managed care plan while in the facility  Not be transferred or discharged out of a facility except for medical necessity; to protect your physical welfare and safety or the welfare and safety of other residents; or because of failure, after reasonable and appropriate notice of nonpayment to the facility from available income as reported on the statement of available income for Medicaid payment  Have your health plan protect and promote your ability to exercise all rights identified in this document  Have all rights and responsibilities outlined here forwarded to your authorized representative or court‐appointed legal guardian Amerigroup has a written policy that addresses our MLTSS members’ responsibility for working with those providing health care services. It is our MLTSS members’ responsibility to:  Provide all health and treatment‐related information, including but not limited to, medication, circumstances, living arrangements, informal and formal supports to the plan’s care manager in order to identify care needs and develop a plan of care  Understand your health care needs and work with your care manager to develop or change goals and services  Work with your care manager to develop and/or revise your plan of care to facilitate timely authorization and implementation of services  Ask questions when additional understanding is needed  Understand the risks associated with your decisions about care 14 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 
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Report any significant changes on your health condition, medication, circumstances, living arrangements, informal and formal supports to the care manager Notify your care manager should any problem occur or if you are dissatisfied with the services being provided Follow your health plan’s rules and/or those rules of institutional or residential settings Inform your assigned care manager if there is any gap in services/care Let your family doctor know as soon as possible after you get emergency treatment
Discuss any problems about following your doctor’s directions
Understand what refusing treatment recommended by a doctor means
Carry your HBID, Medicare and Amerigroup NJ FamilyCare ID card at all times Report any lost or stolen cards to Amerigroup as soon as you can
Contact Amerigroup if information on your ID card is wrong or if you have changes in name or address
Report any changes to your address and phone number by calling Member Services at 1‐800‐600‐4441 (TTY 711).
Complete the NJ FamilyCare redetermination process every year to ensure uninterrupted NJ FamilyCare benefits. And remember, it’s your responsibility to keep your address and phone number current so we can send you updated information or contact you. Renew Your NJ FamilyCare and SSI 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 NJ FamilyCare or SSI 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 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. 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 Bergen 1333 Atlantic Ave. 1st Floor Atlantic City, NJ 08401 609‐348‐3001 216 Route 17 North, Building A Rochelle Park, NJ 07662 201‐368‐4200 15 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES Burlington Camden Human Services Facility Aletha R. Wright Admin. Building 795 Woodlane Road Mount Holly, NJ 08060 600 Market St. Camden, NJ 08102‐1255 856‐225‐8800 609‐261‐1000 Cape May Cumberland 4005 Route 9 South Rio Grande, NJ 08242 275 North Delsea Drive 609‐886‐6200 Vineland, NJ 08360‐3607 856‐691‐4600 Essex Gloucester 18 Rector St., 9th Floor Newark, NJ 07102 973‐733‐3000 400 Hollydell Drive Sewell, NJ 08080 856‐582‐9200 Hudson 257 Cornelison Ave. Jersey City, NJ 07302 201‐420‐3000 Hunterdon 6 Gauntt Place P.O. Box 2900 Flemington, NJ 08822‐2900 908‐788‐1300 Mercer Middlesex 200 Woolverton St. Trenton, NJ 08650‐2099 609‐989‐4320 181 How Lane P.O. Box 509 New Brunswick, NJ 08903 732‐745‐3500 16 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 LOCAL COUNTY WELFARE AGENCY (CWA) OFFICES Monmouth Morris 3000 Kozloski Road P.O. Box 3000 Freehold, NJ 07728 732‐431‐6000 340 W. Hanover Ave. Ocean Passaic 1027 Hooper Ave. 80 Hamilton St. Paterson, NJ 07505‐2060 973‐881‐0100 P.O. Box 547 Toms River, NJ 08753‐0547 P.O. Box 900 Morristown, NJ 07963‐0900 973‐326‐7800 732‐349‐1500 Salem Somerset 147 South Virginia Ave. Penns Grove, NJ 08069‐1797 856‐299‐7200 73 East High St. Sussex Union 83 Spring St., Suite 203 342 Westminster Ave. Elizabeth, NJ 07208‐3290 P.O. Box 218 Newton, NJ 07860‐0218 973‐383‐3600 P.O. Box 936 Somerville, NJ 08876‐0936 908‐526‐8800 908‐965‐2700 Warren Court House Annex 501 Second St. Belvidere, NJ 07823 908‐475‐6301 17 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 How to Disenroll from Amerigroup If you do not like something about Amerigroup, please call Member Services at 1‐800‐600‐4441 (TTY 711). We will try to work with you to fix the problem. We want to keep you as a member. 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. 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 managed care organization, if applicable. Managed Long Term Services and Supports (MLTSS) program provides both State Plan services and long‐
term services and supports to individuals who meet the clinical and Medicaid institutional financial eligibility requirements. Participation in the program is voluntary. If you qualify for MLTSS but do not wish to receive MLTSS services, you may choose to voluntarily withdraw from the program. Withdrawing from MLTSS does not preclude the ability to receive NJ FamilyCare State Plan services through the NJ FamilyCare program, if you are financially eligible. Participants who qualified for MLTSS using financial income limits greater than 100 percent of the Federal Poverty Level (FPL) may not be eligible to receive State Plan services upon withdrawal from MLTSS. Other NJ FamilyCare programs may have lower income limits. If you indicate you would like to withdraw from MLTSS, you must talk to a care manager in person or by telephone. During this discussion, a care manager will: 
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Let you know that withdrawal from MLTSS may result in loss of eligibility for Medicaid State Plan services due to the financial eligibility requirement Ensure you fully understand that if you were not receiving Medicaid State Plan services prior to enrollment into MLTSS, you may NOT be eligible for NJ FamilyCare upon withdrawal from MLTSS Provide information on what MLTSS and State Plan services will be lost or unavailable as a result of the withdrawal Help you understand how to ensure you will remain eligible to receive NJ FamilyCare Give you information on other services or programs for which you may be eligible, including information about contacting the Aging and Disability Resource Connection (ADRC) Teach you how to access MLTSS services in the future Ensure you understand the withdrawal process, time frames and outcomes 18 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 You will be asked to sign the NJ Department of Human Services Voluntary Withdrawal Form indicating your understanding and consent to withdraw from MLTSS. How to withdraw from the MLTSS Program You can request withdrawal from Amerigroup’s MLTSS program if you wish, by informing your respective care manager. We will provide you with the Voluntary Withdrawal Form as well as a copy of the fully executed form. Your care manager will discuss the reasons with you and will document the reason for the Case Closure in your electronic file. Our MLTSS staff submits a Disenrollment Form to the State on a weekly basis. Your voluntary withdrawal does not necessarily mean that you will not be able to get NJ FamilyCare benefits. However, the Office of Community Choice Options (OCCO) will reach out to you regarding your loss of Medicaid upon your withdrawal from the MLTSS program, if you are identified as being above the federal poverty level (FPL). 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). 19 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 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) Filing a Grievance Level1Grievance
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: 20 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 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: 21 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 NJ FamilyCare P.O. Box 712 Trenton, NJ 08625‐0712 Telephone: 1‐800‐701‐0710 TTY 1‐800‐701‐0720 Level2Grievance
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. 22 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 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). 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). 23 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 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: 
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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 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. 24 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Stage1Appeal
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. Stage2Appeal
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 25 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 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 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. 26 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 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 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. 27 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 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. 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. 28 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 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). MLTSS Patient Pay Liability The Division of Medical Assistance and Health Services (DMAHS), through the County Welfare Agency (CWA), is in charge of making decisions about patient pay liability. DMAHS will tell Amerigroup about any patient pay liability amounts you have. Except for cost‐sharing and patient pay liability, Amerigroup will make sure you don’t pay for services for which you are not responsible. Collection of Patient Pay Liability If you have patient pay liability amounts that you owe, here is how it will be collected.
 If you live in nursing facilities (NFs), special care nursing facilities (SCNFs) or community‐based
residential alternatives, Amerigroup will have providers in these facilities collect patient pay liability.  Amerigroup will pay these facilities the balance of the amount that applies.  The patient pay liability amount applied to the claim will be shown on the provider’s Explanation of Payment. Nonpayment of Patient Pay Liability Upon notice from the nursing facility/community‐based residential provider that the patient pay liability has not been paid, the care manager will help you by:  Looking at the efforts made by your nursing facility/community‐based residential provider to collect 29 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 the patient pay liability and documenting this in your electronic medical record  Stressing with you or your representative that it’s important to pay the patient pay liability and what happens if you don’t, including letting the Office of Community Choice Options know if the provider wants to pursue an Involuntary Transfer and documenting this in your case file Upon notice from the nursing facility/community‐based residential provider that the facility/provider is thinking about an Involuntary Discharge (per NJAC 8:85) due to nonpayment, the care manager will work to find another nursing facility/residential provider for you. These efforts will be documented in your case file. If you are in a NF or SCNF and the care manager can’t find another NF/SCNF for you, the care manager will:  Determine if your needs can safely and cost‐effectively be met in the community by doing a transition assessment  Find out if the provider is willing to continue serving a member who has failed to pay his or her patient pay liability If you live in Assisted Living or Adult Family Care and your care manager can’t find an alternate community‐based residential provider that will serve you, Amerigroup will submit a request to DMAHS for further direction. MLTSS Nursing Facility Transitions If you live in a nursing facility and are in New Jersey’s MLTSS program, you have the right to talk with your care manager. Your care manager will help with the transition through the Transition Planning Conference process. You may also qualify for the Money Follows the Person (MFP) Demonstration Program. This program can help you move back to the community through special services, including one‐time transition services such as:  Security deposits for housing and utilities  Household items like bedding and housewares  Furniture and small appliances like a microwave Want to know more about the Nursing Facility Transition Program, including Money Follows the Person? Contact your Amerigroup care manager or nursing facility social worker. How to Contact Us As always, if you have any questions or concerns, we want to hear from you. Write us: Amerigroup Community Care Managed Long Term Services and Supports 101 Wood Ave. South, 8th Floor Iselin, NJ 08830 30 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 Call us: 1‐855‐661‐1996 (TTY 711). Visit us: www.myamerigroup.com/NJ We are here to help. Behavioral Health Services Amerigroup covers behavioral health services including substance use disorder services. 31 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 MEDICAL ASSISTANCE CUSTOMER CENTERS Steven E. Tunney, Supervising MRA Office of Customer Service MACC OFFICE (01) ATLANTIC DIRECTOR & PHONE # ADDRESS Patricia Dana, Acting Director Augusta Building Email
(05) CAPE MAY Phone: (609) 561‐7569 852 South White Horse Pike (06) CUMBERLAND Press Prompt #2 Hammonton, NJ 08037‐2018 Fax: (609) 567‐0572 Patricia.Dana@dhs.state.nj.us *Francine Cirelly, DO (04) CAMDEN Patricia Dana, Acting Director One Port Center, Suite 401 (03) (08) (11) BURLINGTON GLOUCESTER MERCER Phone: (856) 614‐2870 Fax: (856) 614‐2575 2 Riverside Drive Camden, NJ 08103‐1018 (17) SALEM Patricia.Dana@dhs.state.nj.us Francine Cirelly, DO (07) ESSEX Stewart Klaus, Director 153 Halsey St. (09) HUDSON Phone: (973) 648‐3700 4th Floor Fax: (973) 642‐6468 Newark, NJ 07102‐2807 Stewart.Klaus@dhs.state.nj.us John Sawicki, DO 32 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72 (13) MONMOUTH Joanne Dellosso, Director (10) HUNTERDON Evangelia Stamboulis, Director 1st Floor (12) MIDDLESEX Phone: (732) 863‐4400 Freehold, NJ 07728‐2668 (15) OCEAN Fax: (732) 863‐4450 (18) SOMERSET (20) UNION Francine Cirelly, DO joanne.dellosso@dhs.state.nj.us 100 Daniels Way (16) PASSAIC Robert Dueben, Director 100 Hamilton Plaza (02) BERGEN Phone: (973) 977‐4077 5th Floor (14) MORRIS Fax: (973) 684‐8182 Paterson, NJ 07505‐2109 (19) SUSSEX (21) WARREN Robert.Dueben@dhs.state.nj.us *John Sawicki, DO * Denotes Home Office 33 NJ‐MHB‐0017‐15 OMHC: #078‐15‐72