Member Handbook. Real. Solutions. Amerigroup Florida, Inc. Florida Statewide Medicaid Managed Care Long-Term Care Program

Transcription

1 Real Solutions B-TXMHB FL-MHB Member Handbook Amerigroup Florida, Inc. Florida Statewide Medicaid Managed Care Long-Term Care Program n

2 Dear Member: Welcome to Amerigroup Community Care. We re happy to help bring you quality health care benefits. This handbook tells you how Amerigroup works. It can also help you learn about ways to stay healthy and how to get health care services when you need them. You ll get your Amerigroup ID card and more information in a few days. Your ID card will tell you when your Amerigroup membership starts. When you get it, please check it right away. If anything is not right, call us. We ll fix it and send you a new card right away. For Amerigroup members, one phone number is all you need to get help and important information. Call toll free (TTY ) to get: Benefit questions answered Ask for your Case Management Team Medical questions answered day or night Ask for the 24-hour Nurse HelpLine A welcome packet Ask for Member Services Your personal information updated Ask for Member Services Your case management team is available from 8:30 a.m. to 5:00 p.m. Eastern time. Member Services is available Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. You can also go online to for more information. We look forward to helping you. Sincerely, Rosy Cozad Chief Executive Officer Amerigroup Community Care Amerigroup is a company of all kinds of people. We welcome all into our health plans. We do not base membership on health status. If you have questions or concerns, please call and ask for extension Or visit

3 MEMBER SIGNATURE PAGE Please sign below. Return this page to your case manager. I was given the Amerigroup Community Care Statewide Medicaid Managed Care Long-Term Care (SMMC LTC) Program Member Handbook. Member or Authorized Representative Signature Date of Signature

4 Amerigroup Community Care Member Handbook Florida Statewide Medicaid Managed Care Long-Term Care Program 4200 W. Cypress St., Suite 900 Tampa, FL (TTY ) Welcome to Amerigroup Community Care! This member handbook will help you get medical care, home support and community services as an Amerigroup member. Table of Contents WELCOME TO AMERIGROUP COMMUNITY CARE... 1 Your New Health Plan... 1 New Member Tips... 1 How to Get Help... 2 Amerigroup Case Management Team... 2 Amerigroup Case Manager... 2 Important Contact Information... 3 How to Get an Interpreter... 4 Your Amerigroup Member Handbook... 4 Your Identification Card... 4 If You Have Medicare Coverage... 5 AMERIGROUP HEALTH CARE BENEFITS... 6 What is Covered by Amerigroup?... 6 Your Plan of Care... 6 Second Opinions... 6 Home and Community-Based Services... 7 AMERIGROUP COVERED SERVICES AND LIMITATIONS... 7 AMERIGROUP EXPANDED SERVICES SERVICES EXCLUDED BY AMERIGROUP SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID PARTICIPANT DIRECTION OPTION PRIOR AUTHORIZATIONS Services That Don t Require Prior Authorization UNDERSTANDING YOUR PROVIDER DIRECTORY... 13

5 SPECIAL KINDS OF HEALTH CARE Behavioral Health Care Emergency Care After-Hours Emergencies Nonemergency Care Outside the Service Area Out-of-Network Care Special Care for Pregnant Members When You Become Pregnant After You Have Your Baby ELIGIBILITY ENROLLMENT I Want to Enroll with Amerigroup. (Voluntary Enrollee) I Was Assigned to Amerigroup. (Mandatory Enrollee) AMERIGROUP QUALITY ENHANCEMENTS ADVANCE DIRECTIVE OR LIVING WILLS CONCERNS, SUGGESTIONS AND COMPLAINTS Abuse and Neglect Fraud and Abuse in Florida Medicaid COMPLAINTS, GRIEVANCES AND APPEALS Grievances Appeals Medical Appeals Payment Appeals OTHER INFORMATION When You Have a Status Change Disenrollment Reasons You Can Be Disenrolled from Amerigroup Confidentiality of Records How to Make a Personal Disaster Plan How to Tell Us about Changes You Think We Should Make Additional Information About Amerigroup SUMMARY OF THE FLORIDA PATIENT S BILL OF RIGHTS AND RESPONSIBILITIES Your Rights Your Responsibilities NOTICE OF PRIVACY PRACTICES... 35

6 WELCOME TO AMERIGROUP COMMUNITY CARE Your New Health Plan Welcome to Amerigroup Florida, Inc., doing business as Amerigroup Community Care. Amerigroup is a Health Maintenance Organization (HMO) that brings health care and long-term care coverage to our enrolled members. Enrolled members could be: 1. Someone who chooses Amerigroup or 2. Someone assigned to Amerigroup through open enrollment However you came to Amerigroup, we re happy to help you get the care you need when you need it. We want to help you live in your home and community, or nursing home by bringing you: Community services Home care coverage Medical coverage Nursing home services Amerigroup will help handle your medical and home care needs with help from: You Your Primary Care Provider (PCP) Your case manager Your family, caregivers and friends Your PCP will handle your care when you are sick by getting lab tests, X-rays, hospital admissions and emergency care when you need it. Your case manager will handle your medical and long-term care services by looking at your medical and home care needs and getting you the services you need. New Member Tips As a new member, it s important that you: 1. Look at your Amerigroup ID card to make sure it is correct 2. Read through this handbook 3. Keep this handbook in a safe place 1

7 How to Get Help Amerigroup Case Management Team Our Case Management team is here to help you. Your case manager will talk to you, your caregiver and your provider about the services you need. Your Case Management team can help with: Finding personal care aides and homemakers Coordinating with hospitals and home health agencies Getting medical supplies and equipment Finding assisted living facilities and nursing homes Getting rides to your appointments Making a back-up plan for possible gaps in service Amerigroup Case Manager Your case manager will work with you to make a plan of care based on your personal needs. Your plan of care will look at your: Health needs Home setting Support from family and friends When your needs change, your case manager will look at what has changed and make changes to your plan of care. When to call your case manager Call your case manager when you: Are admitted to a hospital Plan to move Are going into hospice Have changes to your health care needs Your case manager can help you: Coordinate all the services on your plan of care Make sure you can still use your benefits Handle your care 2

8 One phone number is all you need to get help and important information. Call toll free (TTY ) to get: Benefit questions answered Ask for your Case Management Team Medical questions answered day or night Ask for the 24-hour Nurse HelpLine A welcome packet Ask for Member Services Your personal information updated Ask for Member Services Your case management team is available from 8:30 a.m. to 5:00 p.m. Eastern time. Member Services is available Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. You can also go online to for more information. Important Contact Information Services Emergency 911 Contact Information 24-hour Nurse HelpLine Agency for Health Care Administration (AHCA) Beneficiary Assistance Program Agency for Health Care Administration (AHCA) Facility Health Finder Aging and Disability Resource Center Broward County Broward Area Medicaid Office DentaQuest (TTY ) The Department of Children and Families (DCF) Automated ACCESS Information and Customer Call Center Department of Elder Affair's Florida elderaffairs.state.fl.us/faal Affordable Assisted Living Elder Helpline Enrollment or disenrollment information eyequest (TTY ) 3

9 How to Get an Interpreter Do you need help understanding your member materials? We can help with many languages. Please call your Case Management team if you need interpreter services. All member materials are also available in: English Spanish Large print Braille Audio tape There is no charge for these materials. Do you need help talking to your provider? We can provide someone who can help you speak to your provider. There is no charge for this service. Please let us know if you need an interpreter at least 24 hours before your checkup. Or tell your provider you need an interpreter before you go to your checkup. The provider can also get an interpreter for you at no cost to you. Your Amerigroup Member Handbook This handbook has information about how to get: Medical care Home support Community services Additional member help Your member handbook also comes in: A large print version An audio version A Braille version Your Identification Card Each Medicaid member will get a Medicaid Identification (ID) card. This card is not for services paid by Amerigroup. For more information about the Medicaid card, please call your local Medicaid office. In Broward County, please call toll free As an Amerigroup member, you will also get an ID card. Keep this ID card, your card and your Medicare ID card with you at all times. 4

10 Your Amerigroup ID card tells providers and hospitals: You are a member of Amerigroup When you became an Amerigroup member Amerigroup will pay for your medically needed covered benefits Your ID card also lists many important phone numbers including: Case Management Dental services Member Services Vision services If your Amerigroup ID card is lost or stolen, call Member Services toll free (TTY ). We will send you a new one. If You Have Medicare Coverage The Statewide Medicaid Managed Care Long-Term Care Program is not a Medicare program. To be a member of this program, you need to meet certain criteria: Clinically Financially If you re in the Medicare fee-for-service program, you will get Medicare-covered services from: Providers Hospitals Other providers who are part of the Medicare program If you re a Medicare HMO member, you ll get Medicare services following the rules of that program. Medicare members get prescription drug coverage under the Medicare Prescription Drug Benefit (Part D). 5

11 AMERIGROUP HEALTH CARE BENEFITS What is Covered by Amerigroup? Your Plan of Care Home-and community-based services are part of your plan of care. The Amerigroup Case Management team makes the plan of care based on: A review Talking with you, your caregiver or your family Additional information Your plan of care brings together services in the: Least restrictive Most appropriate and Affordable setting You are free to pick the providers you would like to see from our provider group. Sometimes, your case manager may remove certain providers for you to pick from as those providers may not have what you need. Some reasons why you might not be able to pick a certain provider could be because he or she doesn t have the right: Experience Licenses Availability Your plan of care has goals and services to meet your health and social needs. For payment of covered services, Amerigroup must authorize (approve) the services. You ll keep getting covered services from Medicare or Medicaid. Amerigroup will pay for Medicare deductibles and coinsurance following the Medicaid rules for long-term care covered services. Amerigroup is not responsible for non-long-term care services in this long-term care program. Many non-long-term care services are paid through the Medicare program or a Medicaid program. Second Opinions Amerigroup members have the right to ask for a second opinion for any plan of care service. Call your case manager for a second opinion. Your plan of care services will be looked at again. There is no cost to you. 6

12 Home and Community-Based Services Payment of the following services is covered by Amerigroup when needed for your health and welfare, not your family s or caregiver s. There is no cost sharing for members. AMERIGROUP COVERED SERVICES AND LIMITATIONS Amerigroup pays for services that are: Medically necessary by the member s plan of care Not duplicates of another provider s service and are: Individualized, specific, and the same as impairments, symptoms or confirmed findings of the sickness or injury under care and not more than the member s needs Not experimental or investigational Reflective of the level of services that can be safely furnished and for which no equally effective and more conservative or less costly treatment is available Furnished in a manner not primarily intended for the convenience of the member, member s caregiver or the provider Even if your provider prescribed, recommended or approved medical or allied care, goods or services, that does not mean those care, goods or services are medically necessary or a covered service. Your plan of care will list the services you need to meet certain goals. It will also look at your health and social service needs. You and your case manager will choose these personal goals. Covered services must be approved by Amerigroup and also by your case manager. These services will be part of your plan of care. Your case manager will also help create a back-up plan to help make sure you don t have any gaps in your services. If you think you should be getting more or different services, call your case management team. We can have another team member look at your plan of care, at no cost to you. COVERED SERVICES Adult Companion Care Services Adult Day Health Care Assisted Care Services COVERAGE LIMITS Nonmedical care, supervision and socialization Help or supervision of tasks such as meal preparation, laundry and shopping Social and health events in a day program at a center Meals are included when the member is at the center during meal time Services such as personal care, help in the home, medication monitoring and social events to help 7

13 COVERED SERVICES Assistive Living Services Attendant Care Services Behavioral Management Care Coordination/ Case Management Caregiver Training Services Home Accessibility Adaptation Services COVERAGE LIMITS the member in an assisted living facility Room and board costs are not included as part of the assisted living facility; they are based on the member s income; the member may also be required to pay an additional amount for assisted living services, as determined by the Florida Department of Children and Families (DCF) Additional costs may need to be paid by the member or member s family if the facility s cost is more than the member s given amount and the plan s payment amount 24-hour services for members living in assisted living facilities, adult family care homes or residential treatment facilities Hands-on care to meet the needs of a medically stable, physically handicapped member Supportive services help replace the absence, loss, reduction or impairment of the physical or mental function Provides behavioral health care services for mental health or substance abuse needs Help the member get medical, social and educational services Develop a personal care plan Manage, combine and continually oversee services Visit the member s home to talk about needs Help find rides Help keeping financial eligibility Training and counseling for caregivers who give unpaid help, training and companionship to member Training caregivers about treatment steps and equipment use Physical changes to the member s home needed by his or her plan of care Needed to help ensure health, welfare and safety, or which allow the member to have greater freedom in the home and without which the member would require a nursing home 8

14 COVERED SERVICES Home-delivered Meals Homemaker Services Hospice Services Intermittent and Skilled Nursing Medical Equipment and Supplies Medication Administration Medication Management Nursing Facility Nutritional Assessment/ Risk Reduction Services COVERAGE LIMITS Home-delivered meals for members that need help shopping for or preparing food Nutritional supplements for members with a medical need Household help such as meal preparation and routine household care A trained homemaker Includes chore and pest-control services End-of-life services offered to members who choose hospice Home health nurse visits by a registered nurse or licensed practical nurse Services might include monitoring health status Disposable diapers, gloves and other consumable medical supplies Durable and non-durable medical equipment needed for any functional limitations Service includes durable medical equipment under the state plan Call your case manager for help using this benefit. Help with self-administration of medications Can be given by a home health aide or attendant Review of all medications, prescription and over-the-counter items Done by a licensed nurse Available for members who need them under medically necessary standards Service is covered to the amount that it isn t covered by Medicare The Florida DCF will decide the cost you need to pay to the nursing facility to cover part of your care When placed in a nursing facility, home and community-based long-term care waiver services are no longer available to the member, except for case management Nutrition review and help given to caregivers and members 9

15 COVERED SERVICES Occupational, Physical, Respiratory and Speech Therapy Services Personal Care Personal Emergency Response Systems (PERS) Respite Care Services Transportation Services to Medical Checkups COVERAGE LIMITS To teach members how to shop and make healthy choices Occupational therapy: help to bring back, improve or keep reduced movement with the plan to increase or keep the member s ability to do tasks needed to live safely at home when decided by a thorough review Physical therapy: help to bring back, keep or keep reduced movement when decided by a thorough review to help a member live safely at home Respiratory therapy: treatment of breathing or lung functions; monitoring and treatment related to lung dysfunction Speech therapy: review and help for oral motor dysfunction when decided by a thorough review to help a member live safely at home Help at home with bathing, dressing, eating, personal hygiene and other activities Help with light cleaning, bed making and meals chores (doesn t include the cost of the meal) Electronic device for members at high risk of needing a nursing home to get help in an emergency For members who live alone most of the day and would otherwise need more supervision Given to a member on a short-term basis when a caregiver is not available or needs relief Does not replace the care given by a registered nurse, a licensed practical nurse or a therapist Must be given in the home/place of residence, nursing facility or assisted living facility Nonemergency transportation service includes trips to and from services offered by Amerigroup AMERIGROUP EXPANDED SERVICES Amerigroup also has services that only our SMMC LTC members can use. We give you these services to help keep you healthy and to thank you for being an Amerigroup member. These extra services are called expanded services. 10

16 AMERIGROUP EXPANDED SERVICES 24-hour Nurse HelpLine Services Assisted Living Facility Bed Holds Cell Phone Minutes Dental Services Over-The-Counter (OTC) Items Transition Allowance COVERAGE LIMITS Members and caregivers have 24-hour, toll-free access to registered nurses to answer medical questions Amerigroup will make a bed-hold payment for up to 21 days for members in an in-network assisted living facility or adult family care home Up to 250 additional lifetime minutes for members eligible for the SafeLink cell phone program* Medically necessary incision and drainage of abscess Nonemergency diagnostic exams Full series of X-rays (one set every two years) Teeth cleaning (one every six months) Instruction about proper oral hygiene (one every six months) Nonemergency simple extractions (four per year) Nonemergency surgical extractions (two per year) Discount of 25-percent off usual fees for other dental services Ask your case manager for help with this service. $15 per month for certain OTC items such as: Certain vitamins Pain relievers Allergy medicines Up to $2,500 per member to help pay for the cost of moving to a different facility: Security and utility deposits Household furnishings Moving costs for members in Medicaid-funded nursing facility One benefit per member per lifetime Must be used within 365 days of transition Ask your case manager for help with this service. 11

17 AMERIGROUP EXPANDED SERVICES COVERAGE LIMITS Vision Services Medically needed eye exams One pair of eyeglasses per year if medically needed One pair of medically needed eyeglass frames Once every two years After the Medicaid benefit of one pair of frames once every two years is used One pair of contact lenses per year if medically needed Ask your case manager for help with this service. *SafeLink Wireless is a Lifeline-supported service. Lifeline is a government benefit program. Only those who qualify may enroll in Lifeline. It can t be transferred. It is limited to one per household. You may need to show proof of income or that you take part in the program to enroll. SERVICES EXCLUDED BY AMERIGROUP If Amerigroup decides not to offer, pay for, or give coverage of a counseling or referral service because of an objection on moral or religious grounds, Amerigroup has the duty to tell you about our decision not to offer, pay for or cover these services within 30 days before the start of the policy not to pay for any service based on these decisions. Call your case manager for more information about services not covered by Amerigroup. SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID Some services are covered by fee-for-service Medicaid instead of Amerigroup Community Care. If you think you need these services, call your case manager. We can help you find a provider. Medical Services Claims for covered medical services are paid for by Amerigroup up to the amount: Not covered by Medicare or Other insurance and Not paid for by Medicaid under Medicaid s Medicare cost-sharing rules PARTICIPANT DIRECTION OPTION The Participant Direction Option (PDO) program is a way the home care member may be able to get some of the home care services he or she needs. It offers more choice and control over who gives a member home care and how care is given. 12

18 The services are: Adult companion care services Attendant care Homemaking services Intermittent and skilled nursing Personal care services Members hire people who give them these services. Your case manager will help you decide if this is the best program for you. PRIOR AUTHORIZATIONS Amerigroup services and benefits require prior authorization (approval). Your plan of care will have all the services you and your case manager decide on and an authorization will be recorded in your plan of care. NOTE: For most services, call your case manager, not your provider, to get authorization (approval) for services. For example, if you need home health or adult day care services, call your case manager to look at your needs and to approve the services. Services That Don t Require Prior Authorization These services don t need prior approval: Emergency services Poststabilization services Urgent care services Dental and vision services (Call the toll-free numbers on your Amerigroup member ID card for help with these benefits.) UNDERSTANDING YOUR PROVIDER DIRECTORY Your provider directory lists providers who are in the Amerigroup network. Your case manager can help you pick providers and handle your care. You can also go online at to search for providers online. If you need help picking providers or getting services, please call your case manager. Are you a member of a participating Medicare Health Maintenance Organization (HMO)? If so, please follow the rules from that plan for Medicare-covered services. 13

19 SPECIAL KINDS OF HEALTH CARE Behavioral Health Care Life can be tough. There are times when you or a family member may feel depressed or anxious, or you may experience marital, family or parenting pressures. Sometimes alcohol or drug abuse is a concern. When the day-to-day becomes hard to face, often it helps to talk to someone else. We can help you find a provider, therapist or counselor. Examples of an emergency behavioral health condition include: Danger to self and others So much harm that the person is not able to handle daily life Harm that will likely cause death or serious injury Medicare and Medicaid fee-for-service pay for inpatient and outpatient behavioral health care. Call your case manager if you need behavioral health care help. Emergency Care For a medical emergency, go to the nearest hospital emergency room right away. Call 911. Show all your insurance cards and Amerigroup ID card if possible. You don t need your ID cards or prior authorization (approval) to get emergency care. Tell your case manager as soon as possible. To help reach your case manager after hours, call our 24-hour Nurse HelpLine toll free (TTY ). After-Hours Emergencies If you have an emergency after hours, you have the right to use any hospital or other setting for emergency care. Nonemergency Care Outside the Service Area Do you need nonemergency care but are outside of the service area? You must call your case manager before getting the care. Home and community-based services are not paid for outside the service area. Participating Providers Amerigroup will not pay for care from providers not authorized (approved) by Amerigroup, except for emergency and urgently needed care. 14

20 Out-of-Network Care Amerigroup wants you to get the care you need. Sometimes, we don t have a provider in our network who can give you covered services. If that happens, we ll pay for the services out-of-network. Amerigroup must approve this care before you get the services. It is important you get prior approval for these services. Amerigroup will pay for the care we approve but you may have to pay for care we don t approve. Special Care for Pregnant Members When You Become Pregnant If you think you are pregnant, call your Primary Care Provider (PCP) or obstetrician and/or gynecologist provider (OB-GYN) right away. Call your case manager and your Department of Children and Families (DCF) case worker when you find out you re pregnant. This will help your baby get health care benefits when he or she is born. After You Have Your Baby After you have had your baby, call your case manager and your DCF case worker. ELIGIBILITY You can be an Amerigroup member if you: Are 18 years of age or older 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 or are Medicaid pending (waiting to find out if you are financially eligible for Medicaid)* *Medicaid Pending Option: You can join Amerigroup while you wait to find out if you are financially eligible for Medicaid. If you are not financially eligible for Medicaid, you will be disenrolled from Amerigroup. You will need to pay for the services you got as an Amerigroup Medicaid-pending member. 15

21 ENROLLMENT I Want to Enroll with Amerigroup. (Voluntary Enrollee) If you are a voluntary enrollee and want to join the Statewide Medicaid Managed Care Long-Term Care (SMMC LTC) Program, please call the Agency for Healthcare Administration (AHCA) Enrollment Broker toll free or go online to I Was Assigned to Amerigroup. (Mandatory Enrollee) Enrollment Lock-In If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Amerigroup or the state enrolls you in a managed care plan, you will have 90 days from the date of your first enrollment to try the managed care plan. During the first 90 days you can change managed care plans for any reason. After the 90 days if you are still eligible for Medicaid, you will be enrolled in the plan for the next nine months. This is called lock-in. Open Enrollment If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your enrollment year telling you that you can change plans if you want to. This is called open enrollment. You do not have to change managed care plans. If you choose to change plans during open enrollment, you will begin in the new plan at the end of your current enrollment year. Whether you pick a new plan or stay in the same plan, you will be locked in to that plan for the next 12 months. Every year, you may change managed care plans during your 60-day open enrollment period. Reinstatement If you lose your ability to be in Medicaid and get it back within 60 days, you ll be reassigned to Amerigroup. For more information, call your case manager. AMERIGROUP QUALITY ENHANCEMENTS To continue to meet your needs, Amerigroup also offers these services: A safety review of your home and ways to prevent falls Disease education about how to manage your symptoms and identify your risks Advance directive and end-of-life education Review of domestic violence and community agency referrals Your case manager can help you with these services. 16

22 Community Events Amerigroup takes part in community events and health fairs in your area. The events offer health information in a fun-filled setting. Each event is different. It s a great time to learn something new, and Amerigroup can answer your questions at the event. To find out when the next event is, call your case manager toll free (TTY ), Monday through Friday from 8:30 a.m. to 5:00 p.m. Eastern time. Domestic Violence Resources Domestic violence is abuse. Abuse is unhealthy. Abuse is unsafe. It is never OK for someone to hit you. It is never OK for someone to make you afraid. Domestic violence causes harm and hurt on purpose. Domestic violence can impact your family and you. If you feel you are a victim of abuse, call your Primary Care Provider (PCP) or case manager. He or she can talk to you about domestic violence. For your safety: If you re hurt, call your PCP. If you need emergency care, call 911 or go to the nearest hospital. For more information, please see the section called Emergency Care. Have a plan to get to a safe place (a friend s or relative s home). Pack a small bag; give it to a friend to keep for you. If you have questions or need help, please call the National Domestic Violence Hotline toll free (TTY ). ADVANCE DIRECTIVE OR LIVING WILLS This following explains the Florida law about advance directives or living wills. Under Florida law (see NOTE below), every adult has the right to make certain decisions about his or her medical treatment. The law lets your rights and personal wishes to be followed even if you are too sick to make decisions yourself. You have the right, under certain conditions, to decide whether to take or turn down medical treatment. This includes whether to continue medical treatments and other steps that would continue your life artificially. These rights can be written by you in a living will. Your personal wishes about life-prolonging treatment in the case of special, serious medical health issues are included. 17

23 You can also choose another person, or surrogate, to make decisions for you if you can t. This surrogate may work for you for a short time. He or she will not do this past the length of the life-threatening or nonlife-threatening illness. Limits to the power of the surrogate making decisions for you should be shared. Do you have noncompliance complaints about your advance directive? Call the Florida Department of Elder Affairs at (TTY ). For more information about advance directive rules in Florida, these websites may help: Internet sites and the information and materials at these sites are not from or handled by Amerigroup. Amerigroup is listing these links to help you. Going to these external sites is at your own risk. Your case manager knows about advance directives. Amerigroup case managers have had special training in advance directives. He or she can talk to you about the choices available to you. A Living Will A living will tells your providers and family your wishes if there is no hope for your recovery. The living will is also used when you are not able to make your own decisions. For example, should a breathing machine be used to keep you alive if you were in a coma after a car accident? A Durable Power of Attorney for Health Care A Durable Power of Attorney for Health Care is a statement where you pick a person to make medical decisions for you if you are not able to. This person should be someone you trust to make health decisions like you would. Usually this is a relative or close friend. Is a Living Will Better Than a Durable Power of Attorney for Health Care? They are different and are used for different things; both are good. These documents help your family and your providers make decisions about your health care when you can t. You may use one or both of these forms to give direction for your medical care. You may combine them into a single statement. 18

24 This would: Choose the person to make medical decisions for you and Tell that person your wishes if there is no hope for your recovery You can change your mind or cancel your statements at any time. Changes should be written, signed and dated. You can also make your changes by telling someone about it. The only time an advance directive can be used is when you are mentally disabled or can t make health care decisions. Once you are able to make decisions again: The advance directive is no longer in use It will be on standby if you are again disabled and can t make decisions NOTE: The legal basis for this right can be found in the Florida Statutes: Life-Prolonging Procedure Act, Chapter 765; Health Care Surrogate Act, Chapter 745; Durable Power of Attorney Section ; and Court Appointed Guardianship, Chapter 744; and in the Florida Supreme Court decision on the constitutional right of privacy, Guardianship of Estelle Browning, Amerigroup cannot provide legal advice. If you have questions regarding this, please consult a legal advisor. CONCERNS, SUGGESTIONS AND COMPLAINTS Do you have questions about your benefits or want to suggest ways to improve our services? Your Case Management team can answer most questions. Call toll free (TTY ). Case management is available Monday through Friday from 8:30 a.m. to 5:00 p.m. Eastern time. Member Services can also help. Call toll free (TTY ) Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. Call the Statewide Consumer Call Center toll free at if you want to: File a complaint about a health care facility Report Medicaid fraud Get information about the Agency for Health Care Administration or Request a booklet Abuse and Neglect Elder abuse and neglect may be reported to the Statewide Elder Abuse Hotline at ABUSE ( ). 19

25 Fraud and Abuse in Florida Medicaid To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll free or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at InspectorGeneral/fraud_complaintform.aspx. If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General s Fraud Rewards Program; call toll free or The reward may be up to 25 percent of the amount recovered or a maximum of $500,000 per case (Section , Florida Statutes). You can talk to the Attorney General s Office about keeping your identity private and protected. How to Report Someone Misusing the Medicaid Program Do you know someone misusing the Medicaid program through fraud, abuse or overpayment? Report providers, clinics, hospitals, nursing homes or Medicaid enrollees by writing or calling Amerigroup at: Corporate Investigations Department Amerigroup Community Care 4425 Corporation Lane Virginia Beach, VA (TTY ) You can fraud and abuse concerns to the Amerigroup Corporate Investigations department. The address is corpinvest@amerigroup.com. You can also report fraud and abuse online at There are fraud and abuse links on the website. Click these links to report a possible concern. It will be sent directly to the Amerigroup Corporate Investigations department at the address above. This address is checked every business day. 20

26 COMPLAINTS, GRIEVANCES AND APPEALS You have the right to tell us if you re not happy with your care or the coverage of your health care needs. These are called complaints, grievances and appeals. A complaint is when you are not happy about your services or care. Your case manager will work with you to correct the issue within one business day. A grievance is when you re unhappy about something besides your benefits. A grievance could be about a provider s behavior or about information you should have gotten, but didn t. An appeal is when you feel you should be getting a service covered and you re not, or that service has been stopped. If you have any questions or concerns about your care or coverage, please call Member Services toll free (TTY ), Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. Grievances I have a concern I would like to report Amerigroup has a process to solve complaints and grievances. If you have a concern that is easy to solve and can be handled within 24 hours, your case manager can help you. If your concern can t be handled within 24 hours and needs to be looked at by our grievance coordinator, your concern will be noted and given to the grievance coordinator. How do I tell Amerigroup about my concern? A complaint or grievance must be given orally or in writing within one year of when the problem happened. To file a complaint or grievance: 1. Call Member Services toll free (TTY ) 2. Write us at: Grievance Coordinator Amerigroup Community Care 4200 W. Cypress St., Suite 1000 Tampa, FL

27 You can have someone else help you with the grievance process. This person can be: A family member A friend Your provider A lawyer Write this person s name on the grievance form and fill out a Request to Designate a Personal Representative form. If you don t understand why we won t pay for a service you wanted, ask us to send you more information. If you need help filing the complaint, Amerigroup can help. Call Member Services toll free (TTY ), Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. If you want to talk to the grievance coordinator to give more information, tell Member Services when you file the complaint or put it in your letter. Once Amerigroup gets your grievance (oral or written), we will send you a letter within five working days telling you the date we got your grievance. What happens next? The grievance coordinator will look at your concern. If more information is needed or you have asked to talk to the coordinator, the coordinator will call you. If you have more information to give us, you can bring it to us in person or mail it to: Grievance Coordinator Amerigroup Community Care 4200 W. Cypress St., Suite 1000 Tampa, FL Medical concerns are looked at by medical staff. Amerigroup will tell you the decision of your grievance within 30 calendar days from the date we got your grievance. 22

28 What can I do if I m unhappy with the decision? You have the right to file a state fair hearing; you must do so no later than 90 calendar days from the date you got notice that coverage of a service has been denied, stopped, reduced or delayed. To ask for a state fair hearing, write to: Office of Appeals Hearings 1317 Winewood Blvd. Bldg. 5, Room 255 Tallahassee, FL The Office of Fair Hearing is not part of Amerigroup. They look at grievances of Medicaid members who live in Florida. If you contact the Office of Fair Hearing, we will give them information about your case, including the information you have given us. Note: You can ask for a Medicaid fair hearing without finishing the Amerigroup grievance and appeals process. You have the right to ask to get benefits while the hearing is in the works by calling Member Services toll free (TTY ), Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. Appeals Medical Appeals There may be times when Amerigroup says it won t pay, in whole or in part, for care that your provider wants. If we do this, you (or your provider for you and with your written approval) can appeal the decision. A medical appeal is when you ask Amerigroup to look again at the care your provider wants, and we said we won t pay for. You must file an appeal within 30 calendar days from the date on the letter that says we won t pay for a service. Amerigroup won t hold it against you or your provider for helping you file an appeal or for filing an appeal for you. 23

29 Amerigroup said it won t pay for care I need. What can I do about this? You or someone helping you can file an appeal. An appeal is when you ask Amerigroup to look again at the service we said we won t pay for. You can ask for an expedited (rushed) appeal if you or your provider thinks you need the services for an emergency or life-threatening illness. If coverage of the service you asked for has been denied, limited, reduced, suspended or terminated, you must ask for an appeal within 30 calendar days of the date on the letter that said Amerigroup would not pay for the service. You can have someone else help you with the appeals process. This person can be: A family member A friend Your provider A lawyer Write this person s name on the appeal form and fill out a Request to Designate a Personal Representative form. If you don t understand why we won t pay for a service you wanted, ask us to send you more information. I want to ask for an appeal. How do I do it? An appeal may be filed verbally or in writing within 30 calendar days of when you get the Notice of Action. Except when an expedited (rushed) decision is needed, an oral notice must be followed by a written notice within 10 calendar days of the oral notice. The date of the oral notice will be the date we get the notice. There are two ways to file an appeal: 1. Write us and ask to appeal. Send your request to: Medical Appeals Amerigroup Community Care P.O. Box Virginia Beach, VA Call Member Services toll free (TTY ) and ask to appeal. 24

30 What else do I need to know? When we get your letter, we will send you a letter within five business days. This will tell you we got your appeal. You can talk to the doctor who looks at your case to get more information. We can arrange for you to meet with or talk to this person. Or you can mail it to us. Send your letter to: Medical Appeals Amerigroup Community Care P.O. Box Virginia Beach, VA Do you want a free copy of the guidelines, records or other information used to make this decision? Contact us at the address above. We will tell you the decision within 30 calendar days of getting your appeal request. If we lower the coverage for a service you re getting and you want to keep getting the service during your appeal, call us to ask for it. You must call within 10 calendar days of the date of the letter mailed to you that tells you we won t pay for the service. If you have more information to give us, bring it or mail it to: Medical Appeals Amerigroup Community Care P.O. Box Virginia Beach, VA Also, you can look at your medical records and information on this decision before and during the appeal process. The time frame for an appeal may be extended up to 14 calendar days if: 1. You ask for an extension 2. Amerigroup finds additional information is needed, and the delay is in your interest If the time frame is extended other than at your request, Amerigroup will tell you in writing within five business days of when the decision is made. If you have a special need, we will give you additional help to file your appeal. Do you need additional help? Please call Member Services toll free (TTY ), Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. 25

31 Where do I mail my letter? Mail all medical information and medical necessity appeals to: Medical Appeals Amerigroup Community Care P.O. Box Virginia Beach, VA What can I do if Amerigroup still will not pay? You (or your provider or legal representative for you with your written consent) has a right to ask for a state fair hearing. You don t need to file an appeal before you request a fair hearing. If you would like to request a fair hearing, you must do so no later than 90 calendar days from the date on the letter that says we won t pay for a service. The Office of Appeal Hearings is not part of Amerigroup. They look at appeals of Medicaid members who live in Florida. If you contact the Office of Appeal Hearings, we ll give them information about your case, including the information you have given us. You have the right to ask to get benefits while the hearing is pending. For more information, call Member Services toll free (TTY ). How do I contact the state for a state fair hearing? You can contact the Office of Appeal Hearings at any time during the Amerigroup appeals process at: Office of Appeal Hearings 1317 Winewood Blvd. Bldg. 5, Room 255 Tallahassee, FL How do I ask for an External Appeal Review? After getting a final decision from Amerigroup, call or write the Beneficiary Assistance Program (BAP) at: Agency for Health Care Administration Beneficiary Assistance Program 2727 Mahan Drive Bldg. 1, MS #26 Tallahassee, FL Toll free: Local:

32 Before filing with the BAP, you must finish the Amerigroup appeals process. You must ask for the appeal to the BAP within one year after you get the final decision letter from Amerigroup. The BAP will not handle an appeal that has already been to a Medicaid fair hearing. The BAP will finish its review and make a decision. What can I do if I think I need an urgent or expedited appeal? You can ask for an urgent or expedited (rushed) appeal if you think the time frame for a standard appeal process could cause serious harm to your: Life or Health or Ability to attain, maintain or regain maximum function You can also ask for an expedited (rushed) appeal by calling Member Services toll free (TTY ), Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. We must get back to you within three business days (72 hours) after we get the appeal request, whether the appeal was made verbally or in writing. If the request to have an appeal expedited is turned down, it will be changed to the time frame for standard resolution. You will be told within three business days (72 hours). If you have any questions or need help, please call Member Services toll free (TTY ), Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. Payment Appeals If you get a provider service and Amerigroup doesn t pay for that service, you may get a notice from Amerigroup called an Explanation of Benefits (EOB). This is not a bill. The EOB will tell you: The date you got the service The type of service and The reason we can t pay for the service 27

33 The provider, health care location or person who gave you this service will get a notice called an Explanation of Payment (EOP). If you get an EOB, you don t need to do anything, unless you or your provider wants to appeal the decision. How do I keep my benefits during a grievance, appeal or Medicaid fair hearing process? To keep your benefits: Your appeal must be about ending, stopping or reducing treatment that had been previously approved Your authorization (approval) time must not have expired Your services must have been ordered by an authorized provider You must file your appeal within 10 working days of the date of the notice of action, or within 10 working days after the intended effective date of the action, whichever is later You must ask for an extension of benefits If we continue your benefits during the hearing process, the benefits will continue until one of the following happens: 1. Ten working days pass from when we sent you the notice of action or notice of resolution of appeal and you have not asked for a Medicaid fair hearing with continuation of benefits until a Medicaid fair hearing decision is made 2. A Medicaid fair hearing decision is made that is not in your favor 3. The authorization expires (ends) or the authorized service limits are met 4. You withdraw (remove) your appeal Services will continue upon appeal of a denied authorization. If you lose the hearing, you may have to pay all costs that happened during the review. Amerigroup may ask you for the cost of the services given to you during this process. What happens if the Medicaid fair hearing decides I am right? Amerigroup will approve and pay for services as quickly as possible. We ll pay for the services that were reviewed in the hearing. We ll do this: According to state policy and rules If the services were given while the hearing was going on If the final decision reverses (changes) our decision 28