THANK YOU. Health HAPPEN. Quality work yields quality results. Make. for being a member of Amerigroup Community Care! Inside Gettng the care you need

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1 Inside Gettng the care you need Make Health HAPPEN Vol. 1, THANK YOU for being a member of Amerigroup Community Care! Every year, we look at how well we re serving you. Then, we look at ways to do better. We want to share information to let you know: n How to use your member handbook n How we measure the quality of your care n What services and programs are available through your health plan Because you asked In the next few months we will be updating our website to give you specific information on how we have performed on some of our quality measures, such as the State of Maryland s Value-Based Purchasing. Value-Based Purchasing is a tool used by the State of Maryland to rate how well we are serving you. Quality work yields quality results. At Amerigroup, your health is important to us. We work hard to make sure you have access to great care. We do this by: n Following state and federal guidelines n Having programs and services to help improve your health care n Educating all pregnant members and new moms about pregnancy and newborn care n Connecting you with local programs, resources and services in your community n Hosting events to answer your questions and help you make the most of your health care n Looking at your feedback to find new ways to provide better care What questions do you have about our Quality Management program? Call Amerigroup Quality Management at A description of the Quality Management program is available upon request. This includes goals, processes and results. We can also tell you more about the ways Amerigroup makes sure you get quality health care services. We want to hear from you. Amerigroup sets up Member and Consumer Health Advisory Committee meetings with our members and providers. If you d like to come to one of our meetings, please call Quality Management at HMD-NL Our TTY number has changed! If you are deaf or hard of hearing, please dial 711. Member Services (TTY 711) Amerigroup On Call/24-hour Nurse HelpLine (TTY 711) n (Español)

2 What do case managers do? Case managers work with you and your PCP to help you manage your health conditions. During our welcome call, we ll find out if you or your child needs case management services. If so, we ll refer you to a case manager. Case managers help members who have: n Serious health problems who need more care n Health problems that need care from multiple providers A case manager can help with: n Setting up appointments n Referrals and prior authorizations n Reviewing your plan of care We use claims data to find out which members qualify for complex case management. Our case managers may call you to take part in this program. You may get a call if: n Your PCP thinks the program would help you n You re sent home from the hospital and need someone to arrange follow-up care n You often go to the emergency room (ER) for non-urgent care your PCP can provide n You call Amerigroup On Call, our 24-hour Nurse HelpLine, and you need ongoing care n You re in a Disease Management program and need help coordinating care If you re called, a nurse or social worker will: n Ask you if you d like to take part in case management n Teach you about the program n Talk with you about your health and any day-to-day challenges in your life If you think you need case management services, please call Member Services at (TTY 711). For behavioral health or substance abuse issues, please call the Public Behavioral Health System at Making decisions on care and services Sometimes, we need to make decisions about how we cover care and services. This is called Utilization Management (UM). Our UM process is based on the standards of the National Committee for Quality Assurance (NCQA). All UM decisions are based on medical needs and current benefits only. We do this to ensure the best possible health outcomes for our members. We also don t tell or encourage providers to underuse services. We don t create barriers to gettng health care or reward our UM staff for denying care. Providers don t get any reward for limiting or denying care. When we decide to hire, promote or remove providers from our network, we don t base it on the fact that they may deny or would be likely to deny benefits.

3 Access to Utilization Management staff Some Amerigroup services and benefits need prior authorization. This means your doctor must ask Amerigroup to approve them. Services that don t need approval include: n Urgent care n Emergency care n Post-stabilization care Amerigroup has a Utilization Review team that looks at approval requests. The team will decide if: n The service meets medical necessity n It s a covered benefit You or your doctor can ask for a review if Amerigroup says it won t pay for the care. Amerigroup will let you and your doctor know after we get the request. The request can be for services that: n Are not approved n Have been changed in the amount, length or scope that is less than requested If you need translation services regarding Utilization Management issues, they are available at no charge by calling Member Services toll free at (TTY 711). If you have questions about an approval request or a denial you received, call Member Services at (TTY 711). If your question is about a service you or a provider feels you need but we will not cover, you can ask us to review your request again. This is called an appeal. If you want to file an appeal, you have to file it within 90 business days from the date you get the letter saying we wouldn t cover the service you wanted. You can call us to file your appeal or send your appeal in writing. We have a simple form you can use to file your appeal. Just call (TTY 711) to get one. We will mail or fax the appeal form to you. We can help you to complete it if you need help. Your handbook is a great tool! In it, you can learn about Amerigroup services, benefits and more! Your member handbook includes information about: n Preventive health care: learn how to help prevent certain illnesses and live a healthier life n Benefits and access to care: learn more about your benefits and how to get medical care n Pharmacy: learn about your drug benefits and how to get the medicines you need n Case management: find ways to care for your health condition(s) n Disease management: learn how we can help you manage chronic health problems n Member rights and responsibilities: read about the rights and responsibilities you have as an Amerigroup member n Notice of Privacy Practices: learn more about our privacy policies n Medical necessity: find out how we decide if care is needed based on coverage and levels of care and service n New medical advances: understand how our medical directors and network providers look at new medical advances and studies. They decide if new treatments: n Should be covered benefits n Are safe and effective according to government standards n Are as good as or better than treatments we already cover n Advance directives: learn about your right to sign an advance directive (living will) and have it available in case you can t share your wishes for your care n Provider directory: find providers in your network Find this information and your member handbook online at Or call Member Services at (TTY 711) to have a copy of the member handbook or any of this information mailed to you.

4 How does Amerigroup know if you re receiving quality services? Each year, our Quality Management program evaluates the care and services you get. They do this through a set of standard performance measures called the Health Care Effectiveness Data and Information Set (HEDIS). Some of the measures include things like: n Wellness checkups n Mammograms and Pap smears n Childhood vaccines n Pregnancy care n Lead screenings n Asthma care n Controlling high blood pressure n Diabetes care Most health care companies track these measures. We re always looking to improve care. Some of our current efforts include: n Outreach and education to help remind you of due or past due health care services n Community events and Amerigroup Clinic Days to encourage you to see your doctor n Meeting with doctors to help them better serve you

5 Getting the CARE you NEED Last year, we sent members a survey about children s health care. In the responses, members said getting appointments could be tough. Asking these questions may make it easier to get an appointment. n Could you add me to the waiting list? Sometimes, the earliest appointment you can get is several weeks away. Ask the office to call you if anyone cancels, and check back with them regularly. n Can you set that appointment up for me? If your PCP refers you to a specialist, ask the office to schedule the appointment. This might help you see the specialist sooner. How can we better help you? n When s the first appointment of the day? Getting the first appointment of the day can help avoid long waits because nobody s in line ahead of you. Monday and Friday tend to be the busiest days, so avoid them if possible. n How can I reach my doctor/pcp if I have questions? Before your appointment ends, find out the best way to reach your PCP with questions. He or she may take calls at certain times, or you might be able to send an or talk to a nurse. One of the ways we find out is to ask our members using surveys, like the one that inspired this article. We listen to your feedback. Your answers help us learn what you like about Amerigroup and what we need to improve. Source: What if your teen has outgrown pediatric care? It may be time for a new PCP As children near adulthood, their health needs start to change. By age 18, your teen may want to find a primary care provider (PCP) who treats adults. Adult PCP offces include: n Family practice n Internal medicine n Gynecology Gettng a yearly wellness checkup can help your teen stay well and keep up with everyday life. Start by asking your child s current PCP to recommend a new adult PCP. Amerigroup is here to help, too. You can change your teen s PCP at any time. Source: kidshealth.org/en/parents/adult-care.html

6 Interpreter services are available for free Help is available in your language: {TTY ). These services are available for free.

7 What can you do when you have an urgent health matter but aren t sure where to go? Call Amerigroup On Call (24/7 Nurse HelpLine) at (TTY 711). Our team of doctors and nurses can answer your health questions 24 hours a day, 7 days a week. How can you take charge of your health? Building a relationship with your PCP can help you get the right care for you. Which of these do you do? Which can you try? n Make and keep appointments for regular wellness checkups. n Get tests and health care services on time. n Read and follow the instructions on any reminders you get from Amerigroup.

8 P.O. Box Virginia Beach, VA Make Health HAPPEN newsletter Our Notice of Privacy Practices This notice explains how health data about you may be used and disclosed by Amerigroup. It also tells you how to get this data. The notice follows the Privacy Rules set by the Health Insurance Portability and Accountability Act (HIPAA). Our Notice of Privacy Practices is in your handbook. You can also read it online at or call Member Services at (TTY 711) and ask for a copy. Member rights and responsibilities Your rights and responsibilities as an Amerigroup member are in your member handbook. If you need, we can send you a copy of the handbook. Call Member Services at (TTY 711). Or read them online at Amerigroup services and programs designed with you in mind We hope you find this information helpful. Please keep it with your member handbook. To find out more about programs or services, go to our website at If you have any questions, call Member Services toll free at (TTY 711). Thanks again for being an Amerigroup member! We re here to help you get the care you need when you need it. The information in this document is for educational purposes only. It is not to be used as medical advice. Make Health Happen is published by Amerigroup to give information. It is not a way to give personal medical advice. Get medical advice directly from your physician All rights reserved. Printed in the USA. MD-Q NL-PC-0916 CMAP HMD-NL