Behavioral Health Services Only (BHSO) Member Handbook. Washington (TTY 711) WA-MHB

Transcription

1 Behavioral Health Services Only (BHSO) Member Handbook Washington (TTY 711) WA-MHB

2 [English] Language assistance services, including interpreters and translation of printed materials, are available free of change. Call (TTY 711).

3 Amerigroup Washington Behavioral Health Services Only (BHSO) Member handbook Washington (TTY 711) WA-MHB

4 Amerigroup Washington WASHINGTON APPLE HEALTH INTEGRATED MANAGED CARE YOUR BEHAVIORAL HEALTH BENEFIT BOOK 2018 WA-MHB Medicaid Behavioral Health Services Handbook V1 1 P a g e

5 Table of contents Welcome to Washington Apple Health from Amerigroup... 4 Important contact information... 4 How to use this book... 5 New technology... 6 Quality Management program... 6 How Amerigroup pays providers in our plan... 7 You will need two cards to access services... 7 Amerigroup ID card... 8 Services Card... 8 Changing behavioral health services plans... 9 Behavioral health services and your primary care provider (PCP)... 9 Using private health insurance and your (Amerigroup) coverage... 9 How to get behavioral health services and prior authorization (preapproval) Payment for behavioral health services How to get care in an emergency or when you are away from home You must go to an Amerigroup behavioral health provider Case management Benefits covered by Amerigroup Services covered by Apple Health fee-for-service Services NOT covered by Amerigroup or Apple Health fee-for-service Making decisions on care and services If you want to file a complaint or grievance Important information about appeals and administrative hearings Your rights Your responsibilities Patient review and coordination Advance directive Mental health advance directive We protect your privacy WA-MHB Medicaid Behavioral Health Services Handbook V1 2 P a g e

6 Please be advised that this handbook does not create any legal rights or entitlements. You should not rely on this handbook as your only source of information about Apple Health (Medicaid). The handbook is intended to just provide a summary of information about your specialty behavioral health benefits. You can get detailed information about the Apple Health programs by looking at the Health Care Authority laws and rules page on the Internet, WA-MHB Medicaid Behavioral Health Services Handbook V1 3 P a g e

7 Welcome to Washington Apple Health from Amerigroup Welcome to Washington Apple Health coverage from Amerigroup for behavioral health services only. Behavioral health is the term used for mental health and drug and alcohol treatment services. We want you to get a good start as a new enrollee. To get to know you better, we will get in touch with you in the next few weeks. You can ask us any questions you have, or get help making behavioral health appointments. If you need to speak with us before we contact you, our phone lines are open Monday through Friday from 8 a.m. to 5 p.m. Pacific time. Important contact information Customer service hours Customer service phone numbers Website address Amerigroup Monday through Friday from 8 a.m. to 5 p.m. Pacific time (TTY 711) Beacon Health Options 24 Hour Crisis phone line is available North Central Washington (NCWA) (Chelan, Douglas, and Grant) Southwest Washington (SWWA) (Clark and Skamania) TTY Health Care Authority (HCA) Apple Health Customer Service Monday Friday 7 a.m. to 5 p.m TTY/TDD or Pages/index.aspx WA-MHB Medicaid Behavioral Health Services Handbook V1 4 P a g e

8 How to use this book This handbook is your guide to behavioral health services. The first several pages will tell you what you need to know right away. When you have a question, check the list below to see who can help. If you have any questions about Contact Changing or disenrolling from Apple Health Behavioral Health Services Eligibility for health care services How to get Apple Health covered services not included through the plan ProviderOne Services card (the Services Card) Choosing or changing a provider Covered services or medications Making a complaint Appealing a decision that affects your benefits Your medical care Referrals to specialists Your behavioral health services (mental health and drug and alcohol treatment services) Changes to your account such as address change, income change, marital status, pregnancy, births or adoptions or Managed Care plan Preapproval questions or to contact our Utilization Management team HCA at: OR ; or Contact your local Community Services Organization (CSO). To find your local CSO, please visit: Amerigroup at (TTY 711) or go online to Your primary care provider. (If you need help to select a primary care provider, call us at (TTY 711) or go online to You may also call Amerigroup On Call at (TTY 711) to speak with a nurse or doctor 24 hours a day, 7 days a week. Washington Health Benefit Exchange at WAFINDER ( ) or go online to Amerigroup at , option 2 If you need behavioral health counseling, testing or need to see a behavioral health specialist, we will coordinate your care with your primary care provider (PCP). WA-MHB Medicaid Behavioral Health Services Handbook V1 5 P a g e

9 Call us if you need information in other formats or help to understand this handbook. If you have a disability, are blind or have limited vision, are deaf or hard of hearing or do not understand this book or other materials, call us. We can help you get the help you need. We can provide materials in another format, like Braille. We can tell you if a provider s office is wheelchair accessible or has special communications devices or other special equipment. Also, we have services like: TTY line (Our TTY phone number is 711). Information in large print. Help making or getting to appointments. Names and addresses of providers who specialize in specific care needs. To ask for information in another language, please call us at (TTY 711). New technology Advances in medical technology often bring new treatments to the market. We want to make sure you have access to medical and behavioral health treatments that are safe and effective. So we review new technologies to make sure they re safe and effective and work the way they re supposed to. We use the following in our review process: Scientific literature. Peer-reviewed medical journals. Nationally recognized guidelines. Current medical community standards. Government agencies, like the Food and Drug Administration (FDA). Medical experts in the condition the new treatment is for. Quality Management program We have quality programs in place to help improve medical care and health outcomes for our members. Our quality program focuses on: Quality of care. Quality of service. Patient safety. We use several tools to get data on how well we re serving you. One such tool is the HEDIS (Healthcare Effectiveness Data and Information Set). HEDIS scores are national standard measures related to clinical care. These scores reflect care members actually receive, like: Childhood immunizations and screenings. WA-MHB Medicaid Behavioral Health Services Handbook V1 6 P a g e

10 Adult preventive care. Respiratory management. Comprehensive diabetes care. Behavioral health care. Prenatal care. And more. We also use the CAHPS (Consumer Assessment of Healthcare Provider and Systems) survey, which measures how pleased our members are with the quality of their care and the customer service we provide. Once a year, members are encouraged to take part in this survey to tell us things like: Your ability to get needed care. Your ability to get care quickly. How well your doctors talk with you. Whether you re being listened to and treated with respect. Your ability to get the information you need. And more. Our quality program is designed with you in mind. When we understand what you need, prefer and expect from us, we re able to improve our services. How Amerigroup pays providers in our plan Different plan providers have agreed to be paid by us in different ways. This is called a Physician Incentive Plan. Your provider may be paid each time they treat you (fee-for-service). Or your provider may be paid a set fee each month for each member whether or not the member actually gets services (capitation). Physician Incentive Plans may include ways to earn more money based on things like member satisfaction, quality of care, accessibility and availability. You can contact Member Services at (TTY 711) to get more information. You will need two cards to access services Most people will receive two cards in the mail, one from Washington Apple Health (the Services Card) that shows Medicaid eligibility and one ID card from Amerigroup for your behavioral health benefits. If you are enrolled in Medicare, private insurance or the statewide foster care plan for your physical health, you will also receive a separate plan ID card from them. WA-MHB Medicaid Behavioral Health Services Handbook V1 7 P a g e

11 Amerigroup ID card Your ID card should arrive within 30 days of your enrollment date. If any information is incorrect on your ID card, call us right away. Your ID card will have your member ID number. Carry your ID card at all times and show it each time you go for behavioral health care. If you are eligible and need care before the card comes, you can call us at (TTY 711). Services Card You will receive a Services Card (also called a ProviderOne card) like the one pictured here. Keep this card. Your Services Card is active and shows you are enrolled in Apple Health. You will also use this card to access your physical health care benefits. are eligible for Apple Health. The number on the card is your ProviderOne client number (nine-digits ending in WA). Health care providers use ProviderOne to see whether their patients Each member of your household who is eligible for Apple Health will receive his or her own Services Card. Each person has a different ProviderOne number that stays with him or her for life. If you had Apple Health coverage in the past (or had Medicaid before it was known as Apple Health), the HCA will not mail you a new card. Your old card and client number is still valid, even if there is a gap in coverage. If you don t receive the card, the information is incorrect or you lose your card: Use the ProviderOne client portal at Request a change online at Select the topic Services Card. WA-MHB Medicaid Behavioral Health Services Handbook V1 8 P a g e

12 Call the HCA Customer Service Center at There is no charge for a new card. It takes seven (7) to ten (10) days to get the new card in the mail. Your old card will stop working when you ask for a new one. Changing behavioral health services plans You have the right to request to change your plan at any time while on Apple Health. Depending on when you request to change plans, your new plan may start as soon as the first of the next month. It s important to make sure you are officially enrolled in the newly requested plan prior to seeing providers in their network. Changing plans must be done through the Health Care Authority. There are several ways to switch your plan: Call the HCA Customer Service Center at Request a change online at Select the topic Enroll/Change Health Plans. NOTE: If you are enrolled in the Patient Review and Coordination program, you must stay with the same health plan for one year. If you move, please contact us. If you are American Indian/Alaskan Native, you have additional options. Contact HCA Customer Service for more information. Behavioral health services and your primary care provider (PCP) Most behavioral health services enrollees may already have a primary care provider (PCP) from another medical network, such as Medicare, private health insurance, Indian Health Centers or the Medicaid fee-for-service network. We will coordinate your mental health and drug and alcohol treatment with your PCP, if necessary. Please call us at (TTY 711) if you need help. Using private health insurance and your (Amerigroup) coverage We may pay co-pays, deductibles and services your private health insurance does not cover. You can avoid out-of-pocket costs if you make sure your health care providers are in our provider network or willing to bill us for any co-pays, deductibles or balances that remain after your primary coverage pays your health care bill. When you go to your doctor or other medical provider(s), show all of your cards including the private health insurance card, your Apple Health services card and (Amerigroup) card. If your private health insurance ends or changes or you have any other questions regarding your private health insurance, contact us. WA-MHB Medicaid Behavioral Health Services Handbook V1 9 P a g e

13 How to get behavioral health services and prior authorization (preapproval) If you need behavioral health or substance use disorder services, you can get help. Call Member Services at (TTY 711). You can also get the name of a behavioral health specialist who will see you if you need one. You do not need a referral from your PCP to get these services or to see a behavioral health specialist in your plan. If you think a behavioral health specialist does not meet your needs, talk to your PCP. He or she can help you find a different kind of specialist. There are some treatments and services your PCP or behavioral health specialist must ask Amerigroup to approve before you can get them. Your doctor will be able to tell you what they are. If you have questions about referrals and when you need one, contact Member Services at (TTY 711). If we do not have a medical or behavioral health specialist in our network who can give you the care you need, we will get you the care you need from a specialist outside the Amerigroup network using the preapproval process. To get preapproval, your PCP or current specialist will submit a request to Amerigroup. The request must tell us why you need to see the non-plan specialist and contain supporting documentation. We ll make a decision within five calendar days of getting the request. If the request is urgent, we ll make our decision within 24 hours. If you or your provider disagrees with our decision, you may ask for an appeal. Please refer to the section titled, Important information about appeals and administrative hearings for more information. If your PCP refers you to a provider outside our network, check with Amerigroup to receive preapproval so you are not responsible for any of the costs. We will pay for these services. Payment for behavioral health services You have no copays. However you might have to pay if: You get a service that is not covered. You get a service that is not medically necessary. You don t know the name of your plan, and a service provider you see does not know who to bill. This is why you must take your Services Card and health plan card with you every time you need services. You get care from a service provider who is not in your plan s network, unless it s an emergency or has been preapproved by your plan. You don t follow your plan s rules for getting care from a specialist. WA-MHB Medicaid Behavioral Health Services Handbook V1 10 P a g e

14 You have other insurance that pays first but you didn t share the information with the provider. If you get a bill, please call us at (TTY 711). How to get care in an emergency or when you are away from home Emergencies: You are always covered for a behavioral health emergency. An emergency means a behavioral health condition that comes on suddenly, is life threatening, is painful or other severe symptoms that cannot wait to be treated. You may have a mental health, drug or alcohol use emergency. Emergency services are covered anywhere in the United States. If you think you have a life threatening emergency, call 911 or go to the nearest hospital location where emergency providers can help you. As soon as possible, call us to arrange for follow-up behavioral health care after an emergency. If you or someone you know is experiencing a behavioral health crisis: Threatens to or talks about hurting or killing themselves Feels anxious, agitated or unable to sleep Increases alcohol or drug use Feels hopeless Withdraws from friends and family Feels rage or uncontrolled anger Encounters dramatic mood changes Feels trapped, like there is no way out Sees no reason for living Engages in reckless behaviors Beacon Health Options (Beacon) operates a 24-hour crisis phone line where professional counselors will answer your call. North Central Washington (Chelan, Douglas, and Grant County) Southwest Washington (Clark and Skamania County) Beacon may dispatch mobile crisis teams, conduct disaster outreach and perform suicide intervention. Designated Mental Health Professionals (DMHPs) may also initiate 72-hour involuntary holds on those persons evaluated to be of high risk to harm themselves or others, or who cannot provide for their own safety and welfare as a result of being gravely disabled. Behavioral health care away from home: If you need behavioral health care that is not an emergency or urgent, or need to get prescriptions filled while you are away from home, call us. WA-MHB Medicaid Behavioral Health Services Handbook V1 11 P a g e

15 Washington Recovery Help Line ( provides a 24-hour crisis intervention and referral line for issues related to mental health, substance abuse and problem gambling. Getting care after hours Getting care after hours: We have a 24 hour toll-free number to call for help. The phone number is (TTY 711). Urgent care is covered anywhere in the United States. If you think you need to be seen quickly, contact us. You can also call your PCP s office or our 24-hour Nurse Advice Line (called Amerigroup On Call) at (TTY 711). How soon you see a behavioral health provider depends on the care you need How soon you get in to see your provider depends on the care you need. You should expect to see one of our providers within the following timelines: Routine care: Office visits with your behavioral health provider within ten (10) days. Routine care is planned and includes regular provider visits for behavioral health problems that are not urgent or an emergency. Preventive care: Office visits with your provider within 30 days. Examples of preventive care are annual physicals (also called checkups), well-child care visits, annual women s health care and immunizations (shots). Transitional services: Services required to discharge an enrollee from inpatient or institutional care or a substance use disorder program for clinical assessment or care planning within seven (7) days. Emergency care: Available 24-hours per day. An emergency is when someone has a sudden or severe behavioral health problem and needs care right away. Call us for help to get follow-up care after an emergency. Urgent care: Call your PCP if you need urgent care. He or she can tell you where to go. Even if you call after hours, he or she or another doctor should be on call and able to help. Urgent care is for behavioral health problems that need care right away, but your life is not in danger. You must go to an Amerigroup behavioral health provider You must use a behavioral health provider who works with us. Call our Member Services line at (TTY 711) or visit our website at to get a provider directory or more information about our providers and hospitals. This includes: WA-MHB Medicaid Behavioral Health Services Handbook V1 12 P a g e

16 The service provider s name, location and phone number. The specialty and medical degree. The languages spoken by those providers. Any limits on the kind of patients (adults, children, etc.) the provider sees. Behavioral health services We can help coordinate your behavioral health care. We cover assessments for mental health services you might need such as, counseling, testing and medications for addressing mental health symptoms. You will have a choice of treatment providers within our network of behavioral health providers. We also provide screening for drug and alcohol use disorders, medication for drug and alcohol treatment and may make a referral to either a plan covered service or a community provider for further assessment. If you want to use your mental health or drug and alcohol treatment benefits, call our Member Services line at (TTY 711). You do not need a referral from your PCP to get these services or to see a behavioral health specialist in your plan. Prescriptions Behavioral health prescriptions are covered as part of your physical health benefit. Enrollees with Medicare coverage will access their prescription coverage through their Medicare Part D plan. If you have questions about your prescription drug coverage, call us. Case management We have case managers who can help you understand your health conditions and how to help care for yourself. Our case managers work with you and your providers to make sure you re getting the care and services that work for you. If you think you need case management services, please call Member Services at (TTY 711). Benefits covered by Amerigroup Some of the behavioral health benefits we cover are listed below. Check with your behavioral health provider or contact us if a service you need is not listed. For some services, you may need a referral from your PCP, behavioral health provider and/or preapproval from us. Some services are limited by number of visits. If you need additional services, your provider may request a Limitation Extension (LE). If you need non-covered services, have your provider request an exception to rule (ETR). Remember to call us at (TTY 711) before you get behavioral health services, or ask your PCP to help you get the care you need. WA-MHB Medicaid Behavioral Health Services Handbook V1 13 P a g e

17 Behavioral health Benefit Drug and alcohol treatment services also referred to as substance use disorder services Emergency services Evaluation and treatment/community hospitalization Hospital, inpatient and outpatient services Laboratory services Mental health treatment Description Drug and alcohol treatment services may include: Assessment Brief intervention and referral to treatment Withdrawal management (detoxification) Outpatient treatment Intensive outpatient treatment Inpatient residential treatment Opiate substitution treatment services Case management Available 24-hours per day anywhere in the United States. Medically necessary inpatient behavioral health care. Must be preapproved. Some services may require preapproval. Mental health services may include: Intake evaluation Individual treatment services Medication management Medication monitoring Group treatment services Peer support Brief intervention and treatment Family treatment High intensity treatment Therapeutic psychoeducation Day support Stabilization services Rehabilitation case management Mental health services provided in a residential setting Special population evaluation Psychological assessment Crisis services Freestanding evaluation and treatment Some additional services might be covered. Contact us for information. WA-MHB Medicaid Behavioral Health Services Handbook V1 14 P a g e

18 Services covered by Apple Health fee-for-service The Apple Health fee-for-service program covers the services listed below. To access these services, you need to use your ProviderOne card. If you have a question about a benefit or service not listed here, call us at (TTY 711). Service Ambulance services (air and ground) Description All ambulance transportation services provided to Washington Apple Health clients, including those enrolled in a managed care organization (MCO), are covered by the Health Care Authority. For emergencies or when transporting between facilities, such as from the hospital to a rehabilitation center. Non-emergency ambulance transportation is covered for clients who are dependent and/or require mechanical transfers, a stretcher to be moved when needed for medical appointments for covered services. Examples include: a person who is ventilator dependent, quadriplegic, etc. Early support for infants and toddlers (ESIT) from birth to age 3 Please call for information. Non-emergency medical transportation (NEMT) for medical and behavioral health appointments Apple Health pays for transportation services to and from necessary non-emergency physical and behavioral health care appointments. If you have a current ProviderOne Services Card, you may be eligible for transportation. Call the transportation provider (broker) in your area to learn about services and limitations. Your regional broker will arrange the most appropriate, least costly transportation for you. A list of brokers can be found at Click on Transportation Broker Directory. Services NOT covered by Amerigroup or Apple Health fee-for-service These are some examples of services that are not available from Amerigroup or Apple Health. If you get any of these services, you may have to pay the bill. If you have any questions, call us at (TTY 711). WA-MHB Medicaid Behavioral Health Services Handbook V1 15 P a g e

19 Services excluded Alternative medicines Description Acupuncture, Christian Science practice, herbal therapy, homeopathy, massage or massage therapy Marriage counseling and sex therapy Personal comfort items Services not allowed by federal or state law Making decisions on care and services Sometimes we need to make decisions about how we pay for care and services. This is called Utilization Management (UM). We have a Utilization Review (UR) team that looks at preapproval requests. They decide: If services are medically needed. If we ll pay for them. If you disagree with our decision, you or your doctor can request an appeal. What our UM program does: We identify what, when and how much of our services are medically needed. We always strive for the best possible health outcomes for you as our member. What our UM program does not do: We don t tell our doctors to withhold services. We don t tell our doctors to give you fewer services. We don t stop certain people or groups from getting services. We don t reward doctors for limiting or denying services. We don t hire, promote or fire doctors or staff based on how they approve or deny services. Plan providers use clinical practice guidelines to determine necessary treatments and services. Our UM program follows the National Committee for Quality Assurance (NCQA) standards. Our UM staff is available Monday through Friday from 8 a.m. to 5 p.m. Pacific time. To speak to a UR team member, please call , option 2. Our Utilization Review team will identify themselves by name, title and organization when taking calls. WA-MHB Medicaid Behavioral Health Services Handbook V1 16 P a g e

20 If you want to file a complaint or grievance You or your authorized representative have the right to file a complaint. This is called a grievance. We will help you file and resolve your grievance. Grievances or complaints can be about: A problem with your doctor s office or behavioral health provider. Getting a bill from your provider. Being sent to collections due to an unpaid medical bill. The quality of your care or how you were treated. Any other problems you may have getting health care. We must let you know by phone or letter that we received your grievance or complaint within two (2) working days. We must address your concerns as quickly as possible and cannot take more than 45 days. You can get a free copy of our grievance policy by calling us. If we cannot resolve your grievance, you can also file a grievance directly with the Health Care Authority by calling Important information about appeals and administrative hearings You have the right to appeal an adverse benefit determination. We will help you file an appeal. Examples of adverse benefit determinations include but are not limited to: Denial or limited authorization of a health care service; Reduction, suspension or termination of a previously authorized service; Failure to provide services in a timely manner; and Failure to process an appeal within required timeframes. When we deny a service, we will send you a letter telling you why we denied the requested service. This letter is the formal notice of adverse benefit determination. It will let you know your rights and information about how to request an appeal. You or your provider may appeal a denied service. An appeal is when you ask us to review your case again because you disagree with our decision. With written consent, you can have someone else appeal on your behalf. You must appeal within 60 calendar days of the date of the denial letter. You may be able to continue to receive care while you appeal. If you keep getting a service during the appeal process and you lose the appeal, you may have to pay for the services you received. You only have 10 days to appeal if you want to keep getting a service that you are receiving while we review our decision. We will reply in writing telling you we received your request for an appeal within five WA-MHB Medicaid Behavioral Health Services Handbook V1 17 P a g e

21 (5) calendar days. In most cases we will review and decide your appeal within 14 days. We must tell you if we need more time to make a decision. We must notify you in writing if we take more than 14 days to make a decision. An appeal decision must be made within 28 days. You may file an appeal in writing by sending a letter to: Amerigroup Washington, Inc th Ave. S., Suite 300 Seattle, WA Fax: You may file an appeal verbally by calling (TTY 711). An expedited appeal is when you or your doctor ask for an expedited (quick) appeal by calling us. If your medical condition requires it, a decision will be made about your care within seventy-two (72) hours after we receive your appeal. We must tell you if we need more time to make a decision. An additional fourteen (14) days may be required to review your appeal upon your request or if we need more information. To ask for an expedited appeal, tell us why you need the faster decision. If we deny your request, your appeal will be reviewed in the same time frames outlined above. We must make reasonable efforts to give you a prompt verbal notice if we deny your request for an expedited appeal. You may file a grievance if you do not like our decision to change your request from an expedited appeal to a standard appeal. We must mail written notice within two (2) calendar days of a decision. If you disagree with the appeal decision, you have the right to ask for an administrative hearing. You have 120 calendar days from the date of our appeal decision to request an administrative hearing. You only have 10 calendar days to ask for an administrative hearing if you want to keep getting the service that you were receiving before our denial. In a hearing, an administrative law judge that does not work for us or the Health Care Authority will review your case. To ask for an administrative hearing: 1. Call the Office of Administrative Hearings ( at OR 2. Write to: Office of Administrative Hearings P.O. Box Olympia, WA AND 3. Tell the Office of Administrative Hearings that Amerigroup is involved; the reason for the WA-MHB Medicaid Behavioral Health Services Handbook V1 18 P a g e

22 hearing; what service was denied; the date it was denied; and the date that the appeal was denied. Also, be sure to give your name, address and phone number. You may talk with a lawyer or have another person represent you at the hearing. If you need help finding a lawyer, visit or call the NW Justice CLEAR line at You will get a notice explaining the decision from the hearing judge. If you disagree with the hearing decision, you have the right to appeal the decision directly to the Health Care Authority s Board of Appeals or by asking for a review of your case by an Independent Review Organization (IRO). An IRO is a group of doctors who do not work for us. To request an Independent Review, you must call us and ask for a review by an IRO after you get the hearing decision letter. Important time limit: The decision from the hearing becomes a final order within 21 calendar days of the date of mailing if you take no action to appeal the hearing decision. If you disagree with the hearing decision, you can ask to have a review judge from the Health Care Authority s Board of Appeals to review your case. You only have 21 days to ask for the review after getting your decision letter. The decision of the review judge is final. To ask a review judge to review your case: Call , OR Write to: HCA Board of Appeals P.O. Box Olympia, WA Your rights As an enrollee, you have a right to: Help make decisions about your health care, including mental health and drug and alcohol treatment services and refusing treatment. Be informed about all treatment options available, regardless of cost. Get a second opinion from another provider in your plan. Get services without having to wait too long. Be treated with respect and dignity. Discrimination is not allowed. No one can be treated differently or unfairly because of his or her race, color, national origin, gender, sexual preference, age, religion, creed or disability. Speak freely about your health care and concerns without any bad results. Have your privacy protected and information about your care kept confidential. WA-MHB Medicaid Behavioral Health Services Handbook V1 19 P a g e

23 Ask for and get copies of your medical records. Ask for and have corrections made to your medical records when needed. Ask for and get information about: Your health care and covered services. Your provider and how referrals are made to specialists and other providers. How we pay your providers for your physical health care or behavioral health services. All options for care and why you are getting certain kinds of care. How to get help with filing a grievance or complaint about your care. Our organizational structure including policies and procedures, practice guidelines and how to recommend changes. Receive the Enrollees Rights and Responsibilities at least yearly. Receive a list of crisis phone numbers. Receive help completing mental or medical advance directive forms. Your responsibilities As an enrollee, you agree to: Help make decisions about your health care, including refusing treatment. Keep appointments and be on time. Give your providers information they need to be paid for providing services to you. Bring your Services Card and plan ID card to all of your appointments. Learn about your plan and what services are covered. Give your providers and Amerigroup complete information about your health so you can get the care you need. Follow your provider s instructions for care that you have agreed to. Renew your coverage annually or report changes to your account using the Washington Health Benefit Exchange at or contact your local Community Services Office (CSO). Changes may include but are not limited to income, marital status, pregnancy, births, adoptions, address changes or when you become eligible for Medicare or other insurance. Patient review and coordination The Patient Review and Coordination (PRC) Program is a federal and state requirement of Medicaid that focuses on the health and safety of enrollees. It's used by both the state and Amerigroup to manage the utilization and use of medical services by enrollees by restricting enrollees to certain providers. WA-MHB Medicaid Behavioral Health Services Handbook V1 20 P a g e

24 The PRC program may assign you to a specific provider(s) you choose or assigned by the program. Enrollees can be assigned to one primary care provider, one pharmacy, one hospital for non-emergency care, one narcotic prescriber or any combination of these providers. The assigned provider will coordinate and monitor your medical needs. If you receive notification that you are on the PRC program, please call us with any questions about your provider assignment or any concerns you have about the program. Advance directive An advance directive puts your choices for health care into writing. The advance directive tells your doctor and family the kind of health care you do or do not want if: You lose consciousness. You can no longer make health care decisions. You cannot tell your doctor or family what kind of care you want. You want to donate your organ(s) after your death. You want someone else to decide about your health care if you can t. There are three types of advance directives in Washington State. 1. Durable power of attorney for health care. This names another person to make medical decisions for you if you are not able to make them for yourself. 2. Healthcare directive (living will). This written statement tells people whether you want treatments to prolong your life. 3. Organ donation request. You can cancel an advance directive at any time. You can get more information from us, your doctor or a hospital about advance directives. The Physician Orders for Life Sustaining Treatment (POLST) form is for anybody who has a serious health condition and needs to make decisions about life-sustaining treatment. Your provider can use the POLST form to represent your wishes as clear and specific medical orders. To learn more, contact us. Mental health advance directive A mental health advance directive (MHAD) puts your choices for mental health treatment and care into writing. You may choose what kind of mental health treatment and care you do or do not want if: You lose consciousness. You can no longer make decisions. WA-MHB Medicaid Behavioral Health Services Handbook V1 21 P a g e

25 You cannot tell your physician, behavioral health provider or family what kind of care and treatment you want for any other reason. If you want someone else to decide about your treatment and care if you can t. The advance directive tells your physician, behavioral health provider and family your mental health care preferences and instructions about: Treatment, facilities, physicians and other providers; Medications for psychiatric treatment; Hospitalization and alternatives; Hospital preferences and instructions; Pre-emergency interventions; Seclusion, restraint and emergency medications; and, Who is permitted to visit. A form and other related documents are available on the DSHS MHAD website at: We protect your privacy Alcohol and drug treatment records are protected under the Federal regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 CFR Parts 160 & 164, and cannot be disclosed without your written consent unless otherwise provided for by the regulations. For medical records in general, we are required by law to protect your protected health information (PHI). This refers to health information such as medical records that include your name, enrollee number or other identifiers used or shared by plans. Managed Care plans and HCA share PHI for the following reasons: Treatment Includes referrals between your PCP and other health care providers. Payment We may use or share PHI to make decisions on payment. This may include claims, approvals for treatment and decisions about medical needs. Health care operations We may use or share PHI about you to run our business. For example, we may use information from your claim to let you know about a health program that could help you. Your PHI may also be used to see that claims are paid correctly. We may use or share your PHI without getting written approval from you under certain circumstances: WA-MHB Medicaid Behavioral Health Services Handbook V1 22 P a g e

26 Disclosure of your PHI to family members, other relatives and your close personal friends is allowed if the information is directly related to the family or friend s involvement with your care or payment for that care; and you have either verbally agreed to the disclosure or have been given an opportunity to object and have not objected. When the U. S. Secretary of the Department of Health and Human Services requires the plan to share your PHI. Public health and safety: This may include helping public health agencies to prevent or control disease. Health care oversight: Your PHI may be used or shared with government agencies. They may need your PHI for audits. Research: Your PHI may be used or shared for research in certain cases, when approved by a privacy or institutional review board. Legal or administrative proceedings: Your PHI may be used or shared for legal proceedings, such as in response to a court order. Law enforcement: Your PHI may be used or shared with police to help find a suspect, witness or missing person. Your PHI may also be shared with other legal authorities, if we believe that you may be a victim of abuse, neglect or domestic violence. Government functions: Your PHI may be shared with the government for special functions, such as national security activities. Workers Compensation: Your PHI may be used or shared to obey Workers Compensation laws. Death: If you pass away, your PHI may also be shared with funeral directors or coroners. Your written approval is required for all other reasons not listed above. You may cancel a written approval that you have given to your health plan. However, your cancellation will not apply to actions taken before the cancellation. You may ask for a copy of your PHI. To request a copy, call Member Services at (TTY 711) Monday through Friday from 8 a.m. to 5 p.m. Pacific time. If you believe we violated your rights to privacy you can: Call us and file a complaint. We will not take any action against you for filing a complaint. The care you get will not change in any way. File a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at OR Write to: U.S. Department of Health and Human Services WA-MHB Medicaid Behavioral Health Services Handbook V1 23 P a g e

27 200 Independence Ave. SW, Room 509F, HHH Building Washington, DC OR Call (TDD ) Note: This information is only an overview. We are required to keep your PHI private and give you written information annually about our privacy practices and your PHI. Please refer to our notice of privacy practices at for additional details. You may also contact us for more information at: Amerigroup Washington, Inc th Ave. S., Suite 300 Seattle, WA (TTY 711) WA-MHB Medicaid Behavioral Health Services Handbook V1 24 P a g e