Member Handbook. Amerigroup Florida, Inc (TTY 711) Florida Statewide Medicaid Managed Care Long-Term Care Program

Transcription

1 Member Handbook Amerigroup Florida, Inc. Florida Statewide Medicaid Managed Care Long-Term Care Program (TTY 711)

2 Amerigroup Florida, Inc. Member Handbook Florida Statewide Medicaid Managed Care Long-Term Care Program (TTY 711)

3 Amerigroup Member Handbook Florida Statewide Medicaid Managed Care Long-Term Care Program 4200 W. Cypress St., Suite 900 Tampa, FL (TTY 711) Welcome to Amerigroup! This member handbook will help you get medical care, home support and community services as an Amerigroup member. Table of Contents WELCOME TO AMERIGROUP... 1 Your new long-term care program... 1 Translation services... 1 New member tips... 2 How to get help... 2 Amerigroup Case Management team... 2 Amerigroup case manager... 2 Important contact information... 4 How to get an interpreter... 4 Your Amerigroup member handbook... 5 Your identification card... 5 If you have Medicare coverage... 6 AMERIGROUP HEALTH CARE BENEFITS... 7 What is covered by Amerigroup?... 7 Your plan of care... 7 Second opinions... 8 Home- and community-based services... 8 Out-of-network care... 8 In lieu of services... 8 Patient responsibility... 8 AMERIGROUP COVERED SERVICES AND LIMITATIONS... 9 AMERIGROUP EXPANDED SERVICES...13 SERVICES EXCLUDED BY AMERIGROUP...14 SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID...14 PARTICIPANT DIRECTION OPTION...15 PRIOR AUTHORIZATIONS...15

4 UNDERSTANDING YOUR PROVIDER DIRECTORY...15 SPECIAL KINDS OF HEALTH CARE...15 Behavioral health care In lieu of services behavioral health Emergency care After-hours emergencies Nonemergency support services outside the service area Participating providers Out-of-network services Special care for pregnant members When you become pregnant After you have your baby ELIGIBILITY...17 ENROLLMENT IN AMERIGROUP...18 Enrollment Open enrollment Disenrollment Reinstatement AMERIGROUP QUALITY ENHANCEMENTS...19 ADVANCE DIRECTIVE OR LIVING WILLS...20 CONCERNS, SUGGESTIONS AND COMPLAINTS...22 Abuse and neglect Fraud and abuse in Florida Medicaid How to report someone misusing the Medicaid program MEMBER GRIEVANCES AND APPEALS...23 Complaints and grievances Medical appeals Payment appeals OTHER INFORMATION...31 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 FLORID! P!TIENT S BILL OF RIGHTS AND RESPONSIBILITIES...34

5 Your rights Your responsibilities AMERIGROUP ADDRESS CHANGE FORM...37 HIPAA NOTICE OF PRIVACY PRACTICES...38

6 WELCOME TO AMERIGROUP Your new long-term care program Welcome to Amerigroup Florida, Inc. Amerigroup is a health maintenance organization (HMO) that brings health care and long-term care coverage to our enrolled members. The purpose of the LTC program is to give you an array of services to meet your needs and allow you to live in the setting of your choice. This includes allowing you to live in the community for as long as you choose. Enrolled members could be: Someone who chooses Amerigroup or Someone assigned to Amerigroup through open enrollment However you came to!merigroup, we re happy to help you get the care you need, when you need it. This is your member handbook. The information in this book will tell you how your health plan works. Please read it with care. You can always find the most up-to-date member handbook online at If you would like a printed copy of this member handbook, please call Member Services at (TTY 711). Translation services Amerigroup wants to talk to you in your language. All Amerigroup materials come in English and Spanish. We also offer everything in: Braille Audio tape Large print Additional languages All versions are free. If you need any materials in another language or format, please call Member Services toll free at (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time. 1

7 We want to help you live in your home and community, or nursing home by bringing you: Community services Home care coverage Nursing home services Amerigroup will help handle your 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 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 s correct 2. Read through this handbook 3. Keep this handbook in a safe place 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 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. 2

8 Your case manager 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 Visit our website at for lots of information about our plan. an t find what you need on the site? One phone number is all you need to get help and important information. Call toll free (TTY 711) to get: Benefit questions answered Ask for your Case Management team Medical questions answered day or night Ask for the 24-hour Nurse HelpLine Printed member handbooks or provider directories 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 p.m. Eastern time. Member Services is available Monday through Friday from 8 a.m. to 7 p.m. Eastern time. 3

9 Important contact information Services Emergency 911 Contact information 24-hour Nurse HelpLine Agency for Health Care Administration (AHCA) Subscriber Assistance Program Agency for Health Care Administration (AHCA) Facility Health Finder Aging and Disability Resource Center Broward County Aging and Disability Resource Center/Alliance for Aging for Miami- Dade and Monroe Counties Broward Area Medicaid Office Miami-Dade and Monroe Counties Medicaid Office DentaQuest (TTY 711) The Department of Children and Families (DCF) Automated ACCESS Information and Customer Call Center Department of Elder Affairs Florida Affordable Assisted Living Elder Helpline Enrollment or disenrollment information eyequest (TTY 711) 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 4

10 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. 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: 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 isn t 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 In Miami-Dade and Monroe counties, please call toll free As an Amerigroup member, you ll also get an Amerigroup member ID card. Keep this ID card, your card and your Medicare ID card with you at all times. 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 5

11 Long-Term Care Member ID card example Medicaid and Long-Term Care Member ID card example 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 at (TTY 711). We ll 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 6

12 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). 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 re free to pick the providers you want to see from our provider group. Sometimes, your case manager may remove certain providers for you to pick from. Those providers may not have what you need. 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. 7

13 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. 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. You have the right to get services in a home or non-home based setting that meets the home- and community-based (HCB) standards. You also have the right to take part in your community. Out-of-network care!merigroup wants to make sure you get the care you need/ Sometimes, we don t have a provider in our group who can give you the services you need/ If that happens, we ll pay for the out-of-network services if medically necessary and approved by us. We ll pay for this quickly/ You ll be able to keep getting these services from outside our network as long as we can t get them from inside our network. In lieu of services Amerigroup may cover services or settings that are in lieu of or in place of services or settings we offer. The in lieu of service we cover is: In lieu of service covered: Nursing facilities The service it substitutes: Hospital inpatient services Patient responsibility Patient responsibility is the amount you must pay toward the cost of your care. This is decided by the Department of hildren and Families Economic Self Sufficiency only and is based on income and type of placement. 8

14 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 given and for which no equally effective and more conservative or less costly treatment is available Given 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 doesn t 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 ll 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 for free. COVERED SERVICES Adult companion care services Adult day health care Assistive care services COVERAGE LIMITS Nonmedical care, supervision and socialization Help or supervision of tasks such as meal preparation, laundry and shopping Does not include hands-on nursing care Social and health events in a day program at a center Meals are included when the member is at the center during meal time Up to twenty-four (24)-hour services for members living in an adult family care home such as personal care, help in the home, medication monitoring and social events Room and board costs aren t included as part of the adult family care home. They are based on the 9

15 COVERED SERVICES Assisted living facility services Attendant care services Behavioral management Care coordination/ Case management Caregiver training services COVERAGE LIMITS member s income/ The member may also need 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 comprised of personal care, homemaker, chore, companion and medication oversight provided to members living in a home-like environment in an assisted living facility Room and board costs aren t part of the assisted living facility. These costs are based on the member s income. The member may also need to pay more toward assisted living services, per the Florida Department of Children and Families (DCF) Members or the member s family may need to pay certain costs if the facility s costs are more than the member s given amount and the plan s payment amount 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 management 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 10

16 COVERED SERVICES Home accessibility adaptation services Home-delivered meals Homemaker services Hospice services Intermittent and skilled nursing Medical equipment and supplies Medication administration Medication management Nursing facility COVERAGE LIMITS 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 allow the member to have greater freedom in the home and without which the member would require a nursing home Home-delivered meals for members that need help shopping for or preparing food 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 nondurable 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 nurse or a qualified, certified unlicensed staff trained per 58A (5) F.A.C Review of all medications, prescription and over-the-counter items Done by a licensed nurse or pharmacist Available for members who need them under medically necessary standards Service is covered up 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 11

17 COVERED SERVICES Nutritional assessment/ Risk reduction services Occupational, physical, respiratory and speech therapy services for those under 21 years of age Personal care Personal emergency response systems (PERS) Respite care services Transportation services to medical checkups COVERAGE LIMITS 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 to teach members how to shop and make healthy choices Occupational therapy: help to bring back, improve, keep or reduce physical movement. Used 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, cooking meals and 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 isn t available or needs relief Doesn t 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 12

18 If you d like to view the Florida Medicaid Statewide Medicaid Managed are Long-term Care Coverage Policy it can be found at AHCA.myflorida.com. You can also request a copy from your case manager. 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. AMERIGROUP EXPANDED SERVICES 24-hour Nurse HelpLine services Assisted living facility and adult family care home bed holds Cellphone 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 Members can get a free cellphone with free monthly minutes, data and text messages. 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 13

19 AMERIGROUP EXPANDED SERVICES Vision services COVERAGE LIMITS One benefit per member per lifetime Must be used within 365 days of transition Ask your case manager for help with this service. 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. SERVICES EXCLUDED BY AMERIGROUP Sometimes Amerigroup decides not to offer, pay for, or give coverage of a counseling or referral service because of an objection on moral or religious reasons. Amerigroup must 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. If you think you need these services, call your case manager. We can help you find a provider. Long-Term care services Claims for covered services under your long term care benefit 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 14

20 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. 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. 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. 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. 15

21 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 In lieu of services behavioral health In lieu of services are services you get in different settings. They are used to take the place of (substitute) other covered services. To get these services, you need an approval. The covered in lieu of services for members over the age of 21 years are: In lieu of service covered: Crisis Stabilization Units Substance Abuse Detoxification Facility Licensed under Chapter 397, F. S. The service it substitutes: Hospital Inpatient Psychiatric Service Hospital Inpatient Detoxification Service Medicare and Medicaid fee-for-service may 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 at (TTY 711). 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 support services outside the service area Do you need nonemergency services but are outside of the service area? You must call your case manager before getting the support services. Home- and community-based services are not paid for outside the service area. Participating providers We won t pay for care from providers not authorized (approved) by Amerigroup. 16

22 Out-of-network services Amerigroup wants you to get the services 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 s important you get prior approval for these services. Amerigroup will pay for the services we approve, but you may have to pay for services 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) caseworker 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 caseworker. ELIGIBILITY You can be an Amerigroup LTC 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 re not financially eligible for Medicaid, you ll be disenrolled from Amerigroup. You ll need to pay for the services you got as an Amerigroup Medicaid-pending member. 17

23 ENROLLMENT IN AMERIGROUP Enrollment If you re a mandatory enrollee required to enroll in a plan, once you re enrolled in Amerigroup or the state enrolls you in a plan, you ll have 120 days from the date of your first enrollment to try the Managed Care Plan. During the first 120 days, you can change Managed Care Plans for any reason. After the 120 days, if you re still eligible for Medicaid, you may be enrolled in the plan for the next eight months. This is called lockin/ Open enrollment If you re a mandatory enrollee, the state will send you a letter 60 days before the end of your enrollment year saying you can change plans if you want to/ This is called open enrollment/ You don t have to change Managed Care Plans. If you choose to change plans during open enrollment, you ll 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 ll be locked into that plan for the next 12 months. Every year, you may change Managed Care Plans during your 60-day open enrollment period, without cause. Disenrollment If you re a mandatory enrollee and you want to change plans after the initial 120-day period ends or after your open enrollment period ends, you must have a state-approved good cause reason to change plans. The following are state-approved cause reasons to change Managed Care Plans: 1. The enrollee doesn t live in a region where the Managed Care Plan is authorized to provide services, as indicated in Florida Medicaid Managed Information System (FMMIS). 2. Their provider is no longer with the Managed Care Plan. 3. The enrollee is excluded from enrollment. 4. A substantiated marketing violation has occurred. 5. The enrollee is prevented from participating in the development of his/her treatment plan/plan of care. 6. The enrollee has an active relationship with a provider who isn t on the Managed are Plan s panel, but is on the panel of another Managed are Plan/ Active relationship is defined as having received services from the provider within the six months preceding the disenrollment request. 7. The enrollee is in the wrong Managed Care Plan as determined by the Agency. 8. The Managed Care Plan no longer participates in the region. 9. The state has imposed intermediate sanctions upon the Managed Care Plan, as specified in 42 CFR (a)(4). 18

24 10. The enrollee needs related services to be performed together, but not all related services are available within the Managed Care Plan network. Or the enrollee s PP has determined getting the services separately would subject the enrollee to unnecessary risk. 11. The Managed Care Plan doesn t, because of moral or religious objections, cover the service the enrollee seeks. 12. The enrollee missed open enrollment due to a temporary loss of eligibility. 13. Other reasons per 42 CFR (d)(2) and s (2), F.S., including, but not limited to: poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; an unreasonable delay or denial of service; lack of access to providers experienced in dealing with the enrollee s health care needs- or fraudulent enrollment/ Amerigroup may ask you to disenroll if you want to stay in an Assisted Living Facility (ALF) or Adult Family Care Home (AFCH) that doesn t, and won t, comply with HCB Settings Requirements. Some Medicaid recipients may change Managed Care Plans whenever they choose, for any reason. To find out if you may change plans, call the Enrollment Broker (TTY ). 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. Community events Amerigroup hosts community events and health fairs in your area. Many events offer health tips in a fun setting/ It s a great time to learn something new/!merigroup can answer your questions at the event. 19

25 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 at (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. 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 won t 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. 20

26 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 aren t 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 re 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. 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. 21

27 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 re 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 711). Case management is available Monday through Friday from 8:30 a.m. to 5 p.m. Eastern time. Member Services can also help. Call toll free (TTY 711) Monday through Friday from 8 a.m. to 7 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 ( ). Fraud and abuse in Florida Medicaid To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll free at or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at InspectorGeneral/fraud_complaintform.aspx. 22

28 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!ttorney 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!ttorney General s Office about keeping your identity confidential 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 4425 Corporation Lane Virginia Beach, VA (TTY 711) 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. MEMBER 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 grievances and appeals. You can talk to someone from grievance and appeals Monday through Friday from 8:30 a.m. to 5:30 p.m. Eastern time. A grievance is when you re not happy about something besides your benefits/! grievance could be about a doctor s behavior or about information you should have received, but didn t/!n appeal is when you feel you should be getting a service covered and you re not or that service has been stopped. 23

29 Complaints and 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 resolved within 24 hours, Member Services will help you. If your concern can t be handled within 24 hours and needs to be looked at by our grievance coordinator, your call will be transferred to the grievance and appeals coordinator. How do I let Amerigroup know about my concern? A complaint or grievance must be given out loud by phone or in person, or in writing anytime after the event happened. To file a complaint or grievance with a grievance and appeals coordinator: 1. Call Member Services at (TTY 711). 2. Write us a letter regarding your concern. Mail it to: Grievance and Appeals Coordinator Amerigroup 4200 W. Cypress St., Suite 900 Tampa, FL You can have someone else help you with the grievance process. This person can be: A family member A friend Your doctor A lawyer Write this person s name on the grievance form/ If you need help filing the complaint, Amerigroup can help. Call Member Services at (TTY 711) and a grievance and appeals coordinator will help you. Once Amerigroup gets your grievance (oral or written), we will send you a letter within five business days. This letter will tell you the date we got your grievance. 24

30 What happens if I have additional information? If you have more information you want us to have: 1. Bring it to us in person or mail it to: Grievance and Appeals Coordinator Amerigroup 4200 W. Cypress St., Suite 900 Tampa, FL Ask for the grievance and appeals coordinator to call you when you send in your grievance 3. Call the grievance and appeals coordinator at (TTY 711) What happens next? The grievance coordinator will review your concern. If more information is needed or you have asked to talk to the coordinator, he or she will call you. 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. What happens if I want an extension? Although Amerigroup normally will resolve your concern within 30 calendar days, there are times when an extension is needed. Amerigroup may extend the time it takes to resolve your concern up to 14 calendar days if: 1. You request an extension 2. Amerigroup needs additional information and we believe by extending the time it is in your best interest Amerigroup will call you the same day and let you know in writing within two business days of our identification that a grievance extension is needed. Medical appeals There may be times when Amerigroup says it won t pay, in whole or in part, for care that your doctor has asked for. If we do this, you (or your doctor 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 doctor asked for, and we said we won t pay for. You must file for an appeal within 60 calendar days from the date on the letter that says we won t pay for a service. Amerigroup won t act differently toward you or the doctor who helped file an appeal. 25

31 I want to ask for an appeal. How do I do it? An appeal may be filed out loud by phone or in writing. This needs to be within 60 calendar days of when you get the notice of adverse benefit determination. There are two ways to file an appeal: 1. Write and ask to appeal. Mail the appeal request and all medical information to: Grievance and Appeals Coordinator Amerigroup 4200 W. Cypress St., Suite 900 Tampa, FL Call the grievance and appeal coordinator toll free at (TTY 711). Except when an expedited ruling 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 of receipt. 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 may talk to the doctor who looks at your case/ We ll help you meet with or talk to him or her. You may ask for a free copy of the guidelines, records or other information used to make this ruling. We ll tell you what the ruling is within 30 calendar days of getting your appeal request/ What if I have more information I want you to have? If you have more information to give us, bring it in person or mail it to the Medical Appeals address above. Also, you can look at your medical records and information on this ruling before and during the appeal process. The time frame for an appeal may be extended up to 14 calendar days if: You ask for an extension Amerigroup finds additional information is needed, and the delay is in your interest If the time frame is extended without your request, Amerigroup will call you on the same day. We ll let you know in writing within two business days of when the ruling is made. 26

32 If you have a special need, we will give you extra help to file your appeal. Please call Member Services at (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time. What can I do if I think I need an urgent or expedited appeal? You or your doctor or someone on your behalf can ask for an urgent or expedited appeal if: You think the time frame for a standard appeal process could seriously harm your life or health or ability to attain, maintain or regain maximum function, based on a prudent layperson s judgment In the opinion of your doctor who has knowledge of your medical condition, a standard appeal would subject you to severe pain that can t be well-managed without the care or treatment that is the subject of the request You can also ask for an expedited appeal by calling Member Services toll free at (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time. Should you need an expedited appeal during nonworking hours, call the 24-hour Nurse HelpLine. They can handle your appeal request. If you have any questions, need help or would like to talk to the grievance and appeals coordinator, please call Member Services toll free at (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time. We must respond to you by phone or in person within 72 hours after we get the appeal request, whether the appeal was made out loud by phone or in writing. Amerigroup will follow up in writing no later than three calendar days after the initial oral notification. If the request for an expedited appeal is denied: The appeal will be reviewed in the time frame for standard resolution You will be notified within 72 hours 27

33 What if my health care was reduced, postponed or ended and I want to keep getting health care while my appeal is in review? Call Member Services if you would like to keep your benefits during your appeal. Amerigroup will continue your benefits if: 1. You or your authorized representative file an appeal with Amerigroup regarding the decision: a. Within 10 business days after the notice of the adverse benefit determination is mailed; or b. Within 10 business days after the intended start date of the action, whichever is later. 2. The appeal involves the end, suspension or reduction of a previously authorized course of treatment 3. The services were ordered by an authorized provider 4. The original period covered by the original authorization hasn t expired; and 5. You request extension of benefits If you meet these requirements, Amerigroup will approve the service until one of the following happens: 1. You withdraw the appeal 2. Ten business days pass after Amerigroup sends you the notice of resolution of the appeal against you, unless within those 10 days you have requested a Medicaid Fair Hearing with continuation of benefits 3. The Medicaid Fair Hearing office issues a hearing decision adverse to you 4. The time period or service limits of a previously authorized service have been met If the state fair hearing or Subscriber Assistance Program agrees with us, you may have to pay for the care you got during the appeal. What can I do if Amerigroup still will not pay? You have a right to ask for a state fair hearing. You must request a grievance or an appeal before you ask for the fair hearing. If you ask for a fair hearing, you must do so before 120 calendar days after you get our letter saying we won t pay for a service. The Medicaid Hearing Unit is not part of Amerigroup. This office looks at appeals from Florida Medicaid members. If you contact the Medicaid Hearing Unit, we will give them facts about your case. This includes the details you have given us. 28