Real. Solutions. Member Handbook. New Mexico Coordination of Long-Term Services Program n

Transcription

1 Real Solutions Member Handbook Amerigroup Community Care of New Mexico, Inc. NM-MHB New Mexico Coordination of Long-Term Services Program n

2 Dear Member: Welcome to Amerigroup Community Care of New Mexico, Inc. We are happy you picked us to arrange your quality health care benefits. This member handbook tells you how Amerigroup works and how to keep you healthy. It tells you how to get health care when it is needed, too. You will get your Amerigroup ID card and more information from us in a few days. Your ID card will tell you when your Amerigroup membership starts. Please check your ID card right away. If any information is not right, please call us at We will send you a new ID card with the correct information. If you need to reach us, you can call Member Services at You can talk to a Member Services representative about your benefits. You can also talk to a nurse on our 24-hour Nurse HelpLine if you need medical advice. We are here to help you get quality health care coverage. Thank you again for picking us as your health plan. Sincerely, Jeanine Davis Chief Operating Officer Amerigroup Community Care of New Mexico, Inc. New Mexico CoLTS program services are funded in part under contract with the state of New Mexico.

3 AMERITIPS HEALTH TIPS THAT MAKE HEALTH HAPPEN YOU NEED TO GO TO YOUR DOCTOR NOW! WHEN IS IT TIME FOR A WELLNESS VISIT? All Amerigroup members need to have regular wellness visits. This way, your Primary Care Provider (PCP) can see if you have a problem before it is a bad problem. When you become an Amerigroup member, call your PCP and make your first appointment before the end of 90 days. WELLNESS VISITS FOR CHILDREN Children need more wellness visits than adults. These wellness visits for children are called Tot-to-Teen HealthChecks. Your child should get wellness visits at the times listed below. Newborn 9 months old 3-5 days old 12 months old 1 month old 15 months old 2 months old 18 months old 4 months old 24 months old 6 months old 30 months old After age 2, you and your child should keep going to your PCP every year for wellness visits. WHAT IF I BECOME PREGNANT? If you think you are pregnant, call your PCP or OB/GYN right away. This can help you have a healthy baby. If you have any questions or need help making an appointment with your PCP or OB/GYN, please call our Member Services department at ALERT! KEEP THE RIGHT CARE. DO NOT LOSE YOUR HEALTH CARE BENEFITS RENEW YOUR ELIGIBILITY FOR MEDICAID BENEFITS ON TIME. SEE PAGE 68 FOR MORE DETAILS. Amerigroup is a culturally diverse company. We welcome all eligible individuals into our health care programs, regardless of health status. If you have questions or concerns, please call (TTY ) and ask for extension Or visit

4 AMERIGROUP COMMUNITY CARE OF NEW MEXICO, INC. MEMBER HANDBOOK Two Park Square 6565 Americas Parkway, N.E., Suite 110 Albuquerque, NM TTY Welcome to Amerigroup Community Care of New Mexico, Inc.! You will get most of your health care services through Amerigroup. This member handbook will tell you how to use Amerigroup to get the health care you need. Table of Contents WELCOME TO AMERIGROUP COMMUNITY CARE OF NEW MEXICO, INC... 1 INFORMATION ABOUT YOUR NEW HEALTH PLAN... 1 HOW TO GET HELP... 1 AMERIGROUP MEMBER SERVICES DEPARTMENT... 1 AMERIGROUP 24-HOUR NURSE HELPLINE... 2 YOUR SERVICE COORDINATOR... 2 OTHER IMPORTANT PHONE NUMBERS... 3 YOUR AMERIGROUP MEMBER HANDBOOK... 3 IF YOU HAVE MEDICARE COVERAGE... 4 YOUR IDENTIFICATION CARDS... 4 YOUR PROVIDERS... 5 PICKING A PRIMARY CARE PROVIDER... 5 SECOND OPINION... 6 IF YOU HAD A DIFFERENT PRIMARY CARE PROVIDER BEFORE YOU JOINED AMERIGROUP... 6 IF YOUR PRIMARY CARE PROVIDER S OFFICE MOVES, CLOSES OR LEAVES THE AMERIGROUP NETWORK... 6 HOW TO CHANGE YOUR PRIMARY CARE PROVIDER... 6 IF YOUR PRIMARY CARE PROVIDER ASKS FOR YOU TO BE CHANGED TO ANOTHER PRIMARY CARE PROVIDER... 7 IF YOU WANT TO GO TO A PROVIDER WHO IS NOT YOUR PRIMARY CARE PROVIDER... 7 PICKING AN OB/GYN... 7 SPECIALISTS... 8 NATIVE AMERICAN MEMBERS... 8 GOING TO THE PRIMARY CARE PROVIDER YOUR FIRST PRIMARY CARE PROVIDER APPOINTMENT HOW TO MAKE AN APPOINTMENT WAIT TIMES FOR APPOINTMENTS WHAT TO BRING WHEN YOU GO FOR YOUR APPOINTMENT HOW TO CANCEL AN APPOINTMENT HOW TO GET TO A DOCTOR S APPOINTMENT OR TO THE HOSPITAL DISABILITY ACCESS TO AMERIGROUP NETWORK PROVIDERS AND HOSPITALS WHAT DOES MEDICALLY NECESSARY MEAN? AMERIGROUP HEALTH CARE BENEFITS... 13

5 PRIOR AUTHORIZATIONS AFFIRMATIVE STATEMENT EXTRA AMERIGROUP BENEFITS SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID SERVICES THAT DO NOT NEED A REFERRAL DIFFERENT TYPES OF HEALTH CARE ROUTINE, URGENT AND EMERGENCY CARE: WHAT IS THE DIFFERENCE? ROUTINE CARE URGENT CARE EMERGENCY CARE HOW TO GET HEALTH CARE WHEN YOUR PRIMARY CARE PROVIDER S OFFICE IS CLOSED HOW TO GET HEALTH CARE WHEN YOU ARE OUT OF TOWN WELLNESS CARE FOR CHILDREN AND ADULTS WELLNESS CARE FOR CHILDREN WHY WELL-CHILD VISITS ARE IMPORTANT FOR CHILDREN WHEN YOUR CHILD SHOULD GET TOT-TO-TEEN HEALTHCHECK VISITS BLOOD LEAD SCREENING EYE EXAMS HEARING EXAMS DENTAL CARE WELLNESS CARE FOR ADULTS WHEN YOU MISS ONE OF YOUR WELLNESS VISITS SPECIAL KINDS OF HEALTH CARE EYE CARE DENTAL CARE BEHAVIORAL HEALTH (MENTAL HEALTH SERVICES) FAMILY PLANNING SERVICES CARE FOR INDIVIDUALS WITH SPECIAL HEALTH CARE NEEDS HERE S HOW IT WORKS GETTING STARTED MEDICINES BIRTHING OPTIONS PROGRAM SPECIAL CARE FOR PREGNANT MEMBERS GUIDE TO PRENATAL CARE DISEASE MANAGEMENT SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING HEALTH INFORMATION HEALTH EDUCATION CLASSES COMMUNITY EVENTS DOMESTIC VIOLENCE ABUSE, NEGLECT AND EXPLOITATION MINORS MAKING A LIVING WILL (ADVANCE DIRECTIVES) GRIEVANCES AND MEDICAL APPEALS GRIEVANCES FILING A GRIEVANCE WITH AMERIGROUP FILING A GRIEVANCE WITH THE STATE... 63

6 MEDICAL APPEALS EXPEDITED APPEALS AUTO-EXPEDITED APPEALS PAYMENT APPEALS FAIR HEARINGS CONTINUATION OF BENEFITS OTHER INFORMATION IF YOU MOVE RENEW YOUR MEDICAID BENEFITS ON TIME IF YOU ARE NO LONGER ELIGIBLE FOR MEDICAID HOW TO DISENROLL FROM AMERIGROUP REASONS WHY YOU CAN BE DISENROLLED FROM AMERIGROUP IF YOU GET A BILL IF YOU HAVE OTHER HEALTH INSURANCE (COORDINATION OF BENEFITS) CHANGES IN YOUR AMERIGROUP COVERAGE HOW TO TELL AMERIGROUP ABOUT CHANGES YOU THINK WE SHOULD MAKE HOW AMERIGROUP PAYS PROVIDERS YOUR AMERIGROUP MEMBER BILL OF RIGHTS YOUR RIGHTS YOUR RESPONSIBILITIES HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID PROGRAM NOTICE OF PRIVACY PRACTICES... 78

7 WELCOME TO AMERIGROUP COMMUNITY CARE OF NEW MEXICO, INC. Information about Your New Health Plan Welcome to Amerigroup Community Care of New Mexico, Inc. We are a Managed Care Organization (MCO) that arranges complete health care coverage for the state of New Mexico s Coordination of Long-Term Services (CoLTS) program members. We arrange the physical, behavioral, long-term and social services care of CoLTS members. Our goal is to help you live in your home and community. We do this by: Offering a wide range of home care coverage and community services Helping members change from a long-term care facility to a community setting Our members include the following groups: Individuals who are eligible for full Medicaid and Medicare benefits Persons 21 years of age or older who are receiving or who qualify for current Medicaid State Plan Personal Care Option services Persons receiving Medicaid and residing in a Nursing Facility Persons currently receiving or who qualify for CoLTS c Waiver (formerly Disabled and Elderly) Home- and community-based waiver services and persons with certain types of brain injury Persons in the Mi Via 1915(c) waiver who qualify for the current CoLTS c Waiver or brain injury services The following groups are not eligible to enroll in Amerigroup: Consumers living in intermediate care facilities for the mentally retarded Consumers getting services under 1915(c) home- and community-based waiver programs for the developmentally disabled, those with AIDS/AIDS-related conditions and the medically fragile Consumers who are in SALUD! Consumers eligible for Medicaid category 029 or family planning services Adults ages eligible for category 062, state coverage insurance This program is sponsored by Amerigroup Community Care of New Mexico, Inc. and the state of New Mexico Human Services Department (HSD) and the New Mexico Aging and Long-Term Services Department (ALTSD). This member handbook tells you how to get home support and community services as an Amerigroup member. It also provides other details about your benefits. How to Get Help Amerigroup Member Services Department You can call our Member Services department at You can call us Monday through Friday from 8:00 a.m. to 5:00 p.m. Mountain time, except for holidays. If you call after 5:00 p.m., you can leave a voice mail message. A Member Services representative will call you back the next business day. Member Services can help you with: This member handbook Transportation Healthy living Member ID cards Health care benefits Grievances and appeals Your doctors Wellness care Rights and responsibilities Going to the doctor Special kinds of health care 1

8 You can also call us: If you wish to request a copy of the Amerigroup Notice of Privacy Practices. This notice tells you: - How medical information about you may be used and disclosed - How you can get access to this information If you move. We will need to know your new address and phone number. You should also call your local Income Support Division Office and tell them your new address. If you want to ask for a copy of the member handbook in a preferred language. For members who do not speak English: We can help in many different languages and dialects We can help translate for visits with your doctor at no cost to you Please let us know if you need an interpreter at least 24 hours before your visit Call Member Services for more details For members who are deaf or hard of hearing: Call the toll-free AT&T Relay Service at We will set up and pay for you to have a person who knows sign language to help you during your doctor visits Please let us know if you need an interpreter at least 24 hours before your appointment Amerigroup 24-hour Nurse HelpLine Call our 24-hour Nurse HelpLine at if you need advice on: How soon you need to get care for an illness What kind of health care you need What to do to take care of yourself before you see the doctor How you can get the care that is needed We want you to be happy with all the services you get from our network of providers and hospitals. If you have any problems, please call us. We want to: Help you with your care Help you correct any problems you may have with your care Your Service Coordinator After enrolling in Amerigroup, you will get a welcome call from a nurse in our Early Case Finding SM (ECF) Unit. If you have not received a welcome call, you will get one soon. During this call, we ask you questions about: Your health care needs The long-term care services you are getting now We go over the CoLTS program with you and answer any questions you may have. If you have special health care needs, the ECF nurse will set up a time for you to talk to a service coordinator. This will help you get the right kind of care. Your service coordinator will: Work with you and your family to develop an Individualized Service Plan (ISP) or treatment plan based on your unique health care needs Discuss your specific needs with you, your family or caregiver, your doctor, and other providers of care 2

9 Help you follow the ISP or treatment plan Work with your providers to help create a medical home for you Help you get timely and coordinated access to your providers and covered services you need, including the correct preventive health services Answer any questions you may have about your health care services Tell you how to get these services If you qualify for home- and community-based services, your service coordinator will: Visit you in your home to assess your unique physical, behavioral, functional, environmental and long-term support service needs Collect complete and correct information about you to help you get the right kind of care Manage your covered long-term support services and your acute care with social and other services you get outside of Amerigroup Encourage you to take part in your care to promote independent living Request approval for long-term support services Just call Member Services and ask to speak with your service coordinator. You should also call your service coordinator if: You are admitted to a hospital Your needs change This helps your service coordinator arrange better care for you. Other Important Phone Numbers SERVICE INFORMATION PHONE NUMBER Emergencies Call or go to the nearest hospital emergency room 911 Medical Assistance Division (MAD) Disease Management Access2Care For information on the program, call the Medical Assistance Division (MAD) of the New Mexico Human Services Department If you want information about our Disease Management programs, call and ask to speak with a disease management care manager If you need help getting transportation for medically needed appointments and treatments toll free toll free toll free Your Amerigroup Member Handbook This handbook will help you understand your health plan. If you have questions or need help reading or understanding your member handbook, call Member Services. We also have this member handbook in: A large-print version An audio-taped version A Braille version If you want a copy of this handbook in one of these versions, call Member Services. The other side of this handbook is in Spanish. 3

10 If You Have Medicare Coverage The CoLTS program is not a Medicare program. But some of our members enrolled in this program also have Medicare coverage and get regular Medicare services through: Medicare fee-for-service Membership in a Medicare Health Maintenance Organization (HMO) If you are in the Medicare fee-for-service program, you will get Medicare-covered services from: Physicians Hospitals Other providers who take part in the Medicare program Amerigroup will pay back these providers for Medicare deductibles and coinsurance. This will be paid in line with Medicare guidelines or contracted amounts. If you are a member of a Medicare HMO, you will get services based on the guidelines of that program. In either case, you will get Medicare services through one of these programs. Your Medicare coverage continues apart from membership in the CoLTS program. If you are enrolled in Medicare, you will: Not choose a Primary Care Provider (PCP) through the CoLTS program Get primary and acute care services, such as inpatient hospital care from Medicare providers Please call your service coordinator to talk about the services offered to you. Your service coordinator will help you arrange for services through Medicare and the long-term-care and community-based services you get through this program. Your Identification Cards If you do not have your Amerigroup identification (ID) card yet, you will get it soon. If you are enrolled in Medicare, you have an ID card through the Medicare program, too. Please carry your Amerigroup ID card and your Medicare ID card with you at all times. Your Amerigroup ID card can be used to get services covered by the New Mexico CoLTS program. It tells providers and hospitals: - You are a member of our health plan - We will pay for the medically needed benefits listed in the section Amerigroup Health Care Benefits Your Amerigroup ID card shows: The name, address and phone number of your PCP if you are not enrolled in Medicare The date you became an Amerigroup member Phone numbers you need to know, such as: - Our Member Services department - Our Nurse HelpLine 4

11 If your Amerigroup ID card is lost or stolen, call us right away at We will send you a new one. YOUR PROVIDERS If you qualify for Medicare, please read the section If You Have Medicare Coverage. This section gives you details on services you get through the Medicare program. Your service coordinator will be able to answer questions about how to arrange for services with your Medicare providers. Picking a Primary Care Provider All Amerigroup members must have a family doctor, also called a Primary Care Provider (PCP). Your PCP must be in the Amerigroup network. Services given by out-of-network providers may not be covered by Amerigroup. If you are not sure if your PCP is in our network, call Member Services. Ask to speak with your service coordinator. Your PCP will give you a medical home. This means he or she will get to know you and your health history. Your PCP is able to help you get quality care. - Your PCP will give you all of the basic health services you need. He or she will also send you to other providers or hospitals when you need special care. - Native American members may choose an Indian Health Services (IHS) or Tribal 638 health care facility as their PCP, whether or not the facility is in the Amerigroup network. Medicare and Medicaid-eligible Members If you are eligible for both Medicaid and Medicare, you will not choose an Amerigroup CoLTS network PCP. You will still get primary and acute care through your Medicare PCP. Medicaid-only Eligible Members If you only qualify for Medicaid, you should have picked a PCP when you enrolled in the Amerigroup CoLTS program. If you did not, we will: Get in touch with you to help you pick a PCP Choose one who should be close by you If you have a PCP through Amerigroup, this PCP s name, address and phone number are on your Amerigroup ID card. If we assigned a PCP to you, you can pick a new one. Look in the provider directory that came with your CoLTS program enrollment package. Call Member Services for help. We can also help you pick a PCP. If you are seeing a PCP now, you can look in the provider directory to see if that provider is in our network. If so, you can tell us you want to keep that PCP. PCPs can be any of the following as long as they are in the Amerigroup network: Family or general practitioners Obstetrician/gynecologists (OB/GYNs) Geriatricians Physician assistants Internists Certified nurse practitioners Pediatricians Specialists (for individuals with special health care needs) 5

12 Family members do not have to have the same PCP. Second Opinion Amerigroup members have the right to ask for a second opinion. This applies to the use of any health care services. You can get a second opinion from a network provider or a non-network provider (if a network provider is not available). Call Member Services for help in finding a nearby provider. You may choose this provider. This is at no cost to you. Once approved: You will hear from your Primary Care Provider (PCP). Your PCP will tell you the date and time of the appointment. Your PCP will also send copies of all related records to the doctor who will give the second opinion. Your PCP will let you and Amerigroup know the outcome of the second opinion. If You Had a Different Primary Care Provider before You Joined Amerigroup You may have been seeing a Primary Care Provider (PCP) who is not in our network for an illness or injury before you joined Amerigroup. In some cases, you may be able to keep seeing this PCP for care while you pick a new PCP who is in our network. Call Member Services to find out more. Amerigroup will make a plan with you and your providers. We will do this so we all know when you need to start seeing your new Amerigroup network PCP. If you are in the third trimester of your pregnancy when you join Amerigroup, you may keep seeing the OB/GYN, certified nurse midwife, certified nurse practitioner or lay midwife you were seeing before you became a member, even if that provider is not in our network. If Your Primary Care Provider s Office Moves, Closes or Leaves the Amerigroup Network Your Primary Care Provider s (PCP s) office may move, close or leave the Amerigroup network. If this happens, we will: Call or send you a letter to tell you. In some cases, you may be able to keep seeing this PCP for care while you pick a new PCP. Call Member Services for more details about this. Make a plan with you and your PCP so we all know when you need to start seeing your new Amerigroup network PCP. Help you pick a new PCP if you ask us. Call Member Services. Send you a new ID card within 10 working days after you pick a new PCP. How to Change Your Primary Care Provider If you need to change your Primary Care Provider (PCP), you may pick a new one from our network at any time. You can write to us or call us. To change your PCP, do one of the following: Look in the Amerigroup provider directory you got with your enrollment package. Go to to view the provider directory online. Call Member Services at We will help you pick a new PCP. You may ask us to change your PCP: 6

13 On or before the 20th day of the month; if you do, the change will begin by the first day of the next month After the 20th day of the month; if you do, the change will begin by the 1st of the month after the next month Once your PCP has been changed, you will get a new ID card in the mail within 10 working days. Call the PCP s office if you want to make an appointment. The phone number is on your Amerigroup ID card. If you need help, call Member Services. We will help you make the appointment. If Your Primary Care Provider Asks for You to be Changed to Another Primary Care Provider Your Primary Care Provider (PCP) may ask you to change to a new PCP. Your PCP may do this if: Your PCP does not have the right experience to treat you The assignment to your PCP was made in error (like an adult assigned to a child s PCP) You fail to keep your appointments You do not follow his or her medical advice over and over again Your PCP agrees that a change is best for you If You Want to Go to a Provider Who Is Not Your Primary Care Provider If you want to go to a provider who is not your Primary Care Provider (PCP), please talk to your PCP first. In some cases, your PCP needs to give you a referral so you can see another provider. In these cases, if you go to a provider that your PCP has not referred you to, the care you get may not be covered by Amerigroup. Please read the section Specialists to learn more about referrals. Also read the section Services That Do Not Need A Referral for more details. Native American members may always self-refer to an Indian Health Services or Tribal 638 health care facility for services. Picking an OB/GYN Female members can see an Amerigroup network obstetrician and/or gynecologist (OB/GYN) for OB/GYN health needs. These services include: Well-woman visits Prenatal care Care for any female medical condition Family planning Referral to a special provider within the network 7

14 You do not need a referral from your Primary Care Provider (PCP) to see your OB/GYN. If you do not want to go to an OB/GYN, your PCP may be able to treat you for your OB/GYN health needs. Ask your PCP if he or she can give you OB/GYN care. If not, you will need to see an OB/GYN. Choose an OB/GYN from the list of network OB/GYNs in the Amerigroup provider directory that came with your enrollment package. You can also find the provider directory online at While you are pregnant, your OB/GYN can be your PCP. The nurses on our 24-hour Nurse HelpLine can help you decide if you should see your PCP or an OB/GYN. If you need help picking an OB/GYN, you can: Refer to the Amerigroup provider directory Call Member Services Specialists Your Primary Care Provider (PCP) can take care of most of your health care needs, but you may also need care from other kinds of providers. Amerigroup offers services from many different kinds of providers that provide other medically needed care. These providers are called specialists because they have training in a special type of medicine. Examples of specialists are: Allergists (allergy doctors) Dermatologists (skin doctors) Cardiologists (heart doctors) Podiatrists (foot doctors) Your PCP will refer you to a specialist in our network if your PCP cannot give you the care you need. In some cases, you need to have a referral from your PCP to see a specialist. In these cases: Your PCP will give you a referral form so you can see the specialist. The referral form tells you and the specialist what kind of health care you need. Be sure to take the referral form with you when you go to the specialist. Native American members may always self-refer to an Indian Health Services or Tribal 638 health care facility for services. Read the section in this handbook Services That Do Not Need A Referral for more details. Sometimes a specialist can be your PCP. This may happen if you have a special health care need that is being taken care of by a specialist. If you have already talked with a service coordinator, he or she can help you make this change. If you have not talked with a service coordinator, call Member Services. Native American Members Native American members may always self-refer to Indian Health Services or a Tribal 638 health care facility for services. 8

15 Please refer to the listing of these facilities below: INDIAN HEALTH SERVICES Acoma Canoncito Laguna Indian Health Services Hospital Practice #: B Veterans Blvd. Pueblo of Acoma M-F 8:00 a.m. 4:30 p.m. Albuquerque Indian Dental Center Practice #: Coors Blvd. NW Albuquerque M-F 8:00 a.m. 5:00 p.m. Albuquerque Indian Health Center Practice #: Vassar Drive NE Albuquerque M-F 8:00 a.m. 5:00 p.m. Mescalero Indian Hospital Practice #: Sage Ave. P.O. Box 210 Mescalero M-F 8:00 a.m. 5:00 p.m. Sandia Health Clinic Practice #: A School Road P.O. Box 6008 Bernalillo M-F 8:00 a.m. 5:00 p.m. Santa Ana Health Clinic Practice #: Dove Road P.O. Box 02C Bernalillo M-F 8:00 a.m. 5:00 p.m. Canoncito Health Center Practice #: Exit 131 off I-40 6 miles N Tohajiilee M-F 8:00 a.m. 5:00 p.m. Cochiti Health Clinic Practice #: Cochiti St. P.O. Box 105 Cochiti Pueblo M-F 8:00 a.m. 5:00 p.m. Jicarilla Indian Health Center Practice #: Stone Lake Road P.O. Box 187 Dulce M-F 8:00 a.m. 5:00 p.m. Santo Domingo Health Clinic Practice #: W Hwy. Santo Domingo Pueblo M-F 8:00 a.m. 5:00 p.m. Taos Picuris Service Unit Practice #: Goat Springs Road P.O. Box 1946 Taos M-F 8:00 a.m. 5:00 p.m. Zia Health Center Practice #: Capitol Square Drive Ste B Zia Pueblo M-F 8:00 a.m. 5:00 p.m. 9

16 INDIAN HEALTH SERVICES (cont d) Santa Clara Health Center Practice #: State Road 30 Los Alamos Hwy RR 5 P.O. Box 446 Espanola M-F 8:00 a.m. 5:00 p.m. Santa Fe Indian Hospital Practice #: Cerrillos Road Santa Fe M-F 8:00 a.m. 5:00 p.m. TRIBAL 638 FACILITIES Isleta Dental Clinic Practice #: Sagebrush St. P.O. Box 580 Isleta Pueblo M-F 8:00 a.m. 5:00 p.m. Isleta EMS Practice #: Sagebrush St. P.O. Box 580 Isleta Pueblo M-F 8:00 a.m. 5:00 p.m. Isleta Health Center Practice #: Sagebrush St. Isleta M-F 8:00 a.m. 5:00 p.m. Isleta Pharmacy Practice #: Sagebrush St. P.O. Box 580 Isleta Pueblo M-F 8:00 a.m. 5:00 p.m. Zuni Indian Health Service Practice #: Rte 301 North B St. Zuni M-F 8:00 a.m. 5:00 p.m. Isleta Elderly Center Practice #: Tribal Road 40 Bldg 70 Isleta M-F 8:00 a.m. 5:00 p.m. Jemez Health Center Practice #: Sheep Spring Way Jemez Pueblo M-F 8:00 a.m. 5:00 p.m. Pine Hill Health Center - Ramah Navajo Practice #: BIA Rte 125 Pinehill M-F 8:00 a.m. 5:00 p.m. San Felipe Health Clinic Practice #: Cedar Road San Felipe Pb M-F 8:00 a.m. 5:00 p.m. 10

17 TRIBAL 638 FACILITIES (cont d) Isleta Physical Therapy Practice #: Sagebrush St. P.O. Box 580 Isleta M-F 8:00 a.m. 5:00 p.m. Isleta Pueblo Behavioral Health Practice #: Sagebrush St. P.O. Box 580 Isleta Pueblo M-F 8:00 a.m. 5:00 p.m. San Felipe Pueblo Practice #: Cedar Road Algodones M-F 8:00 a.m. 5:00 p.m. GOING TO THE PRIMARY CARE PROVIDER If you qualify for Medicare, please read the section If You Have Medicare Coverage. This section gives you details on services you get through the Medicare program. Your service coordinator will be able to answer your questions about how to arrange for services with your Medicare providers. Your First Primary Care Provider Appointment You can call your Primary Care Provider (PCP) to set up your first visit. Call your PCP for a wellness visit (a general checkup) within 90 days of enrolling in Amerigroup. If you have already been seeing the PCP who is now your Amerigroup network PCP, call the PCP to see if it is time for you to get a checkup. If it is, set up a visit with your PCP as soon as you can. If you do not have a home phone or have just changed your phone number, call Member Services. We can also help you set up your first visit. By finding out more about your health now, your PCP can take better care of you if you get sick. How to Make an Appointment It is easy to set up a visit with your Primary Care Provider (PCP). Call the PCP s office. The phone number is on your Amerigroup ID card. Let the person you talk to at the doctor s office know what you need (for example, a checkup or a follow-up visit). Tell the PCP s office if you are not feeling well. This will let them know how soon you need to be seen. If you need help, call Member Services. We will help you make the appointment. 11

18 Wait Times for Appointments We want you to be able to get care at any time. When your Primary Care Provider s (PCP s) office is closed, an answering service will take your call. Your PCP should call you back within 30 minutes. Talk to your PCP and set up an appointment. You will be able to see the PCP as follows: Routine preventive care Routine primary care Routine specialty care visits Emergency care Urgent, nonemergency care Routine laboratory and radiology Urgent laboratory and radiology Within 30 days Within 14 days Within 21 days Immediately Within 24 hours Within 14 days Within 48 hours When you get to the office for your visit, you should not have to wait more than 30 minutes to be seen. What to Bring When You Go for Your Appointment When you go to the Primary Care Provider s (PCP s) office for your visit, be sure to bring: Your ID cards Any medicines you take now Any questions you may want to ask your PCP If the appointment is for your child, bring your child s ID cards Shot records Any medicines he or she takes now How to Cancel an Appointment If you make an appointment with your Primary Care Provider (PCP) and then cannot go: Call the PCP s office or call Member Services if you want us to cancel the appointment for you - Try to call at least 24 hours before you are supposed to be there - This will let someone else see the PCP at that time Tell the office to cancel the visit Make a new appointment when you call If you do not call to cancel your PCP visits over and over again, your PCP may ask for you to be changed to a new PCP. How to Get to a Doctor s Appointment or to the Hospital As an Amerigroup member, you are eligible to receive transportation to your medical appointments. We offer this service through Access2Care. If you need transportation services: Call Access2Care at once you schedule your medical appointments; it is best to call at least 48 hours before you need a ride Be prepared to provide the following information when you call: - Your Amerigroup CoLTS member ID number 12

19 - The phone number, address and ZIP code for pickup (this could be your home, a nursing home or the place that you usually stay) - The name, address, ZIP code and phone number of the health care provider you will be seeing - Date and time of your medical appointment We will help arrange a ride for medically necessary physical and behavioral health services. These services can be in or out of the community where you live. You can call to schedule a ride up to 30 days in advance. If you have routine medical appointments such as dialysis, we can schedule rides up to 180 days in advance. Please call Access2Care before your last scheduled ride to set up your next series of trips. If you have an emergency and need transportation, call 911 for an ambulance. Be sure to tell the hospital staff you are an Amerigroup member. Get in touch with your Primary Care Provider (PCP) as soon as you can so your PCP can: - Arrange your treatment - Help you get the needed hospital care Disability Access to Amerigroup Network Providers and Hospitals Amerigroup network providers and hospitals should help members with disabilities get the care they need. Members who use wheelchairs, walkers or other aids may need help getting into an office. If you need a ramp or other help: Make sure your provider s office knows this before you go there. This will help them be ready for your visit. Call Member Services if you want help talking to your provider about your special needs. WHAT DOES MEDICALLY NECESSARY MEAN? Your Primary Care Provider (PCP) will help you get the services you need that are medically necessary as defined below. Medically necessary services are clinical and rehabilitative physical, mental or behavioral health services that are: Vital to prevent, diagnose or treat medical conditions or are needed to allow the member to attain, maintain or regain the member s optimal functional capacity Given in the amount, time, scope and setting that is both enough and able to reasonably achieve their purposes and are clinically fitting to the specific physical, mental and behavioral health care needs of the member Given within professionally accepted standards of practice and national guidelines Required to meet the physical, mental and behavioral health needs of the member and are not mainly for the ease of the member, the provider or payer AMERIGROUP HEALTH CARE BENEFITS Below is a summary of the health care services and benefits the Amerigroup CoLTS program covers when you need them. Your PCP will either: 13

20 Give you the care you need Refer you to a provider that can give you the care you need In some cases, your PCP needs to give you a referral so you can see another provider. Please read the section Specialists to learn more about referrals. If you have a question or are not sure if we offer a certain benefit or if there are coverage limits, you can call Member Services for help. Below is a list of the services covered under Amerigroup. COVERED SERVICE ADULT DAY HEALTH SERVICES Services given by a licensed adult day care, community-based facility that offers health and social services to help the member reach the greatest level of functioning. Services that may be given with adult day health services include: Private duty nursing services Skilled maintenance therapies - Physical - Occupational - Speech These services may be given by the adult day health provider or another provider. COVERAGE LIMITS As a rule, services are given for two or more hours per day on a regular basis, for one or more days per week. Private duty nursing and skilled maintenance therapies must be given in a private setting at the facility. Prior approval is required for services given by network and non-network providers. This is a 1915(c) waiver service. AMBULATORY SURGICAL SERVICES Surgical services rendered in an ambulatory surgical center setting. ANESTHESIA SERVICES These services must be medically needed to perform surgical or diagnostic procedures; they include: Anesthesia Monitoring services Amerigroup covers these services if use of the facility is medically needed. Prior approval is required for services given by network and non-network providers. All services must be given within benefit limits and the scope and practice of anesthesia as defined by state law and according to federal, state and local laws and rules. Prior approval is required if services are given by an anesthesiologist for pain management. 14

21 COVERED SERVICE AUDIOLOGY SERVICES Certain services are covered when furnished by physicians, licensed audiologists or licensed hearing aid dealers. COVERAGE LIMITS Services include: Hearing aid purchase, rental and loans; repair and handling; and replacements Hearing aid accessories and supplies Hearing aid insurance against loss and breakage up to four years for all purchased hearing aids Certain coverage limits apply. No prior approval is required for: Diagnostic and hearing screening tests Hearing aid evaluations and counseling ASSISTED LIVING SERVICES Residential services for members who need or want help with one or more activities of daily living. This is a 1915(c) waiver service. CASE MANAGEMENT SERVICES AS AN EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) SERVICE Amerigroup covers EPSDT case management services for those who are under 21 and medically at risk. These services are covered if: Prescribed by the member s PCP Part of a treatment plan EPSDT services must be accessed through the Totto-Teen HealthCheck program. For information on the Tot-to-Teen HealthCheck program, see the section Wellness Care for Children. CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND THEIR INFANTS Covered services include those that help members Prior approval is required for all hearing aids and dispensing fees. Services include: Personal support services needed for the member s continued well-being Companion services Help with managing medicines Prior approval is required for services given by network and non-network providers. Covered services include: Doing a review of the member s medical and social needs, and functional limits Developing and carrying out a plan of care to help the member keep or reach the highest level of independence Setting up helping networks for a member such as: - Family members - Community organizations - Other support groups EPSDT case management services for members in institutions are covered only for the last 30 days of the stay to ensure follow-up services. Prior approval may be required for certain services. These services cover: Five hours of case management services per member per pregnancy 15

22 COVERED SERVICE gain access to medical, social, educational or other needed services. CASE MANAGEMENT SERVICES FOR TRAUMATIC BRAIN INJURED ADULTS CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE 3 CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES These services are offered to those who qualify for Medicaid and are: 21 or older Living in New Mexico Defined by the state as a person with a developmental disability Placed on the list to receive these services by the Community Services Team (CST) of the Developmental Disabilities Division of the Department of Health Living outside a Medicaid-certified Intermediate Care Facility for the Mentally Retarded Not in a Home- and Community-based Services Waiver program Covered services vary based on the urgency-ofneed priority assigned to each person by the CST: Priority One Persons assigned a priority one are those in danger of being homeless or victims of abuse if suitable placement services are not received. COVERAGE LIMITS Care for up to 60 days following the end of the month of delivery Coverage of added services may require prior approval. Covered services include services that are medically needed to help adults with traumatic brain injuries gain access to medical, social, educational or other needed services. Prior approval may be required for certain services. Covered services include: Those that help children gain access to medical, social, educational or other needed services Four hours of case management services per child per year Coverage of added services may require prior approval. Priority Three Services These services are covered for an initial 90 days unless the person s urgency of need priority changes to priority one or two. Medicaid covers: - Arranging and performing evaluations and assessments - Performing a follow-up review during the third month and suggesting suitable changes Priority One or Priority Two Services These services are covered for up to 60 days after suitable placement or services are received. Medicaid covers: - Assessing a person s medical and social needs and functional limits - Arranging and checking evaluations and services - Help in finding service providers and programs to assist a person with access to services in the community, 16

23 COVERED SERVICE Priority Two Persons assigned a priority two are those whose condition will get worse without placement. Priority Three Persons assigned a priority three are those who could benefit from case management but whose present condition is all right. COMMUNITY TRANSITION GOODS AND SERVICES AND COMMUNITY RELOCATION SPECIALIST SERVICES Community Transition Goods and Services are services a person may need to set up a basic household when moving from a nursing facility (long-term-care facility) setting into the community. Community Relocation Specialist Services are services given: While a person is a resident in a nursing facility setting During a person s move into and while living in the community This is a 1915(c) waiver service. COVERAGE LIMITS including: Setting up transportation Finding housing Locating providers to teach living skills Finding vocational, educational, civic or recreational services - Arranging and taking part in setting up and reviewing a plan of care, and revising the plan when needed - Assessing a person s progress and continued need for services Community Transition Goods and Services include: Security deposits Necessary household furnishings and moving expenses required to live in the community Setup fees or deposits for utility or service access Services needed for a person s health and safety Community Relocation Specialist Services include: Reviewing a person s needs and helping to arrange and get needed goods and services for a move from a nursing facility setting to the community Setting up a person-centered, communitybased services and transition plan Checking the first 60 days a person resides in the community to make sure: - He or she gets services based on the transition plan - The plan meets the person s needs Making sure a person has the chance to teach and train his or her caregivers Making sure the service plan is in place as written Making sure the person has access to the right home- and community-based services Prior approval may be required for certain 17

24 COVERED SERVICE COVERAGE LIMITS services. DENTAL SERVICES Amerigroup covers the following dental services. Certain limits apply. Emergency services Covered services include emergency care for all eligible members. Care includes operative procedures needed to: - Prevent abscess and the imminent loss of teeth - Treat injuries to the teeth or supporting structures such as bone or soft tissue next to the teeth Diagnostic services - For members under 21, services include one clinical oral exam every six months and one added clinical oral exam by a second dental provider - For members 21 and over, coverage is limited to one clinical oral exam per year Amerigroup covers emergency oral exams performed as part of an emergency service to relieve pain and suffering. Radiology services Amerigroup covers: - One intra-oral complete series or panoramic film every 60 months per member recipient - Bitewing X-rays once every 12 months per member Preventive services Amerigroup covers the following preventive services. Certain limits apply. - Prophylaxis One cleaning every six months for members under 21 One cleaning per year for members 21 and over - Fluoride treatment One fluoride treatment every six months for members under 21 If medically needed, fluoride treatments for members 21 and older - Molar sealants 18

25 COVERED SERVICE DIAGNOSTIC IMAGING AND THERAPEUTIC RADIOLOGY SERVICES Amerigroup covers: Medically needed imaging Blood flow measurement COVERAGE LIMITS Sealants for permanent molars for members under 21 Each eligible member can get one treatment per tooth every five years - Space maintenance Fixed unilateral and fixed bilateral space maintainers (passive appliances) - Restorative services Certain restorative services are covered - Endodontic services Certain services for members under 21 are covered - Periodontic services Certain services are covered: Surgical Nonsurgical Other periodontic services, subject to certain limits - Removable prosthodontic services Two denture adjustments per calendar year per member Repairs to complete and partial dentures - Fixed prosthodontic services One recementation of a fixed bridge - Oral surgery services Amerigroup covers these services for all members: Simple and surgical extractions Emergency palliative treatment of dental pain Amerigroup covers these services for members with proof of medical need: General anesthesia Intravenous sedation Prior approval is required for coverage of certain services. Amerigroup covers orthodontics for members under 21 if prior approved. These services must be: Ordered by physicians or other licensed providers Performed or provided as follows: - Performed by the ordering providers or 19

26 COVERED SERVICE Plethysmographic exams Radiology services DIALYSIS SERVICES DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLIES COVERAGE LIMITS under their direction in their office - Provided by a radiology lab that meets state Medicaid guidelines Other covered medically needed related services include: Treatment planning Minor surgical procedures Injections Prior approval is required for any diagnostic services given by non-network providers with the exception of emergency-related care. Prior approval is not required for certain diagnostic tests given by network providers. Amerigroup covers medically needed: Dialysis supplies furnished to homedialyzed members Renal dialysis services, including: - All renal-related facility and home dialysis services - Supplies and equipment and routine lab tests Prior approval is required if the facility is hospital-based or the service is given by a nonnetwork provider. Medically necessary durable medical equipment and supplies are covered by Amerigroup. This includes: Repairs Maintenance Delivery, in some cases Coverage for medical equipment and supplies may be limited for members in: Hospitals Nursing homes Other facilities expected to provide the needed items Prior approval is required for all DME rentals or services given by non-network providers. Prior approval is not required for certain 20

27 COVERED SERVICE COVERAGE LIMITS covered medical supplies that are purchased. EMERGENCY RESPONSE SERVICES This service provides an electronic device that allows members to get help in an emergency. Members may also wear a portable help button to allow for mobility. This is a 1915(c) waiver service. EMERGENCY SERVICES Covered services include: Testing and maintaining equipment Training members, caregivers and first responders on the use of equipment Twenty-four-hour monitoring for alarms Checking systems monthly or more often if there is an electrical outage, severe weather, etc. Reporting member emergencies and changes in the member s condition that may affect service delivery Prior approval is required. Covered services include inpatient and outpatient services needed to review and stabilize an emergency condition. See the section Emergency Care for more details. ENVIRONMENTAL MODIFICATIONS Services include: Purchasing and/or installing equipment Making physical changes to a member s residence needed to: - Help ensure the health, welfare and safety of the member - Enhance the member s independence This is a 1915(c) waiver service. EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) SERVICES Prior approval is not required. Covered services include such changes as: Installing ramps and grab bars Widening doorways or hallways Installing special electric and plumbing systems to allow for medical equipment and supplies Installing lifts/elevators All changes must be given as defined by federal and state laws and local building codes. Prior approval is required. For members under age 21, Amerigroup covers EPSDT services. These services: Improve health and prevent and treat illness Must be accessed through the Tot-to-Teen HealthCheck program For information on the Tot-to-Teen HealthCheck program, see the section 21

28 COVERED SERVICE COVERAGE LIMITS Wellness Care for Children. Other Amerigroup-covered EPSDT services for members under 21 include: Case management Personal care Private duty nursing Rehabilitation services These services are covered if prescribed by the member s PCP and part of a treatment plan. EPSDT Case Management Services Amerigroup covers case management services for those who are medically at risk. Covered services include: A review of needs Development and evaluation of a treatment plan Helping networks EPSDT case management services for members in institutions are covered only for the last 30 days of the stay. Some case management services require prior approval to be covered. EPSDT Personal Care Services Amerigroup covers medically needed services, such as: Basic personal care Help with eating and nutrition Cognitive assistance These services must be prior approved. EPSDT Private Duty Nursing Services Medically needed EPSDT private duty nursing services are covered by Amerigroup when the services are given by a registered or licensed practical nurse in a member s home or school setting. Services must be prior approved. EPSDT Rehabilitation Services Amerigroup covers these therapies if medically needed and given for diagnostic study or treatment: 22

29 COVERED SERVICE EXPERIMENTAL TECHNOLOGY Medicaid covers medically necessary services given by Medicaid providers to eligible members. HEALTH EDUCATION AND PREVENTIVE CARE COVERAGE LIMITS Speech Physical Occupational therapy All therapy services except the initial evaluation require prior approval to be covered. Medicaid does not cover these experimental procedures: Medical Surgical Other health care procedures or treatments, including the use of: - Drugs - Biological products - Other products or devices, except for routine patient care costs related to certain Phase I, II, III and IV cancer clinical trials Amerigroup works to help keep you healthy. You can get health information by: Asking your PCP Calling our Nurse HelpLine; our nurses are available 24 hours a day, 7 days a week to answer your health questions Amerigroup also offers health education programs. We can help you find classes near your home. Call Member Services to find out where and when these classes are held. See the section Special Amerigroup Services For Healthy Living for more details. All Amerigroup members need to have regular wellness visits with their PCP. When you become an Amerigroup member, call your PCP and set up your first visit within 90 days. During a wellness visit, your PCP can see if you have a problem before it is a bad problem. See the section Wellness Care for Children and Adults for details. If you are eligible for Medicare, see the section If You Have 23

30 COVERED SERVICE HOME HEALTH SERVICES COVERAGE LIMITS Medicare Coverage for details on services you get through the Medicare program. Your service coordinator can answer your questions about how to arrange for wellness visits with your Medicare providers. Amerigroup covers medically needed home health care if it is recommended by the member s PCP or specialist. To get home health services, you must meet at least one of these requirements: You cannot leave home without a wheelchair, walker, crutches or help from someone else Your PCP or specialist tells you to avoid all stressful physical activity because of a severe illness or injury You cannot leave home because of danger caused by a mental condition You just got home from the hospital after a severe illness or surgery; your activities have been limited by your PCP or specialist because of pain, suffering, medical limits or infection You are at high risk (during a pregnancy, infancy or childhood), and home health care is appropriate for your needs The following home health services are covered if prescribed by the member s PCP or specialist and part of the plan of care: Skilled nursing services Home health aide services Physical and occupational therapy services Speech therapy services Durable medical equipment and supplies Maternal/child services Coverage of all home health services after the initial visits for evaluation require prior approval. 24

31 COVERED SERVICE HOSPICE SERVICES COVERAGE LIMITS Amerigroup covers hospice care for members who choose it and have a terminal illness with a life expectancy of six months or less. Hospice care must be reasonable and necessary to manage the member s illness and conditions. The following are covered as part of hospice care: Nursing services based on the treatment plan that are given by registered nurses Medical social services given by a social worker at the direction of a PCP or specialist Physician services from a qualified provider for a medical need not met by the member s attending physician Counseling services to the member and his or her family Home health aide and homemaker services Physical, occupational and speech-language therapy if needed Durable medical equipment and supplies, and pharmacy services related to the member s illness and conditions Short-term inpatient services for pain control and symptom management Short-term inpatient respite services Continuous nursing care services for pain control and symptom management HOSPITAL SERVICES INPATIENT Prior approval is required for facility-based hospice care. Prior approval may be required for certain home health hospice care services such as durable medical equipment. Amerigroup covers inpatient hospital and emergency services that are medically needed for the diagnosis and/or treatment of an illness or injury. Items or services must be given through an Amerigroup physician, podiatrist or dentist who provides services in an Amerigroup network hospital. Prior approval is required for services given by 25

32 COVERED SERVICE HOSPITAL SERVICES OUTPATIENT INDIAN HEALTH SERVICES LABORATORY SERVICES COVERAGE LIMITS network and non-network providers except emergency-related care. Covered hospital outpatient care includes: Use of minor surgery or cast rooms Intravenous infusions Catheter changes First aid care of injuries Lab and radiology services, and diagnostic and therapeutic radiation, including radioactive isotopes Outpatient physical, occupational or speech therapy services require prior approval. Amerigroup covers services provided by promotores and traditional healers in our network. This service is available only to Native American members. Covered services include medically needed lab services that are: Ordered by physicians or other licensed providers Performed by ordering providers or under their direction in an office lab or a clinical lab that meets state Medicaid guidelines Prior approval is required for certain services. NURSING FACILITIES AND SWING BED HOSPITAL SERVICES Low- or high-level nursing facility and swing bed hospital services are covered by Amerigroup when medically needed for diagnosis and/or treatment of an illness or injury. Amerigroup covers physical, occupational and speech therapy services at these facilities in accordance with allowable costs and New Mexico Medicaid requirements. 26

33 COVERED SERVICE NUTRITIONAL SERVICES OCCUPATIONAL THERAPY SERVICES These services: Promote fine motor skills and coordination, combined with sensory functions Aid in the use of adaptive or other support equipment COVERAGE LIMITS Prior approval is required for these therapies given to swing bed facility residents: Physical Occupational Speech Certain services in nursing facilities may also require prior approval. Amerigroup covers medically necessary nutritional services for women who are pregnant or for members under 21. Covered services include: Nutritional assessments for: - Eligible pregnant women - Members under 21 as part of the EPSDT program Nutrition counseling for members under 21 who have been referred for a nutritional need Prior approval is not required. Covered services include: Teaching of daily living skills Developing perceptual motor skills combined with sensory functions Designing, building or changing of assistive equipment or adaptive devices Using specially designed crafts and exercise to improve function Consulting with other service providers or family members as asked for by the member Prior approval is required. 27

34 COVERED SERVICE PERSONAL CARE OPTION SERVICES COVERAGE LIMITS Personal Care Option (PCO) services are for members who: Are age 21 and over Qualify for nursing facility level of care but want to live at home Members work with their service coordinator and primary care provider to help decide if they are still eligible for PCO services. Consumer-directed personal care lets members, with the help of a service coordinator, oversee their own personal care delivery. Delegated personal care allows a member to work with an agency to meet their personal care needs. Talk with your service coordinator or a case specialist to make sure you know how to stay eligible for PCO services. The extent and length of time of these services are based on input from the member through a thorough service assessment completed by the service coordinator. This assessment takes into account many parts such as: The member s health and daily needs Natural supports or help the member gets from friends or family Your service coordinator will talk about your assessment results with you in detail. Amerigroup covers these personal care services: Hygiene and grooming Bowel and bladder services Meal preparation Eating Household support services such as: - Light housekeeping - Shopping - Minor upkeep of medical equipment (changing batteries, etc.) Help with walking, transferring, or using a wheelchair or walker 28

35 COVERED SERVICE PHARMACY SERVICES PHYSICAL HEALTH SERVICES COVERAGE LIMITS Most medically needed prescription drugs are covered by Amerigroup when prescribed by a licensed provider. Some over-the-counter drugs are covered when prescribed by a licensed provider. Prior approval is required for certain drugs. Covered services include primary and specialty physical health services furnished by a licensed provider within the provider s scope and practice as defined by state law. Midwife Services Amerigroup-covered services given by certified or licensed midwives include lab and diagnostic imaging services related to normal pregnancies Podiatry Services Covered services include routine foot care if certain conditions of the foot, such as corns, warts, calluses and conditions of the nails, pose a hazard to members with a medical condition Rural Health Clinic Services Covered services include: - Medically needed diagnostic and therapeutic services and supplies, and treatment of medical conditions, including medically needed family planning services - Lab and diagnostic imaging services for diagnosis and treatment - Surgical procedures, emergency room physician services and inpatient hospital visits given at a different facility when performed by a physician under contract to a rural health clinic - Visiting nurse services with prior approval Federally Qualified Health Center Services Amerigroup covers the following medically needed services given by a Federally Qualified Health Center (FQHC) - Dental Services See the Dental Services listing - Mid-level Practitioners Covered 29

36 COVERED SERVICE PHYSICAL THERAPY SERVICES These services: Promote gross/fine motor skills Aid in independent functioning COVERAGE LIMITS FQHC services include those provided by a nurse practitioner, physician assistant or nurse midwife - Pharmacy Services Prescription drugs and some over-the-counter drugs and medical supplies are covered when ordered by a licensed provider - Physician Services Coverage includes these services and supplies given by FQHC physicians (including psychiatrists): Radiology services Laboratory services Specimen collection for laboratory services given by an off-site lab Preventive Services FQHCs may provide these covered preventive services: - Medical social services - Nutritional assessment and referral - Preventive health education - Well-child care - Prenatal and postpartum care - Immunizations - Family planning services - Physical exams targeted to risk - Visual acuity screening - Hearing screening - Cholesterol screening - Stool testing for occult blood - Dipstick urinalyses - Risk assessment and initial risk counseling - Tuberculosis testing for those at risk - Preventive dental services - For women: Pap smears, clinical breast exams, mammography referral and thyroid function tests Prior approval may be required for certain services. Services include: Professional evaluations and monitoring Physical therapy treatments and interventions 30

37 COVERED SERVICE Prevent progressive disabilities PREGNANCY TERMINATION SERVICES COVERAGE LIMITS Training on physical therapy activities, use of equipment or any other part of members physical therapy services Designing, changing or monitoring use of related activities that support members individual service plans Consulting with other service providers or family members as asked for by the member Prior approval is required. Amerigroup covers services to terminate a pregnancy in accordance with New Mexico state guidelines. Covered services for pregnant women include: Surgical abortions Psychological services Medicines when given by a doctor or other licensed provider according to New Mexico law PREVENTIVE HEALTH SERVICES Prior approval is required for all services except emergency-related care. Preventive health services include: Immunizations (shots) Screens Tot-to-Teen HealthChecks Counseling services 24-hour Nurse HelpLine Family planning services Prenatal care services See the sections Wellness Care for Children and Adults, Special Kinds of Health Care, and Special Amerigroup Services for Healthy Living for more information. 31

38 COVERED SERVICE PRIVATE DUTY NURSING SERVICES Services include activities, procedures and care for a physical condition, physical illness or chronic disability. This is a 1915(c) waiver service. PROSTHETICS AND ORTHOTICS COVERAGE LIMITS Amerigroup covers services such as: Medication management Feeding tube and urinary catheter management Weight management Bowel and bladder care Wound and skin care Infection control Nutrition management Oxygen management Seizure management and safety Behavior and self-care help Prior approval is required. Medically needed prosthetics and orthotics are covered by Amerigroup only under these conditions: The item has been ordered by a doctor or other licensed provider The need for the item is not met by a device that the member already has Prior approval requirements have been met Coverage of compression stockings for adults is limited to those that are custommade for the member s needs Coverage of orthopedic shoes for adults is limited to the shoe that is attached to a leg brace Replacement of items is limited to one item every three years, unless medically needed sooner Therapeutic shoes for diabetics is limited to one of the following in one calendar year: - No more than one pair of custommolded shoes and two added pairs of inserts - No more than one pair of depth shoes and three pairs of inserts Prior approval is required for: All prosthetics except for limbs attached right after a surgery for traumatic injuries while the member is a hospital inpatient Orthotic items for the foot or for shoes 32

39 COVERED SERVICE REHABILITATION SERVICES COVERAGE LIMITS Physical, occupational and speech therapy services are covered by Amerigroup when: Reasonable and necessary for the treatment of a member s condition Ordered by the member s PCP Part of a treatment plan Covered services can be given by the following facilities: Hospitals Home health agencies Outpatient hospitals Rehabilitation hospitals Licensed rehabilitation centers REPRODUCTIVE HEALTH SERVICES RESPITE SERVICES Services provided to members who live in the community and cannot care for themselves. These services may be given in the member s home or in the community. This is a 1915(c) waiver service. All therapy services (except the initial evaluation for physical or occupational therapy) require prior approval to decide if care is medically needed. Amerigroup covers these medically needed reproductive health services given by or under the supervision of a licensed provider: Sterilization services to mentally competent and noninstitutionalized members 21 and older who consent to the procedure Hysterectomies not for the sole purpose of sterilization Methods, procedures and pharmaceutical supplies to prevent unintended pregnancy or contraception Prior approval is required for all services except emergency-related care. Covered services include: Helping with routine activities of daily living Improving self-help skills Assisting with getting access to fun and leisure activities Prior approval is required. 33

40 COVERED SERVICE SCHOOL-BASED SERVICES SERVICE COORDINATION Service coordination gives members the support and services needed to reach a desired quality of life in a safe and healthy setting. This is both a 1915(b) and 1915(c) waiver service. SKILLED MAINTENANCE THERAPY SERVICES This is a 1915(c) waiver service. SPECIAL REHABILITATION SERVICES Medicaid pays for medically needed health services given to eligible children. These services are paid as part of early and periodic screening, diagnosis, and treatment services. The need for special rehabilitation services may be found in the: Tot-to-Teen HealthCheck screen Other assessment given through a health check referral or by a PCP or specialist These services support and improve a child s development in one or more of the following areas: Physical/motor Communication Adaptive Cognitive Social or emotional Sensory development COVERAGE LIMITS For members under 21, Amerigroup covers medically needed services given in a school setting. The following services must be approved by the child s PCP and not be part of an Individualized Education Plan or Individualized Family Service Plan: Therapy services (physical, occupational, audiological and speech) Nutritional assessment and counseling Transportation if the member has to travel from the school to get a covered service Case management for medically at-risk members Nursing services Amerigroup assists members in getting access to services they need such as: CoLTS waiver services Medicaid state plan services Medical, social and educational services For members age 21 and older, covered services include occupational, physical therapy and speech language therapy services. Prior approval is required. Medically needed covered services include: Speech, language and hearing services Occupational therapy services Physical therapy services Psychological, counseling and social work services Developmental assessment and rehab services Nursing services Prior approval is required. 34

41 COVERED SERVICE SPEECH LANGUAGE THERAPY SERVICES These services: Preserve independent communication Help with oral motor and swallowing function Aid in the use of assistive equipment Prevent progressive disabilities TRANSPLANT SERVICES COVERAGE LIMITS Services include: Identifying communicative disorders and delays in developing communication skills Preventing communicative disorders and delays in developing communication skills Developing eating and swallowing plans and monitoring their success Using specially designed equipment, tools and exercises to improve function Designing, building or changing of assistive equipment or adaptive devices Adjusting the member s surroundings to meet his or her needs Offering speech language therapy training Consulting with other service providers or family members as asked for by the member Prior approval is required. Amerigroup covers medically needed transplant services that are not considered unproven, new or experimental for the condition for which they are meant or used. Types of transplants include: Heart Lung Heart-lung Liver Kidney Autologous bone marrow Allegoric bone marrow Corneal transplants Covered services include: Hospital Doctor Lab Outpatient surgical Other covered services needed to perform the transplant Prior approval is required. 35

42 COVERED SERVICE TRANSPORTATION SERVICES COVERAGE LIMITS If a member does not have access to free transportation, Amerigroup will cover emergency and nonemergency transportation. We will cover the least costly transportation that is fitting for a member s health condition. Ambulance services are covered for emergencies or for nonemergencies if any other transportation service would be a risk to the member s health. As an added benefit (see the section Extra Amerigroup Benefits), Amerigroup reimburses volunteers for transportation costs for a member s office visits. The following transportation-related services are also covered by Amerigroup: Long-distance transportation from common carriers if the member must leave his or her home community to get medical services Air ambulance services in an emergency and when medically needed Lodging services for members who have to travel more than four hours one way to get medical services and need to stay overnight Meal services for members who need to leave their communities for more than eight hours to get medical services Transportation, meals and lodging for one attendant, if the attendant is medically needed or if the member who is getting medical services is under 18 years of age; the attendant for members under 18 should be the member s parent or legal guardian Transportation to Medicaid waiver facilities for Medicaid waiver members receiving occupational, physical, speech and behavioral therapy All out-of-state transportation services require prior approval. Other transportation services may also need prior approval. 36

43 COVERED SERVICE VISION SERVICES COVERAGE LIMITS Amerigroup covers services that are medically needed to diagnose and treat eye diseases and correct refractive errors, as required by the condition of the member. Covered services include: Routine eye exams As an added benefit, Amerigroup covers routine eye exams every 12 months, instead of every 36 months as required by Medicaid. Exams for an existing medical condition such as diabetes will be covered for required follow-up and treatment. Corrective lenses Amerigroup covers the added benefit of one set of corrective lenses every 12 months, instead of every 36 months as required by Medicaid. The ophthalmologist or optometrist may recommend lenses sooner if there is a change in prescription due to a medical condition that affects vision. Bifocal lenses Tinted lenses Lenses with filtered or photochromic lenses are covered by Amerigroup for certain conditions. Balance lenses For members under 21, these lenses are covered when used to balance an aphakic eyeglass lens or if the person is blind in one eye and the visual acuity in the eye that requires correction meets the correction standard. Frames As an added benefit, Amerigroup covers one frame for corrective lenses every 12 months instead of every 36 months as required by Medicaid. Contact lenses Amerigroup covers contact lenses, either the original prescription or replacement, only with prior approval. Coverage for adults is limited to one pair of contact lenses in a 24-month period, unless an ophthalmologist or an optometrist recommends a change in prescription due to a medical condition that affects vision. 37

44 COVERED SERVICE COVERAGE LIMITS Replacement Eyeglasses or contact lenses that are lost, broken or have worsened to the point that the examiner feels they can no longer be useful to the member may be replaced if: - The member is under 21 years of age - The member is 21 years of age or older and has developmental disabilities - Required documentation for replacement has been reported Prisms All prisms are covered if medically needed to prevent double vision. Lens tempering Amerigroup covers lens tempering on new glass lenses only. Lens edging Amerigroup covers lens edging and lens insertion. Minor repairs Amerigroup covers minor repairs to eyeglasses. Eye prosthesis Amerigroup covers artificial eyes. Certain procedures or services may require prior approval. PRIOR AUTHORIZATIONS Some Amerigroup services and benefits require prior approval. This means that your provider must ask Amerigroup to approve those services or benefits before you get them. These services do not require prior approval: Emergency services Poststabilization services Urgent care Affirmative Statement Amerigroup follows the quality standards set forth by the National Committee for Quality Assurance (NCQA). All Utilization Management (UM) decisions are based on: Your medical needs Benefits offered by Amerigroup Our policies do not promote use of fewer services through our UM decision process. Practitioners and others who take part in UM decision-making do not get any type of reward for denial of care or coverage. 38

45 EXTRA AMERIGROUP BENEFITS Amerigroup covers some extra benefits members cannot get from fee-for-service Medicaid. These extra benefits are also called value-added services. To get any of these services, you must call your service coordinator first. Amerigroup offers the following: Enhanced Adaptive Aids Amerigroup covers adaptive aids or equipment not covered by fee-forservice Medicaid or the 1915(c) Home- and Community-based Services Waiver, up to $200 per month. Prior approval for supplies or equipment is required from your service coordinator. Respite Care Amerigroup will offer up to 72 hours per year of respite care and services to families and caregivers who live in the community. Enhanced Transportation Amerigroup will reimburse your caretakers, friends, non-household family members and volunteers for transportation costs for office visits to your PCP. Caregivers who are paid through the Personal Care Options program do not qualify to be reimbursed; this is based on state law. See the section Transportation Services or call Member Services and ask to speak with your service coordinator for details. Enhanced Vision Care Amerigroup covers exams, lenses and frames every 12 months instead of every 36 months. See Eye Care in the Special Kinds of Health Care section for complete details. Transitional Services If you live in a nursing home, you may want to move back into the community. Please talk to your service coordinator. He or she will: - Look at your health care needs - Work with you and your family to decide if a change would be best for you If your health care needs can be better met in a home and community setting, you may qualify for the Money Follows the Person program. Amerigroup will arrange the change. We will cover care coordination and services up to $2,500 to help you move back into the community. We can help with the following costs to set up your own household: - Moving costs - Security deposits - Cost of basic household furnishings - Setup fees or deposits for utility or service access - Services you need for health and safety Annual Physical for Adults Amerigroup covers an annual physical exam for adults age 21 and older given by their PCP We give you these benefits to help keep you healthy and to thank you for choosing Amerigroup as your health care plan. SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID Some services are covered by fee-for-service Medicaid instead of Amerigroup. You do not need a referral from your Primary Care Provider (PCP) to get these services. But, if you think you need these services, please call Member Services. We can help refer you to the right provider. 39

46 Intermediate Care Facility Services for the Mentally Retarded Medicaid pays for medically needed health services provided by intermediate care facilities for the mentally retarded. Emergency Services to Undocumented Aliens Medicaid pays for needed emergency services given to persons who are undocumented aliens, live in New Mexico and qualify for Medicaid. Experimental or Investigational Procedures, Technologies or Nondrug Therapies Medicaid covers routine patient care costs related to certain Phase I, II, III and IV cancer clinical trials. These services: - Can only be performed in New Mexico - Must be prior approved Case Management Services for Children Provided by Child Protective Services and Juvenile Probation and Parole Officers Medicaid pays for medically needed case management services, including behavioral health services given to persons under age 19 who qualify. They must be: - Supervised by a Juvenile Probation and Parole Officer - Have a physical or mental status which will likely impair their cognitive, emotional, neurological, social or physical growth These services are offered through the Comprehensive Community Support Services (CCSS) program, managed by the Children, Youth and Families Department (CYFD) and their Juvenile Probation and Parole Officers. Amerigroup case managers will work with CYFD case managers to arrange services members can get through the CoLTS and CCSS programs. Adult Protective Services Case Management Medicaid pays for these medically needed health services for adults who have been abused, neglected or exploited: - Supplying access to medical, social or other needed services - Assessing persons medical and social needs - Setting up a plan of care to help persons keep their greatest level of self-support - Arranging natural helping networks such as family members, church members, community groups and friends - Setting up and monitoring the delivery of services; reviewing the value and quality of service; and changing the plan of care if needed School-based Services for Persons under Age 21 Medicaid pays for medically needed services given to those persons under age 21 who qualify for Medicaid when the services are part of a person s Individualized Education Plan or Individualized Family Service Plan to treat a known medical condition. Services given to the Home- and Community-based Waiver Services programs which include the Mentally Fragile waiver, HIV/AIDS waiver and the Developmentally Disabled waiver. SERVICES THAT DO NOT NEED A REFERRAL If you qualify for Medicare, please see the section If You Have Medicare Coverage for details on services you get through the Medicare program. Your service coordinator can answer your questions about whether you need a referral for a service. 40

47 It is always best to ask your PCP for a referral for any Amerigroup service. But you can get these services without a referral from your PCP: EPSDT services Routine shots Screening or testing for sexually transmitted diseases including HIV Services given by a school health center Yearly exams from an Amerigroup network OB/GYN DIFFERENT TYPES OF HEALTH CARE Routine, Urgent and Emergency Care: What Is the Difference? Routine Care In most cases when you need medical care, you call your Primary Care Provider (PCP) to make an appointment. Then you go to see your PCP. This type of care is known as routine care. This will cover: Most minor illnesses and injuries Regular checkups You should be able to see your PCP within days for routine care. Your PCP is someone you see when you are not feeling well, but that is only part of your PCP s job. Your PCP also takes care of you before you get sick. This is called wellness care. See the section in this handbook Wellness Care For Children And Adults. Urgent Care The second type of care is urgent care. Some injuries and illnesses are not emergencies, but can turn into emergencies if they are not treated within 24 hours. Some examples are: Throwing up Minor burns or cuts Earaches Headaches Sore throat Fever over 101 degrees Muscle sprains/strains If you need urgent care: Call your PCP. Your PCP will tell you what to do. Follow your PCP s instructions. Your PCP may tell you to go to: - His or her office right away - Some other office to get immediate care - The emergency room at a hospital for care; see the next section about emergency care for more details You can also call our 24-hour Nurse HelpLine at for advice about urgent care. You should be able to see your PCP within 24 hours for an urgent care visit. 41

48 Emergency Care After routine and urgent care, the third type of care is emergency care. If you have an emergency, you should call 911. Or you can go to the nearest Emergency Room (ER) right away. A listing of hospitals in your area can be found on the inside back cover of your provider directory. If you want advice, call your Primary Care Provider (PCP). Or call our 24-hour Nurse HelpLine at The most important thing is to get medical care as soon as you can. You should be able to see your PCP at once for emergency care. If you must go to the ER, please remember to take the following information with you: Your medical history A list of medications you are taking A list of your allergies Your Amerigroup member ID card; and if you have Medicare, take your Medicare card, too A list of emergency contacts Any advance directives you may have Your PCP s name and phone number Any other data that may help the emergency room provide the care you need What is an emergency? An emergency is when you need to get care right away. If you do not get it, it could cause your death. It could cause very serious harm to your body. This means that someone with an average knowledge of health and medicine can tell the problem may threaten your life, cause serious harm to your body or harm your unborn child if you are pregnant. Here are some examples of problems that are most likely emergencies: Trouble breathing Chest pains Loss of consciousness Very bad bleeding that does not stop Very bad burns Shakes called convulsions or seizures What is poststabilization? Poststabilization services are covered services that you get after emergency medical care. You get these services to help keep your condition stable. Medical emergencies and poststabilization care that have to do with your emergency do not need prior approval by Amerigroup. After you visit the emergency room: Call your PCP as soon as you can. If you cannot call, have someone else call for you. Your PCP will give or set up any follow-up care you need. 42

49 How to Get Health Care When Your Primary Care Provider s Office Is Closed Except in the case of an emergency (see previous section) or when you need care that does not need a referral (see the section Services That Do Not Need A Referral), you should always call your Primary Care Provider (PCP) first before you get medical care. If you call your PCP s office when it is closed, leave a message. Give your name and a phone number where you can be reached. If it is not an emergency, someone should call you back soon. He or she will tell you what to do. You may also call our Nurse HelpLine 24 hours a day, 7 days a week for help. If you think you need emergency care (see previous section), call 911 or go to the nearest emergency room right away. How to Get Health Care When You Are Out of Town If you need emergency care when you are out of town or outside of New Mexico*, go to the nearest hospital emergency room or call 911. If you need urgent care: - Call your Primary Care Provider (PCP)*. (See the section Urgent Care for more details.) If your PCP s office is closed, leave a phone number where you can be reached. Your PCP or someone else should call you back soon. - Follow the PCP s instructions. You may be told to get care where you are if you need it very quickly. - Call our 24-hour Nurse HelpLine for help. If you need routine care like a checkup or prescription refill: - Call your PCP. - Call our 24-hour Nurse HelpLine for help. *If you are outside of the United States and get health care services, they will not be covered by Amerigroup or fee-for-service Medicaid. WELLNESS CARE FOR CHILDREN AND ADULTS If you qualify for Medicare, please see the section If You Have Medicare Coverage for details on services you get through the Medicare program. Your service coordinator will be able to answer questions about how to arrange for well-care visits with your Medicare providers. All Amerigroup members need to have regular wellness visits with their Primary Care Provider (PCP). During a wellness visit, your PCP can see if you have a problem. If you do, your PCP can help you before it is a bad problem. When you become an Amerigroup member: Call your PCP Make your first appointment within 90 days 43

50 Wellness Care for Children Why Well-child Visits Are Important for Children Children need more wellness visits than adults. These wellness visits for children are called Tot-to-Teen HealthChecks. Tot-to-Teen HealthChecks is a program for anyone in Medicaid that is under 21 years old. Babies need to: See their PCP at least seven times by the time they are 12 months old Go more often if they get sick Your child may have special needs or an illness like asthma or diabetes. If so, one of our service coordinators can help your child get his or her well-child checkups, tests and shots. Your child can get Tot-to-Teen HealthChecks from any Amerigroup network provider. You do not need a referral for these visits. At these Tot-to-Teen HealthCheck visits, your child's PCP will: Make sure your baby is growing well Help you care for your baby, talk to you about what to feed your baby and how to help your baby go to sleep Answer questions you have about your baby See if your baby has any problems that may need more health care Give your baby shots that will help protect him or her from illnesses When Your Child Should Get Tot-To-Teen Healthcheck Visits The first well-child visit will be in the hospital. This happens right after the baby is born. For the next six visits, you must take your baby to his or her PCP s office. You must set up a well-child visit with the doctor when the baby is: Between 3-5 days old 6 months old 1 month old 9 months old 2 months old 12 months old 4 months old Well-child care in your baby s second year of life In your baby s second year of life, he or she should see the PCP at least four more times at: 15 months 18 months 24 months 30 months Well-child care for children ages 3 through 20 Your child should see the doctor again at ages 3, 4 and 5. Be sure to set up these visits. Take your child to his or her PCP when scheduled. From age 6 through age 20, your child should see his or her PCP at least one time each year for a well-child checkup. 44

51 Blood Lead Screening Your child s PCP will screen your child for lead poisoning if he or she is at risk of being exposed to lead. Your child s PCP will also give your child a blood test at: 12 months 24 months Your child s PCP will take a blood sample by pricking your child s finger or taking blood from his or her vein. This test will tell if your child has lead in his or her blood. Eye Exams Your child s PCP will check your child s vision at every well-child visit. Between the ages of 3 and 4, your child s doctor will screen him or her for visual problems. Please see Eye Care in the Special Kinds of Health Care section for more details. Hearing Exams Your child s PCP will check your child s hearing at every well-child visit. Dental Care Your child s PCP will check your child s teeth and gums as part of each well-child visit. Please see Dental Care in the Special Kinds of Health Care section for more details. IMMUNIZATION (SHOT) SCHEDULE FOR CHILDREN AGE VACCINE Birth 1 mo 2 mo 4 mo 6 mo 12 mo 15 mo 18 mo mo 2-3 years 4-6 years 7-10 years years years Hepatitis B HepB HepB HepB HepB Series if not given Rotavirus Rota Rota Rota Diphtheria, Tetanus, Pertussis Haemophilus influenzae type b DTaP DTaP DTaP DTaP DTaP Tdap Hib Hib Hib if needed Hib Tdap if not given Pneumococcal PCV PCV PCV PCV PPSV if PPSV if high-risk high-risk Inactivated Poliovirus Influenza IPV IPV IPV IPV Influenza (Yearly) IPV Series if not given Influenza (Yearly) Measles, Mumps, Rubella MMR MMR MMR Series if not given 45

52 IMMUNIZATION (SHOT) SCHEDULE FOR CHILDREN Varicella Varicella Varicella Varicella Series if not given Hepatitis A HepA (2 doses) HepA Series if high-risk Meningococcal Human Papillomavirus MCV4 if high-risk MCV4 HPV (3 doses) MCV4 if not given HPV Series if not given Wellness Care for Adults Staying healthy means going to see your Primary Care Provider (PCP) for regular checkups. You should see your PCP within six months of enrolling in Amerigroup to see if you are up-to-date with the screenings shown in the chart below. Your PCP will do these screenings as you need them. Use this chart to help make sure you stay up-todate with your yearly wellness visits. WELLNESS VISITS SCHEDULE FOR ADULT MEMBERS EXAM TYPE WHO NEEDS IT? HOW OFTEN? WELLNESS VISIT Age Every three years Age 40 and over Every year PAP SMEAR AND PELVIC EXAM Women: Under age 18 who are Every year sexually active Age 18 and over Every year CLINICAL BREAST EXAM Women: Age Every three years Age 40 and over Every year BREAST SELF-EXAM Women: Age 20 and over Once a month MAMMOGRAMS (BREAST X-RAY) Women: Age 40 and over Every one to two years CERVICAL CANCER SCREENING Women: Age At least once by age 21; every three years thereafter At-risk members Every year FECAL BLOOD OCCULT TEST Age 50 and over Every year SIGMOIDOSCOPY & DRE/PSA Age 50 and over Every five years OR COLONOSCOPY & DRE/PSA BLOOD PRESSURE MEASUREMENT Age 18 and over At least every two years SERUM CHOLESTOROL MEASUREMENT Women: Age 45 and over Men: Age 35 and over At-risk members age 20 and over Every five years At least once OBESITY SCREENING All members Every year DIABETES SCREENING All members At least once TUBERCULOSIS SCREENING At-risk members As recommended by your PCP RUBELLA SCREENING Women of childbearing age First visit with OB/GYN HEARING IMPAIRMENT SCREENING Age 50 and over Routine as recommended by your PCP 46

53 WELLNESS VISITS SCHEDULE FOR ADULT MEMBERS EXAM TYPE WHO NEEDS IT? HOW OFTEN? PROBLEM DRINKING AND SUBSTANCE ABUSE SCREENING Adolescent and adult members At least once; added screens will be based on results of first screen and other clinical signs or warnings CHLAMYDIA SCREENING Women: Age 25 or younger who At least once are sexually active Women: Over age 25 who are at risk BEHAVIORAL HEALTH SCREENING FOR Age 22 and over First visit with PCP HIGH-RISK CONDITIONS PRENATAL SCREENING All pregnant members As recommended by your PCP or OB/GYN 47

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57 When You Miss One of Your Wellness Visits If you or your child does not get a wellness visit on time: Set up a visit with the PCP as soon as you can Call Member Services if you need help setting up the visit If your child has not visited his or her PCP on time, Amerigroup will send you a postcard reminding you to make your child s Tot-to-Teen HealthCheck appointment. SPECIAL KINDS OF HEALTH CARE If you qualify for Medicare, please see the section If You Have Medicare Coverage. This is information on services you get through the Medicare program. Your service coordinator can answer your questions about how to get special kinds of health care from your Medicare doctors. Eye Care As an extra Amerigroup benefit, members age 21 and older get: A vision exam every 12 months; this is instead of every 36 months as required by Medicaid Coverage for required follow-up exams and treatment needed for an existing medical condition such as diabetes; Amerigroup covers one pair of eyeglasses every 12 months, instead of every 36 months as required by Medicaid See Vision Care Services in the Amerigroup Covered Services section for complete details. Please see your provider directory for the vision center near you. You can also call Block Vision at for help finding an Amerigroup network eye doctor (optometrist) in your area. Dental Care We offer these dental services. Members under age 21 get: - One cleaning and one fluoride treatment every six months - Medically necessary orthodontic services with prior approval Members age 21 and older get: - One cleaning every 12 months All members get: - Emergency care - X-rays - Fillings - Simple extractions as needed - Anesthesia when required See Dental Services in the Amerigroup Covered Services section for complete details. Please see your provider directory for a list of dentists near you. You can also call DentaQuest at for help finding an Amerigroup network dentist in your area. 51

58 Behavioral Health (Mental Health Services) Sometimes dealing with all the tasks of a home and family can lead to stress. Stress can lead to depression and anxiety. It can also lead to marriage problems, family problems and parenting problems. Stress can lead to alcohol and drug abuse, too. If you or a family member is having these kinds of problems, you can get help. Call OptumHealth New Mexico at You can also get the name of a provider who will see you if you need one. All services and treatments are kept private. You do not need a referral from your PCP to get these services. Many medically necessary services are covered, such as: Inpatient mental health treatment Outpatient mental health treatment, including individual and family therapy Alternative care, such as care in your home for members under 21 years of age Substance abuse treatment Family Planning Services Amerigroup will arrange for counseling and education about planning a pregnancy. You can also learn about preventing pregnancy. You can call your PCP and set up a time for a visit. You can also go to any Medicaid family planning provider. You do not need a referral from your PCP. Care for Individuals with Special Health Care Needs Amerigroup will arrange for health care services for Individuals with Special Health Care Needs (ISHCN). ISHCN include: Persons who have or are at an increased risk for a chronic, physical, developmental, behavioral, neurobiological or emotional condition Those who have low to severe functional limits; these members may need certain types of health and other related services that go beyond the service and care required by persons in general If you or an Amerigroup family member needs this special care, we will give you the services and support you need while helping you keep your greatest level of freedom. Here s How It Works Within 30 days of enrolling in the Amerigroup CoLTS program, you will get a welcome call from a nurse in our Early Case Finding SM Unit. During this call, you will be asked questions by the nurse so that we can find out: What kind of care you need The long-term-care services you are getting now Once you are identified as an ISHCN member, we will: Help arrange health and social services for you Work with you to find the best level of care for you This way, you have the best chance of reaching your desired goals and outcomes. 52

59 Amerigroup manages the service needs of ISHCN through a service coordinator. The service coordinator will work with you and your family or caregiver to: Assess your needs, including physical health, mental health, social and long-term support services Develop an Individualized Service Plan (ISP) or treatment plan with and for you to meet your needs; the ISP includes: - Your history - A summary of your current medical and social needs and concerns - Short- and long-term care needs and goals - A list of required services and how often these services are needed - Details on who will provide these services Inform and teach you about CoLTS 1915(b) and 1915(c) waiver services Give you a list of specific waiver service network providers in your area from which you can choose Help arrange timely access to a wide range of providers and services related to ISHCN, including: - Direct access to CoLTS specialty providers as needed - Rehabilitation therapy services - Utilization management services Help arrange other services given outside the ISP as needed Amerigroup also provides service coordination to ISHCN, as needed through the Special Needs Coordinator (SNC). The SNC will: Review your care needs and help you with access to care, specialty referrals, durable equipment and PCP changes Contact you after your first health risk screen to find out if you have a PCP that can best serve you based on your health care needs Ensure a case manager is assigned to you at the time of the initial health screen if needed Help set up PCP visits and referrals for ongoing case management as needed Teach and allow you and your family or caregivers to make informed decisions based on your ISP or treatment plan Getting Started The assessment The process begins with an assessment. During the assessment, several people will help you plan your care. They are called your planning team. The planning team includes: You Your family Legal guardian or representative Service coordinator Others the service coordinator identifies to adequately plan the care you need Your individual service plan The planning team meets (as needed) when it is time to develop and begin your ISP. The ISP process begins within 14 business days from the date your assessment is completed. You, together with your planning team, create your ISP. That is why your input and information all through the process is very important to us. 53

60 We want you to: Take an active part in creating your ISP. You are in control, to the extent possible, of all aspects of your ISP, and you are the one who must agree to the ISP. Hire and direct personal assistance services if you want them. You and your family or caregivers take part in all aspects of care, including primary, acute and home care as fitting. Your service coordinator can help arrange the care you need. Medicines Amerigroup has a list of commonly prescribed drugs. Your or your child s Primary Care Provider (PCP) or specialist can choose from this list of drugs to help you get well. This list is called a Preferred Drug List (PDL). It is part of the Amerigroup formulary. The covered medicines on the PDL include: Prescriptions Certain over-the-counter medicines Things to remember about the PDL All Amerigroup network providers have access to this drug list. Your or your child s PCP or specialist should use this list when he or she writes a prescription. Certain medicines on the PDL need prior approval. All medicines that are not listed on the Amerigroup PDL need prior approval. You can get prescriptions filled at Amerigroup network pharmacies. For a list of Amerigroup pharmacies: See the provider directory that came with your new member packet Go to If you do not know if a pharmacy is in the Amerigroup network, ask the pharmacist. You can also call Member Services for help. To get a prescription filled, follow these steps: 1. Take the written prescription from your provider to the pharmacy, or your provider can call in the prescription to the pharmacy. 2. If you use a new pharmacy, tell the pharmacist about all of the medicines you are taking; include over-the-counter medicines, too. 3. Show your Amerigroup member ID card and your Medicaid ID card to the pharmacy. If you are enrolled in Medicare, you will also need to show the pharmacy your Medicare ID card. See the section If You Have Medicare Coverage for details. It is good to use the same pharmacy each time. This way your pharmacist: Will know all the medicines you are taking Can watch for problems that may occur when you are taking more than one prescription You should always show your Amerigroup member ID card and your Medicaid ID card when you have a prescription filled. 54

61 Birthing Options Program If you are pregnant and eligible for Medicaid, you have choices about who will provide care for you and where your baby will be born. Many health care practitioners offer pregnancy-related services, and many times they work together to provide care for you and your baby. These providers include: Clinics Doctor offices Health centers Hospitals Indian Health Services health centers Private practice offices Women in New Mexico have many choices about where to give birth: A birth center A hospital Your own home If you choose to have out-of-hospital birthing services through a midwife, you must contact the New Mexico Human Services Department, Medical Assistance Division and give them the following information: Your name, address and phone number The name and phone number of the midwife you have chosen You can call or mail this information to: Pregnancy-Related Services Benefits Bureau New Mexico Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM You will be sent a confirmation that will need to be completed in order for Medicaid to cover the outof-hospital service. For more information and to choose a health care practitioner, you may call Amerigroup at or the New Mexico Medical Assistance Division at For more information about the services provided by midwives, you may contact: New Mexico Midwives Association at or in Albuquerque American College of Nurse-Midwives New Mexico Chapter at: nmmidwives.org/practices.php Maternal Health Program Department of Health at

62 Special Care for Pregnant Members When You Become Pregnant If you think you are pregnant: Call your PCP or OB/GYN provider right away; you do not need a referral from your PCP to see an OB/GYN doctor Call Member Services if you need help finding an OB/GYN in the Amerigroup network When you find out you are pregnant, you must also call Amerigroup Member Services. While you are pregnant, you need to take good care of your health. You may be able to get healthy food from the Women, Infants and Children Program (WIC). Member Services can give you the phone number for the WIC program close to you. Just call us. When you are pregnant, you must go to your PCP or OB/GYN at least: Every four weeks for the first six months Every two weeks for the seventh and eighth months Every week during the last month Your PCP or OB/GYN may want you to visit more than this based on your health needs. Amerigroup also helps pregnant members with complex health care needs. Nurse case managers work closely with these members to: Help teach them about these needs Give emotional support Help them to follow their providers care plan Our nurses also work with providers. They help with other services members may need. The goal is to promote better health for members and the birth of healthy babies. When You Have a New Baby When you have your baby, you and your baby may stay in the hospital at least: Forty-eight hours after a vaginal delivery Ninety-six hours after a cesarean section (C-section) You may stay in the hospital less time. If your PCP or OB/GYN and the baby s doctor see that you and your baby are doing well, you may go home earlier. If you do, your PCP or OB/GYN may ask you to have an office or in-home nurse visit within 48 hours. After you have your baby, you must: Call Amerigroup Member Services as soon as you can to let your service coordinator know you had your baby. We will need to get details about your baby. Call your caseworker with the New Mexico Human Services Department to let him or her know you had your baby. 56

63 Guide to Prenatal Care These guidelines are intended to help you know what to expect during pregnancy. You and your physician will decide what is best for you while you are pregnant. First Trimester Visit frequency Every four weeks Your first visit to your PCP or OB/GYN while you are pregnant will cover many things: Getting a complete health exam, including checking your weight and blood pressure and taking a urine sample Gathering facts about your health history, including information on former pregnancies, any history of infections such as Chlamydia, Gonorrhea, Herpes, bacterial vaginosis, HPV, RPR-VDRL (tests for syphilis), Hepatitis B and C, TB, and HIV testing Getting lab work, including urine testing; genetic testing may also be included Getting a prescription for prenatal vitamins Getting a Pap smear of your cervix within the first six months of your pregnancy You should also get a flu shot if you are pregnant during flu season. Second Trimester Visit frequency Every four weeks Visits to your PCP or OB/GYN during your second trimester will include: Getting routine lab work, including screening for birth defects between weeks gestation Listening to the baby s heart; checking abdominal growth, fetal movement and the position of the fetus during each visit Third Trimester Visit frequency Every four weeks up to 28 weeks gestation Every 2-3 weeks from weeks gestation Weekly from 36 weeks gestation until delivery Visits to your PCP or OB/GYN during your third trimester will include: Getting lab work, including: - Blood sugar and other blood count screenings between weeks - Group B Strep bacteria screening between weeks - Testing for sexually transmitted diseases - Testing for markers on blood that could be a problem after delivery, called antibody screen - Listening to the baby s heart; checking abdominal growth, fetal movement and the position of the fetus during each visit 57

64 Education Amerigroup works to keep you healthy with our health education programs. We can help you find classes near your home, including: Learning about: - How pregnancy affects a woman s body and what to expect while you are pregnant - How to avoid early delivery of your baby and what the warning signs are - How your pregnancy can be affected due to: Alcohol, smoking and drug use Mental health problems, including depression The environment, including dangerous workplaces - Sexual practices and how to prevent sexually transmitted diseases - How to prevent injury to your body Making healthy choices, such as: - Eating healthy - Getting proper exercise - Keeping your mouth clean and healthy Quitting cigarette smoking Protecting yourself from violence We can also help you find classes or information on: Child birth Labor and delivery, including ways to help with pain if you have anesthesia, a C-section or a baby after you had a C-section Breastfeeding Postpartum care Birth control counseling Call your service coordinator to find out where and when these classes are held. Adapted from the American College of Obstetricians and Gynecologists, Guidelines for Prenatal Care Disease Management Amerigroup has a Disease Management Centralized Care Unit (DMCCU) program. A team of licensed nurses and social workers, called DMCCU care managers, educate you about your condition and help you learn how to manage your care. Your Primary Care Provider or PCP and our team of DMCCU care managers will help you with your health care needs. DMCCU care managers work with you to create health goals and help you develop a plan to reach these goals. As a member in the program, you will benefit from having a care manager who: Listens to you and takes the time to understand your specific needs Helps you create a care plan to reach your health care goals Gives you the tools, support and community resources that can help you improve your quality of life Provides health information that can help you make better choices Assists you in coordinating care with your providers 58

65 Amerigroup has earned NCQA (National Committee for Quality Assurance) Patient and Practitioner Oriented Accreditation for our disease management programs. Earning NCQA accreditation for disease management represents our continued commitment to help you get quality health care coverage. Our programs include: Asthma Chronic obstructive pulmonary disease Coronary artery disease Diabetes As an Amerigroup member enrolled in the DMCCU program, you have certain rights and responsibilities. You have the right to: Have information about Amerigroup; this includes all Amerigroup programs and services, as well as our staff s education and work experience; it also includes contracts we have with other businesses or agencies Refuse to take part in or disenroll from programs and services we offer Know which staff members arrange your health care services and who to ask for a change Have Amerigroup help you to make choices with your providers about your health care Learn about all DMCCU-related treatments; these include anything stated in the clinical guidelines, whether covered by Amerigroup or not; you have the right to discuss all options with your providers Have personal and medical information kept private under HIPAA; know who has access to your information; know what Amerigroup does to keep it private Be treated with courtesy and respect by Amerigroup staff File a complaint with Amerigroup and be told how to make a complaint; this includes knowing about the Amerigroup standards of timely response to complaints and resolving issues of quality Get information that you can understand Have Amerigroup act as an advocate for you if needed You are encouraged to: Listen to and know the effects of taking or not taking health care advice Provide Amerigroup with information needed to carry out our services Tell Amerigroup and your providers if you decide to disenroll from the DMCCU program If you have one of these conditions or would like to know more about our DMCCU, please call Monday through Friday from 8:00 a.m. to 5:00 p.m. Mountain time. Ask to speak with a DMCCU care manager. You can also visit our website at Log in with your member information. Then, choose Programs and Info in Your Community. You can also call the DMCCU if you would like a copy of DMCCU materials you find online. SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING Health Information Learning more about health and healthy living can help you stay healthy. Here are some ways to get health information: Ask your Primary Care Provider (PCP). 59

66 Call us. Our Nurse HelpLine is on hand 24 hours a day, 7 days a week. One of our nurses can tell you: - If you need to see your PCP - How you can help take care of some health problems you may have Health Education Classes Amerigroup works to keep you healthy with our health education programs. We can help you find classes near your home. You can call Member Services to find out where and when these classes are held. Some of the classes include: Our services and how to get them Childbirth Infant care Parenting Pregnancy Quitting cigarette smoking Protecting yourself from violence Other health topics Some of the larger medical offices in our network (like clinics) show health videos. The videos talk about immunizations (shots) and prenatal care. They talk about other vital health topics. Please watch these videos. Learn more about staying healthy. We will also mail a member newsletter to you every year. This gives you health news about well care and taking care of illnesses. It gives you tips on how to be a better parent and other topics. Community Events Amerigroup sponsors and takes part in special community events and family fun days. This is one way you can get health news and have a good time. You can learn about topics like: Healthy eating Asthma Stress You and your family can play games, win prizes or take part in other fun community events. Amerigroup representatives will be there to answer your questions about your benefits, too. Call Member Services to find out when and where these events will be. Domestic Violence Domestic violence is abuse. Abuse is unhealthy and 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 happens in the home. It can affect your children, and it can affect you. If you feel you may be a victim of abuse, call or talk to your PCP. 60

67 Safety tips for your protection: If you are hurt, call your PCP. Call 911 or go to the nearest hospital if you need emergency care. Please see the section Emergency Services for more information. Have a plan for how you can get to a safe place (like a women s shelter or a friend s or relative s home). Pack a small bag and give it to a friend to keep for you until you need it. If you have questions or need help: Call our Nurse HelpLine at Call the National Domestic Violence hotline number at Abuse, Neglect and Exploitation There are other types of abuse besides domestic violence. If you or someone you know is being hurt or taken advantage of, you can report this. Abuse means: Hurting someone on purpose Holding someone against his or her will Threatening or punishing someone; causing pain or physical or mental harm Neglect means not giving someone the things he or she needs to avoid physical or mental harm such as: Food Shelter Medical care Exploitation means: Stealing someone s property or money Using someone s accounts or credit cards Misplacing someone s things on purpose without his or her permission Abuse, neglect and exploitation can be reported to: Your service coordinator Amerigroup; call our Case Coordination Line at The member advocate You can also call the state of New Mexico Adult Protective Services Department at If you wish, you can keep your identity secret when you make a report. Minors For most Amerigroup members under age 18, Amerigroup network providers and hospitals cannot give them care without their parent s or legal guardian s consent. This does not apply under the following conditions: If emergency care is needed For pregnancy testing, delivery, and prenatal and postnatal care 61

68 HIV-related services Other reproductive health services such as testing and treatment for sexually transmitted diseases These rules do not apply to emancipated minors. Members under age 18 may be emancipated minors if they: Are married Are pregnant Have a child Have served in the armed forces Are emancipated minors by court order Emancipated minors may make their own decisions about their medical care. They also may make decisions about the medical care of their children. MAKING A LIVING WILL (ADVANCE DIRECTIVES) Emancipated minors and members over 18 years old have rights under advance directive law. An advance directive talks about making a living will. A living will says you may not want medical care if you have a serious illness or injury and may not get better. To make sure you get the kind of care you want if you are too sick to decide for yourself, you can sign a living will. This is a type of advance directive. It is a paper that tells your provider and your family what kinds of care you do not want if you are seriously ill or injured. If you wish to sign a living will, you can: Ask your PCP for a living will form or call Member Services to get one. A sample form is also in this member handbook. Fill out the form by yourself, or call us for help. Take the form or mail it to your PCP or specialist. Your PCP or specialist will then know what kind of care you want to get. You can change your mind anytime after you have signed a living will. Call your PCP or specialist to remove the living will from your medical record. Fill out and sign a new form if you wish to make changes in your living will. You can sign a paper called a durable power of attorney, too. This paper will let you name a person to make decisions for you when you cannot make them yourself. Ask your doctor about these forms. GRIEVANCES AND MEDICAL APPEALS If you have any questions or concerns with your Amerigroup benefits, please call Member Services at Grievances If you have a problem with our services or network providers and would like to tell us about it, please call Member Services. 62

69 Filing a Grievance with Amerigroup We will try to solve your problem on the phone. If we cannot take care of the problem when you call us, you can file a grievance. You can: Call Member Services at and ask for help with writing a letter; include information such as the date the problem happened and the people involved File your grievance by fax or mail or in person within 90 calendar days of the date you were aware of the problem Send your letter to: Quality Management Amerigroup Community Care of New Mexico, Inc Americas Parkway N.E., Suite 110 Albuquerque, NM When we get your call or letter, we will: Send you a letter within five working days to let you know we got your grievance and when we expect to have it resolved Look into your grievance when we get it Send you a letter within 30 calendar days from the date you first told us about your grievance; it will tell you the decision made by Amerigroup and all the information that we reviewed If we need more details, we may extend the grievance process for 14 calendar days. If we do this, we will let you know the reason for the delay within two working days. You may also ask us to extend the process if you have more details that we should see. Filing a Grievance with the State You can also file a grievance with the state if you are not pleased with our final decision. You can do this at any time during the Amerigroup grievance process. To do this, contact: New Mexico Human Services Department Medical Assistance Division, Client Services Bureau P.O. Box 2345 Santa Fe, NM or OR Aging and Long-Term Services Department (ALTSD) 2550 Cerrillos Road Santa Fe, NM or

70 Medical Appeals There may be times when we say we will not pay for care that has been advised by your provider. This may be all of the care or only part of the care. If we do this, you, a person acting on your behalf or your provider (with your written OK) can appeal the decision. A medical appeal is when you ask Amerigroup to look again at the care your provider asked for and we said we would not pay for. You must file for an appeal within 90 calendar days from the date on the letter that said we would not pay for a service. You can appeal our decision in two ways: Call Member Services. If you call us, you must still send us your appeal in writing unless it is an emergency. We will send you an appeal form. - Fill out the whole form. - Mail it back to us at the address below within 10 calendar days of when you call us. If you do not fill out and return the appeal form within 10 days, we will close your appeal. If you need help, call Member Services. Send us a letter or the appeal form to the address below: Appeals Processing Amerigroup Community Care of New Mexico, Inc Americas Parkway, Suite 110 Albuquerque, NM You can file your own appeal or have someone else do it for you. If someone else is going to file for you, we must have your written OK that you want that person to file your appeal for you. You can do this in two ways: Call Amerigroup Member Services at the above number for a form that gives another person the right to file an appeal for you (an agent). Write your own letter. Amerigroup will not take any action against you or your agent for filing an appeal. You can also ask Amerigroup to see a copy of the file we have about your case. When we get your letter or form, we will send you a letter saying we got your appeal. This will be sent to you within five working days. This letter will also tell you: When we expect to have it resolved If we need more details to process your appeal; we will contact your doctor if we need medical information about this service After we receive your appeal: A reviewer who has not seen your case before will look at your appeal. He or she will decide how we should take care of your appeal. We will send you a letter with the answer to your appeal. We will do this within 30 calendar days from when we get your appeal. 64

71 If we need more details about your appeal: We may extend the appeals process for 14 calendar days. We will let you know the reason for the delay. We will tell you within two working days from when we decide to extend the process. You may also ask us to extend the process if you have more information that we should consider. To continue to get services that have already been approved and may be part of the reason for your appeal, you must file the appeal within 13 calendar days from the date we mail the notice to you saying that we will not pay for this care. We must continue coverage of your benefits until: You withdraw the appeal Authorization expires or your service limits are met Ten business days have passed since Amerigroup mailed a resolution letter; this applies only if the decision is not in your favor and you have taken no further action You may have to pay for the cost of any continued benefit if the final decision is not in your favor. If a decision is made in your favor as a result of your appeal, Amerigroup will approve and pay for the service we denied coverage of before. Expedited Appeals You or the person you ask to file an appeal for you can ask for an expedited appeal. You can ask for an expedited appeal if you or your provider feels that taking the time for the standard appeals process could seriously harm your life or your health. You can ask for an expedited appeal in two ways: You can call Member Services. You can send us a letter to the address below. Call Member Services if you need help filing an appeal. Medical Management Amerigroup Community Care of New Mexico, Inc Americas Parkway N.E., Suite 110 Albuquerque, NM If we agree your request for an appeal should be expedited, we will send you a letter with the answer to your appeal. We will do this within three calendar days. If we need more information from you or the person you asked to file the appeal for you: We may extend the appeals process for 14 calendar days We will let you know the reason for the delay; we will do this within two working days from when we decide to extend the process You may also ask us to extend the process if you have more details that we should review. 65

72 If we do not agree that your request for an appeal should be expedited, we will: Call you right away Send you a letter within two working days to let you know how the decision was made and that your appeal will be reviewed through the standard review process If we do not agree to expedite your appeal, you can file a complaint about that, too. Even if you file a complaint about Amerigroup denying your request to expedite your appeal, we will still continue to review your appeal within the standard 30 calendar days. You can also fax your request toll free to If the decision on your expedited appeal upholds our first decision and we will not pay for the care your provider asked for, we will call you and send you a letter. This letter will: Let you know how the decision was made Tell you about your rights to request a state fair hearing Auto-expedited Appeals If we get an expedited request for approval of services and a decision is made to deny or limit these services, Amerigroup will: File an appeal on your behalf within 72 hours of getting the request for services Call you to give you the appeal decision Payment Appeals If you get a service from a provider and we do not pay for that service, you may get a notice from Amerigroup called an Explanation Of Benefits (EOB). This is not a bill. The EOB will tell you: The date you got the service The type of service The reason we cannot pay for the service The provider, health care place or person who gave you this service will get a notice called an Explanation Of Payment (EOP). If you get an EOB, you do not need to call or do anything at that time, unless you or your provider wants to appeal the decision. A payment appeal is when you ask Amerigroup to look again at the service we said we would not pay for. Your provider must ask for an appeal within 90 calendar days of receiving the EOP. To appeal, your provider can mail the request and medical information for the service to: Central Appeals Processing Amerigroup Community Care of New Mexico, Inc. P.O. Box Virginia Beach, VA Payment appeals must be submitted in writing by your provider. 66

73 Fair Hearings You have the right to ask for a fair hearing from the state. You may do this before, during, after or in lieu of the appeal process. You must ask for a fair hearing within 90 days from the date you get our Notice of Proposed Action letter denying coverage of services. You can ask for a fair hearing by calling the New Mexico Human Services Department, Medical Assistance Division at ; choose option 6 or by sending a letter to: New Mexico Human Services Department Fair Hearings Bureau P.O. Box 2348 Santa Fe, NM If you have any questions about your rights to appeal or request a fair hearing, call Member Services. If you ask for a fair hearing, you will get a letter from the hearing officer. The letter will tell you: The date and time of the hearing What you need to know to get ready for the hearing The hearing can be held by phone, and you can explain why you asked for this service. You can also ask the hearing officer to review the information you send in and make a decision. Continuation of Benefits To continue to get services that have already been approved and may be part of the reason you are filing for a fair hearing, you must call Member Services to request it within 13 calendar days from when we mail the notice to you saying we will not pay for this care. We must continue coverage of your benefits until: You withdraw the request for a fair hearing A fair hearing decision is reached and is not in your favor Authorization expires or your service limits are met You may have to pay for the cost of any continued benefit if the final decision is not in your favor. If a decision is made in your favor as a result of your fair hearing, we will approve and pay for the services we denied coverage of before. OTHER INFORMATION If You Move You should contact your local Income Support Division (ISD) Office as soon as you move to report your new address. If you get Social Security benefits, you should also contact your local Social Security office to let them know you moved. Once you contact ISD and Social Security, you should then call Amerigroup Member Services. 67

74 You will continue to get health care services through us in your current area until the address is changed. You must call Amerigroup before you can get any services in your new area unless it is an emergency. Renew Your Medicaid Benefits on Time Keep the right care. Do not lose your health care benefits! You could lose your benefits even if you still qualify. Every year, members enrolled in the CoLTS program with a nursing facility level of care will need to renew their benefits. If you do not renew your eligibility, you will lose your health care benefits. Your local Income Support Division (ISD) office can answer your questions about renewing your benefits. We want you to keep getting your health care benefits from us as long as you still qualify. Your health is very important to us. You can look in your Amerigroup provider directory you got with your enrollment package for an ISD office near you. You can also find the provider directory online at If You Are No Longer Eligible for Medicaid You will be disenrolled from Amerigroup if you no longer qualify for Medicaid. If you do not qualify for Medicaid for six months or less and then become eligible again, you will be re-enrolled in Amerigroup if: You still qualify for nursing facility level of care You have been in a nursing facility level of care setting while disenrolled Your eligibility for Medicaid is confirmed back to the date you were disenrolled How to Disenroll from Amerigroup If you do not like something about Amerigroup, please call Member Services. We will work with you to try to fix the problem. Members enrolled in the CoLTS program may ask to be disenrolled from Amerigroup for cause at any time during the lock-in period. You or your representative may call or submit your request in writing to the state at: Human Services Department Medical Assistance Division, Client Services Bureau P.O. Box 2348 Santa Fe, NM The change will take place no later than the first day of the second month following the month in which you make the request. 68

75 Reasons Why You Can Be Disenrolled from Amerigroup Listed below are several reasons you could be disenrolled from Amerigroup. You can be disenrolled without asking to be disenrolled. If you have done something that may cause you to lose your enrollment, we will contact you. We will ask you to tell us what happened. You could be disenrolled from Amerigroup if: Amerigroup is no longer able to meet your health care or other medically necessary covered needs Your conduct is such that it is not safe or wise to provide covered services You have been made aware in writing and through other means of the chance to use the grievance process You try to hurt a provider, a staff person or an Amerigroup associate If you have any questions about your enrollment, call Member Services. If You Get a Bill Always show your Amerigroup and Medicare ID cards when you: See a provider Go to the hospital Go for tests Even if your provider told you to go, you must show your ID cards to make sure you are not sent a bill for services covered by Amerigroup. If you do get a bill, send it to us with a letter saying that you have been sent a bill. Send the letter to the address below: Claims Amerigroup Community Care of New Mexico, Inc. P.O. Box Virginia Beach, VA You can also call Member Services for help. If You Have Other Health Insurance (Coordination of Benefits) Please call Member Services if you or your children have other health insurance. Always show your Amerigroup and other health insurance cards when you see a provider, go to the hospital or go for tests. The other insurance plan needs to be billed for your health care services before Amerigroup can be billed. Amerigroup will work with the other insurance plan on payment for these services. Changes In Your Amerigroup Coverage Sometimes Amerigroup may have to change the way we work, our covered services, or our network providers and hospitals. We will mail you a letter when we make changes to the services that are covered. Your Primary Care Provider s (PCP s) office may move, close or leave our network. If this happens, we will call or send you a letter to tell you about this. 69

76 We can also help you pick a new PCP. You can call Member Services if you have any questions. Member Services can also send you a current list of our network PCPs. How to Tell Amerigroup about Changes You Think We Should Make We want to know what you like and do not like about Amerigroup. Your ideas will help us make Amerigroup better. Please call Member Services to tell us your ideas. You can also send a letter to: Amerigroup Community Care of New Mexico, Inc. P.O. Box Virginia Beach, VA Amerigroup has a group of members who meet quarterly to give us their ideas; these meetings are called Consumer Advisory Board meetings. This is a chance for you to find out more about us. You may also ask questions and tell us ways we can improve. If you want to be part of this group, call Member Services. We also send surveys to some members. The surveys ask questions about how you like Amerigroup. If we send you a survey, please fill it out and send it back. Our staff may also call to ask how you like Amerigroup. Please tell them what you think. Your ideas can help us make Amerigroup better. If you want to know more about the Amerigroup quality program, you can find the most up-to-date information about our quality program in our annual quality report to members at Also, this information will include the results of our member surveys. How Amerigroup Pays Providers Different providers in our network have agreed to be paid in different ways by us. Your provider may be paid each time he or she treats you (fee-for-service). Or your provider may be paid a set fee each month for each member even if that member does not get services (capitation). These kinds of pay may include ways to earn more money. This kind of pay is based on different things like how happy a member is with the care or quality of care. It is also based on how easy it is to find and get care. If you want more details about how our contracted providers or any other providers in our network are paid, please call the Amerigroup Member Services department or write to us at: Amerigroup Community Care of New Mexico, Inc. P.O. Box Virginia Beach, VA

77 YOUR AMERIGROUP MEMBER BILL OF RIGHTS Your Rights As an Amerigroup member, you have the right to: Privacy Be sure your medical record is private; be cared for with dignity and without discrimination; that includes the right to: Be treated fairly and with respect and get care in a non-discriminatory way Know that your medical records and talks with your providers will be kept private and confidential Not be harassed by Amerigroup or Amerigroup providers over contract problems Choose your health plan and providers Have the chance to choose a health care plan and Primary Care Provider or PCP, and change to another health plan or provider in a reasonably easy manner; that includes the right to: Choose a surrogate-decision maker to be involved in health care decisions as fitting Be informed of how to choose your health plan or your PCP Choose any health plan you want that is offered in your area Choose your PCP or specialist from that plan s network; this choice must be within the limits of the referral and prior approval process Change your PCP or specialist Change your health plan for cause Ask questions about your health care Ask questions and get answers about anything you do not understand; that includes the right to have your provider: Explain your health care needs to you Talk to you about ways your health care problems can be treated Take part in decisions about your health care Consent to or refuse treatment, and take part in treatment decisions; that includes the right to: Work as part of a team with your provider or have someone that you choose work with your provider to decide what health care is best for you Say yes or no to the care your provider recommends Get a second medical opinion at no cost to you Make advance directives; tell your PCP how you wish to be treated if you become too ill to decide for yourself Use the grievance, appeal and fair hearing process Use each complaint process on hand through Amerigroup and through Medicaid without penalty; get a timely response to complaints; that includes the right to: Make a complaint to Amerigroup or to the state Medicaid program about your health care, your provider or your health plan Ask for a fair hearing from the state Medicaid program about your complaint Get a copy of your medical records 71

78 Receive care in a timely manner Get timely access to care that does not have any communication or physical access barriers; this includes the right to: Have phone access to a medical professional 24 hours a day, 7 days a week in order to get any needed emergency or urgent care Get medical care in a timely manner Be able to get in and out of a health care provider's office; this includes barrier-free access for persons with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act Have interpreters, if needed, during times set up to see your providers and when you talk with your health plan; interpreters include people who can speak in your language, assist with a disability or help you understand the information Get information in an alternate format in accord with the Americans with Disabilities Act Have your health plan rules explained so that you know them; this includes the health care services you can get and how to get them, and the providers who are in the Amerigroup network Receive care without restraint Not be restrained or secluded if doing so is: For someone else s convenience Meant to force you to do something you do not want to do To punish you Your Responsibilities As an Amerigroup member, you have the responsibility to: Tell your providers about your health care needs Share information that relates to your health status with your Primary Care Provider (PCP); become fully informed about service and treatment options; this includes the responsibility to: Tell your PCP about your health Talk to your providers about your health care needs; ask questions about ways your health care problems can be treated Help your providers get your medical records Give your providers the right information Follow the prescribed treatment of care advised by your provider or let the provider know the reasons the treatment cannot be followed as soon as possible Make and keep doctor appointments and be on time; call the doctor s office if you need to cancel an appointment or will be late Take part in making decisions about your health Take part in decisions that relate to service and treatment options, make personal choices, and take action to maintain your health; this includes the responsibility to: Work as a team with your provider to decide what health care is best for you Know how the things you do can affect your health Do the best you can to stay healthy Treat providers and staff with respect 72

79 Call Member Services if you have a problem and need help. Amerigroup provides health coverage to our members on a nondiscriminatory basis according to state and federal law, regardless of gender, race, age, religion, national origin, physical or mental disability, or type of illness or condition. HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID PROGRAM If you know someone who is misusing the Medicaid program, you can report him or her. To report primary care providers, specialists, clinics, hospitals, nursing homes or Medicaid enrollees, write or call Amerigroup at: Corporate Investigations Department Amerigroup Community Care of New Mexico, Inc Corporation Lane Virginia Beach, VA Suspicions of fraud and abuse can be ed directly to the Amerigroup Corporate Investigations Department at corpinvest@amerigroupcorp.com. Online: Suspicions of fraud and abuse can also be sent to the Corporate Investigations department through the Amerigroup website at There are fraud and abuse links on the website to report details about a possible issue. This information is sent directly to the address above, which is checked every business day. You can also call the Medicaid Fraud and Abuse Hotline at or the Inspector General s Fraud and Abuse Unit at WE HOPE THIS BOOK HAS ANSWERED MOST OF YOUR QUESTIONS ABOUT AMERIGROUP. FOR MORE INFORMATION, CALL THE AMERIGROUP MEMBER SERVICES DEPARTMENT AT

80 NEW MEXICO ADVANCE HEALTH CARE DIRECTIVE PART I POWER OF ATTORNEY FOR HEALTH CARE PART 1 of this form is a power of attorney for health care. PART 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator or employee of a health care institution at which you are receiving care. Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. This part is the health care power-of-attorney form, which allows you to name an individual to act as your agent to make health care decisions for you (1) DESIGNATION OF AGENT: I,, name the following individual as my agent to make health care decisions for me: Name Phone Number Address City State ZIP Code If I revoke my agent s authority or if my agent is not willing, able or reasonably available to make a health care decision for me, I designate as my first alternate agent: Name Phone Number Address City State ZIP Code If I revoke the authority of my agent and first alternate agent or if neither is willing, able or reasonably available to make a health care decision for me, I designate as my second alternate agent: Name Phone Number Address City State ZIP Code If you give your agent unlimited authority, they will have the right to: (a) Consent or refuse any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition (b) Select or discharge health care providers and institutions (c) Approve or disapprove diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate and (d) Direct the provision, withholding or withdrawal of artificial nutrition and hydration and all other forms of health care 74