Table of Contents. Important Phone Numbers Having a baby...22 What to do if you are pregnant Prenatal and Post-Partum Care...

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1 Member Handbook

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3 Table of Contents Important Phone Numbers... 2 Welcome to AmeriHealth Caritas District of Columbia... 4 How this handbook works... 4 How this member handbook can help you... 4 Your Rights and Responsibilities... 5 Your Member Identification Card... 7 Member Portal... 7 Your Primary Care Provider (PCP) and Primary Dental Provider (PDP)... 8 What is a Primary Care Provider (PCP)... 8 How to change your PCP... 9 Your Primary Dental Provider (PDP)... 9 Routine Care, Urgent Care and Emergency Care...10 Routine Care Urgent Care Emergency Care Care When You Are Out-of-Town...11 In-Network and Out-of-Network Providers...12 Making An Appointment...13 Making an appointment with your PCP Changing or canceling an appointment Getting care when your PCP s office is closed How long it takes to see your doctor Support Services...15 Interpretation Services Translation Services Services for the Hearing and Visually Impaired Specialty Care and Referrals...16 How to get specialty care Self-Referral Services Birth control and other family planning services Pharmacy services and prescription drugs Disease Management Services to keep you from getting sick...21 Recommendations for check-ups ( screenings ) Preventive counseling Adult immunizations Having a baby...22 What to do if you are pregnant Prenatal and Post-Partum Care Your Health Benefits...23 Services AmeriHealth Caritas District of Columbia covers Services we do not pay for (exclusions) Other Important Information...28 What to do if you move What to do if you have a baby What to do if you adopt a child What to do if someone in your family dies How to change your MCO What to do if you get a bill for a covered service Paying for Non-Covered Services Advance Directives What to do if you have other insurance Physician (doctor) Incentive Plan disclosure Fraud How we pay your doctors New technology Complaints, Grievances, Appeals and Fair Hearings...32 Complaints and Grievances Appeals and Fair Hearings Appeals Expedited (emergency) Complaints, Grievances and Appeals Process Your rights during the Complaints, Grievances, Appeals and Fair Hearings Process The Ombudsman Program Notice of Privacy Practices...35 What Some Words Mean...40 Member Handbook 1

4 Quick Reference Guide Important telephone numbers For questions about AmeriHealth Caritas District of Columbia, your benefits or our doctors, call: Member Services TTY/TDD (toll free) (toll free) 24 hours a day 7 days a week 24 hours a day 7 days a week If you need care after your doctor s office closes or you have a question for a nurse, call: Nurse Call Line TTY Nurse Call Line (toll free) 24 hours a day 7 days a week 24 hours a day 7 days a week Your PCP s office (Add your PCP s office information) If you need mental health care or have a mental health question, call: Nurse Call Line hours a day 7 days a week DC Department of Mental Health Hotline (toll free) 24 hours a day 7 days a week If you need to see a doctor within 24 hours (urgent care), call: Your PCP s office (Add your PCP s office information) Nurse Call Line hours a day 7 days a week If you need someone who speaks your language or if you are hearing-impaired, call: Member Services TTY/TDD (toll free) (toll free) 24 hours a day 7 days a week 24 hours a day 7 days a week For dental questions, call: Member Services (toll free) TTY/TDD (toll free) 24 hours a day 7 days a week 2 AmeriHealth Caritas District of Columbia

5 Quick Reference Guide Other important telephone numbers To confirm eligibility or to change your MCO, call: DC Healthcare Alliance :00 a.m. 7:00 p.m. Monday, Tuesday, Thursday, Friday 8:00 a.m. 9:00 p.m. Wednesday To report fraud, call: DC Department of Health Care Finance s Fraud Hotline AmeriHealth Caritas District of Columbia s Compliance Hotline :00 a.m. 4:30 p.m. Monday Friday 24 hours a day 7 days a week To speak with a case manager, call: Rapid Response and Outreach Team hours a day 7 days a week Call center hours: 8:15 a.m. 4:45 p.m. If you are pregnant, and need to check for Medicaid eligibility, call: DC Economic Security Administration (ESA) Customer service: 8:15 a.m. 4:45 p.m. Monday, Tuesday, Thursday, Friday 8:15 a.m. 8:00 p.m. Wednesday For an emergency, dial 911 or go to your nearest emergency room. Your main doctor: Child s main doctor: Other child s main doctor: Other child s main doctor: Phone: Phone: Phone: Phone: Member Handbook 3

6 Welcome to AmeriHealth Caritas District of Columbia Thank you for choosing AmeriHealth Caritas District of Columbia Inc. (AmeriHealth Caritas District of Columbia) as your DC Healthcare Alliance (Alliance) Managed Care Organization (MCO). We are committed to providing you with access to quality health care and exceptional member services. As an Alliance member, you do not have any coverage from AmeriHealth Caritas District of Columbia for services provided by Out-of-Network Providers. This member handbook contains important information about AmeriHealth Caritas District of Columbia and how it works. Please review it carefully. As a member of AmeriHealth Caritas District of Columbia, you will enjoy great benefits and services. If AmeriHealth Caritas District of Columbia changes how it works or learns information about its providers that you need to know (like which doctors are taking new patients and the doctors office hours), we will tell you about the change 30 days before it is made. Each month AmeriHealth Caritas District of Columbia will host a member orientation session. The member orientation is another way you can learn all about AmeriHealth Caritas District of Columbia benefits. During the member orientation session, you can also speak one-to-one with an AmeriHealth Caritas District of Columbia representative to get your questions answered. Please visit or call the Member Services department to get the date and time of each session. If you have any questions, please call our Member Services department 24 hours a day, 7 days a week, at or toll-free at You may also stop by our office from 8:00 a.m. 5:30 p.m., Monday through Friday. We are located at 1120 Vermont Avenue NW, Suite 200, Washington, DC How This Handbook Works AmeriHealth Caritas District of Columbia is a managed care plan paid by the District of Columbia to help you get health care. This handbook explains how AmeriHealth Caritas District of Columbia works, how to find doctors, how to call us, and the things for which we pay. Telling you about these things can be hard to do and hard for everyone to read. Words used in health care and words used by your doctor can sometimes be hard to understand. Sometimes, we have to tell you about laws that you need to know about. These also can be hard to understand. To help you, we have explained these words in the back of this book. If you ever have any questions about things you read in this book or other questions about AmeriHealth Caritas District of Columbia, you can call AmeriHealth Caritas District of Columbia s Member Services at or toll-free at , or visit We will do our best to help you. How This Member Handbook Can Help You This member handbook tells you: How to get health care How to pick your primary care provider (your PCP) The services for which AmeriHealth Caritas District of Columbia will pay (covered services) The services for which AmeriHealth Caritas District of Columbia will not pay (excluded services) What to do if you get sick What you should do if you have a complaint (also called a grievance ) or want to change ( appeal ) a decision by AmeriHealth Caritas District of Columbia This member handbook gives you basic information about how AmeriHealth Caritas District of Columbia works and its rules. Please call AmeriHealth Caritas District of Columbia s Member Services department if you have any questions. 4 AmeriHealth Caritas District of Columbia

7 Your Rights and Responsibilities You have a right to: Be treated with respect and dignity Know that when you talk with your doctors and other providers, it s private Have an illness or treatment explained to you in a language you can understand Participate in decisions about your care Receive a full, clear and understandable explanation of treatment options and risks of each option so you can make an informed decision, regardless of cost or benefit coverage (Female enrollees only) Have direct access to a women s health specialist within the network for the covered care necessary to provide women s routine and preventive health care services. Also, female enrollees have a right to designate as their PCP a participating provider or an advanced-practicing registered nurse who specializes in obstetrics (OB) and gynecology (GYN). Refuse treatment or care Be able to see your medical records and to request that they be fixed if they are wrong Choose an eligible PCP from within AmeriHealth Caritas District of Columbia s network and change your PCP Request information about any of our providers, including medical school education, residency and board certification Make a complaint ( grievance ) about AmeriHealth Caritas District of Columbia or the care provided to you and receive an answer Request an appeal or a Fair Hearing if you believe AmeriHealth Caritas District of Columbia was wrong in denying, reducing or stopping a service or item Receive family planning services and supplies from the provider of your choice Obtain medical care without unnecessary delay Receive information on Advance Directives and choose not to have or continue any life-sustaining treatment Ask for a chaperone to be present when you receive health care Receive a copy of this member handbook Continue treatment you are currently receiving until you have a new treatment plan Receive interpretation and translation services free of charge if you need them, and refuse oral interpretation services Get an explanation of prior authorization procedures Receive information about AmeriHealth Caritas District of Columbia s financial condition and any special ways we pay our doctors Obtain summaries of customer satisfaction surveys Receive AmeriHealth Caritas District of Columbia s Dispense as Written policy for prescription drugs Receive information about AmeriHealth Caritas District of Columbia, our services, our providers and other health care workers, our facilities and your rights and responsibilities as a member Make recommendations about AmeriHealth Caritas District of Columbia s member rights and responsibilities policy Be free from any form of restraint or seclusion used as coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion Receive a second opinion from a qualified health care professional within the network, or arrange for the enrollee to obtain one outside the network, at no cost to you Be informed about cost sharing, if any, upon enrollment, annually and at least 30 days prior to any change Be informed about how and where to access any benefits available under the district plan but not covered under the contract, including any cost sharing, and how transportation is provided, upon enrollment, annually and at least 30 days prior to any change Member Handbook 5

8 Your Rights and Responsibilities Be informed that you may be required to pay the cost of services furnished while an appeal is pending, if the final decision is adverse to you Not be held liable for AmeriHealth Caritas District of Columbia s debts in the event of AmeriHealth Caritas District of Columbia s insolvency Use any hospital or other setting for emergency care Be treated no differently by providers or by AmeriHealth Caritas District of Columbia for exercising your rights listed here You are responsible for: Treating those providing your care with respect and dignity Following the rules of the DC Healthcare Alliance managed care program and AmeriHealth Caritas District of Columbia Following instructions you receive from your doctors and other providers Going to appointments you schedule or that AmeriHealth Caritas District of Columbia schedules for you Telling your doctor at least 24 hours before the appointment if you have to cancel Asking for more explanation if you do not understand your doctor s instructions Going to the emergency room only if you have a medical emergency Telling your PCP about medical and personal problems that may affect your health to help the PCP provide you care Reporting to the DC Economic Security Administration (ESA) and AmeriHealth Caritas District of Columbia if you or a family member have other health insurance Trying to understand your health problems and participate in developing treatment goals Helping your doctor get medical records from providers who have treated you in the past Telling AmeriHealth Caritas District of Columbia if you were injured as the result of an accident or at work AmeriHealth Caritas District of Columbia wants you to know your rights and responsibilities. AmeriHealth Caritas District of Columbia will inform you of your rights and responsibilities when you enroll, annually and 30 days before any change is made. If you have questions about your rights, responsibilities or how to request information, call Member Services at and a Customer Service Representative will help you. 6 AmeriHealth Caritas District of Columbia

9 Your Member ID Card After you sign up for AmeriHealth Caritas District of Columbia and you have picked a primary care provider (PCP), we will send your member identification (ID) card in the mail. This card lets your doctors, hospitals, drug stores and others know that you are a member of AmeriHealth Caritas District of Columbia. Please make sure that the information on your member identification card is correct. If there are any problems, or if you have lost your card, call Member Services at or toll-free at Each AmeriHealth Caritas District of Columbia member has his or her own card. Your children will also have their own cards. You must keep your children s cards so they don t get lost. It is against the law to let anyone else use your member ID card. Please remember to carry your member ID card with you all the time. Always show your card before receiving any medical care or getting medicine at a pharmacy. Member First Name, Last Name Facets ID Number Member ID: XXXXXXXXXXX Sex: M DOB: MM/DD/YYYY Alliance Primary Doctor PCP First Name, PCP Last Name PCP Group Name PCP Phone Number AmeriHealth Caritas District of Columbia 1120 Vermont Ave. NW, Suite 200 Washington, DC If you cannot keep your appointment, please call your doctor. If you lose eligibility for health benefits, this card is no longer valid. Member Services Department 24/7 (by phone) ( ) Office: 9:00 a.m. - 5:00 p.m. Mon. - Fri. TTY: Nurse Advice Line hours a day, 7 days a week Provider Services & Prior Authorization Pharmacy Member Services & After-Hour Prescriptions TTY: Pharmacy Provider Services Economic Security Administration (ESA) Change Center (re-certify, case information) Mental Health, Drug & Alcohol Services AmeriHealth Caritas DC Claims Processing P.O. Box 7354 London, KY Member Portal The Member Portal gives you useful information about your AmeriHealth Caritas District of Columbia benefits. You can use the Member Portal to: Take a health assessment. This is a health questionnaire that can help you find possible health risks. It will give you tools you can use to help manage those risks. It only takes a few minutes. The results will tell you how to control those risks. This important information can make a big difference in your life. Change your PCP. You can change your PCP at any time. Get benefit details. Get up to 6 months of your prescription drug history, find the locations of in-network pharmacies and more. To find the Member Portal, go to Click Members, Medicaid Members or Alliance Members, and then choose Member Portal from the left menu. If you are a first-time user, you will need to sign up. To do this, you will need the number above your member ID number on your member ID card. Then you will need to choose a user ID and password. If you have already signed up, just log in. Member Handbook 7

10 Your Primary Care Provider (PCP) and Primary Dental Provider (PDP) What Is a Primary Care Provider (PCP) When you join AmeriHealth Caritas District of Columbia, one of your doctors will coordinate your care. This doctor is called your primary care provider or PCP. Your PCP will help you and your family get the health care you need. It is important to call your PCP first when you need care. If you had a doctor before you signed up with AmeriHealth Caritas District of Columbia, call Member Services at or toll-free at We can help you stay with that doctor if he or she is in AmeriHealth Caritas District of Columbia s network. If you don t have a PCP, you can pick from a list of doctors in our provider directory. The provider directory has the office locations, hours of operation, telephone numbers and other information about AmeriHealth Caritas District of Columbia s providers. For the most up-to-date information, go to AmeriHealth Caritas District of Columbia s website, or call our Member Services department at or If you need help picking a PCP or want more information about any of our providers, including medical school education, residency and board certification, Member Services can help you. 8 AmeriHealth Caritas District of Columbia

11 Your Primary Care Provider (PCP) and Primary Dental Provider (PDP) How to Change Your PCP You can change your PCP anytime. Just pick a new PCP from the provider directory. Call Member Services at or toll-free at once you have picked a new PCP. If you need help picking a new PCP or want more information about any of our providers, Member Services can help you. Your Primary Dental Provider (PDP) When you join AmeriHealth Caritas District of Columbia, the plan s dental program will send you information about choosing your dentist. Your dentist is called your primary dental provider or PDP. You can also call Member Services at or toll-free at for questions about how to choose or change your PDP. Member Handbook 9

12 Routine Care, Urgent Care and Emergency Care There are 3 kinds of health care you may need: routine care, urgent care and emergency care. Routine Care Routine care is the regular care you get from your PCP. Routine care can be check-ups, physicals, health screenings and care for health problems like diabetes, hypertension and asthma. If you need routine care, call your PCP s office and ask to make an appointment. You should see your doctor at least once a year. Children under 3 should see the doctor more frequently. Urgent Care Urgent care is medical care you need within 24 hours. Some urgent care issues are: A sprain or strain A cut or scrape A sore throat A cough or cold Diarrhea Throwing up Lice, scabies and ringworm An earache Diaper rash Mild headache Refills for medicine If you need urgent care, call your PCP s office. If your PCP s office is closed, leave a message with the person who answers the phone when the office is closed. Then call the Nurse Call Line at A nurse will help you decide if you need to go to the doctor right away. The nurse will tell you how to get care. You do not have to go to the emergency room or use an ambulance for urgent care. Emergency Care Emergency care is medical care you need right away for a serious injury or illness. An emergency medical condition is a serious, sudden injury or illness that requires care right away. If an emergency medical condition is not treated right away, it could put your health at serious risk or lead to death. It could also cause your whole body or parts of your body to stop working or not to work correctly. Some examples of medical conditions that require emergency care are: Miscarriage or a pregnancy with vaginal bleeding Bleeding that won t stop A broken bone A bad burn Being in labor A drug overdose Shock (you may sweat, feel thirsty or dizzy, or have pale skin) Seizures Poisoning Fainting/unconsciousness Gun or knife wounds Suddenly not being able to see, move or speak 10 AmeriHealth Caritas District of Columbia

13 Routine Care, Urgent Care and Emergency Care Post-stabilization services Emergency care also includes post-stabilization services. Post-stabilization services are those needed to understand whether or not you have an emergency medical condition. They also include services to treat your emergency so that your condition does not get worse. After you receive emergency care, you may need other care to make sure you remain in stable condition. Depending on the need, you may be treated in the emergency room, in an inpatient hospital room, or in another setting. This is called post-stabilization services. If your child does not live at home and needs to see a doctor, please call Member Services at or toll-free at What to do if you have an emergency: 1. Call 911 or go to your nearest emergency room (ER). 2. Show the ER your AmeriHealth Caritas District of Columbia member ID card. 3. As soon as you can, call your PCP. Care When You Are Out of Town The Alliance program does not cover you for any services when you are out of the District of Columbia. You are only covered by AmeriHealth Caritas District of Columbia for non-emergency services provided in the District of Columbia at a network hospital. Routine and urgent care are only available from participating providers in DC. Alliance does not cover services outside of the United States and does not cover any services provided by Out-of-Network Providers. Member Handbook 11

14 In-Network and Out-of-Network Providers AmeriHealth Caritas District of Columbia Providers and Providers Who Are Not Part of AmeriHealth Caritas District of Columbia AmeriHealth Caritas District of Columbia will pay for the care you get when you go to one of our doctors or other health care providers. We call these doctors and other health care providers our network providers. All these in-network doctors can be found in your provider directory. A doctor or provider who is not one of ours is called an out-of- network provider. If you go to an out-of-network doctor, hospital or lab, you will have to pay for the care you get. AmeriHealth Caritas District of Columbia does not cover services if you go to an Out-of-Network Provider. Call Member Services for a list of the Network Providers, labs or hospitals. If AmeriHealth Caritas District of Columbia does not have an in-network provider who can perform a covered service, we will approve an out-of-network provider. The covered service must be a service your doctor says you need (this is called a medically necessary service). Approval will be given to the out-of-network provider in writing. This service will be provided at no cost to you. The out-of-network provider will be paid for all approved services for as long as you need the services. Prior authorization (or preapproval) means approval for a health service that is more than routine care, like a hospital stay or surgery. Call your PCP or the Member Services department at or to ask about getting a prior authorization. You don t need prior authorization when you have an emergency. You may also go to a family planning provider who is out of network even if you do not have prior authorization. See page 17 for more information on family planning services. 12 AmeriHealth Caritas District of Columbia

15 Making an Appointment Making an Appointment with Your PCP 1. Have your member ID card, a pen and paper for notes 2. Call your PCP s office. Look for your PCP s phone number on the front of your member ID card. You can also find it in your provider directory or online at 3. Tell the person who answers that you are a DC Healthcare Alliance member. Tell him or her you want to make an appointment with your PCP. 4. Tell the person why you need an appointment. For example: You or a family member is feeling sick You hurt yourself or had an accident You need a check-up or follow-up care 5. Write down the time and date of your appointment 6. Tell your PCP if you have any pre-existing conditions. Pre-existing conditions are conditions you had before your AmeriHealth Caritas District of Columbia coverage went into effect. 7. If you need help making an appointment, please call Member Services at or toll-free at Changing or Canceling an Appointment It is very important to go to your appointment and to be on time. If you need to change or cancel your appointment, please call the doctor at least 24 hours before your appointment For some appointments, you may have to call more than 24 hours before to cancel. If you do not show up for your appointment or if you are late, your doctor may decide you cannot be his or her patient. Getting Care When Your PCP s Office Is Closed If you need to speak to your PCP when the office is closed, call your PCP s office and leave a message with the person who answers the phone when the office is closed. Be sure to give the person who answers your phone number. Someone will call you back as soon as possible. You can also call the Nurse Call Line 24 hours a day at If you think you have an emergency, call 911 or go to the emergency room. Member Handbook 13

16 Making an Appointment How Long It Takes to See Your Doctor Your doctor s office must give you an appointment within a certain number of days after you call. The table below shows how long it will take to get an appointment. Please call or toll-free at if you cannot get an appointment during these time periods. Type of visit Your condition How long it takes to see your doctor Urgent Visit You are hurt or sick and need care within 24 hours to avoid getting worse, but you don t need to see a doctor right away. Some examples of when you need urgent care are: a sprain or strain, diarrhea, throwing up, a cut or scrape, an earache, a sore throat, a cough or cold, diaper rash, refills for medicine, mild headache, lice, scabies, and ringworm. Within 24 hours Routine Visit You have a minor illness or injury or you need a regular check-up, but you don t need an urgent appointment. Within 30 days Follow-Up Visit You need to see your doctor after a treatment you just had to make sure you are healing well. Within 1 2 weeks, depending on the kind of treatment Adult Wellness Visits You are having your first appointment with a new doctor You are due for a regular adult check-up You are due for a prostate exam, a pelvic exam, a pap smear or a breast exam Within 30 days or sooner if necessary Non-urgent Appointments with Specialists (by referral) Your PCP referred you to see a specialist for a nonurgent condition. Within 30 days 14 AmeriHealth Caritas District of Columbia

17 Support Services Interpretation and Translation Services Services for the Hearing and Visually Impaired Interpretation and translation services and services for the hearing and visually impaired are free. Interpretation Services AmeriHealth Caritas District of Columbia will provide oral interpretation services if you need them, including at the hospital. Please call Member Services at or toll-free at to get interpretation services. Please call us before your doctor s appointment if you need interpretation services. Interpreter services are usually provided over the telephone. If you need an interpreter to be with you at your doctor s appointment, you must let us know 2 business days before the appointment. Translation Services If you get information from AmeriHealth Caritas District of Columbia and need it translated in another language, call Member Services at or toll-free at Services for the Hearing and Visually Impaired If you have trouble hearing, call Member Services at or toll-free at or through our TTY service at If you have trouble seeing, call Member Services at or toll-free at We can give you information on an audio tape, in Braille, in large print or in another language. Member Handbook 15

18 Specialty Care and Referrals How to Get Specialty Care Specialty care is when care is given by a specialist doctor who has extra training and cares for a specific condition or part of the body. For example, a cardiologist cares for the heart, and a podiatrist cares for the feet. Your PCP will help you know when you need to see a specialist and give you a referral. A referral is a written note given to you by your PCP to see a different doctor. You must get a referral to see a doctor other than your PCP except for well-women visits, family planning and some mental health services. If you want to see a specialist, but AmeriHealth Caritas District of Columbia tells you that we won t pay for the visit, you can: Appeal our decision (see page 32 on Appeals) Ask for a Fair Hearing (see page 32 on Fair Hearings) Self-Referral Services There are certain services you can get without getting prior permission from your PCP or doctor. These are called Self-Referral Services and are listed below. You do not need a referral to: See your PCP Get care at an Alliance hospital when you have an emergency. Call Member Services for a list of Alliance hospitals. Receive services from your OB/GYN doctor in the AmeriHealth Caritas District of Columbia network for routine or preventive services (female members only) Receive family planning services Receive services for sexually transmitted diseases (STDs) Receive immunizations (shots) Visit a vision provider in the network Visit a dental provider in the network Receive emergency mental health services or services for problems with alcohol or other drugs Services needing approval (authorization) Some services, like a surgery or when you have to stay in the hospital, need approval before you get them. This is to make sure that the care is medically needed and right for you. Your doctor will take care of this. You should know that these decisions are based only on if the care or service is right for you and if you are covered by AmeriHealth Caritas District of Columbia. AmeriHealth Caritas District of Columbia does not reward doctors or any other persons for issuing denials of coverage or care. Extra money is never given to anyone who makes a decision to say no to a request for care. 16 AmeriHealth Caritas District of Columbia

19 Specialty Care and Referrals Birth Control and Other Family Planning Services You do not need a referral to receive birth control or other family planning services. You can get birth control and other family planning services from any provider you pick. You do not need a referral to get these services. If you choose a family planning services doctor other than your PCP, tell your PCP. It will help your PCP take better care of you. Talk to your PCP or call AmeriHealth Caritas District of Columbia s Member Services at or toll-free at for more information on birth control or other family planning services. All birth control and other family planning services are confidential. Family Planning Services include: Pregnancy testing Counseling for the woman and the couple Routine and emergency contraception Counseling and immunizations Screening for all sexually transmitted diseases Treatment for all sexually transmitted diseases Sterilization procedures (you must sign a form 30 days before the procedure) HIV/AIDS testing and counseling Family Planning Services do not include: Routine infertility studies or procedures Hysterectomy for sterilization Reversal of voluntary sterilization Abortions HIV/AIDS treatment HIV/AIDS testing, counseling and treatment You can get HIV/AIDS testing and counseling: When you have family planning services From your PCP From an HIV testing and counseling center For information on where you can get HIV testing and counseling, call Member Services at or toll-free at If you need HIV treatment, your PCP will help you get care. Member Handbook 17

20 Pharmacy Services and Prescription Drugs Pharmacies are where you pick up your medicine (drugs). If your doctor gives you a prescription, you must go to one of the pharmacies listed below. This list is also available at You must go to a pharmacy in the DC Healthcare Alliance pharmacy network for Alliance members. AIDS Healthcare Foundation Blair Underwood Healthcare Center 2141 K Street NW, Suite 606 Washington, DC Phone: Fax: Hours: Monday Friday 8:30 a.m. 5:30 p.m. Closed for lunch 12:00 p.m. 1:00 p.m. Saturday and Sunday closed Alpha Peoples Drug Store 1642 R Street NW, Suite 100 Washington, DC Phone: Fax: Hours: Monday Friday 9:00 a.m. 6:00 p.m. Saturday 10:00 a.m. 2:00 p.m. Sunday closed Capitol Hill Pharmacy 650 Pennsylvania Avenue SE Washington, DC Phone: Fax: Hours: Monday Friday 10:00 a.m. 6:00 p.m. Saturday 10:00 a.m. 2:00 p.m. Sunday closed Cathedral Pharmacy 3000 Connecticut Ave, NW Washington, DC Phone: Fax: Hours: Monday Friday 9:00 a.m. 6:00 p.m. Saturday 10:00 a.m. 4:00 p.m. Sunday closed Columbia Heights Pharmacy th Street NW Washington, DC Phone: Fax: Hours: Monday Friday 10:00 a.m. 6:00 p.m. Saturday 10:00 a.m. 4:00 p.m. Sunday closed Goodcare Pharmacy I 2910 MLK Jr. Ave SE Washington, DC Phone: Fax: Hours: Monday Friday 9:00 a.m. 6:00 p.m. Saturday 10:00 a.m. 2:00 p.m. Sunday closed Grubb s Pharmacy NE Inc. 326 East Capitol Street NE Washington, DC Phone: Fax: Hours: Monday Friday 8:30 a.m. 6:00 p.m. Saturday 9:00 a.m. 3:00 p.m. Sunday closed Grubb s Pharmacy NW Inc th Street NW Washington, DC Phone: Fax: Hours: Monday Friday 7:30 a.m. 6:30 p.m. Saturday 10:00 a.m. 3:00 p.m. Sunday closed Grubb s Pharmacy SE Inc Martin Luther King Jr. Avenue SE Washington, DC Phone: Fax: Hours: Monday Friday 8:00 a.m. 6:00 p.m. Saturday and Sunday closed H Street Care Pharmacy & Wellness Center 812 H Street NE Washington, DC Phone: Fax: Hours: Monday Friday 8:00 a.m. 6:00 p.m. Saturday 10:00 a.m. 4:00 p.m. Sunday closed Metrocare Pharmacy 6323 Georgia Ave, NW Washington, DC Phone: Fax: Hours: Monday Friday 9:00 a.m. 6:00 p.m. Saturday and Sunday closed Morgan Pharmacy 3001 P Street NW Washington, DC Phone: Fax: Hours: Monday Friday 8:30 a.m. 6:00 p.m. Saturday and Sunday closed 18 AmeriHealth Caritas District of Columbia

21 Pharmacy Services and Prescription Drugs Mount Pleasant Pharmacy 3169 Mount Pleasant Street NW Washington, DC Phone: Fax: Hours: Monday Saturday 9:00 a.m. 7:30 p.m. Sunday closed Nations Care Pharmacy th Street NE Washington, DC Phone: Fax: Hours: Monday Friday 10:00 a.m. 6:30 p.m. Saturday 10:00 a.m. 4:00 p.m. Sunday closed Neighborhood Pharmacy 1932 MLK Jr. Avenue SE Washington, DC Phone: Fax: Hours: Monday Friday 9:30 a.m. 6:00 p.m. Saturday (Call for information) Sunday closed Seat Pleasant Pharmacy 350 Eastern Avenue NE Washington, DC Phone: Fax: Hours: Monday Friday 9:00 a.m. 6:00 p.m. Saturday 10:00 a.m. 4:00 p.m. Sunday closed State Pharmacy 2041 Martin Luther King Jr. Avenue SE, Suite 100 Washington, DC Phone: Fax: Hours: Monday Friday 9:00 a.m. 6:00 p.m. Saturday 9:00 a.m. 1:00 p.m. Sunday closed Sterling Care Pharmacy 1647 Benning Road NE, Suite 101 Washington, DC Phone: Fax: Hours: Monday Friday 9:00 a.m. 7:00 p.m. Saturday and Sunday closed Super Pharmacy and Medical Equipment 1019 H Street, NE Washington, DC Phone: Fax: Hours: Monday Friday 10:00 a.m. 7:00 p.m. Saturday 10:00 a.m. 2:00 p.m. Sunday closed Community, a Walgreens Pharmacy th Street, NW (First Floor) Washington, DC Phone: Fax: Hours: Monday Friday 9:00 a.m. 6:00 p.m. Saturday and Sunday closed Walgreens Pharmacy nd Street NW Washington, DC Phone: Fax: Hours: Monday Friday 8:00 a.m. 10:00 p.m. Saturday 9:00 a.m. 6:00 p.m. Sunday 10:00 a.m. 6:00 p.m. Whitman-Walker Health Pharmacy th Street, NW Washington, DC Phone: Fax: Hours: Monday Friday 9:00 a.m. 6:00 p.m. Saturday and Sunday closed Member Handbook 19

22 Pharmacy Services and Prescription Drugs To get a prescription filled: Pick a pharmacy that is part of the Alliance network and is close to your work or home. When you have a prescription, go to the pharmacy and give the pharmacist your prescription and your Alliance member ID card. If you need help, please call Member Services at or toll-free at You can also call Pharmacy Member Services at or TTY Sometimes your doctor may need to get permission from AmeriHealth Caritas District of Columbia for a drug that is not on the Alliance formulary If the Alliance pharmacy is closed, and you need to fill your prescription, contact AmeriHealth Caritas District of Columbia Pharmacy Member Services at or TTY , or Member Services at or toll-free at , for permission to get your medication at an alternate pharmacy. You can get certain medications for either: Up to 72 hours 1 full round of the medicine if you take it less than once a day Things to remember: You should not be asked to pay for your medicines. Call AmeriHealth Caritas District of Columbia s Member Services if the pharmacy or drug store asks you to pay. If you are going out of town, get your prescriptions filled before you go. AmeriHealth Caritas District of Columbia will not pay for medicines at out-of-town pharmacies. Disease Management If you have a chronic illness or special health care need such as Asthma, Diabetes, Cardiovascular Disease, High Blood Pressure or Mental Illness, AmeriHealth Caritas District of Columbia may place you in one of our special programs. This means you will have a Care Manager. A Care Manager is someone who works for AmeriHealth Caritas District of Columbia to help you get the services and information you need to manage your illness and improve your health. You can also call the Rapid Response and Outreach Team at to get help with all of your health care needs. 20 AmeriHealth Caritas District of Columbia

23 Services to Keep You from Getting Sick AmeriHealth Caritas District of Columbia wants you to take care of your health. We also want you to sign up for health and wellness services we offer to you. Health and wellness services include screenings, counseling and immunizations. Recommendations for Check-ups ( Screenings ) Please make an appointment and go see your PCP at least 1 time every year for a check-up. The list below tells you the type of things to talk with your PCP about during your check-up. Adult Screening Recommendations Screenings for Women Only Screenings for Men Only Blood Pressure and Cholesterol (lipid disorder) screening Sexually transmitted diseases HIV/AIDS screening and testing Diabetes screening Tobacco use Alcohol and other drug use Depression Colorectal cancer (50 years and older) Obesity Hepatitis C Breast Cancer screening (mammogram) Cervical Cancer (Pap Smear) Osteoporosis (post-menopausal women) HPV screening Chlamydia Prostate Cancer screening Abdominal Aortic Aneurysm HPV screening Preventive Counseling Preventive counseling is available to help you stay healthy. You can get preventive counseling on: Diet and Exercise Alcohol and drug use Smoking Cessation HIV/AIDS prevention Obesity Adult Immunizations If you are an adult, you may need some immunizations (shots). Please talk to your PCP about which ones you may need. Member Handbook 21

24 Having a Baby If you are pregnant or think you are pregnant, it is very important to go to your OB/GYN doctor right away. You do not need to see your PCP before making this appointment. You should start pregnancy care as soon as you think or learn you are pregnant. Early and complete health care before your child s birth is the key to having a healthy baby! Bright Start helps moms-to-be make healthy choices for themselves and their unborn babies. Any member who is pregnant can be a member of Bright Start. Bright Start is free. When you join Bright Start you will talk to a Bright Start outreach coordinator about your needs, services and classes you may attend. The Bright Start outreach coordinator will also help you choose an OB/GYN and a PCP for your baby. They will mail information to you during your pregnancy. After your baby is born, the Bright Start outreach coordinator will talk with you to help you get health services for your baby. Remember, if you are pregnant or think you are pregnant, do not drink alcohol, use drugs or smoke. What to Do If You Are Pregnant If you are pregnant, please call: The DC Economic Security Administration (ESA) at Member Services at or toll-free at and ask for the Bright Start program AmeriHealth Caritas District of Columbia s Bright Start program at Your OB/GYN to make an appointment There are certain things that you need to get checked if you are pregnant. These checks will help make sure that you have a healthy pregnancy, delivery, and baby. This is called prenatal care. You get prenatal care before your baby is born. You should start prenatal care as soon as you know you are pregnant. Prenatal and Post-Partum Care When you participate with AmeriHealth Caritas District of Columbia s Bright Start program, you get these services: Pregnancy case manager Assistance obtaining WIC Prenatal health information and classes Home nursing visits after delivery, as medically necessary You may qualify for rewards for healthy behavior. Call Bright Start at An invitation to a group baby shower for you and your baby Once you have had your baby, call: Member Services Your Bright Start case manager 22 AmeriHealth Caritas District of Columbia

25 Your Health Benefits Services AmeriHealth Caritas District of Columbia Covers The list below shows the health care services and benefits for all Alliance members. For some benefits, you have to be a certain age or have a certain need for the service. AmeriHealth Caritas District of Columbia will not charge current members for any of the health care services in this list if current members go to a network provider or hospital, or have a written OK. If you have a question about whether AmeriHealth Caritas District of Columbia covers certain health care, call AmeriHealth Caritas District of Columbia Member Services at or toll-free at Benefit What You Get Who Can Get This Benefit Primary Care Services Preventive, acute and chronic health care services generally provided by your PCP All members Specialist Services Health care services provided by specially trained doctors or advanced practice nurses Referral is required from your PCP All members Laboratory and X-ray Services Lab tests and X-rays All members Hospital Services Outpatient services (preventive, diagnostic, therapeutic, rehabilitative and palliative services) Inpatient services (hospital stay) with the exceptions listed below under Non-Covered Services, not covered by Alliance Any member with a referral from their PCP or who has an emergency must be seen at an in-network hospital. Pharmacy Services (prescription drugs) Prescription drugs included on Alliance drug formulary. They are available only from Alliance program pharmacies. You can find the drug formulary at or by calling Pharmacy Member Services. If medically necessary, your PCP may request an override authorization for prescription drugs not on the formulary All members Dialysis Services Treatment up to 3 times per week (limited to once per day) All members Member Handbook 23

26 Your Health Benefits Benefit What You Get Who Can Get This Benefit Pregnancy testing; counseling for the woman Routine and emergency contraception Family Planning Services Voluntary sterilizations for members over 21 years of age (requires signature on an approved sterilization form by the member 30 days prior to the procedure) Screening, counseling and immunizations (including for Human Papilloma Virus HPV) Screening and preventive treatment for all sexually transmitted diseases Does not include sterilization procedures for members under age 21 All members as appropriate Podiatry Special care for foot problems Regular foot care when medically needed All members Rehabilitation Services Rehabilitation services when pre-authorized as medically necessary to help improve functioning following an acute injury or other medical event. This includes physical, speech and occupational therapy. All members Home Health Services In-home health care services, when pre-authorized for members who are determined to be homebound and in need of the following services: Wound care Physical, Occupational and Speech Therapy Health Education Home IV therapy Routine visits to check on patient health status, check on the status of wounds, prescription drug monitoring and to assess readiness prior to discharge Home health care can be done in any community setting including a home, residential facility or a shelter All members 24 AmeriHealth Caritas District of Columbia

27 Your Health Benefits Benefit What You Get Who Can Get This Benefit Nursing Home Care Full-time skilled nursing care in a nursing home up to 30 consecutive days All members Emergency Transportation for emergency services such as an ambulance All members Adult Wellness Services Immunizations Routine screening for sexually transmitted diseases HIV/AIDS screening, testing and counseling Breast Cancer screening (women only) Cervical Cancer screening (women only) Osteoporosis screening (post-menopausal women) HPV screening Prostate Cancer screening (men only) Abdominal Aortic Aneurysm screening (men only) Obesity screening Diabetes screening High Blood Pressure and Cholesterol screenings (lipid disorders) Depression screening Colorectal Cancer screening (members 50 years and older) Smoking Cessation counseling Diet and exercise counseling Mental Health counseling Alcohol and drug counseling and screening Members over age 21 as appropriate Member Handbook 25

28 Your Health Benefits Benefit What You Get Who Can Get This Benefit Care and treatment of the teeth and gums, including: General dental exams every 6 months Simple and complex surgical services and extractions Emergency dental care Dental Benefits Fillings Cleaning and fluoride treatments every 6 months Space maintainers (partial dentures) when medically necessary X-rays (full series limited to 1 time every 3 years Dentures (one new set every 5 years) and denture repair Oral surgery $1000 limit for services per calendar year Any dental service that requires inpatient hospitalization must have prior authorization Elective surgical procedures requiring general anesthesia Members over age 21 For dental services, call Member Services at or Durable Medical Equipment (DME) and Disposable Medical Supplies (DMS) Durable Medical Equipment (DME), such as a hospital bed or wheelchair Disposable medical supplies (DMS), such as wound care bandages All members 26 AmeriHealth Caritas District of Columbia

29 Your Health Benefits Services We Do Not Pay For (Exclusions) Exclusions are benefits and/or services that AmeriHealth Caritas District of Columbia does not pay for. They include the following: Emergency services Services furnished in schools Any covered service furnished by Out-of-Network Providers Services and supplies related to surgery and treatment for temporal mandibular joint problems (TMJ) Chiropractic services Cosmetic surgery, except for surgery required to correct a condition resulting from surgery or disease, created by an accidental injury or a congenital deformity, or is a condition that impairs the normal function of your body Open heart surgery Organ transplantation Sclerotherapy Vision care and services for adults (members over age 21) Treatment for obesity Infertility treatment Experimental or investigational services, surgeries, treatments, and medications Mental health and substance abuse services Treatment for mental health, behavioral health and alcohol or substance abuse services, except for inpatient psychiatric services and services related to medical treatment received in a hospital for life-threatening withdrawal from alcohol or narcotic drugs Delivery of your baby. If you are pregnant, contact the DC Economic Security Administration (ESA) at to determine eligibility for Medicaid. Non-emergency Transportation Services Hearing services and devices for adults (enrollees over 21) Immunizations for travel Services not listed on AmeriHealth Caritas District of Columbia s covered services list (see page 23) Services outside the United States Member Handbook 27

30 Other Important Information What to Do If You Move Do both of these steps: Call the District of Columbia (DC) Economic Security Administration (ESA) Change Center at Call AmeriHealth Caritas District of Columbia s Member Services at or toll-free at What to Do If You Have a Baby Do both of these steps: Call DC Economic Security Administration (ESA) Change Center at Call AmeriHealth Caritas District of Columbia s Member Services at or toll-free at What to Do If You Adopt a Child Call DC Economic Security Administration (ESA) Change Center at What to Do If Someone in Your Family Dies Call ESA at or and AmeriHealth Caritas District of Columbia s Member Services at or if: You move You have a baby Someone in your family dies Call ESA only at or if: You adopt a child Do both of these steps: Call DC Economic Security Administration (ESA) Change Center at Call AmeriHealth Caritas District of Columbia s Member Services at or toll-free at How to Change Your MCO You can change your Managed Care Organization (MCO) once a year during the 90 days before your anniversary date the month and date you first joined AmeriHealth Caritas District of Columbia DC Healthcare Alliance will send you a letter 2 months or 60 days before your anniversary date. The letter tells you how to change MCOs. Changing your MCO if you have a good reason You have the right to change your MCO at any time after the first 90 days if you have a good reason. Examples of good reasons are poor quality of care and you cannot see the providers you need. Call DC Healthcare Alliance at if you would like more information on how to change MCOs. 28 AmeriHealth Caritas District of Columbia

31 Other Important Information You will not be allowed to get health care from AmeriHealth Caritas District of Columbia anymore if you: Lose your Alliance eligibility Establish Social Security income (SSI) eligibility A child will be removed from AmeriHealth Caritas District of Columbia if the child: Becomes a ward of the district The DC government may remove you from AmeriHealth Caritas District of Columbia if any of the following occur: You let someone else use your member ID card The district finds that you committed fraud You do not follow your member responsibilities What to Do If You Get a Bill for a Covered Service If you get a bill for a covered service that is in the list above, call Member Services at or toll-free at as soon as you get the bill. Paying for Non-Covered Services If you decide you want a service we do not pay for and you do not have written permission from AmeriHealth Caritas District of Columbia, you will have to pay for the service yourself If you decide to get a service we do not pay for, you must sign a statement that you agree to pay for the service yourself Remember to always show your member ID card and tell your doctors that you are a member of AmeriHealth Caritas District of Columbia before you get services Member Handbook 29

32 Other Important Information Advance Directives An Advance Directive is a legal document you sign that lets others know your health care choices. It is used when you are not able to speak for yourself. Sometimes this is called a living will or a durable power of attorney. An Advance Directive can let you pick a person to make choices about your medical care for you. An Advance Directive also lets you say what kind of medical treatment you want to receive if you become too ill to tell others what your wishes are. It is important to talk about an Advance Directive with your family, your PCP, or others who might help you with these things If you want to fill out and sign an Advance Directive, ask your PCP for help during your next appointment, or call Member Services at or toll-free at and they will help you What to Do If You Have Other Insurance If you are a member of AmeriHealth Caritas District of Columbia and eligible for Medicaid, you must tell us right away. Please call Member Services at or toll-free at and tell us right away. Physician (Doctor) Incentive Plan Disclosure You have the right to find out if AmeriHealth Caritas District of Columbia has special payment arrangements with AmeriHealth Caritas District of Columbia s doctors. Please call AmeriHealth Caritas District of Columbia s Member Services at or toll-free at for this information. Fraud Fraud is a serious matter. What is fraud? Fraud is making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. An example of fraud for members is falsely claiming that you live in the district, when you actually live outside the boundaries of the District of Columbia. An example of fraud for providers is billing for services that were not furnished and/or supplies not provided. If you suspect fraud, please let us know. It is not required that you identify yourself or give your name. If you would like more information about what constitutes fraud, visit AmeriHealth Caritas District of Columbia s website at To report fraud, call AmeriHealth Caritas District of Columbia s Compliance Hotline, , or call the DC Department of Health Care Finance s Fraud Hotline at How We Pay Your Doctors You have the right to find out if AmeriHealth Caritas District of Columbia has special financial arrangements with your doctors. Please call Member Services at or toll-free at for this information. 30 AmeriHealth Caritas District of Columbia

33 Other Important Information New Technology AmeriHealth Caritas District of Columbia wants members to have safe and effective care. AmeriHealth Caritas District of Columbia looks at new medical technology, new drugs and new uses for existing technology throughout the year. The new technology may be approved when it is proven to be at least as medically safe and useful as existing technology. AmeriHealth Caritas District of Columbia uses nationally known technology guidelines from scientific journals and the Center for Medicaid & Medicare Services (CMS). AmeriHealth Caritas District of Columbia also has a Quality of Clinical Care Committee that will review individual technology and drug requests from members and AmeriHealth Caritas District of Columbia providers. The Quality of Clinical Care Committee or chief medical officer can decide to cover the new technology and drug. If AmeriHealth Caritas District of Columbia adopts the new technology or drug, you and your providers will be told about the change. Member Handbook 31

34 Complaints, Grievances, Appeals and Fair Hearings AmeriHealth Caritas District of Columbia and the DC government both have ways for you to complain about the care you get or the services AmeriHealth Caritas District of Columbia provides to you. You may choose how you would like to complain as described below. Complaints and Grievances If you are unhappy with something that happened to you when you received health care services, you can file a complaint or grievance. Examples of why you might file a complaint or grievance include: You feel you were not treated with respect You are not satisfied with the health care you got It took too long to get an appointment To file a complaint or grievance, you should call Member Services at or toll-free at To file a complaint or grievance in writing, you may fax it to Member Services at or mail it to AmeriHealth Caritas District of Columbia, Member Services Grievance Department, 200 Stevens Drive, Philadelphia, PA Your doctor can also file a complaint or grievance for you You should file a complaint or grievance as soon as possible and no later than 90 days after the event about which you are unhappy. AmeriHealth Caritas District of Columbia will conduct a full investigation after we receive your Complaint or Grievance. We will usually give you a decision within 30 days and no later than 44 days, but may ask for extra time to give a decision. Appeals and Fair Hearings If you believe your benefits were unfairly denied, reduced, delayed or stopped, you have a right to file an appeal with AmeriHealth Caritas District of Columbia and request a Fair Hearing with the DC Office of Administrative Hearings. To file an appeal with AmeriHealth Caritas District of Columbia, call Member Services at or toll-free at To file a request for a Fair Hearing, call or write the District government at: Government of the District of Columbia Office Administrative Hearings Clerk of the Court 441 4th St., NW Suite 4150 Washington, DC Telephone Number: Deadlines: You must file an appeal or request a Fair Hearing within 90 days of the date you receive the AmeriHealth Caritas District of Columbia s notice of action If you want to continue receiving the benefit during your Fair Hearing or appeal, you must request the Fair Hearing or appeal within the later of the following: 10 days from the postmark of the AmeriHealth Caritas District of Columbia s notice of action The intended effective date of the AmeriHealth Caritas District of Columbia s proposed action (or, in other words, when the benefit is to stop) Your provider may file an appeal or request for a Fair Hearing on your behalf if you give written permission 32 AmeriHealth Caritas District of Columbia

35 Complaints, Grievances, Appeals and Fair Hearings Appeals If you call and give your appeal over the phone, AmeriHealth Caritas District of Columbia will summarize your appeal in a letter and send you the letter to sign. Be sure to read the letter carefully. You must sign the letter and return it to the Managed Care Organization (MCO) to have an appeal. Your appeal will be decided by AmeriHealth Caritas District of Columbia within 15 calendar days from the date your appeal was received If AmeriHealth Caritas District of Columbia needs more time to get information and the district decides this would be best for you, or if you or your advocate requests more time, AmeriHealth Caritas District of Columbia may increase this time period for the decision by 5 calendar days. AmeriHealth Caritas District of Columbia must give you written notice of the extension. You will receive written notice of AmeriHealth Caritas District of Columbia s decision about your appeal in the mail If you are not happy with AmeriHealth Caritas District of Columbia s decision about your appeal, you may request a Fair Hearing. If you want to continue your benefits during the Fair Hearing, you must request a Fair Hearing within 10 days from the postmark of AmeriHealth Caritas District of Columbia s notice of action. Expedited (Emergency) Complaints, Grievances and Appeals Process If your appeal is determined to be an emergency, AmeriHealth Caritas District of Columbia will give you a decision within 3 calendar days. An appeal is considered an emergency if it would be harmful or painful to you if you had to wait for the standard time frame of the appeal procedure. All appeals filed by members with HIV/AIDS, mental illness or any other condition that requires attention right away, will be resolved and communicated back to the member within 24 hours of filing the appeal. Your Rights During the Complaints, Grievances, Appeals and Fair Hearings Process You have the right to a Fair Hearing. You may request a Fair Hearing from the Office of Administrative Hearings at any time before, during or after you have filed an appeal with AmeriHealth Caritas District of Columbia, but no more than 90 days from the date notice of action is mailed You have a right to keep receiving the benefit we denied while your appeal or Fair Hearing is being reviewed. To keep your benefit during a Fair Hearing, you must request the Fair Hearing within a certain number of days. This could be as short as 10 days. You have the right to have someone from AmeriHealth Caritas District of Columbia help you through the grievances and appeals process You have a right to represent yourself or be represented by your family caregiver, lawyer, executor of your estate or other representative You have a right to have accommodations made for any special health care need you have You have a right to adequate TTY/TTD capabilities, and services for the visually impaired You have a right to adequate translation services and an interpreter You have a right to see all documents related to the complaint, grievance, appeal or Fair Hearing You have the right to be notified 30 days before a major change in the complaint, grievance, appeal or Fair Hearing processes If you have any questions about the complaints, grievances, appeals or Fair Hearings process, please call Member Services at or toll-free at Member Handbook 33

36 Complaints, Grievances, Appeals and Fair Hearings The Ombudsman Program The Ombudsman Program is a District of Columbia government program that provides assistance and advice to you in receiving health care from your Managed Care Organization (MCO). The Ombudsman can: Explain the health care you have a right to receive Respond to your questions and concerns about your health care Help you understand your rights and responsibilities as an enrollee in AmeriHealth Caritas District of Columbia Help you get the health care you are supposed to have Answer questions and concerns you may have about the quality of your health care Help resolve problems with your doctor or other health care provider Help resolve complaints and problems with AmeriHealth Caritas District of Columbia The Ombudsman Program does not make decisions in complaints, grievances, appeals or Fair Hearings. To reach the Ombudsman Program, call AmeriHealth Caritas District of Columbia