Member Handbook Amerigroup Florida, Inc. Statewide Medicaid

Transcription

Member
Handbook
Amerigroup Florida, Inc.
Statewide Medicaid Managed Care
Managed Medical Assistance Program
FL-MHB-0038-15B MMA 01.16
1-800-600-4441 (TTY 711)
www.myamerigroup.com/fl
Find a doctor on your
smartphone or tablet at
directory.amerigroup.com.
Amerigroup Member Handbook
4200 W. Cypress St., Suite 900 ● Tampa, FL 33607-4173
1-800-600-4441 (TTY 711)
www.myamerigroup.com/FL
Table of Contents
WELCOME TO AMERIGROUP!............................................................................................................1
GETTING STARTED.............................................................................................................................1
Translation Services ............................................................................................................................... 1
New Member Tips.................................................................................................................................. 1
How to Get Help..................................................................................................................................... 3
MEMBER INFORMATION...................................................................................................................4
Informed Consent .................................................................................................................................. 4
Confidentiality........................................................................................................................................ 4
Enrollment in Amerigroup ..................................................................................................................... 4
Enrollment......................................................................................................................................... 4
Open Enrollment ............................................................................................................................... 5
Disenrollment.................................................................................................................................... 5
If You Get a Bill ....................................................................................................................................... 6
Changes in Amerigroup Coverage.......................................................................................................... 6
New Technology..................................................................................................................................... 6
HOW TO GET YOUR MEDICAL SERVICES.............................................................................................6
Continuity of Care .................................................................................................................................. 7
How to Get Authorized (Approved) Services ......................................................................................... 7
SECOND MEDICAL OPINION ..............................................................................................................8
Your Doctor ............................................................................................................................................ 8
What to Do In an Emergency ............................................................................................................... 10
Out-of-Area Emergency Care ............................................................................................................... 11
Out-of-network care ............................................................................................................................ 12
Special care for pregnant members..................................................................................................... 13
Wellness Care for Children, Teens and Adults..................................................................................... 15
Wellness Visits Schedule for Adults ..................................................................................................... 18
HOW TO ACCESS OTHER AMERIGROUP SERVICES ............................................................................ 18
Prescription Benefit ............................................................................................................................. 18
Psychotropic Drugs That Now Require Consent ............................................................................. 19
What Over-The-Counter Medicines Are Covered?.............................................................................. 19
Common Over-The-Counter (OTC) Medicines ................................................................................ 20
ACCESS TO BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES ............................................... 21
Behavioral Health Emergency Coverage.............................................................................................. 21
Behavioral Health and Substance Abuse Care ..................................................................................... 21
Behavioral Health Limitations and Exclusions ..................................................................................... 22
ACCESS TO MEDICAL SERVICES ........................................................................................................ 22
Amerigroup Covered Health Services .................................................................................................. 22
Vision Services...................................................................................................................................... 24
Hearing Services................................................................................................................................... 25
Dental Services..................................................................................................................................... 25
Value-Added Benefits .......................................................................................................................... 26
IMPORTANT INFORMATION ............................................................................................................ 27
Information You Should Know about Amerigroup .............................................................................. 27
Compare Amerigroup to Other Health Plans in Florida....................................................................... 28
Fraud, Abuse and Overpayment .......................................................................................................... 28
SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING ................................................................... 28
Special Programs.................................................................................................................................. 28
Health Information.......................................................................................................................... 28
Amerigroup On Call ......................................................................................................................... 28
Health Education Classes ................................................................................................................ 28
Healthy Behaviors Program............................................................................................................. 29
Community Events .......................................................................................................................... 30
Domestic Violence Resources ......................................................................................................... 30
Smoking Cessation........................................................................................................................... 32
Disease Management........................................................................................................................... 33
Case Management Services ................................................................................................................. 34
HIPAA NOTICE OF PRIVACY PRACTICES ............................................................................................ 36
IMPORTANT PHONE NUMBERS ....................................................................................................... 40
STATEMENT OF ADVANCE DIRECTIVE OR LIVING WILLS ................................................................... 40
MEMBER GRIEVANCES AND APPEALS.............................................................................................. 42
Complaints and Grievances.................................................................................................................. 42
Medical Appeals ................................................................................................................................... 43
SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES ............................... 47
APPENDIX ....................................................................................................................................... 50
WELCOME TO AMERIGROUP!
GETTING STARTED
Welcome to Amerigroup Florida, Inc., doing business as Amerigroup.
This is your member handbook. The information in this book will tell you how your health plan works.
Please read it with care. You can always find the most up-to-date member handbook online at
www.myamerigroup.com/FL. If you would like a printed copy of this member handbook, please call
Member Services at 1-800-600-4441 (TTY 711).
As a new Amerigroup member, we will also give you a welcome call to get to know you better.
Translation Services
Amerigroup wants to talk to you in your language. All Amerigroup materials come in English and
Spanish. We also offer everything in:
 Braille
 Audio tape
 Large print
 Additional languages
All versions are free of charge. If you need any materials in another language or format, please call
Member Services toll free at 1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m.
Eastern time.
New Member Tips
Review Your ID Card
Check your Amerigroup identification (ID) card and keep it with you. Always show your ID card when
you need health care. Don’t have your Amerigroup ID card yet? Please call Member Services toll free at
1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
Your card lists important information about your health care. Be sure to keep this card and your
Medicaid gold card with you at all times. As a Medicaid member, you will also have a gold card. This ID
comes from the Department of Children and Families (DCF) office. To learn more about the gold card,
please call your local DCF office.
When you get your ID card, check the primary care provider (PCP) name listed on your card. If you
want to change your PCP for any reason, call Member Services toll free at 1-800-600-4441 (TTY 711)
Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
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Your ID card shows providers and hospitals that you’re a member of Amerigroup, and the date you
became a member. Your ID card also lists these important phone numbers:  Your PCP
 Member Services
 Amerigroup On Call, our 24-hour nurse helpline
If your Amerigroup ID card is lost or stolen, call Member Services toll free at 1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time. We will send you a new one.
Medicaid only Member ID card example
Medicaid and Long-Term Care Member ID card example
Getting to Know Your Primary Care Provider
Plan a visit with your primary care provider (PCP). Your PCP takes care of all nonemergency health care
for you and will help you get care from specialists or hospitals if you need it. For nonemergency health
care, call your PCP. The number is on your ID card.
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It’s important that you get to know your PCP. You must be seen by your PCP within 90 days of being an
Amerigroup member. If you’re pregnant, you must be seen by your PCP within 30 days of being a new
Amerigroup member.
What do I do if I move?
If you move, please call the Florida Department of Children and Families (DCF) at 1-866-762-2237
(TTY 1-800-955-8771), if you have changes to your name, mailing address, county or phone number. DCF will tell Amerigroup.
You may also need to tell the Social Security Administration (SSA) about your move. You can tell
them by:
 Calling 1-800-772-1213 (TTY 1-800-325-0778) Monday through Friday from 7 a.m. to 7 p.m.
 Mailing a letter to: Social Security Administration
Office of Public Inquiries
Windsor Park Building
6401 Security Blvd.
Baltimore, MD 21235
 Or go online to www.ssa.gov
In Case of an Emergency
For a real health emergency, go to the nearest emergency room or call 911. If you’re not sure if you
have a real health emergency, please see the Emergency Care section to learn more about
emergency care.
Your Rights and Responsibilities
Amerigroup members have certain rights and responsibilities. Florida law requires that your health
care providers know your rights and that you respect the rights your providers have, too. Please see
the Member Rights and Responsibilities Section for an outline of your rights and responsibilities. You
will also see them in your providers’ offices.
How to Get Help
Amerigroup Member Services Department
If you have any questions about your Amerigroup health plan, call Member Services toll free at
1-800-600-4441 (TTY 711) Monday through Friday 8 a.m. to 7 p.m. Eastern time except on holidays. If
you call after 7 p.m., leave a voice mail message. Member Services will call back the next working day.
Member Services can help you with:
• Printed copies of your member handbook and provider directory
• Member ID cards
• Health care benefits
• Choosing or changing your doctor
• What services are offered at Amerigroup network hospitals
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Where to find urgent care centers
Going to the emergency room
Doctor appointments
Finding an Amerigroup network pharmacy
Grievances and appeals
Health education
We want you to be happy with the care you get through our group of providers and hospitals. If you
have any problems or concerns, please call Member Services.
MEMBER INFORMATION
Informed Consent
When you’re getting medical care, unless in a crisis and your life is in danger, we must get your consent
to treat you. Sometimes we’ll need your written consent. You have a right to know any steps that will
be taken. You have a right to know why the steps are needed.
If you don’t want to have certain medical care, talk to your PCP. He or she will tell you about your
choices. You make the final choice.
Confidentiality
Amerigroup understands your right to privacy. You must say it is OK for us to give out your private
health records. You will do this by signing a release that lets us share your records.
If you do this, we will only share your records with those who need to have it for your care. If we’re
asked to share your records by law, we must share them. If this happens, our report will not list
your name.
Enrollment in Amerigroup
Enrollment
If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Amerigroup or the
state enrolls you in a plan, you will have 120 days from the date of your first enrollment to try the
Managed Care Plan. During the first 120 days you can change Managed Care Plans for any reason. After
the 120 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next eight
months. This is called “lock-in.”
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Open Enrollment
If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your
enrollment year telling you that you can change plans if you want to. This is called “open enrollment.”
You do not have to change Managed Care Plans. If you choose to change plans during open enrollment,
you will begin in the new plan at the end of your current enrollment year. Whether you pick a new plan
or stay in the same plan, you will be locked into that plan for the next 12 months. Every year you may
change Managed Care Plans during your 60 day enrollment period.
Disenrollment
If you are a mandatory enrollee and you want to change plans after the initial 120 day period ends or
after your open enrollment period ends, you must have a state-approved good cause reason to change
plans. The following are state-approved cause reasons to change Managed Care Plans:
1. The enrollee does not live in a region where the Managed Care Plan is authorized to provide
services, as indicated in FMMIS.
2. The provider is no longer with the Managed Care Plan.
3. The enrollee is excluded from enrollment.
4. A substantiated marketing or community outreach violation has occurred.
5. The enrollee is prevented from participating in the development of his/her treatment plan/plan
of care.
6. The enrollee has an active relationship with a provider who is not on the Managed Care Plan’s
panel, but is on the panel of another Managed Care Plan. “!ctive relationship” is defined as having
received services from the provider within the six months preceding the disenrollment request.
7. The enrollee is in the wrong Managed Care Plan as determined by the Agency.
8. The Managed Care Plan no longer participates in the region.
9. The state has imposed intermediate sanctions upon the Managed Care Plan, as specified in 42 CFR
438.702(a)(3).
10. The enrollee needs related services to be performed concurrently, but not all related services are
available within the Managed Care Plan network, or the enrollee’s PCP has determined that
receiving the services separately would subject the enrollee to unnecessary risk.
11. The Managed Care Plan does not, because of moral or religious objections, cover the service the
enrollee seeks.
12. The enrollee missed open enrollment due to a temporary loss of eligibility.
13. Other reasons per 42 CFR 438.56(d)(2) and s. 409.969(2), F.S., including, but not limited to: poor
quality of care; lack of access to services covered under the Contract; inordinate or inappropriate
changes of PCPs; service access impairments due to significant changes in the geographic location
of services; an unreasonable delay or denial of service; lack of access to providers experienced in
dealing with the enrollee’s health care needs- or fraudulent enrollment.
If you want to check your enrollment status, call the Florida Statewide Medicaid Managed Care Help
Line toll free at 1-877-711-3662 (TTY 1-866-467-4970). For more about enrollment and disenrollment,
go online to www.myamerigroup.com/FL.
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If You Get a Bill
Always show your Amerigroup ID card and your gold card when you see a PCP, go to the hospital or go
for tests. Even if your PCP told you to go, you must show your Amerigroup ID card to make sure you’re
not sent a bill for services paid for by Amerigroup.
If you get a bill, send it to us with a letter telling us you got a bill. Send the letter to:
Grievance and Appeals Coordinator
Amerigroup
4200 W. Cypress St., Suite 900
Tampa, FL 33607-4173
Need more help or have questions? Call Member Services toll free at 1-800-600-4441 (TTY 711)
Changes in Amerigroup Coverage
Sometimes we need to make changes in the way we work, our covered services or our network:
1. When we make changes in services that are paid for, we’ll mail you a letter about the changes.
2. If your primary care provider (PCP) moves, closes an office or leaves our network, we’ll call or send
you a letter to tell you. If your leaves our network, call Member Services. We can help you pick a
new primary care provider (PCP) from our network. Or you can go online to look at our provider
directory at www.myamerigroup.com/FL. Click on “Find a Doctor”.
New Technology
The Amerigroup medical director and providers look at new medical improvements. They also look at
changes to technology being used now. They will look at these changes in:
 Medical procedures
 Behavioral health procedures
 Pharmaceuticals
 Devices
They also look at scientific research. They decide whether these new medical advances and
treatments:
 Are thought to be safe and helpful by the government
 Give equal or better results than what is being used now
This is done to decide if these changes should be benefits paid for by Amerigroup.
HOW TO GET YOUR MEDICAL SERVICES
Health care is given through doctors, hospitals and other medical providers. They have agreed to work
with Amerigroup. An Amerigroup provider or Amerigroup must approve all your care. Amerigroup will
pay for the cost of care that is approved by Amerigroup. If your care isn’t approved by Amerigroup, you
may have to pay for the cost of the care.
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Continuity of Care
If you’re new to Amerigroup and getting a treatment or service from a provider, you can keep getting
that service for 60 days. If you need the service for more than 60 days after joining Amerigroup, please
contact us. We will help make sure you’re getting what you need from a provider in our provider
group.
Pregnancy
If you’re pregnant and already going to an OB/GYN, you don’t need to change providers during your
pregnancy. If you’re pregnant, please call Member Services toll free at 1-800-600-4441 (TTY 711)
Monday through Friday from 8 a.m. to 7 p.m. Eastern time. We can help make sure you’re getting
everything you need to have a healthy baby.
Cancer Treatments
If you have cancer and are going to a provider for radiation and/or chemotherapy services, you don’t
need to change providers while you’re in this set of services. Once this set of services is done,
Amerigroup may help you find another provider in our provider group.
Transplant Services
If you’ve recently had a transplant or are in the process of having a transplant, you can go to your
current provider for one year after your transplant.
Orthodontic Services
If your child is going to an orthodontist not in our provider group, he/she can keep going to that dentist
for 60 days. When the 60 days are over, you’ll need to go to a dentist in our provider group.
Pharmacy (Drugstore) Services
If you get your medicines from a pharmacy (drugstore) not part of our pharmacy network, you’ll need
to pick another pharmacy. We can help you pick another pharmacy from our pharmacy network.
If you have questions, we can help. Please call Member Services toll free at 1-800-600-4441
(TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
How to Get Authorized (Approved) Services
When you need nonemergency health care, call your primary care provider (PCP). If you need tests or a
specialist, your PCP will help you get this care. This is called a referral. Amerigroup pays for this care. If
your provider or Amerigroup doesn’t help you get these services or doesn’t approve of these services
and you go ahead and get them, you’ll have to pay for them. Be sure your provider approves your need
to see a specialist. If you need care from a doctor that isn’t part of our group, ask your PCP for help.
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SECOND MEDICAL OPINION
If you want a second medical opinion about your health care, call your PCP and ask for one. You can
pick a provider from our group of providers or a provider not part of Amerigroup. The second opinion
is at no cost to you. Your PCP will look at your second medical opinion and decide on a treatment plan
that is best for you. Amerigroup On Call is a free service for our members. This 24-hour nurse helpline
is ready to answer your health care questions. When you’re not sure what kind of care you need,
please call Amerigroup On Call toll free at 1-866-864-2544 (TTY 711). A trained medical professional is
there to answer your questions any time, any day.
Your Doctor
Choosing a Primary Care Provider
Your Amerigroup primary care provider (PCP) is the provider who will care for you. Your PCP’s phone
number is on your ID card. Call the office to set up a visit to get care. We make sure our providers are
the right ones to see you. We check their education and training. We look at their skills. If you have any
questions about your providers, call Member Services at 1-800-600-4441 (TTY 711) Monday through
Friday from 8 a.m. to 7 p.m. Eastern time. Some providers may not offer certain care based on religious
or moral beliefs.
PCPs can be any of the following:
 Family practitioners
 Pediatricians
 Obstetrician/Gynecologists (OB/GYNs)
 Advanced registered nurse practitioners
 Physician assistants
Choosing an OB/GYN
Female members can see an Amerigroup network obstetrician, gynecologist (OB/GYN) and/or a
certified nurse-midwife (for low-risk members) for OB/GYN health needs.
Services include:
 Well-woman visits
 Prenatal care
 Care for any female medical condition
 Family planning
 Referral to a special doctor within the network
You don’t need a referral from your PCP to see an OB/GYN. If you don’t want to go to an OB/GYN, your
PCP may be able to handle 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.
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There is a list of network OB/GYNs in your provider directory. The provider directory is online at
www.myamerigroup.com/FL.Click on “Find a Doctor”. To get a printed copy, please call Member Services. While you’re pregnant, your OB/GYN can be your PCP. If you need help picking an OB/GYN, you can:  Speak with a registered nurse by calling Amerigroup On Call at 1-866-864-2544.  Go to the online provider directory at www.myamerigroup.com/FL.
 Call Member Services at 1-800-600-4441 (TTY 711).
Changing your Primary Care Provider
If you want to change your provider, call Member Services toll free at 1-800-600-4441 (TTY 711)
Monday through Friday from 8 a.m. to 7 p.m. Eastern time. We’re happy to help family members who
are Amerigroup members to each pick a different PCP or the same PCP. You can also change your PCP
online at www.myamerigroup.com/FL. Your PCP can help you get the care you need that is
medically necessary.
Medically necessary health services are:
 Necessary to protect life, to prevent significant illness or disability, or to lessen severe pain
 Consistent with the symptoms or diagnosis of the illness or injury under treatment
 Consistent with generally accepted professional medical standards (i.e., not experimental or
investigational)
 Furnished at the most appropriate level that can be provided safely and effectively to the member
 Not mainly for the ease of the member, the member’s caregiver or the doctor
Your First Office Visit
You can call your PCP to set up your first appointment. You should see your PCP for a wellness visit (a
general checkup) within 90 days of enrolling in Amerigroup. By finding out more about your health
now, your PCP can take better care of you if you get sick. We can also help you set up your first
appointment. Call Member Services if you want our help.
Moral or Religious Objections
In accordance with 42 CFR 438.100, for a counseling or referral service that Amerigroup does not cover
because of moral or religious objections, Amerigroup does not need to furnish information on how and
where to obtain the service. If this happens, Amerigroup will send you a letter telling you we have a
moral or religious objection.
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Wait Times for Appointments
We want you to be able to get care at any time. When your PCP’s office is closed, an answering service
will take your call. Your PCP should call you back within 30 minutes. Once you talk to your PCP and set
up an appointment, you will be able to see your PCP as follows:
Urgent care
Routine sick patient
care
Wellness visit
Within one day
Within one week
Within one month
What to Bring When You Go for Your Appointment
When you go to your office visit, bring:
 Your Amerigroup ID card
 Your gold card
 Any medicines you take now
 A list of questions
If the visit is for your child, bring your child’s:
 ID card
 Gold card
 Shot records
 Any medicine he or she takes now
How to Get to an Office Visit or to the Hospital
You can get a ride to and from your health care visits. Please call Member Services toll free at
What to Do In an Emergency
Emergency Care
If you have an emergency, call 911 or go to the nearest hospital emergency room right away. If you
want advice, call your PCP or Amerigroup On Call at 1-866-864-2544 (TTY 711).
Most importantly, get medical care right away. When you go to the hospital, you’ll get a health
screening. After the screening, you’ll need to show your Amerigroup ID card and your gold card. Ask
the hospital to call Amerigroup. The steps are on your Amerigroup ID card.
What is an emergency medical condition?
 An emergency medical condition is when not seeing a provider right away could cause death or
very bad harm to your body
 The problem is so bad that the problem may result in death or may cause bad damage to any organ
or part of the body (or, in the case of a pregnant woman, the health of the woman or her
unborn child)
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In the case of a pregnant woman, an emergency medical condition is when:
 There is not enough time to safely move her to a different hospital before delivery
 A transfer may be a threat to the health and safety of the patient or her unborn child
 There is proof of prolonged uterine contractions or rupture of the membranes
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 an emergency behavioral health condition?
An emergency behavioral health and/or substance abuse condition meets the descriptions above.
Examples of an emergency behavioral health and/or substance abuse condition include:
 Likely danger to self or others
 Symptoms that cause so much distress that the person can’t carry out activities of daily life
 Harm that will likely cause death or serious harm
What is Post-stabilization?
Post-stabilization services are services you get after emergency medical care. You get these services to
help keep your condition stable. These services are paid for.
Medical emergencies and post-stabilization care that have to do with your emergency don’t need prior
approval by Amerigroup. You should call your PCP as soon as you can after you visit the emergency
room. If you can’t call, have someone call for you. Your PCP will give or help you with any follow-up
care you need.
Out-of-Area Emergency Care
Except in the case of an emergency (see previous section), you should always call your PCP first before
you get medical care. If you call your PCP’s office when it is closed, leave a message with your name
and a phone number. If it isn’t an emergency, someone should call you back quickly to tell you what to
do. You may also call Amerigroup On Call toll free at 1-866-864-2544 (TTY 711).
If you need help right away and it isn’t an emergency, you can go to one of our many urgent
care centers.
If you think you need emergency services (see Emergency Services), call 911 or go to the nearest
emergency room right away.
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How to get health care when you’re out of town
If you need emergency services when you’re out of town or outside of Florida,* go to the nearest
hospital emergency room or call 911. You must get in touch with your PCP as soon as you can about
your out-of-area emergency care. This will allow your PCP to set up follow-up care. If you’re placed in
the hospital, have the hospital call Amerigroup. This call should be made within 24 hours of admission
or as soon as possible to confirm your care is covered.
Any nonemergency care you get outside the service area isn’t paid for unless you get prior approval
from Amerigroup. If you need urgent care when you’re out of town, call your PCP. 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 doctor’s instructions. You may be told to get care where you are if you need it very quickly.
You can also call Amerigroup On Call toll free at 1-866-864-2544 (TTY 711).
If you need routine care like a checkup or a prescription refill when you’re out of town, call your PCP or
our Amerigroup On Call.
*If you’re outside the United States and need health care services, the services won’t be paid for by
Amerigroup or Fee-For-Service Medicaid.
How to get care when you can’t leave your home
If you need medical help but can’t leave your home, Amerigroup will find a way to help take care of
you. Call Member Services toll free at 1-800-600-4441 (TTY 711). We will put you in touch with a case
manager who will help you get the health care you need.
Out-of-network care
Amerigroup wants to make sure you get the care you need. Sometimes, we don’t have a provider in
our group who can give you the services you need. If that happens, we’ll pay for the services out of
network if medically needed.
If Amerigroup can’t get you the services you need from our network, we will pay for the services you
need to get from outside our network, once it is approved by us. We will pay for this quickly. You’ll be
able to keep getting these services from outside our network as long as we can’t get them from inside
our network.
Your PCP will ask us for the approval. Amerigroup must approve this care before you get the services.
Amerigroup will pay for the care we approve. You may have to pay for care we don’t approve. We only
approve care that is medically needed.
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Special care for pregnant members
Taking Care of Baby and Me® is the Amerigroup program for all pregnant members. It is very important
to see your primary care provider (PCP) or OB/GYN for care when you’re pregnant. This kind of care is
called prenatal care. It can help you have a healthy baby. Prenatal care is vital even if you have already
had a baby. With our program, members receive health advice and a baby gift for getting
prenatal care.
When you use Taking Care of Baby and Me, you will get a care manager. The care manager can work
with you to help you get the prenatal care and services you need during your pregnancy and until your
six-week postpartum checkup. Your care manager may call you to see how you’re doing with your
pregnancy. He or she can help you if you have any questions. Your care manager can also help you find
prenatal help in your community to help you when you’re pregnant. To find out more about Taking
Care of Baby and Me, call Member Services.
When you become pregnant
If you think you’re pregnant, call your PCP or OB/GYN provider right away. You don’t need a referral
from your PCP to see an OB/GYN doctor. Your OB/GYN should see you within two weeks. We can help
you find an OB/GYN in our group of providers.
Call Member Services and your Department of Children and Families (DCF) case worker when you find
out you’re pregnant. This will help your baby get Amerigroup health care benefits when he or she is
born. You will need to choose a PCP for your baby in your last trimester of pregnancy.
The third trimester begins in week 28 through the end of your pregnancy. If you don’t choose a PCP for
your baby during this time, we’ll choose one for you. When you’re pregnant, Amerigroup will send you
a pregnancy education package.
The package will include:
 A letter welcoming you to Taking Care of Baby and Me
 A self-care book
 A Taking Care of Baby and Me rewards guide
 An Amerigroup On Call Ameritips fact sheet
 A Healthy Start Hot Tip fact sheet
The book gives you information about your pregnancy. You can also use the book to write down things
that happen during your pregnancy. The Taking Care of Baby and Me guide tells you how to get your
gift for getting prenatal care. While you’re pregnant, you need to take good care of your health.
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Amerigroup would like you to contact these two free programs:
1. Healthy Start – a program for pregnant women and families with babies less than 1 year old.
Healthy Start offers classes on:
 How to have a healthy pregnancy
 Eating well while you are pregnant
 How to stop smoking
 Breastfeeding
 How to care for your baby
 Family planning
 Childbirth
 Parenting
The Healthy Start Coalition offers services throughout Florida. To learn more, visit
healthystartflorida.com/find-a-coalition to find services near you.
2. Women, Infants, and Children (WIC) – a program for pregnant women, infants and children under 5
years old. WIC offers:
 Health foods at no cost
 Nutrition education and counseling
 Breastfeeding support
 Referrals for health care and immunizations
To learn more about WIC, call 1-800-342-3556.
When should you go to your PCP or OB/GYN?
Stages of Your Pregnancy
When to Go to Your Doctor
Less than 13 weeks pregnant
Get your first prenatal visit as soon as possible
(or sooner if you think you are
pregnant)
14-28 weeks pregnant
Every 4 weeks
Every 2 weeks
Every week
After you deliver your baby
Get your postpartum checkup between 21-56 days after
you had your baby, even if you see your doctor before
three weeks have passed
Your PCP or OB/GYN may want you to visit more than this based on your health needs.
When you have a new baby
When you deliver your baby, you and your baby may stay in the hospital at least:
 48 hours after a vaginal delivery
 96 hours after a Caesarean section (C-section)
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You may stay in the hospital less time if your PCP or OB/GYN and the baby’s provider see that you and
your baby are doing well. If you and your baby leave the hospital early, your PCP or OB/GYN may ask
you to have an office or in-home nurse visit within 48 hours.
Amerigroup pays for elective circumcisions for newborn members up to 28 days of age. Circumcision
will be a one-time, lifetime benefit.
You must call Member Services as soon as you can to let your care manager know you had your baby.
We’ll need to get information about your baby, too. You may have already picked a PCP for your baby
before he or she was born. If not, we can help you pick a PCP for him or her. You must also call your
DCF case worker when you have your baby. If you do not wish for the baby to become a member, you
must call Choice Counseling toll free at 1-877-711-3662 (TTY 1-866-467-4970) to pick a different health
plan for your baby.
After you have your baby, Amerigroup will send you the Taking Care of Baby and Me postpartum
education package. It includes:
 A letter welcoming you to the postpartum part of Taking Care of Baby and Me
 A baby care book
 A Taking Care of Baby and Me rewards guide about going to your postpartum visit
 A brochure about postpartum depression
 An Amerigroup On Call Ameritips fact sheet
 A Healthy Start Hot Tip fact sheet
You can use the baby-care book to write down things that happen during your baby’s first year. This
book will give you information about your baby’s growth.
After your baby is born, you will need to see your OB/GYN or PCP for a postpartum visit 38 weeks after
your baby is born. Your baby should be seen 1-2 weeks after birth or sooner.
Wellness Care for Children, Teens and Adults
All Amerigroup members need to have regular wellness visits with their primary care provider (PCP).
During a wellness visit, your PCP will check your overall health. Many health problems can be treated
and controlled if found early. Your PCP can also answer your medical questions and help you stay
healthy. When you become an Amerigroup member, call your PCP and make your first appointment
within 90 days.
Well Care for Children and Teens
Why Well-Child Visits are Important for Children
Babies need to see their PCP seven times by the time they are 12 months old and more times if they
get sick. If your child has special needs or an illness like asthma or diabetes, one of our care
coordinators can help your child get checkups, tests and shots.
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The American Academy of Pediatrics recommends your child be seen for a well-child visit as follows:
3-5 days
9 months
30 months
7 years
1 month
12 months
3 years
8 years
2 months
15 months
4 years
9 years
4 months
18 months
5 years
10 years
6 months
24 months
6 years
Your child can get well-child visits from his or her PCP or any Amerigroup primary care provider (PCP).
Your child does not need a referral for these visits.
At these Health Check-Up 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
 Do vision, hearing and dental screenings
 Do laboratory tests (including blood lead testing for children ages 12 and 24 months)
 Give your baby shots that will help protect him or her from illnesses
 Tell you about health education and help with preventive care
 See if your baby has any problems that may need more health care
 Provide referrals and follow-up as needed
For the complete recommendations for preventive pediatric health care guidelines, please see
the Appendix.
Teenagers should also see their PCP for a well-child visit every year starting at age 11 until 21.
When Should Your Child Get Well-Child Visits?
The first well-child visit will happen in the hospital right after the baby is born. For the six visits after
that, you must take your baby to his or her PCP’s office. You must set up a well-child visit with the
baby’s PCP when the baby is born. Be sure to make these doctor visits. Take your child to his or her PCP
when scheduled. Amerigroup will send out reminders and call you to help remind you about
well-child visits.
If you’re new to Amerigroup and your child or teen has not had a well-child visit as listed above,
please schedule a visit within the first 30 days you have Amerigroup. If you need help to make a wellchild exam, please call Member Services toll free at 1-800-600-4441 (TTY 711) Monday through Friday
from 8 a.m. to 7 p.m. Eastern time.
School-age children and teens need yearly well-child exams too. Remember that during a back-to
school exam or sports physical, the provider doesn’t do a complete physical and may miss important
health issues. Ask the PCP to do a complete well-child exam.
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School-Based Health Centers
To make it easier for you to get your child’s annual well-child exam, Amerigroup has partnered with
over 70 school-based health centers in Florida to allow your child to have his or her well-child exam
completed at his or her school. This service is at NO cost to you.
Amerigroup is partners with school-based health centers located in these counties:
Hillsborough
Pinellas
Orange
Miami-Dade
To find out if your child’s school is one of !merigroup’s partner sites, please call Member Services at
1-800-600-4441 (TTY 711). We’ll also tell you how to make an appointment.
When making the appointment for your child, you will need to fill out a consent form. This form will
give the school nurse practitioner or doctor the OK to give a well-child exam. After the exam, the
report will be sent to you and your child’s PCP.
Blood Lead Testing
Your child’s PCP will test your child for lead poisoning. Your child will be tested at:
 12 months
 24 months
 Between 24 and 72 months if the child has not been tested before
For the blood test, your child’s doctor will take a blood sample by pricking the child’s finger or taking
blood from the vein. This test will tell if your child has harmful lead in his or her blood.
Vision Screening
Your child’s PCP should check your child’s vision at every well-child visit.
Hearing Screening
Your child’s PCP should check your child’s hearing at every well-child visit.
Dental Screening
Your child should have his or her teeth and gums checked by his or her PCP as a part of the routine
well-child visits. At age 3, your child should begin seeing a dentist every six months. Fluoride
treatments are covered by Amerigroup if provided by your child’s PCP or a dentist.
Immunizations
It is important for your child to get his or her immunizations (shots) on time. Take your child to the
doctor when his or her PCP says a shot is needed. Use the charts at the end of this handbook to help
keep track of the shots your child needs.
For a complete list of shots your child needs, please see the shots schedule in the back of the book.
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Wellness Care for Adults
Preventive screenings can help you find problems early. Earlier findings may mean you have more
treatment choices. Staying healthy means seeing your PCP for regular checkups. Use the chart below to
make sure you’re up-to-date with your yearly wellness exams.
Wellness Visits Schedule for Adults
Who Needs It?
Adults: Age 18 and over
Men: Age 35-65
Women: Age 45-65
Women: Age 16-24
Type of Exam
Wellness visit
Cholesterol screening
Women: Age 21-64
Cervical cancer screening
(Pap)
Mammogram (Breast X-ray)
Chlamydia screening
Women: Age 40 and
over
Adults: Age 50 and over  Colorectal cancer screening
 Fecal blood occult test
Adults: Age 65 and over Eye exam (Glaucoma
screening)
How Often?
Every year
Every 5 years (more often, if
elevated)
Every year and at PCP’s
recommendation
Every 1-3 years
Every 1-2 years
Every year
Every year
When You Miss One of Your Wellness Visits
If you or your child does not get a wellness care visit on time, make a visit with the PCP as soon as you
can. If you need help setting up the visit, call Member Services. If your child has not visited his or her
PCP on time, Amerigroup will send you a postcard that reminds you to make your child’s
well-child visit.
HOW TO ACCESS OTHER AMERIGROUP SERVICES
Prescription Benefit
You’ll get covered prescription drugs at no cost when written by a licensed prescriber. Plus, you can
choose from community pharmacies and major drugstores. Your provider directory is online at
www.myamerigroup.com/FL. Click on “Find a Doctor”. You can get a printed directory by calling
Member Services at 1-800-600-4441 (TTY 711).
There is no copayment for prescription drugs. Certain medicines your child may use are now under a
new Florida state law. Medicaid will not pay for psychotropic medication prescribed for a child under
13 years old in the Medicaid program unless express and informed consent of the child’s parent or
legal guardian is given. Your child’s doctor must have a record of consent in your child’s records.
Also, the doctor will need to give the drugstore an approval form with the prescription. The consent
forms are online at ahca.myflorida.com/medicaid/Prescribed_Drug/pharm_thera/paforms.
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What Are Psychotropic Drugs?
 Psychotropic drugs are antipsychotics, antidepressants, antianxiety medications and mood
stabilizers. Anticonvulsants and ADHD medications (stimulants and nonstimulants) are not included
at this time. If your child uses one or more of the medicines listed below, informed consent is
needed. Only the generic names of the medicines are listed. Your child may be receiving the brandname product, but this requirement still applies. The requirement will also apply to similar drugs
that may be released onto the market after you receive this document.
Psychotropic Drugs That Now Require Consent
Alprazolam
Amitriptyline
Amobarbital
Amoxapine
Aripiprazole
Armodafinil
Asenapine
Bupropion
Buspirone
Butabarbital
Carbamazepine
Chloralhydrate
Chlordiazepoxide
Chlorpromazine
Citalopram
Clomipramine
Clorazepate
Clozapine
Desipramine
Desvenlafaxine
Dexmedetomidine
Doxepin
Droperidol
Duloxetine
Escitalopram
Estazolam
Eszopiclone
Fluoxetine
Fluphenazine
Flurazepam
Fluvoxamine
Haloperidol
Iloperidone
Imipramine
Isocarboxazid
Lithium
Loxapine
Lurasidone
Maprotiline
Meprobamate
Midazolam
Mirtazapine
Modafinil
Molindone
Nefazodone
Nortriptyline
Olanzapine
Oxazepam
Paliperidone
Paroxetine
Pentobarbital
Perphenazine
Phenelzine
Pimozide
Protriptyline
Quazepam
Quetiapine
Ramelteon
Risperidone
Secobarbital
Selegiline
Sertraline
Sodium Oxybate
Temazepam
Thioridazine
Thiothixene
Tranylcypromine
Trazodone
Triazolam
Trifluoperazine
Trimipramine
Venlafaxine
Vilazodone
Zaleplon
Ziprasidone
Zolpidem
Amerigroup works with your doctor to get you and your family the best medical care possible. If you
have questions about your child’s prescription drugs, please contact Member Services toll free at 1
800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time. The Florida
Medicaid Preferred Drug list is at
http://ahca.myflorida.com/Medicaid/prescribed_drug/pharm_thera/fmpdl.shtml. This is a listing of
drugs paid for on our formulary. The formulary is the complete listing of all drugs we pay for.
What Over-The-Counter Medicines Are Covered?
In addition to the over-the-counter (OTC) products covered on our formulary, you also have an OTC
drug benefit. Your household can get up to $25 worth of certain OTC products per month at any
Amerigroup network drugstore. Just pick the product and show the pharmacist your Amerigroup ID
card. The pharmacist will let you know when your household has reached the $25 limit for
the month.
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Some of the types of OTC drugs you can get include:
 Vitamins and minerals
 Pain relievers
 First aid supplies
 Cough, cold and allergy medicine
OTC items can be picked up at any network pharmacy. This list below isn’t a complete list. It gives
examples of some common brand names of OTC drugs. Not all members will be able to get cough and
cold medications.
Common Over-The-Counter (OTC) Medicines
Cough/Cold/
Analgesics (pain relief)
Decongestants
Anacin
(age limits apply)
Arthritis pain relief
Afrin Nasal Spray
Aspirin/baby aspirin
Dimetapp
Midol
Ocean Nasal Spray
Motrin
Robitussin
Muscle rubs
Sudafed
Tylenol
Antacids
Gas-X
Maalox
Mylanta
Pepcid
Pepto-Bismol
Prevacid OTC
Zantac
Antidiarrheals
Imodium
Pepto-Bismol
Antiemetics (nausea)
Antivert
Dramamine
Meclizine
Antihistamines
(allergy)
Benadryl
Claritin
Tavist
Zyrtec
Diabetic Supplies
Blood glucose test
strips (TRUEtest brand)
Glucose (oral)
Insulin
syringes/needles
Isopropyl alcohol
Ketone strips
Lancets
Urine test strips
Dermatologicals
(skin/topical)
Antifungals
Lotrimin
Monistat
Tinactin
Laxatives
Correctol
Dulcolax
Fiberlax
Laxative enemas
Laxative suppositories
Anti-infectives
Bacitracin
Neosporin
Polysporin
Other Topicals
Benzoyl Peroxide Cream
Calamine
Clearasil
Compound W
Diaper rash ointment
Hydrocortisone
Lac-Hydrin
Lice/scabies treatments
OxyClean
Sunscreen
Vaseline
Medical
Supplies/Other
Bandages
Condoms(male/female
)
Spermicidal Foam
Today® sponge
Nicotine patches/gum
Peroxide
Pregnancy tests
Mouth/Throat
Oragel
Throat lozenges
Ophthalmic
Alaway
Artificial tears
Hypo Tears
Naphcon
Steri Optics
Vasocon
Visine
Rectal
Anusol
Preparation H
Vaginal
Conceptrol
Gyne-Lotrimin
Monistat
Vitamins/Minerals
Calcium
Folic Acid
Iron
Niacin, Slo-Niacin
Pediatric vitamins
(Flintstones, One-a-Day
Kids)
Prenatal Vitamins
(Complete Prenatal,
GNP Daily Prenatal,
Mission Prenatal,
Stuart Prenatal)
Vitamins: A, B, BComplex, C, D, E, K and
Zinc
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ACCESS TO BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES
Behavioral Health Emergency Coverage
Amerigroup behavioral health emergency coverage is available 24 hours a day, 7 days a week. You can
use any hospital or other location for emergency behavioral health care.
Behavioral Health and Substance Abuse Care
Sometimes the stress of handling the many tasks of a home and family can lead to depression, anxiety,
marriage and family problems, parenting problems, and alcohol and drug abuse.
If you or family members are having these kinds of problems, you can get help. You can call
Amerigroup Member Services for help. You can also get the name of a provider who will see you if you
need one. We will set up all outpatient behavioral health care services and inpatient hospital stays.
You DON’T need a referral from your PCP to get behavioral health and/or substance abuse services.
A behavioral health care provider is a licensed provider, nurse, psychologist, social worker or licensed
mental health worker trained and skilled to offer behavioral health or substance abuse care. You can
pick another behavioral health case manager or provider, if one is available. The one you pick needs to
be part of our provider group. Do you want to change your behavioral health care case manager or
behavioral health care provider? Please call Member Services toll free at 1-800-600-4441 (TTY 711)
You can get these nonemergent services within the service area by calling Member Services. Member
Services will help you get:
 Outpatient hospital services for behavioral health conditions
 Psychiatric physician services for behavioral health conditions
 Community behavioral health services for mental health conditions
 Community behavioral health services for substance abuse conditions
 Statewide Inpatient Psychiatric Program (SIPP) services for members under 21 years old
 Residential care
 Specialized therapeutic foster care
 Therapeutic group care
 Comprehensive behavioral health assessment
 Behavioral health overlay services in child welfare settings
 Mental Health Targeted Case Management
 Mental Health Intensive Targeted Case Management
Amerigroup isn’t responsible for nonemergency behavioral health or substance abuse care you get
from an out-of-network provider, unless we approve coverage of such services.
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Behavioral Health Limitations and Exclusions
 Adults can get up to 45 inpatient treatment days a year. Ongoing stays must meet nationally
recognized medical standards for medical necessity.
 Most outpatient behavioral health and substance abuse services don’t need approval before
services are given. Limits are based on Medicaid rules from the Agency of Health Care
Administration (AHCA).
ACCESS TO MEDICAL SERVICES
Amerigroup Covered Health Services
The following list shows the health care services and benefits Amerigroup will pay for when you need
them. Your primary care provider (PCP) will give you the care you need or refer you to a doctor who
can give you the care you need. For a few special benefits, members have to be a certain age or have a
certain kind of health problem.
Authorization Requirements
Some health care services and benefits need prior approval from Amerigroup. Your PCP will work with
Amerigroup to get approval. If you have questions or want to know more about your benefits, call
Member Services. All inpatient admissions need approval from Amerigroup.
The following services do not need prior authorization:
 Emergency services
 Preventive care services
Well visits
Immunizations (shots)
Inpatient Hospital Stay (including Behavioral Health and Substance Abuse Care)
Inpatient hospital stay is the care you get when you’re in a hospital. This is all items and services you
need to get the right care during your stay.
• Room and board
• Nursing care
• Medical supplies
• Diagnostic and therapeutic services
Amerigroup pays for the care of:
 Members age 20 years and under for 365 days (July 1-June 30) and 366 days in leap year.
 Members age 21 years and older for no more than 45 days.
Inpatient behavioral health and substance abuse care services are included.
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Outpatient Services
 Include all medically needed diagnostic services
 Therapeutic care and services provided in an outpatient hospital setting
 Must be ordered by your Amerigroup provider
 Outpatient behavioral health services are included
Emergency Medical Services and Care
 All emergency care
 24 hours a day, 7 days a week
 Includes emergency care at a facility not part of Amerigroup, until the member can be moved to an
Amerigroup facility
Emergency service and care includes:
 A medical screening
 An exam and review by a doctor or, when allowed by law, by proper personnel managed by a
doctor to help find out if there is an emergency medical condition.
If there is, the doctor will decide the care, treatment or surgery to ease or end the condition
within the service means of a hospital.
See the section Emergency Care for what an emergency medical condition is. Emergency behavioral
health and substance abuse care is 24 hours a day, 7 days a week.
Provider Services
Provider services include all services and treatments you get from an Amerigroup provider when
medically needed for:
 Preventive care
 Diagnostic care
 Therapeutic or palliative (pain relief) care
 Treating a certain illness or disease
These services also include immunizations (shots).
Provider services do not include:
 Nonclinically proven procedures
 Cosmetic surgery
 Abortions, unless the life of the mother is or would be in danger or if the woman is a victim of
rape or incest
Family Planning Services
Family planning services let you plan family size or think about when you want to have children. These
services include:
 Information and referral for learning and counseling
 Diagnostic procedures
 Contraceptive drugs and supplies
 Sterilization and follow-up care
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You may use these services if you wish. You can choose the method and the family planning service.
You don’t need prior approval for family planning services. You must get these services from a
provider who accepts Medicaid.
Want to go to a pregnancy prevention program? Member Services can give you a complete list. Here
are a few to visit:
 Florida Abstinence Education program at www.greattowait.com
 Local school districts
 Local health departments
 Florida Department of Health – Teen Outreach program
Maternity Care
Maternity services include:
 Nursing review and counseling
 Nutrition review
 Prenatal care
 OB delivery
 Elective circumcision and follow-up care
For more information, see the section Special Care for Pregnant Members.
Vision Services
Amerigroup members don’t need a PCP referral to use the medically needed eye care benefits. Vision
services include:
 Medically needed eye exams and corrective vision eyewear.
 Eyeglass frames
Age 20 years and under:
o Limited to two frames during a 365-day period.
o A third frame may be covered, when medically needed and prior approval is given.
Age 21 years and older:
o Limited to one frame every two years.
o A second frame may be covered, when medically needed and prior approval is given.
 Eyeglass lenses
Age 20 years and under:
o Limited to two pairs of lenses during a 365-day period.
o A third pair of lenses may be covered, when medically needed and prior approval is given.
Age 21 years and older:
o Limited to one pair of lenses during a 365-day period.
o A second pair of lenses may be covered, when medically needed and prior approval is given.
 Contact lenses and related services, when medically needed and prior approval is given.
 Eyeglass repairs and adjustments.
For help finding an eye doctor, please call EyeQuest toll free at 1-855-418-1627 (TTY 711).
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Hearing Services
Amerigroup covers the following hearing services:
 Hearing evaluation and diagnostic testing
 Cochlear implant (limit of one) and cochlear implant repairs
 Hearing aid fitting and dispensing
 Hearing aid repairs and accessories
Look in your provider directory for a list of hearing providers. Please call HEARx toll free at
1-800-698-6767 (TTY 1-888-300-3277) to find a HEARx center near you.
Dental Services
Amerigroup provides full Medicaid coverage for dental services to all members age 20 years and under.
For our adult members age 21 years and older, Amerigroup offers:  Dentures
 Denture-related services
 Emergency dental services
For all members, we also offer oral and maxillofacial surgery services.
As an extra benefit for adult members, Amerigroup offers:
 One dental exam every six months
 One dental cleaning every six months
 For SSI non-Medicaid/Medicare dual eligible members: One set of bitewings per year
Unlimited fillings (limit one filling per tooth every 36 months)
One fluoride treatment every six months
Do you have questions about your dental coverage or need to find a dentist? Please call DentaQuest at
1-855-418-1627 (TTY 711).
Lab and X-ray Services
These services include:
 Medically needed lab and radiology services ordered by an Amerigroup provider
 These services are also part of emergency care
Home Health Care
Home health care coverage includes medically needed:
 Short-term or part-time nursing services by a registered nurse or licensed practical nurse
 Personal care services by a home health aide
 Medical items
 Medical items are limited to:
 Approved supplies, appliances and durable medical gear fit for use in the home
 Services, supplies and gear must be ordered by an Amerigroup network doctor in a
written plan
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Some services may need prior approval.
Hospice
Hospice care focuses on giving pain relief and comfort to terminally ill members and families. It is
about bringing comfort instead of finding a cure. This service includes care and services that help meet:
 Medical needs
 Physical needs
 Social needs
 Psychological needs
 Emotional needs
 Spiritual needs
Some services need prior approval.
Transplant Services
Transplant services include evaluations for a transplant and care before and after a transplant is
performed. The types of medically necessary transplants covered are:
• Bone marrow
• Cornea
• Kidney
• Heart
• Lung
• Liver
• Pancreas
Transportation
Amerigroup pays for nonemergent and emergency transportation.
For questions or to schedule a pick-up for nonemergent transportation, call LogistiCare at
1-866-372-9794 (TTY 1-866-288-3133). Or call Amerigroup Member Services toll free at
If you need emergency transportation, call 911.
Value-Added Benefits
Amerigroup offers the following:
 Waived copayments – Enrollees are not subject to copayments for any services or benefits
 Over The-Counter (OTC) medication or supplies – $25 per household per month
 Adult dental services – One exam every six months; one cleaning every six months. For SSI nonMedicaid/Medicare dual eligible enrollees: one set of bitewings per year; unlimited fillings (limit
one filling per tooth every 36 months); one fluoride treatment every six months
 Additional vision benefit – Up to $100 for contact lenses and contact lens services per year for
enrollees age 21 and over
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 Additional hearing benefit – Sixty hearing aid batteries every 12 months, if medically necessary;
includes battery sizes: 10, 13, 312, 675
 Newborn circumcision – Available upon request for newborns up to 28 days old; does not require
prior approval
 Home health care – No-cost, unlimited home visits by a nurse for homebound adults, when
medically necessary. Prior approval is needed.
 Art therapy – Helps members better understand their emotions and other mental health issues;
often used with talk therapy and drugs. Unlimited visits for members receiving behavioral health
services.
 Post-discharge meals – Two meals a day for seven days after a three-day surgical hospital stay ; to
help improve healing and recovery
 Nutritional counseling – To help reduce diabetes and heart disease risk factors, prevent and treat
high blood pressure, improve the immune system; one session every three months and four
sessions per calendar year; no prior authorization (approval) needed
 Adult Pneumonia vaccine – One vaccination (shot) per lifetime without prior approval; one
vaccine (shot) every five years based on prior approval
 Adult Influenza vaccine – One vaccination (shot) per year
 Adult Shingles vaccine – One vaccination (shot) per lifetime; limited to enrollees age 60 and older
 Physician home visits – Unlimited visits; limited to adult, homebound enrollees who otherwise
require ambulance transport to access primary care
 Outpatient services – No limit on outpatient services; subject to medical necessity; needs prior
approval. Does not include laboratory services.
 Unlimited prenatal/perinatal visits
 Unlimited primary care visits
 Additional programs – Disease management and health education; see Disease Management and
Special Amerigroup Services for Healthy Living
We give you these benefits to help keep you healthy and thank you for choosing Amerigroup.
IMPORTANT INFORMATION
Information You Should Know about Amerigroup
Amerigroup wants you to have the information you want and need. We make getting to know about
Amerigroup easy. You can visit www.myamerigroup.com/FL or call Member Services toll free at
You can get information about:
 Quality performance scores
 Member satisfaction scores
 Provider satisfaction scores
 The structure and operation of Amerigroup
 Physician incentive payments
 Quality enhancements
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Compare Amerigroup to Other Health Plans in Florida
You can get performance outcome and financial data that is handled by the Florida Agency for Health
Care Administration (AHCA) at www.FloridaHealthStat.com.
Fraud, Abuse and Overpayment
Fraud happens when Amerigroup gets billed for a service that costs more than the service cost. Fraud
happens when Amerigroup pays for a service that was never used. If you know that fraud has
happened, please tell us. Call Member Services toll free at 1-800-600-4441 (TTY 711) Monday through
Friday from 8 a.m. to 7 p.m. Eastern time.
To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll
free at 1-888-419-3456 or complete a Medicaid Fraud and Abuse Complaint Form, which is available
online at: https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx.
If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a
doctor or other health care provider, you may be eligible for a reward through the Attorney General’s
Fraud Rewards Program (toll-free 1-866-966-7226 or 850-414-3990). The reward may be up to twentyfive percent (25%) of the amount recovered or a maximum of $500,000 per case (Section 409.9203,
Florida Statutes). You can talk to the Attorney General’s Office about keeping your identity confidential
and protected.
Suspicions of fraud and abuse can also be sent to the Amerigroup Corporate Investigations Department
through the Amerigroup website at www.myamerigroup.com. There are fraud and abuse links on the
website to report details about a possible issue.
SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING
Special Programs
Health Information
To learn more about healthy living and our Quality Enhancement Programs, ask your primary care
provider (PCP) or call Member Services toll free at 1-800-600-4441 (TTY 711) Monday through Friday
from 8 a.m. to 7 p.m. Eastern time.
Amerigroup On Call
Amerigroup On Call is available 24 hours a day, 7 days a week toll free at 1-866-864-2544 (TTY 711) to
answer your medical questions. Amerigroup On Call can tell you if you need to see your PCP and can
offer medical advice.
Health Education Classes
Amerigroup works to keep you healthy with our health education programs. We can also help you find
classes near your home. Call Member Services to find out where and when these classes are held.
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Some of the classes include:
• Amerigroup services and how to get them
• Childbirth
• Children’s programs
• Infant care
• Parenting
• Pregnancy
• Protecting yourself from violence
• Quitting cigarette smoking
• Substance abuse programs
• Other health topics
Some larger medical offices (like clinics) in our network show health videos that talk about
immunizations (shots), prenatal care and other important health topics. We hope you will learn more
about staying healthy by watching these videos.
Healthy Behaviors Program
We will offer programs to members who want to stop smoking, lose weight or address any drug abuse
problems. We will reward members who join and meet certain goals.
Take steps to stay healthy
Amerigroup wants you to be and stay healthy, at every age. Preventive screenings and tests can help
providers find health concerns early.
Regular visits with your provider are important. When you take those steps, Amerigroup will reward
you. Getting your rewards are easy. Once you finish your screening, we will mail you a letter about how
to choose your gift card.
Set healthy goals
We all need help from time to time. The Amerigroup Healthy Behaviors Rewards program is here to
help our members. We can help you make a plan and set goals to beat tough health issues:
1. Alcohol and Substance Abuse – help and support through coaching and being part of
community groups
2. Smoking Cessation – help and support through coaching and being part of community groups
3. Weight Management and Nutrition – help and support from a nurse to make good exercise and
food choices
Meet your goals
Your doctors, nurses and even a nurse coach will be here to help you. Through the Healthy Behaviors
Rewards program, you’ll get tips, help and support. We’re here to help you reach your goals. Goals will
be different from member to member.
Get rewarded
Meet your goals. We’ll reward you with a gift card. The more goals you meet, the more gift cards you
can get.
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Learn more
Do you want to know more about our Healthy Behaviors Rewards program? Enroll today by calling a
Healthy Behaviors nurse coach toll free at 1-888-830-4300 (TTY 711) Monday through Friday from
9 a.m. to 8 p.m. Eastern time. The nurse coach can tell you more about the program, talk about setting
goals and send you a consent form. When we get your signed consent form, we’ll send you the first gift
card.
Gift cards are nontransferable and can’t be used for gambling or to buy firearms, tobacco, prescription
drugs or alcohol. If you are voluntarily disenrolled or lose Medicaid eligibility for more than 180 days,
we may cancel your earned gift cards.
Get the care you need when you’re pregnant
Are you pregnant? Have you just had a baby? Amerigroup will reward you for getting the care you
need during pregnancy and after delivery. All you have to do is go to all of your scheduled visits with
your provider. When you go to each of these appointments, we’ll send you a $20 gift card for
each visit:
 Complete a prenatal care visit during your second trimester
 Complete a prenatal care visit during your third trimester
 Complete a postpartum care visit 21 to 56 days after delivery
Amerigroup will send you a mailer for each visit. Take the mailer with you to your visit. Your provider
will sign the mailer. All you need to do is mail it to us. We even pay for the postage. After we get your
mailer, we’ll send you the gift card you picked.
Community Events
Amerigroup sponsors and attends community events and health fairs where you can:
 Get health information and have a good time
 Learn about healthy living and fitness
 Get answers to your questions from Amerigroup
Domestic Violence Resources
Domestic violence is abuse. Abuse is not healthy. Abuse is unsafe. It is never OK for someone to hurt
you. It is never OK for someone to make you afraid. Domestic violence causes harm and hurt on
purpose. Domestic violence in the home can affect your children, and it can affect you. If you feel you
may be a victim of abuse, call or talk to your doctor. Your doctor can talk to you about domestic
violence. He or she can help you understand you have done nothing wrong and do not deserve abuse.
Safety tips for your protection:
 If you’re hurt, call your PCP. Call 911 or go to the nearest hospital if you need emergency care; see
the section on Emergency Care for more information
 Have a plan on 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
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If you have questions or need help, please call:  Amerigroup On Call toll free at 1-866-864-2544 (TTY 711)
 National Domestic Violence hotline number at 1-800-799-7233 (TTY 1-800-787-3224)
 Abuse hotline at 1-800-96-ABUSE
Bullying Resources
Bullying has become a serious problem and can happen anywhere: face to face, text messages or on
the web. It isn’t limited to age, gender or school level. Bullying can cause real harm.
Amerigroup wants you to know the warning signs that could mean someone is bullying others or by
being bullied. These warning signs may show other issues or problems as well. To learn more about
bullying, visit www.stopbullying.gov.
These may be signs of someone being bullied if he or she:
 Comes home with damaged or missing clothing or items
 Loses things like books, electronics, clothing or jewelry
 Has unexplained injuries
 Complains often of headaches, stomachaches or feeling sick
 Has trouble sleeping or has frequent bad dreams  Has changes in eating habits  Hurts themselves  Is very hungry after school from not eating lunch
 Runs away from home
 Loses interest in visiting or talking with friends  Is afraid of going to school or other activities with peers
 Loses interest in school work or begins to do poorly
 Appears sad, moody, angry, anxious or depressed when he or she comes home  Talks about suicide
 Feels helpless
 Often feels like he or she is not good enough
 Suddenly has fewer friends  Avoids certain places  Acts differently than usual
These may be signs of someone bullying others:
 Becomes violent with others
 Gets into physical or verbal fights with others
 Gets sent to the principal’s office or detention a lot
 Has extra money or new belongings that can’t be explained
 Is quick to blame others
 Will not accept responsibility for his or her actions
 Has friends who bully others
 Needs to win or be best at everything
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If you suspect you or your child is being bullied:
RESPONSE
ACTION
Someone is in immediate risk of harm because of bullying Call 911
Your child is feeling suicidal because of bullying
Call the suicide prevention hotline
toll free at 1-800-273-TALK (8255)
Your child’s teacher is not keeping your child safe from
being bullied
Contact local school leaders
(principal or superintendent)
Your school is not keeping your child safe from being
bullied
Contact the State School Department
Your child is sick, stressed, not sleeping or is having other Contact your counselor or other
problems because of bullying
health professional
Your child is bullied because of his or her race, ethnicity
or disability, and local help is not helping to solve the
problem
Contact the U.S. Department of
Education’s Office on Civil Rights
Smoking Cessation
The smoking cessation program is to help you find the way to quit smoking and stay smoke-free. Amerigroup offers a variety of resources and services free of charge with many options, including:  Community classes – A listing of classes taught in the community
 Phone counseling – Trained health coaches work with you to find a program designed just for you
that looks at how you act and how you live
 Prescription benefits
 Additional resources and tools
– Phone counseling for stopping tobacco use
o The Florida Quitline: a toll-free, phone-based tobacco use cessation service. Any person
living in Florida who wants to try to quit smoking can use the Quitline. The following
services are available:
 Counseling sessions
 Self-help materials
 Counseling and materials in English and Spanish
 Translation service for other languages
 Pharmacotherapy assistance
 TDD service for deaf and hard of hearing
– Online Resources
o www.smokefree.gov
o www.quitnet.com
o www.quitsmokingsupport.com
– Printed Resources Member
o You Can Quit Smoking Flier
o Ameritip “Tobacco Use — Breaking the Habit”
o Ameritip “Tobacco Use — Reasons To Quit”
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Disease Management
Amerigroup has a Disease Management Centralized Care Unit (DMCCU) program. This team of licensed
nurses and social workers, called DMCCU care managers, will:
 Teach you about your condition
 Help you learn how to manage your care
Your primary care provider (PCP) and our team of DMCCU care managers will help you with your
health care needs. DMCCU care managers provide support over the phone for members with:
 Diabetes
 HIV/AIDS
 Behavioral health conditions
– Bipolar disorder
– Major depressive disorder
– Schizophrenia
– Substance abuse
 Heart conditions
– Coronary artery disease
– Congestive heart failure
– Hypertension
 Lung conditions
– Asthma
– Chronic obstructive pulmonary disease
DMCCU care managers work with you to make health goals and a plan to reach them. 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 needs
 Helps you make 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 to help you make better choices
 Helps you coordinate care with your providers
As an Amerigroup member enrolled in the DMCCU, you have certain rights and responsibilities.
You have the right to:
 Have information about Amerigroup. This includes programs, services and our staff’s education and
work experience. It also includes contracts we have with other businesses.
 Refuse to take part in or disenroll from programs and services we offer
 Know which staff members help with your health care services and who to ask for a change
 Have Amerigroup help you make choices with your doctors about your health care
 Know about all DMCCU-related treatments. These include anything stated in the clinical guidelines,
and whether covered by Amerigroup or not. You have the right to discuss all options with
your doctors.
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Have personal and medical information kept private under HIPAA; know who has access to your
information; know what Amerigroup does to keep it private and maintain your privacy
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 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 have the responsibility to:
 Listen and know the importance of accepting or rejecting health care advice
 Provide Amerigroup with information needed to carry out our services
 Tell Amerigroup and your doctors if you decide to disenroll from the DMCCU program
If you want to know more about our DMCCU, please call 1-888-830-4300 (TTY 711) Monday through
Friday from 8:30 a.m. to 5:30 p.m. Eastern time.
Case Management Services
Amerigroup has case managers to help you understand and care for your condition. Your PCP will help
you with your special condition. It is also important you learn to care for yourself.
As a new Amerigroup member, you will get a welcome call. During the call, we’ll find out if you need
case management services. If you need case management services, we’ll refer you to a case manager.
Your case manager will work with you and your PCP to set up a plan of care for your condition. Do you
think you need case management services? Please call Member Services at 1-800-600-4441 (TTY 711).
We can help refer you to the Case Management department.
Our case managers may also call you if:
 Your PCP thinks you would benefit from the program
 You’re discharged from the hospital and need some follow-up coordination of care
 We see you’re often in the emergency room (ER) for nonurgent care that can be handled by
your PCP
 You call Amerigroup On Call and need follow-up for your care
Your case manager can help:
• Set up health care services
• Referrals and prior authorizations (approvals)
• Look at your plan of care as needed
We may also call you to be part of our Complex Case Management program. Complex case
management is for members with serious physical and/or mental health conditions that need more
care coordination.
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If you’re called, a nurse or social worker will:
• Ask you if you want to be part of case management
• Teach you about the program
• Talk to you about your health and other parts of your life
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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION WITH REGARD TO YOUR HEALTH BENEFITS. PLEASE REVIEW IT
CAREFULLY.
HIPAA NOTICE OF PRIVACY PRACTICES
The original effective date of this notice was April 14, 2003. The most recent revision date is shown at
the end of this notice.
Please read this notice carefully. This tells you who can see your protected health information (PHI).
It tells you when we have to ask for your OK before we share it. It tells you when we can share it
without your OK. It also tells you what rights you have to see and change your information.
Information about your health and money is private. The law says we must keep this kind of
information, called PHI, safe for our members. That means if you’re a member right now or if you used
to be, your information is safe.
We get information about you from state agencies for Medicaid and the Children’s Health Insurance
Program after you become eligible and sign up for our health plan. We also get it from your doctors,
clinics, labs and hospitals so we can OK and pay for your health care.
Federal law says we must tell you what the law says we have to do to protect PHI that’s told to us, in
writing or saved on a computer. We also have to tell you how we keep it safe. To protect PHI:
 On paper (called physical), we:
– Lock our offices and files
– Destroy paper with health information so others can’t get it
 Saved on a computer (called technical), we:
– Use passwords so only the right people can get in
– Use special programs to watch our systems
 Used or shared by people who work for us, doctors or the state, we:
– Make rules for keeping information safe (called policies and procedures)
– Teach people who work for us to follow the rules
When is it OK for us to use and share your PHI?
We can share your PHI with your family or a person you choose who helps with or pays for your health
care if you tell us it’s OK. Sometimes, we can use and share it without your OK:
 For your medical care
– To help doctors, hospitals and others get you the care you need
 For payment, health care operations and treatment
– To share information with the doctors, clinics and others who bill us for your care
– When we say we’ll pay for health care or services before you get them
– To find ways to make our programs better, as well as giving your PHI to health information
exchanges for payment, health care operations and treatment. If you don’t want this, please
visit www.myamerigroup.com/pages/privacy.aspx for more information.
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 For health care business reasons
– To help with audits, fraud and abuse prevention programs, planning, and everyday work
– To find ways to make our programs better
 For public health reasons
– To help public health officials keep people from getting sick or hurt
 With others who help with or pay for your care
– With your family or a person you choose who helps with or pays for your health care,
if you tell us it’s OK
– With someone who helps with or pays for your health care, if you can’t speak for yourself and
it’s best for you
We must get your OK in writing before we use or share your PHI for all but your care, payment,
everyday business, research or other things listed below. We have to get your written OK before we
share psychotherapy notes from your doctor about you.
You may tell us in writing that you want to take back your written OK. We can’t take back what we
used or shared when we had your OK. But we will stop using or sharing your PHI in the future.
Other ways we can — or the law says we have to — use your PHI:
 To help the police and other people who make sure others follow laws
 To report abuse and neglect
 To help the court when we’re asked
 To answer legal documents
 To give information to health oversight agencies for things like audits or exams
 To help coroners, medical examiners or funeral directors find out your name and cause of death
 To help when you’ve asked to give your body parts to science
 For research
 To keep you or others from getting sick or badly hurt
 To help people who work for the government with certain jobs
 To give information to worker’s compensation if you get sick or hurt at work
What are your rights?
 You can ask to look at your PHI and get a copy of it. We don’t have your whole medical record,
though. If you want a copy of your whole medical record, ask your doctor or health clinic.
 You can ask us to change the medical record we have for you if you think something is wrong or
missing.
 Sometimes, you can ask us not to share your PHI. ut we don’t have to agree to your request.
 You can ask us to send PHI to a different address than the one we have for you or in some other
way. We can do this if sending it to the address we have for you may put you in danger.
 You can ask us to tell you all the times over the past six years we’ve shared your PHI with someone
else. This won’t list the times we’ve shared it because of health care, payment, everyday health
care business or some other reasons we didn’t list here.
 You can ask for a paper copy of this notice at any time, even if you asked for this one by email.
 If you pay the whole bill for a service, you can ask your doctor not to share the information about
that service with us.
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What do we have to do?
 The law says we must keep your PHI private except as we’ve said in this notice.  We must tell you what the law says we have to do about privacy.
 We must do what we say we’ll do in this notice.  We must send your PHI to some other address or in a way other than regular mail if you ask for reasons that make sense, like if you’re in danger.
 We must tell you if we have to share your PHI after you’ve asked us not to.
 If state laws say we have to do more than what we’ve said here, we’ll follow those laws.
 We have to let you know if we think your PHI has been breached.
We may contact you
You agree that we, along with our affiliates and/or vendors, may call or text any phone numbers you
give us, including a wireless phone number, using an automatic telephone dialing system and/or a
prerecorded message. Without limit, these calls or texts may be about treatment options, other
health-related benefits and services, enrollment, payment, or billing.
What if you have questions?
If you have questions about our privacy rules or want to use your rights, please call Member Services at
1-800-600-4441. If you’re deaf or hard of hearing, call 711.
What if you have a complaint?
We’re here to help. If you feel your PHI hasn’t been kept safe, you may call Member Services or
contact the Department of Health and Human Services. Nothing bad will happen to you if you
complain.
Write to or call the Department of Health and Human Services:
Office for Civil Rights
U.S. Department of Health and Human Services
Sam Nunn Atlanta Federal Center, Suite 16T70
61 Forsyth St. SW
Atlanta, GA 30303-8909
Phone: 1-800-368-1019
TDD: 1-800-537-7697
Fax: 404-562-7881
We reserve the right to change this Health Insurance Portability and Accountability Act (HIPAA) notice and
the ways we keep your PHI safe. If that happens, we’ll tell you about the changes in a newsletter. We’ll also
post them on the Web at www.myamerigroup.com/pages/privacy.aspx.
Your personal information
We may ask for, use and share personal information (PI) as we talked about in this notice. Your PI is not
public and tells us who you are. It’s often taken for insurance reasons.
 We may use your PI to make decisions about your:
– Health
– Habits
– Hobbies
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We may get PI about you from other people or groups like:
– Doctors
– Hospitals
– Other insurance companies
We may share PI with people or groups outside of our company without your OK in some cases.
We’ll let you know before we do anything where we have to give you a chance to say no.
We’ll tell you how to let us know if you don’t want us to use or share your PI.
You have the right to see and change your PI.
We make sure your PI is kept safe.
This information is available for free in other languages. Please contact our customer service number at
1-800-600-4441 (TTY 711), Monday to Friday from 8 a.m. to 7 p.m. Eastern time.
Revised April 28, 2015
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IMPORTANT PHONE NUMBERS
Services Needed
If you have an emergency
Amerigroup Member Services
Enrollment or disenrollment information
Statewide Florida Medicaid Managed Care Helpline
The Department of Children and Families (DCF)
Automated ACCESS Information and Member Call
Center
Elderly Helpline (Aging and Disability Resource
Center)
The Subscriber Assistance Program
Statewide Consumer Complaint Hotline
Behavioral health care
Eye care - EyeQuest
Disease management
Dental – DentaQuest
Transportation – LogistiCare
Medicaid Recipient Support
Phone Number
911
1-800-600-4441 (TTY 711)
Choice Counseling 1-877-711-3662
1-877-711-3662
1-866-762-2237
1-800-96-ELDER (1-800-963-5337)
1-850-412-4502
1-888-419-3456
1-800-600-4441 (TTY 711)
1-855-418-1627
1-888-830-4300 (TTY 711) ask for a care
manager
1-855-418-1627
1-866-372-9794
1-877-254-1055
Medicaid Area Offices
Recipient and Provider Assistance is online at
ahca.myflorida.com/Medicaid/Operations/assistance/recipients.Advance Directive or Living Will
STATEMENT OF ADVANCE DIRECTIVE OR LIVING WILLS
This section tells you about Florida law on advance directives or living wills. Under Florida Law (see
note below), every adult age 18 and older has the right to make certain decisions about his or her
medical treatment. The law allows for the respect of your rights and personal wishes, even if you are
too sick to make choices yourself.
You have the right, under certain cases, to choose whether to accept or reject medical treatment,
including whether to keep getting medical treatment and other procedures that would keep you alive
by artificial means. You have the right to participate in decisions regarding your health care, including
the right to refuse treatment.
You may spell out these rights in a living will. Your living will has your personal orders about how to
keep you alive in the case of serious illness that could cause death.
You may also choose another person, or surrogate, who may decide for you if you become mentally or
physically unable to do so. This surrogate may act on your behalf for the life-threatening or nonlife
threatening illness. Any limits to the power of the surrogate to decide for you should be clearly expressed.
If you have questions, call Member Services at 1-800-600-4441.
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You have the right to file a complaint if you think any of the laws about advance directives or living
wills are not being followed. To file a complaint, call the Consumer Complaint Hotline toll free at
1-888-419-3456.
The Living Will and Designation of Health Care Surrogate forms are at the end of this handbook.
A Living Will
A living will is a statement that lets your doctor and family know your wishes if:
 There were no hope for you to recover
 You can’t make your own choices
For instance, whether to keep using a breathing machine to stay alive if you were in a permanent coma
after a car accident.
A Durable Power of Attorney for Health Care
A Durable Power of Attorney for Health Care is a statement in which you choose a person to make
medical judgments for you if you can’t make those choices for yourself. That person should be
someone you trust to make health choices like the ones you would make if you were able. Usually, that
person would be a relative or close friend.
Is a Living Will Better Than a Durable Power of Attorney for Health Care?
A living will and a durable power of attorney for health care aren’t the same. They are used for
different things. For these reasons, they both are good. These statements are to help your family and
your doctor make choices about your health care at a time when you’re not able.
You may use a Living Will or a Durable Power of Attorney for Health Care or both of these forms for
direction of your medical care. You can combine them into one statement that chooses a person to
make medical choices for you but also tells that person what to do if there is no hope for you to
get better.
You can change your mind or cancel your statements at any time. Changes should be written, signed
and dated. You can also change your mind by telling someone. Give your PCP a copy of the new living
will or durable power of attorney for health care to keep with your medical records.
The only time an advance directive can be used is when you’re mentally disabled and can’t make
health care choices. Once you’re able to make choices again, the advance directive isn’t in effect. It will
be on standby should you ever become disabled again and can’t make choices for yourself.
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Note: The legal basis for this right can be found in the Florida Statutes: Life-Prolonging Procedure Act,
Chapter 765; Health Care Surrogate Act, Chapter 745; Durable Power of Attorney Section 709.08; and
Court Appointed Guardianship, Chapter 744; and in the Florida Supreme Court, decision on the
constitutional right of privacy, Guardianship of Estelle Browning, 1990. Amerigroup shall reflect
changes in state law as soon as possible, but no later than ninety (90) calendar days after the effective
change. If you have any questions about the legal requirements or issues with these forms, you should
talk to a licensed attorney in the state of Florida. Amerigroup cannot provide you with any legal advice.
MEMBER GRIEVANCES AND APPEALS
You have the right to tell us if you’re not happy with your care or the coverage of your health care
needs. These are called grievances and appeals. You can talk to someone from grievance and appeals
Monday through Friday from 8:30 a.m. to 5:30 p.m. Eastern time.
A grievance is when you’re not happy about something besides your benefits. A grievance could be
about a doctor’s behavior or about information you should have received, but didn’t. An appeal is
when you feel you should be getting a service covered and you’re not or that service has been
stopped.
Complaints and Grievances
I Have a Concern I Would Like to Report
Amerigroup has a process to solve complaints and grievances. If you have a concern that is easy to
solve and can be resolved within 24 hours, Member Services will help you.
If your concern can’t be handled within 24 hours and needs to be looked at by our grievance
coordinator, your call will be transferred to the grievance and appeals coordinator.
How do I let Amerigroup know about my concern?
A complaint or grievance must be given out loud by phone or in person, or in writing within one (1)
year of when it happened.
To file a complaint or grievance with a grievance and appeals coordinator:
1. Call Member Services at 1-800-600-4441 (TTY 711).
2. Write us a letter regarding your concern. Mail it to:
Amerigroup
Tampa, FL 33607-4173
You can have someone else help you with the grievance process. This person can be:
 A family member
 A friend
 Your doctor
 A lawyer
Write this person’s name on the grievance form.
42
If you need help filing the complaint, Amerigroup can help. Call Member Services at 1-800-600-4441
(TTY 711) and a grievance and appeals coordinator will help you.
Once Amerigroup gets your grievance (oral or written), we will send you a letter within five business
days. This letter will tell you the date we got your grievance.
What happens if I have additional information?
If you have more information you want us to have:
1. Bring it to us in person or mail it to:
Amerigroup
Tampa, FL 33607-4173
2. Ask for the grievance and appeals coordinator to call you when you send in your grievance
3. Call the grievance and appeals coordinator at 1-800-600-4441 (TTY 711)
What happens next?
The grievance coordinator will review your concern. If more information is needed or you have asked
to talk to the coordinator, he or she will call you.
Medical concerns are looked at by medical staff. Amerigroup will tell you the decision of your
grievance within 30 calendar days from the date we got your grievance.
What happens if I want an extension?
Although Amerigroup normally will resolve your concern within 30 calendar days, there are times
when an extension is needed.
Amerigroup may extend the time it takes to resolve your concern up to 14 calendar days if:
1. You request an extension
2. Amerigroup needs additional information and we believe by extending the time it is in your
best interest
Amerigroup will notify you within five business days of our identification that a grievance extension
is needed.
Medical Appeals
There may be times when Amerigroup says it will not pay, in whole or in part, for care that your doctor
has asked for. If we do this, you (or your doctor for you and with your written approval) can appeal the
decision. A medical appeal is when you ask Amerigroup to look again at the care your doctor asked for,
and we said we will not pay for. You must file for an appeal within 30 calendar days from the date on
the letter that says we will not pay for a service. Amerigroup will not act differently toward you or the
doctor who helped file an appeal.
43
I want to ask for an appeal. How do I do it?
An appeal may be filed out loud by phone or in writing. This needs to be within 30 calendar days of
when you get the notice of action.
There are two ways to file an appeal:
1. Write and ask to appeal. Mail the appeal request and all medical information to:
Amerigroup
Tampa, FL 33607-4173
2. Call the grievance and appeal coordinator toll free at 1-800-600-4441 (TTY 711). Except when an
expedited ruling is needed, an oral notice must be followed by a written notice within 10 calendar
days of the oral notice. The date of the oral notice will be the date of receipt.
What else do I need to know?
When we get your letter, we will send you a letter within five business days. This will tell you we got
your appeal.
You may talk to the doctor who looks at your case. We’ll help you meet with or talk to him or her.
You may ask for a free copy of the guidelines, records or other information used to make this ruling.
We’ll tell you what the ruling is within 30 calendar days of getting your appeal request.
What if I have more information I want you to have?
If you have more information to give us, bring it in person or mail it to the Medical Appeals address
above. Also, you can look at your medical records and information on this ruling before and during the
appeal process.
The time frame for an appeal may be extended up to 14 calendar days if:
You ask for an extension
Amerigroup finds additional information is needed, and the delay is in your interest


If the time frame is prolonged other than at your request, Amerigroup will let you know in writing
within five business days of when the ruling is made.
If you have a special need, we will give you extra help to file your appeal. Please call Member Services
at 1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
What can I do if I think I need an urgent or expedited appeal?
You or your doctor or someone on your behalf can ask for an urgent or expedited appeal if:
 You think the time frame for a standard appeal process could seriously harm your life or health or
ability to attain, maintain or regain maximum function, based on a prudent layperson’s judgment
44
 In the opinion of your doctor who has knowledge of your medical condition, a standard appeal
would subject you to severe pain that cannot be well-managed without the care or treatment that
is the subject of the request
You can also ask for an expedited appeal by calling Member Services toll free at 1-800-600-4441
(TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time. Should you require an expedited
appeal during nonworking hours, Amerigroup On Call. This 24-hour nurse helpline can handle your
appeal request.
If you have any questions, need help or would like to talk to the grievance and appeals coordinator,
please call Member Services toll free at 1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m.
to 7 p.m. Eastern time.
We must respond to you by phone or in person within 72 hours after we receive the appeal request,
whether the appeal was made out loud by phone or in writing. Amerigroup will follow up in writing no
later than three calendar days after the initial oral notification.
If the request for an expedited appeal is denied:
 The appeal will be transferred to the time frame for standard resolution
 You will be notified within 72 hours
What if my health care was reduced, postponed or ended and I want to keep getting health care
while my appeal is in review?
Call Member Services if you would like to keep your benefits during your appeal. Amerigroup will
continue your benefits if:
1. You or your authorized representative file an appeal with Amerigroup regarding the decision:
a. Within 10 business days after the notice of the adverse action is mailed; or
b. Within 10 business days after the intended effective date of the action, whichever is later.
2. The appeal involves the termination, suspension or reduction of a previously authorized course of
treatment
3. The services were ordered by an authorized provider
4. The original period covered by the original authorization has not expired; and
5. You request extension of benefits
If you meet these requirements, Amerigroup will approve the service until one of the following
happens:
1. You withdraw the appeal
2. Ten business days pass after Amerigroup sends you the notice of resolution of the appeal against
you, unless within those 10 days you have requested a Medicaid Fair Hearing with continuation of
benefits
3. The Medicaid Fair Hearing office issues a hearing decision adverse to you
4. The time period or service limits of a previously authorized service have been met
If the state fair hearing or Subscriber Assistance Program agrees with us, you may have to pay for the
care you got during the appeal.
45
What can I do if Amerigroup still will not pay?
You have a right to ask for a state fair hearing. You do not need to file an appeal before you ask for the
fair hearing. If you ask for a fair hearing, you must do so no later than 90 calendar days of getting our
letter that says we will not pay for a service.
The Office of Appeal Hearings is not part of Amerigroup. This office looks at appeals from Florida
Medicaid members.
If you contact the Office of Appeal Hearings, we will give them facts about your case. This includes the
details you have given us.
Note: You cannot ask for a Medicaid fair hearing if you have MediKids.
How do I contact the state for a fair hearing?
You can contact the Office of Appeal Hearings at any time during the Amerigroup appeals process.
They are at:
Department of Children and Families
Office of Appeal Hearings
1317 Winewood Blvd., Building 5, Room 255
Tallahassee, FL 32399-0700
Phone: 1-850-488-1429
Fax: 1-850-487-0662
Email: [email protected]
Website: www.myflfamilies.com/about-us/office-inspector-general/investigation-reports/appeal
hearings
You have the right to ask to get benefits during your hearing. Call Member Services toll free at
1-800-600-4441 (TTY 711). If the Office of Fair Hearing agrees with Amerigroup, you may have to pay
for services you got during the appeal.
How do I ask for an external appeals review?
After getting a final ruling from Amerigroup, call or write the Subscriber Assistance Program (SAP):
Agency for Health Care Administration (AHCA)
Subscriber Assistance Program
Building 3, MS #45
2727 Mahan Drive
Tallahassee, FL 32308
Toll-free phone number: 1-888-419-3456
Local phone number: 850-412-4502
Before filing with the SAP, you must finish the Amerigroup appeals process. You must ask for your SAP
appeal within one year after you get the final ruling letter from Amerigroup. The SAP will not look at an
appeal that has already been to a Medicaid fair hearing.
46
FL MHB ENG 01.16
The SAP will complete its review and make a ruling. Rulings made through a state fair hearing or
Subscriber Assistance Program review are final.
If you have any questions or need help filing an appeal with Amerigroup, call Member Services toll free
at 1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND
RESPONSIBILITIES
The Patient's Bill of Rights and Responsibilities was created to:
 Promote the interests and well-being of patients
 Help improve communication between the patient and the health care provider
Florida law requires that:
 Your health care provider or health care facility recognize your rights while you are receiving
medical care
 You respect the health care provider’s or health care facility’s right to expect certain behavior on
the part of patients (see Section 381.026, Florida Statutes)
As a patient, you have the right to:
 Be treated with respect and with due consideration for your dignity and privacy.
 A prompt and reasonable response to questions and requests.
 Know who is providing medical services and who is responsible for your care. Know what member
support services are available, including whether an interpreter is available if you don’t speak
English.
 Know what rules and regulations apply to your conduct.
 Receive information on available treatment options and alternatives, presented in a manner
appropriate to your condition and ability to understand. Members are given the opportunity to be
involved in decisions involving their health care, except when such participation is contraindicated
(not recommended) for medical reasons.
 Participate in decisions regarding your health care, including the right to refuse treatment.
 Be given health care services in line with federal and state regulations.
 Be given, upon request, full information and necessary advice of available financial help for
your care.
 Know, as a member eligible for Medicare, upon request and before treatment, whether your health
care provider or health care facility accepts the Medicare assignment rate.
 Receive, upon request, before treatment, a reasonable estimate of charges for medical care.
 Receive a copy of a reasonably clear and easy-to-understand itemized bill and, upon request, to
have the charges explained.
 Impartial access to medical treatment or accommodations, no matter of race, national origin,
religion, physical handicap or source of payment.
 Treatment for any emergency medical condition that will get worse from not getting the proper
treatment.
 Know if medical treatment is for experimental research and to give your consent or refusal to be
involved in that research.
47
 File grievances regarding any violation of your rights, as states in Florida law, through the grievance
procedure to the health care provider or health care facility which served you and to the
appropriate state licensing agency.
 Be free from any form of restraint (control) or seclusion used as coercion (force), discipline,
convenience or retaliation (revenge).
 Ask for and get a copy of your medical records and ask that they be updated or corrected.
Also, the state must make sure you’re able to use your rights and those rights do not change the way
Amerigroup and its providers or the state agency treat you.
As a patient, you have the responsibility to:
 Provide your health care provider, to the best of your knowledge, correct and complete
information about present complaints, past illnesses, hospitalizations, medications (including over
the-counter products), dietary supplements, any allergies or sensitivities, and other matters
relating to your health.
 Report unexpected changes in your condition to your health care provider.
 Report to your health care provider whether you understand a planned action and what is
expected of you.
 Follow the treatment plan recommended by the health care provider.
 Keep appointments and, when you’re not able to for any reason, tell the health care provider or
health care facility.
 Understand your actions if you refuse treatment or don’t follow the health care provider’s
instructions.
 Inform your provider about any living will, medical power of attorney or other directive that could
change your care.
 Make sure the needs of your health care are met as quickly as possible.
 Follow health care facility rules and regulations about member care and conduct.
 Behave in a way that is respectful of all health care providers and staff, as well as of
other members.
Amerigroup members also have these additional rights and responsibilities. You have the right to:
 An honest talk about appropriate or medically necessary treatment choices for your conditions, no
matter what the cost or benefit coverage.
 Address your grievance (complaint) or appeals about Amerigroup, our services, practitioners and
providers or the care we give.
 Get information about Amerigroup, our services, practitioners and providers, and member rights
and responsibilities.
 Make suggestions about our member rights and responsibilities policy.
 Understand your health problems and be part of creating a treatment goal with your providers, as
is possible.
This information is available for free in other languages. Please contact our customer service number at
48
Amerigroup is a Managed Care Plan with a Florida Medicaid contract.
The benefit information provided is a brief summary, not a complete description of benefits. For more
information, contact Amerigroup.
49
FL MHB ENG 01.16
APPENDIX
50
FL MHB ENG 01.16
51
FL MHB ENG 01.16
52
FL MHB ENG 01.16
Amerigroup Address Change Form
If your name, address, county or phone number has changed, you must tell us. Please fill out this form.
Mail it back to us in the postage-paid envelope.
You must also report changes to the Department of Children and Family Services (DCF). You can:
1. Call toll free 1-866-762-2237 (TTY 1-800-995-8771), Monday through Friday from 8 a.m. to
5:30 p.m. Eastern time.
2. Go online to download the DCF Change Report Form (form ID: 243) at
www.dcf.state.fl.us/DCFForms.
a. Mail the form to your local DCF office; local offices can be found online at
www.myflfamilies.com/contact-us.
b. Fax the form toll free to 1-866-886-4342.
3. Create an online account at https://myaccessaccount.dcf.state.fl.us/Login.aspx; update your
information at www.myflfamilies.com.
If you get benefits through Medicare, you must report your address change to the Social Security
Administration office. You can:
1. Call 1-800-772-1213 (TTY 1-800-325-0778) Monday through Friday from 7 a.m. to 7 p.m. Eastern
time.
2. Visit your local Social Security office; find a local office at https://secure.ssa.gov/ICON/main.
Name:
Street address:
City:
ZIP code: State:
County (required):
Phone number:
Signature:
Date:
53
FL MHB ENG 01.16
54
FL MHB ENG 01.16
55
FL MHB ENG 01.16
2015 Recommended Immunizations for Adults: By Age
If you are this age,
talk to your healthcare professional about these vaccines
Flu
Influenza
Td/Tdap
Tetanus,
diphtheria,
pertussis
Shingles
Zoster
Pneumococcal
PCV13
Meningococcal
PPSV23
MMR
Measles,
mumps,
rubella
HPV
Human papillomavirus
for women
19 - 21 years
Chickenpox
Varicella
Hepatitis A Hepatitis B
for men
Hib
Haemophilus
influenzae
type b
3 doses
3 doses
22 - 26 years
27 - 49 years
50 - 59 years
3 doses
1or 2
doses
1 dose
1 dose
of Tdap*
Flu
vaccine
every
year
1 or 2
doses
1 or
more
doses
Td
booster
every 10
years
2 doses
2 doses
3 doses
1 or 3
doses
60 - 64 years
1 dose
65+ year
More Information:
1 dose
There are
several flu
vaccines
available.
Talk to your
healthcare
professional
about which
flu vaccines
is right for you.
* If you are
pregnant, you
should get a
Tdap vaccine
during the
3rd trimester
of every
pregnancy to
help protect
your babies
from pertussis
(whooping
cough).
You should
get zoster
vaccine even
if you’ve
had shingles
before.
Recommended For You: This vaccine is recommended for you unless your healthcare professional tells you that you cannot safely receive it or that you do not need it.
May Be Recommended For You: This vaccine is recommended for you if you have certain risk factors due to your health, job, or lifestyle that are not listed here. Talk to your healthcare professional to see if you need this vaccine.
1 or 2
doses
1 dose
There are two different types of
pneumococcal vaccine: PCV13
(conjugate) and PPSV23
(polysaccharide). Talk with
your healthcare professional
to find out if one or both
pneumococcal vaccines are
recommended for you.
Your healthcare
professional will
let you know how
many doses you
need.
Recommended for you if you did not get it when you were a child.
If you were born
in 1957 or after,
and don’t have a
record of being
vaccinated or
having had
measles, mumps
and rubella,
talk to your
healthcare
professional
about how
many doses you
may need.
There are two HPV vaccines but
only one HPV vaccine (Gardasil®)
should be given to men.
If you are a male 22 through 26
years old and have sex with men
you should complete the HPV
vaccine series if you have not
already done so.
For more information, call 1-800-CDC-INFO
(1-800-232-4636) or visit www.cdc.gov/vaccines
If you are traveling outside the United States, you
may need additional vaccines.
Ask your healthcare professional about which vaccines
you may need at least 6 weeks prior to your travel.
56
Your healthcare
professional will
let you know
how many doses
you need.
FL MHB ENG 01.16

Member Handbook Amerigroup Florida, Inc. Statewide Medicaid

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