What is AMERICAID Community Care?

Transcription

Real
Solutions
Member Handbook
NM-MHB-0004-12 12.12
Amerigroup Community Care of New Mexico, Inc.
New Mexico Coordination of
Long-Term Services Program
1-800-600-4441
n
www.myamerigroup.com/nm
www.myamerigroup.com
Dear Member:
Welcome to Amerigroup Community Care of New Mexico, Inc. We are happy you picked us to arrange
your quality health care benefits.
This member handbook tells you how Amerigroup works and how to keep you healthy. It tells you how
to get health care when it is needed, too.
You will get your Amerigroup ID card and more information from us in a few days. Your ID card will tell
you when your Amerigroup membership starts. Please check your ID card right away. If any
information is not right, please call us at 1-800-600-4441. We will send you a new ID card with the
correct information.
If you need to reach us, you can call Member Services at 1-800-600-4441. You can talk to a Member
Services representative about your benefits. You can also talk to a nurse on our 24-hour Nurse
HelpLine if you need medical advice. We are here to help you get quality health care coverage.
Thank you again for picking us as your health plan.
Sincerely,
Jeanine Davis
Chief Operating Officer
New Mexico CoLTS program services are funded in part under contract with the state of New Mexico.
AMERITIPS
HEALTH TIPS THAT MAKE HEALTH HAPPEN
YOU NEED TO GO TO YOUR DOCTOR NOW!
WHEN IS IT TIME FOR A WELLNESS VISIT?
All Amerigroup members need to have regular wellness visits. This way, your Primary Care Provider
(PCP) can see if you have a problem before it is a bad problem. When you become an Amerigroup
member, call your PCP and make your first appointment before the end of 90 days.
WELLNESS VISITS FOR CHILDREN
Children need more wellness visits than adults. These wellness visits for children are called Tot-to-Teen
HealthChecks. Your child should get wellness visits at the times listed below.
Newborn
3-5 days old
1 month old
2 months old
4 months old
6 months old
9 months old
12 months old
15 months old
18 months old
24 months old
30 months old
After age 2, you and your child should keep going to your PCP every year for wellness visits.
WHAT IF I BECOME PREGNANT?
If you think you are pregnant, call your PCP or OB/GYN right away. This can help you have a healthy
baby.
If you have any questions or need help making an appointment with your PCP or OB/GYN, please call
our Member Services department at 1-800-600-4441.
ALERT! KEEP THE RIGHT CARE. DO NOT LOSE YOUR HEALTH CARE BENEFITS — RENEW YOUR
ELIGIBILITY FOR MEDICAID BENEFITS ON TIME. SEE PAGE 68 FOR MORE DETAILS.
Amerigroup is a culturally diverse company. We welcome all eligible individuals into our health care
programs, regardless of health status. If you have questions or concerns, please call
1-800-600-4441 (TTY 1-800-855-2880) and ask for extension 34925. Or visit
www.myamerigroup.com.
AMERIGROUP COMMUNITY CARE OF NEW MEXICO, INC.
MEMBER HANDBOOK
Two Park Square • 6565 Americas Parkway, N.E., Suite 110 • Albuquerque, NM 87110
1-800-600-4441
TTY 1-800-855-2880
www.myamerigroup.com/NM
Welcome to Amerigroup Community Care of New Mexico, Inc.! You will get most of your health care
services through Amerigroup. This member handbook will tell you how to use Amerigroup to get the
health care you need.
Table of Contents
WELCOME TO AMERIGROUP COMMUNITY CARE OF NEW MEXICO, INC............................................. 1
INFORMATION ABOUT YOUR NEW HEALTH PLAN ................................................................................ 1
HOW TO GET HELP ................................................................................................................................. 1
AMERIGROUP MEMBER SERVICES DEPARTMENT ........................................................................................... 1
AMERIGROUP 24-HOUR NURSE HELPLINE ...................................................................................................... 2
YOUR SERVICE COORDINATOR......................................................................................................................... 2
OTHER IMPORTANT PHONE NUMBERS ........................................................................................................... 3
YOUR AMERIGROUP MEMBER HANDBOOK .................................................................................................... 3
IF YOU HAVE MEDICARE COVERAGE ...................................................................................................... 4
YOUR IDENTIFICATION CARDS ............................................................................................................... 4
YOUR PROVIDERS ............................................................................................................................. 5
PICKING A PRIMARY CARE PROVIDER .................................................................................................... 5
SECOND OPINION................................................................................................................................... 6
IF YOU HAD A DIFFERENT PRIMARY CARE PROVIDER BEFORE YOU JOINED AMERIGROUP ................. 6
IF YOUR PRIMARY CARE PROVIDER’S OFFICE MOVES, CLOSES OR LEAVES THE AMERIGROUP
NETWORK ............................................................................................................................................... 6
HOW TO CHANGE YOUR PRIMARY CARE PROVIDER ............................................................................. 6
IF YOUR PRIMARY CARE PROVIDER ASKS FOR YOU TO BE CHANGED TO ANOTHER PRIMARY CARE
PROVIDER ............................................................................................................................................... 7
IF YOU WANT TO GO TO A PROVIDER WHO IS NOT YOUR PRIMARY CARE PROVIDER ......................... 7
PICKING AN OB/GYN .............................................................................................................................. 7
SPECIALISTS ............................................................................................................................................ 8
NATIVE AMERICAN MEMBERS ............................................................................................................... 8
GOING TO THE PRIMARY CARE PROVIDER ....................................................................................... 11
YOUR FIRST PRIMARY CARE PROVIDER APPOINTMENT ...................................................................... 11
HOW TO MAKE AN APPOINTMENT...................................................................................................... 11
WAIT TIMES FOR APPOINTMENTS ....................................................................................................... 12
WHAT TO BRING WHEN YOU GO FOR YOUR APPOINTMENT .............................................................. 12
HOW TO CANCEL AN APPOINTMENT................................................................................................... 12
HOW TO GET TO A DOCTOR’S APPOINTMENT OR TO THE HOSPITAL ................................................. 12
DISABILITY ACCESS TO AMERIGROUP NETWORK PROVIDERS AND HOSPITALS.................................. 13
WHAT DOES MEDICALLY NECESSARY MEAN? .................................................................................. 13
AMERIGROUP HEALTH CARE BENEFITS ............................................................................................ 13
PRIOR AUTHORIZATIONS ................................................................................................................ 38
AFFIRMATIVE STATEMENT ................................................................................................................... 38
EXTRA AMERIGROUP BENEFITS ....................................................................................................... 39
SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID ........................................................................ 39
SERVICES THAT DO NOT NEED A REFERRAL...................................................................................... 40
DIFFERENT TYPES OF HEALTH CARE ................................................................................................. 41
ROUTINE, URGENT AND EMERGENCY CARE: WHAT IS THE DIFFERENCE? .......................................... 41
ROUTINE CARE ............................................................................................................................................... 41
URGENT CARE ................................................................................................................................................ 41
EMERGENCY CARE.......................................................................................................................................... 42
HOW TO GET HEALTH CARE WHEN YOUR PRIMARY CARE PROVIDER’S OFFICE IS CLOSED................ 43
HOW TO GET HEALTH CARE WHEN YOU ARE OUT OF TOWN ............................................................. 43
WELLNESS CARE FOR CHILDREN AND ADULTS.................................................................................. 43
WELLNESS CARE FOR CHILDREN .......................................................................................................... 44
WHY WELL-CHILD VISITS ARE IMPORTANT FOR CHILDREN ........................................................................... 44
WHEN YOUR CHILD SHOULD GET TOT-TO-TEEN HEALTHCHECK VISITS ........................................................ 44
BLOOD LEAD SCREENING ............................................................................................................................... 45
EYE EXAMS ..................................................................................................................................................... 45
HEARING EXAMS ............................................................................................................................................ 45
DENTAL CARE ................................................................................................................................................. 45
WELLNESS CARE FOR ADULTS .............................................................................................................. 46
WHEN YOU MISS ONE OF YOUR WELLNESS VISITS.............................................................................. 51
SPECIAL KINDS OF HEALTH CARE ..................................................................................................... 51
EYE CARE .............................................................................................................................................. 51
DENTAL CARE ....................................................................................................................................... 51
BEHAVIORAL HEALTH (MENTAL HEALTH SERVICES) ............................................................................ 52
FAMILY PLANNING SERVICES ............................................................................................................... 52
CARE FOR INDIVIDUALS WITH SPECIAL HEALTH CARE NEEDS ............................................................. 52
HERE’S HOW IT WORKS.................................................................................................................................. 52
GETTING STARTED.......................................................................................................................................... 53
MEDICINES ........................................................................................................................................... 54
BIRTHING OPTIONS PROGRAM ............................................................................................................ 55
SPECIAL CARE FOR PREGNANT MEMBERS ........................................................................................... 56
GUIDE TO PRENATAL CARE .................................................................................................................. 57
DISEASE MANAGEMENT ...................................................................................................................... 58
SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING ................................................................... 59
HEALTH INFORMATION ........................................................................................................................ 59
HEALTH EDUCATION CLASSES .............................................................................................................. 60
COMMUNITY EVENTS........................................................................................................................... 60
DOMESTIC VIOLENCE ........................................................................................................................... 60
ABUSE, NEGLECT AND EXPLOITATION ................................................................................................. 61
MINORS ................................................................................................................................................ 61
MAKING A LIVING WILL (ADVANCE DIRECTIVES) .............................................................................. 62
GRIEVANCES AND MEDICAL APPEALS .............................................................................................. 62
GRIEVANCES ......................................................................................................................................... 62
FILING A GRIEVANCE WITH AMERIGROUP .................................................................................................... 63
FILING A GRIEVANCE WITH THE STATE .......................................................................................................... 63
MEDICAL APPEALS................................................................................................................................ 64
EXPEDITED APPEALS ............................................................................................................................. 65
AUTO-EXPEDITED APPEALS .................................................................................................................. 66
PAYMENT APPEALS .............................................................................................................................. 66
FAIR HEARINGS..................................................................................................................................... 67
CONTINUATION OF BENEFITS .............................................................................................................. 67
OTHER INFORMATION .................................................................................................................... 67
IF YOU MOVE........................................................................................................................................ 67
RENEW YOUR MEDICAID BENEFITS ON TIME ...................................................................................... 68
IF YOU ARE NO LONGER ELIGIBLE FOR MEDICAID ............................................................................... 68
HOW TO DISENROLL FROM AMERIGROUP .......................................................................................... 68
REASONS WHY YOU CAN BE DISENROLLED FROM AMERIGROUP ...................................................... 69
IF YOU GET A BILL ................................................................................................................................. 69
IF YOU HAVE OTHER HEALTH INSURANCE (COORDINATION OF BENEFITS) ........................................ 69
CHANGES IN YOUR AMERIGROUP COVERAGE..................................................................................... 69
HOW TO TELL AMERIGROUP ABOUT CHANGES YOU THINK WE SHOULD MAKE................................ 70
HOW AMERIGROUP PAYS PROVIDERS ................................................................................................. 70
YOUR AMERIGROUP MEMBER BILL OF RIGHTS ................................................................................ 71
YOUR RIGHTS ....................................................................................................................................... 71
YOUR RESPONSIBILITIES ....................................................................................................................... 72
HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID PROGRAM ..................................... 73
NOTICE OF PRIVACY PRACTICES ....................................................................................................... 78
WELCOME TO AMERIGROUP COMMUNITY CARE OF NEW MEXICO, INC.
Information about Your New Health Plan
Welcome to Amerigroup Community Care of New Mexico, Inc. We are a Managed Care Organization
(MCO) that arranges complete health care coverage for the state of New Mexico’s Coordination of
Long-Term Services (CoLTS) program members. We arrange the physical, behavioral, long-term and
social services care of CoLTS members.
Our goal is to help you live in your home and community. We do this by:
Offering a wide range of home care coverage and community services
Helping members change from a long-term care facility to a community setting
Our members include the following groups:
Individuals who are eligible for full Medicaid and Medicare benefits
Persons 21 years of age or older who are receiving or who qualify for current Medicaid State Plan
Personal Care Option services
Persons receiving Medicaid and residing in a Nursing Facility
Persons currently receiving or who qualify for CoLTS “c” Waiver (formerly Disabled and Elderly)
Home- and community-based waiver services and persons with certain types of brain injury
Persons in the Mi Via 1915(c) waiver who qualify for the current CoLTS “c” Waiver or brain injury
services
The following groups are not eligible to enroll in Amerigroup:
Consumers living in intermediate care facilities for the mentally retarded
Consumers getting services under 1915(c) home- and community-based waiver programs for the
developmentally disabled, those with AIDS/AIDS-related conditions and the medically fragile
Consumers who are in SALUD!
Consumers eligible for Medicaid category 029 or family planning services
Adults ages 19-64 eligible for category 062, state coverage insurance
This program is sponsored by Amerigroup Community Care of New Mexico, Inc. and the state of New
Mexico Human Services Department (HSD) and the New Mexico Aging and Long-Term Services
Department (ALTSD).
This member handbook tells you how to get home support and community services as an Amerigroup
member. It also provides other details about your benefits.
How to Get Help
Amerigroup Member Services Department
You can call our Member Services department at 1-800-600-4441. You can call us Monday through
Friday from 8:00 a.m. to 5:00 p.m. Mountain time, except for holidays. If you call after 5:00 p.m., you
can leave a voice mail message. A Member Services representative will call you back the next business
day. Member Services can help you with:
This member handbook
Transportation
Healthy living
Member ID cards
Health care benefits
Grievances and appeals
Your doctors
Wellness care
Rights and responsibilities
Going to the doctor
Special kinds of health care
1
NM-MHB-0004-12
NM MHB ENG 12/12
You can also call us:
If you wish to request a copy of the Amerigroup Notice of Privacy Practices. This notice tells you:
- How medical information about you may be used and disclosed
- How you can get access to this information
If you move. We will need to know your new address and phone number. You should also call your
local Income Support Division Office and tell them your new address.
If you want to ask for a copy of the member handbook in a preferred language.
For members who do not speak English:
We can help in many different languages and dialects
We can help translate for visits with your doctor at no cost to you
Please let us know if you need an interpreter at least 24 hours before your visit
Call Member Services for more details
For members who are deaf or hard of hearing:
Call the toll-free AT&T Relay Service at 1-800-855-2880
We will set up and pay for you to have a person who knows sign language to help you during your
doctor visits
Please let us know if you need an interpreter at least 24 hours before your appointment
Amerigroup 24-hour Nurse HelpLine
Call our 24-hour Nurse HelpLine at 1-800-600-4441 if you need advice on:
How soon you need to get care for an illness
What kind of health care you need
What to do to take care of yourself before you see the doctor
How you can get the care that is needed
We want you to be happy with all the services you get from our network of providers and hospitals. If
you have any problems, please call us. We want to:
Help you with your care
Help you correct any problems you may have with your care
Your Service Coordinator
After enrolling in Amerigroup, you will get a welcome call from a nurse in our Early Case Finding SM
(ECF) Unit. If you have not received a welcome call, you will get one soon.
During this call, we ask you questions about:
Your health care needs
The long-term care services you are getting now
We go over the CoLTS program with you and answer any questions you may have.
If you have special health care needs, the ECF nurse will set up a time for you to talk to a service
coordinator. This will help you get the right kind of care. Your service coordinator will:
Work with you and your family to develop an Individualized Service Plan (ISP) or treatment plan
based on your unique health care needs
Discuss your specific needs with you, your family or caregiver, your doctor, and other providers of
care
2
NM-MHB-0004-12
NM MHB ENG 12/12
Help you follow the ISP or treatment plan
Work with your providers to help create a medical home for you
Help you get timely and coordinated access to your providers and covered services you need,
including the correct preventive health services
Answer any questions you may have about your health care services
Tell you how to get these services
If you qualify for home- and community-based services, your service coordinator will:
Visit you in your home to assess your unique physical, behavioral, functional, environmental and
long-term support service needs
Collect complete and correct information about you to help you get the right kind of care
Manage your covered long-term support services and your acute care with social and other
services you get outside of Amerigroup
Encourage you to take part in your care to promote independent living
Request approval for long-term support services
Just call Member Services and ask to speak with your service coordinator.
You should also call your service coordinator if:
You are admitted to a hospital
Your needs change
This helps your service coordinator arrange better care for you.
Other Important Phone Numbers
SERVICE
INFORMATION
Emergencies
Call or go to the nearest hospital emergency room
Medical Assistance
For information on the program, call the Medical
Division (MAD)
Assistance Division (MAD) of the New Mexico
Human Services Department
Disease Management If you want information about our Disease
Management programs, call and ask to speak with
a disease management care manager
Access2Care
If you need help getting transportation for
medically needed appointments and treatments
PHONE NUMBER
911
toll free 1-888-997-2583
toll free 1-800-600-4441
toll free 1-866-442-4937
Your Amerigroup Member Handbook
This handbook will help you understand your health plan. If you have questions or need help reading
or understanding your member handbook, call Member Services. We also have this member handbook
in:
A large-print version
An audio-taped version
A Braille version
If you want a copy of this handbook in one of these versions, call Member Services. The other side of
this handbook is in Spanish.
3
NM-MHB-0004-12
NM MHB ENG 12/12
If You Have Medicare Coverage
The CoLTS program is not a Medicare program. But some of our members enrolled in this program also
have Medicare coverage and get regular Medicare services through:
Medicare fee-for-service
Membership in a Medicare Health Maintenance Organization (HMO)
If you are in the Medicare fee-for-service program, you will get Medicare-covered services from:
Physicians
Hospitals
Other providers who take part in the Medicare program
Amerigroup will pay back these providers for Medicare deductibles and coinsurance. This will be paid
in line with Medicare guidelines or contracted amounts.
If you are a member of a Medicare HMO, you will get services based on the guidelines of that program.
In either case, you will get Medicare services through one of these programs. Your Medicare coverage
continues apart from membership in the CoLTS program.
If you are enrolled in Medicare, you will:
Not choose a Primary Care Provider (PCP) through the CoLTS program
Get primary and acute care services, such as inpatient hospital care from Medicare providers
Please call your service coordinator to talk about the services offered to you. Your service coordinator
will help you arrange for services through Medicare and the long-term-care and community-based
services you get through this program.
Your Identification Cards
If you do not have your Amerigroup identification (ID) card yet, you will get it soon. If you are enrolled
in Medicare, you have an ID card through the Medicare program, too.
Please carry your Amerigroup ID card and your Medicare ID card with you at all times.
Your Amerigroup ID card can be used to get services covered by the New Mexico CoLTS program. It
tells providers and hospitals:
- You are a member of our health plan
- We will pay for the medically needed benefits listed in the section Amerigroup Health Care
Benefits
Your Amerigroup ID card shows:
The name, address and phone number of your PCP if you are not enrolled in Medicare
The date you became an Amerigroup member
Phone numbers you need to know, such as:
- Our Member Services department
- Our Nurse HelpLine
4
NM-MHB-0004-12
NM MHB ENG 12/12
If your Amerigroup ID card is lost or stolen, call us right away at 1-800-600-4441. We will send you a
new one.
YOUR PROVIDERS
If you qualify for Medicare, please read the section If You Have Medicare Coverage. This section gives
you details on services you get through the Medicare program. Your service coordinator will be able to
answer questions about how to arrange for services with your Medicare providers.
Picking a Primary Care Provider
All Amerigroup members must have a family doctor, also called a Primary Care Provider (PCP).
Your PCP must be in the Amerigroup network. Services given by out-of-network providers may not
be covered by Amerigroup. If you are not sure if your PCP is in our network, call Member Services.
Ask to speak with your service coordinator.
Your PCP will give you a medical home. This means he or she will get to know you and your health
history.
Your PCP is able to help you get quality care.
- Your PCP will give you all of the basic health services you need. He or she will also send you to
other providers or hospitals when you need special care.
- Native American members may choose an Indian Health Services (IHS) or Tribal 638 health care
facility as their PCP, whether or not the facility is in the Amerigroup network.
Medicare and Medicaid-eligible Members
If you are eligible for both Medicaid and Medicare, you will not choose an Amerigroup CoLTS network
PCP. You will still get primary and acute care through your Medicare PCP.
Medicaid-only Eligible Members
If you only qualify for Medicaid, you should have picked a PCP when you enrolled in the Amerigroup
CoLTS program. If you did not, we will:
Get in touch with you to help you pick a PCP
Choose one who should be close by you
If you have a PCP through Amerigroup, this PCP’s name, address and phone number are on your
Amerigroup ID card.
If we assigned a PCP to you, you can pick a new one.
Look in the provider directory that came with your CoLTS program enrollment package.
Call Member Services for help. We can also help you pick a PCP. If you are seeing a PCP now, you
can look in the provider directory to see if that provider is in our network. If so, you can tell us you
want to keep that PCP.
PCPs can be any of the following as long as they are in the Amerigroup network:
Family or general practitioners
Obstetrician/gynecologists (OB/GYNs)
Geriatricians
Physician assistants
Internists
Certified nurse practitioners
Pediatricians
Specialists (for individuals with special health care needs)
5
NM-MHB-0004-12
NM MHB ENG 12/12
Family members do not have to have the same PCP.
Second Opinion
Amerigroup members have the right to ask for a second opinion. This applies to the use of any health
care services. You can get a second opinion from a network provider or a non-network provider (if a
network provider is not available). Call Member Services for help in finding a nearby provider. You may
choose this provider. This is at no cost to you.
Once approved:
You will hear from your Primary Care Provider (PCP).
Your PCP will tell you the date and time of the appointment.
Your PCP will also send copies of all related records to the doctor who will give the second opinion.
Your PCP will let you and Amerigroup know the outcome of the second opinion.
If You Had a Different Primary Care Provider before You Joined Amerigroup
You may have been seeing a Primary Care Provider (PCP) who is not in our network for an illness or
injury before you joined Amerigroup. In some cases, you may be able to keep seeing this PCP for care
while you pick a new PCP who is in our network. Call Member Services to find out more. Amerigroup
will make a plan with you and your providers. We will do this so we all know when you need to start
seeing your new Amerigroup network PCP.
If you are in the third trimester of your pregnancy when you join Amerigroup, you may keep seeing the
OB/GYN, certified nurse midwife, certified nurse practitioner or lay midwife you were seeing before
you became a member, even if that provider is not in our network.
If Your Primary Care Provider’s Office Moves, Closes or Leaves the Amerigroup
Network
Your Primary Care Provider’s (PCP’s) office may move, close or leave the Amerigroup network. If this
happens, we will:
Call or send you a letter to tell you. In some cases, you may be able to keep seeing this PCP for care
while you pick a new PCP. Call Member Services for more details about this.
Make a plan with you and your PCP so we all know when you need to start seeing your new
Amerigroup network PCP.
Help you pick a new PCP if you ask us. Call Member Services.
Send you a new ID card within 10 working days after you pick a new PCP.
How to Change Your Primary Care Provider
If you need to change your Primary Care Provider (PCP), you may pick a new one from our network at
any time. You can write to us or call us. To change your PCP, do one of the following:
Look in the Amerigroup provider directory you got with your enrollment package.
Go to www.myamerigroup.com to view the provider directory online.
Call Member Services at 1-800-600-4441. We will help you pick a new PCP.
You may ask us to change your PCP:
6
NM-MHB-0004-12
NM MHB ENG 12/12
On or before the 20th day of the month; if you do, the change will begin by the first day of the next
month
After the 20th day of the month; if you do, the change will begin by the 1st of the month after the
next month
Once your PCP has been changed, you will get a new ID card in the mail within 10 working days.
Call the PCP’s office if you want to make an appointment. The phone number is on your Amerigroup ID
card. If you need help, call Member Services. We will help you make the appointment.
If Your Primary Care Provider Asks for You to be Changed to Another Primary Care
Provider
Your Primary Care Provider (PCP) may ask you to change to a new PCP. Your PCP may do this if:
Your PCP does not have the right experience to treat you
The assignment to your PCP was made in error (like an adult assigned to a child’s PCP)
You fail to keep your appointments
You do not follow his or her medical advice over and over again
Your PCP agrees that a change is best for you
If You Want to Go to a Provider Who Is Not Your Primary Care Provider
If you want to go to a provider who is not your Primary Care Provider (PCP), please talk to your PCP
first. In some cases, your PCP needs to give you a referral so you can see another provider. In these
cases, if you go to a provider that your PCP has not referred you to, the care you get may not be
covered by Amerigroup.
Please read the section Specialists to learn more about referrals. Also read the section Services That Do
Not Need A Referral for more details. Native American members may always self-refer to an Indian
Health Services or Tribal 638 health care facility for services.
Picking an OB/GYN
Female members can see an Amerigroup network obstetrician and/or gynecologist (OB/GYN) for
OB/GYN health needs. These services include:
Well-woman visits
Prenatal care
Care for any female medical condition
Family planning
Referral to a special provider within the network
7
NM-MHB-0004-12
NM MHB ENG 12/12
You do not need a referral from your Primary Care Provider (PCP) to see your OB/GYN. If you do not want to go
to an OB/GYN, your PCP may be able to treat you for your OB/GYN health needs.
Ask your PCP if he or she can give you OB/GYN care. If not, you will need to see an OB/GYN.
Choose an OB/GYN from the list of network OB/GYNs in the Amerigroup provider directory that
came with your enrollment package. You can also find the provider directory online at
www.myamerigroup.com/NM.
While you are pregnant, your OB/GYN can be your PCP. The nurses on our 24-hour Nurse HelpLine can
help you decide if you should see your PCP or an OB/GYN. If you need help picking an OB/GYN, you
can:
Refer to the Amerigroup provider directory
Call Member Services
Specialists
Your Primary Care Provider (PCP) can take care of most of your health care needs, but you may also
need care from other kinds of providers. Amerigroup offers services from many different kinds of
providers that provide other medically needed care. These providers are called specialists because they
have training in a special type of medicine. Examples of specialists are:
Allergists (allergy doctors)
Dermatologists (skin doctors)
Cardiologists (heart doctors)
Podiatrists (foot doctors)
Your PCP will refer you to a specialist in our network if your PCP cannot give you the care you need.
In some cases, you need to have a referral from your PCP to see a specialist. In these cases:
Your PCP will give you a referral form so you can see the specialist. The referral form tells you and
the specialist what kind of health care you need.
Be sure to take the referral form with you when you go to the specialist.
Native American members may always self-refer to an Indian Health Services or Tribal 638 health care
facility for services. Read the section in this handbook Services That Do Not Need A Referral for more
details.
Sometimes a specialist can be your PCP. This may happen if you have a special health care need that is
being taken care of by a specialist.
If you have already talked with a service coordinator, he or she can help you make this change.
If you have not talked with a service coordinator, call Member Services.
Native American Members
Native American members may always self-refer to Indian Health Services or a Tribal 638
health care facility for services.
8
NM-MHB-0004-12
NM MHB ENG 12/12
Please refer to the listing of these facilities below:
INDIAN HEALTH SERVICES
Acoma Canoncito Laguna
Indian Health Services Hospital
Practice #: 01189796
80 B Veterans Blvd.
Pueblo of Acoma 87034
505-552-5386
M-F 8:00 a.m. – 4:30 p.m.
Albuquerque Indian Dental
Center
9169 Coors Blvd. NW
Albuquerque 87125-0927
505-922-4249
M-F 8:00 a.m. – 5:00 p.m.
Albuquerque Indian Health
Center
801 Vassar Drive NE
Albuquerque 87106-2725
505-248-7711
M-F 8:00 a.m. – 5:00 p.m.
Mescalero Indian Hospital
301 Sage Ave.
P.O. Box 210
Mescalero 88340-0210
505-464-4441
M-F 8:00 a.m. – 5:00 p.m.
Sandia Health Clinic
203-A School Road
P.O. Box 6008
Bernalillo 87004-2513
505-867-4487
M-F 8:00 a.m. – 5:00 p.m.
Santa Ana Health Clinic
2 Dove Road
P.O. Box 02C
Bernalillo 87004-5906
505-867-2497
M-F 8:00 a.m. – 5:00 p.m.
Canoncito Health Center
Exit 131 off I-40 6 miles N
Tohajiilee 87026
505-831-6300
M-F 8:00 a.m. – 5:00 p.m.
Cochiti Health Clinic
255 Cochiti St.
P.O. Box 105
Cochiti Pueblo 87072-0105
505-465-2587
M-F 8:00 a.m. – 5:00 p.m.
Jicarilla Indian Health Center
12000 Stone Lake Road
P.O. Box 187
Dulce 87528-0187
505-759-3291
M-F 8:00 a.m. – 5:00 p.m.
Santo Domingo Health Clinic
85 W Hwy.
Santo Domingo Pueblo 87052
505-465-3060
M-F 8:00 a.m. – 5:00 p.m.
Taos Picuris Service Unit
1090 Goat Springs Road
P.O. Box 1946
Taos 87571-1946
575-758-4224
M-F 8:00 a.m. – 5:00 p.m.
Zia Health Center
155 Capitol Square Drive Ste B
Zia Pueblo 87053-6013
505-867-5258
M-F 8:00 a.m. – 5:00 p.m.
9
NM-MHB-0004-12
NM MHB ENG 12/12
INDIAN HEALTH SERVICES (cont’d)
Santa Clara Health Center
State Road 30 Los Alamos Hwy
RR 5 P.O. Box 446
Espanola 87532-8908
505-753-9421
M-F 8:00 a.m. – 5:00 p.m.
Santa Fe Indian Hospital
1700 Cerrillos Road
Santa Fe 87505-3554
505-988-9821
M-F 8:00 a.m. – 5:00 p.m.
TRIBAL 638 FACILITIES
Isleta Dental Clinic
1 Sagebrush St.
P.O. Box 580
Isleta Pueblo 87022-0580
505-869-3200
M-F 8:00 a.m. – 5:00 p.m.
Zuni Indian Health Service
Rte 301 North B St.
Zuni 87327
505-782-4431
M-F 8:00 a.m. – 5:00 p.m.
Isleta Elderly Center
Tribal Road 40 Bldg 70
Isleta 87022
505-869-6661
M-F 8:00 a.m. – 5:00 p.m.
Isleta EMS
1 Sagebrush St.
P.O. Box 580
505-869-3200
M-F 8:00 a.m. – 5:00 p.m.
Jemez Health Center
110 Sheep Spring Way
Jemez Pueblo 87024
575-834-7413
M-F 8:00 a.m. – 5:00 p.m.
Isleta Health Center
1 Sagebrush St.
Isleta 87022-0580
505-869-3200
M-F 8:00 a.m. – 5:00 p.m.
Pine Hill Health Center Ramah Navajo
BIA Rte 125
Pinehill 87357
505-775-3271
M-F 8:00 a.m. – 5:00 p.m.
Isleta Pharmacy
1 Sagebrush St.
P.O. Box 580
505-869-3200
M-F 8:00 a.m. – 5:00 p.m.
San Felipe Health Clinic
8 Cedar Road
San Felipe Pb 87001
505-867-9616
M-F 8:00 a.m. – 5:00 p.m.
10
NM-MHB-0004-12
NM MHB ENG 12/12
TRIBAL 638 FACILITIES (cont’d)
Isleta Physical Therapy
1 Sagebrush St.
P.O. Box 580
Isleta 87022
505-869-4863
M-F 8:00 a.m. – 5:00 p.m.
Isleta Pueblo Behavioral
Health
1 Sagebrush St.
P.O. Box 580
505-869-3200
M-F 8:00 a.m. – 5:00 p.m.
San Felipe Pueblo
8 Cedar Road
Algodones 87001
505-867-5025
M-F 8:00 a.m. – 5:00 p.m.
GOING TO THE PRIMARY CARE PROVIDER
If you qualify for Medicare, please read the section If You Have Medicare Coverage. This section gives
you details on services you get through the Medicare program. Your service coordinator will be able to
answer your questions about how to arrange for services with your Medicare providers.
Your First Primary Care Provider Appointment
You can call your Primary Care Provider (PCP) to set up your first visit.
Call your PCP for a wellness visit (a general checkup) within 90 days of enrolling in Amerigroup.
If you have already been seeing the PCP who is now your Amerigroup network PCP, call the PCP to
see if it is time for you to get a checkup. If it is, set up a visit with your PCP as soon as you can.
If you do not have a home phone or have just changed your phone number, call Member Services.
We can also help you set up your first visit.
By finding out more about your health now, your PCP can take better care of you if you get sick.
How to Make an Appointment
It is easy to set up a visit with your Primary Care Provider (PCP).
Call the PCP’s office. The phone number is on your Amerigroup ID card.
Let the person you talk to at the doctor’s office know what you need (for example, a checkup or a
follow-up visit).
Tell the PCP’s office if you are not feeling well. This will let them know how soon you need to be
seen.
If you need help, call Member Services. We will help you make the appointment.
11
NM-MHB-0004-12
NM MHB ENG 12/12
Wait Times for Appointments
We want you to be able to get care at any time. When your Primary Care Provider’s (PCP’s) office is
closed, an answering service will take your call. Your PCP should call you back within 30 minutes. Talk
to your PCP and set up an appointment. You will be able to see the PCP as follows:
Routine preventive care
Routine primary care
Routine specialty care visits
Emergency care
Urgent, nonemergency care
Routine laboratory and radiology
Urgent laboratory and radiology
Within 30 days
Within 14 days
Within 21 days
Immediately
Within 24 hours
Within 14 days
Within 48 hours
When you get to the office for your visit, you should not have to wait more than 30 minutes to be
seen.
What to Bring When You Go for Your Appointment
When you go to the Primary Care Provider’s (PCP’s) office for your visit, be sure to bring:
Your ID cards
Any medicines you take now
Any questions you may want to ask your PCP
If the appointment is for your child, bring your child’s
ID cards
Shot records
Any medicines he or she takes now
How to Cancel an Appointment
If you make an appointment with your Primary Care Provider (PCP) and then cannot go:
Call the PCP’s office or call Member Services if you want us to cancel the appointment for you
- Try to call at least 24 hours before you are supposed to be there
- This will let someone else see the PCP at that time
Tell the office to cancel the visit
Make a new appointment when you call
If you do not call to cancel your PCP visits over and over again, your PCP may ask for you to be changed
to a new PCP.
How to Get to a Doctor’s Appointment or to the Hospital
As an Amerigroup member, you are eligible to receive transportation to your medical appointments.
We offer this service through Access2Care. If you need transportation services:
Call Access2Care at 1-866-442-4937 once you schedule your medical appointments; it is best to call
at least 48 hours before you need a ride
Be prepared to provide the following information when you call:
- Your Amerigroup CoLTS member ID number
12
NM-MHB-0004-12
NM MHB ENG 12/12
-
The phone number, address and ZIP code for pickup (this could be your home, a nursing home
or the place that you usually stay)
The name, address, ZIP code and phone number of the health care provider you will be seeing
Date and time of your medical appointment
We will help arrange a ride for medically necessary physical and behavioral health services. These
services can be in or out of the community where you live. You can call to schedule a ride up to 30 days
in advance. If you have routine medical appointments such as dialysis, we can schedule rides up to 180
days in advance. Please call Access2Care before your last scheduled ride to set up your next series of
trips.
If you have an emergency and need transportation, call 911 for an ambulance.
Be sure to tell the hospital staff you are an Amerigroup member.
Get in touch with your Primary Care Provider (PCP) as soon as you can so your PCP can:
- Arrange your treatment
- Help you get the needed hospital care
Disability Access to Amerigroup Network Providers and Hospitals
Amerigroup network providers and hospitals should help members with disabilities get the care they
need. Members who use wheelchairs, walkers or other aids may need help getting into an office. If you
need a ramp or other help:
Make sure your provider’s office knows this before you go there. This will help them be ready for
your visit.
Call Member Services if you want help talking to your provider about your special needs.
WHAT DOES MEDICALLY NECESSARY MEAN?
Your Primary Care Provider (PCP) will help you get the services you need that are medically necessary
as defined below.
Medically necessary services are clinical and rehabilitative physical, mental or behavioral health
services that are:
Vital to prevent, diagnose or treat medical conditions or are needed to allow the member to attain,
maintain or regain the member’s optimal functional capacity
Given in the amount, time, scope and setting that is both enough and able to reasonably achieve
their purposes and are clinically fitting to the specific physical, mental and behavioral health care
needs of the member
Given within professionally accepted standards of practice and national guidelines
Required to meet the physical, mental and behavioral health needs of the member and are not
mainly for the ease of the member, the provider or payer
AMERIGROUP HEALTH CARE BENEFITS
Below is a summary of the health care services and benefits the Amerigroup CoLTS program covers
when you need them.
Your PCP will either:
13
NM-MHB-0004-12
NM MHB ENG 12/12
Give you the care you need
Refer you to a provider that can give you the care you need
In some cases, your PCP needs to give you a referral so you can see another provider. Please read the
section Specialists to learn more about referrals.
If you have a question or are not sure if we offer a certain benefit or if there are coverage limits, you
can call Member Services for help.
Below is a list of the services covered under Amerigroup.
COVERED SERVICE
COVERAGE LIMITS
ADULT DAY HEALTH SERVICES
Services given by a licensed adult day care,
community-based facility that offers health and
social services to help the member reach the
greatest level of functioning.
As a rule, services are given for two or more
hours per day on a regular basis, for one or
more days per week.
Private duty nursing and skilled maintenance
therapies must be given in a private setting at
the facility.
Services that may be given with adult day health
services include:
Private duty nursing services
Skilled maintenance therapies
- Physical
- Occupational
- Speech
Prior approval is required for services given by
network and non-network providers.
These services may be given by the adult day
health provider or another provider.
This is a 1915(c) waiver service.
AMBULATORY SURGICAL SERVICES
Surgical services rendered in an ambulatory
surgical center setting.
Amerigroup covers these services if use of the
facility is medically needed.
All services must be given within benefit limits
and the scope and practice of anesthesia as
defined by state law and according to federal,
state and local laws and rules.
ANESTHESIA SERVICES
These services must be medically needed to
perform surgical or diagnostic procedures; they
include:
Anesthesia
Monitoring services
Prior approval is required if services are given
by an anesthesiologist for pain management.
14
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
AUDIOLOGY SERVICES
Services include:
Certain services are covered when furnished by
Hearing aid purchase, rental and loans;
physicians, licensed audiologists or licensed hearing
repair and handling; and replacements
aid dealers.
Hearing aid accessories and supplies
Hearing aid insurance against loss and
breakage up to four years for all purchased
hearing aids
Certain coverage limits apply.
No prior approval is required for:
Diagnostic and hearing screening tests
Hearing aid evaluations and counseling
Prior approval is required for all hearing aids
and dispensing fees.
Services include:
Personal support services needed for the
member’s continued well-being
Companion services
Help with managing medicines
ASSISTED LIVING SERVICES
Residential services for members who need or
want help with one or more activities of daily
living.
CASE MANAGEMENT SERVICES AS AN EARLY AND
PERIODIC SCREENING, DIAGNOSTIC, AND
TREATMENT (EPSDT) SERVICE
Amerigroup covers EPSDT case management
services for those who are under 21 and medically
at risk.
These services are covered if:
Prescribed by the member’s PCP
Part of a treatment plan
EPSDT services must be accessed through the Totto-Teen HealthCheck program. For information on
the Tot-to-Teen HealthCheck program, see the
section Wellness Care for Children.
CASE MANAGEMENT SERVICES FOR PREGNANT
WOMEN AND THEIR INFANTS
Covered services include those that help members
Covered services include:
Doing a review of the member’s medical
and social needs, and functional limits
Developing and carrying out a plan of care
to help the member keep or reach the
highest level of independence
Setting up helping networks for a member
such as:
- Family members
- Community organizations
- Other support groups
EPSDT case management services for members
in institutions are covered only for the last 30
days of the stay to ensure follow-up services.
Prior approval may be required for certain
services.
These services cover:
Five hours of case management services
per member per pregnancy
15
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
gain access to medical, social, educational or other
needed services.
Care for up to 60 days following the end of
the month of delivery
Coverage of added services may require prior
approval.
Covered services include services that are
medically needed to help adults with traumatic
brain injuries gain access to medical, social,
educational or other needed services.
CASE MANAGEMENT SERVICES FOR TRAUMATIC
BRAIN INJURED ADULTS
CASE MANAGEMENT SERVICES FOR CHILDREN UP
TO AGE 3
CASE MANAGEMENT SERVICES FOR ADULTS WITH
DEVELOPMENTAL DISABILITIES
These services are offered to those who qualify for
Medicaid and are:
21 or older
Living in New Mexico
Defined by the state as a person with a
developmental disability
Placed on the list to receive these services by
the Community Services Team (CST) of the
Developmental Disabilities Division of the
Department of Health
Living outside a Medicaid-certified
Intermediate Care Facility for the Mentally
Retarded
Not in a Home- and Community-based Services
Waiver program
Covered services vary based on the urgency-ofneed priority assigned to each person by the CST:
Priority One – Persons assigned a priority one
are those in danger of being homeless or
victims of abuse if suitable placement services
are not received.
services.
Those that help children gain access to
medical, social, educational or other
needed services
Four hours of case management services
per child per year
Coverage of added services may require prior
approval.
Priority Three Services – These services are
covered for an initial 90 days unless the
person’s urgency of need priority changes
to priority one or two.
Medicaid covers:
- Arranging and performing evaluations
and assessments
- Performing a follow-up review during
the third month and suggesting suitable
changes
Priority One or Priority Two Services –
These services are covered for up to 60
days after suitable placement or services
are received.
Medicaid covers:
- Assessing a person’s medical and social
needs and functional limits
- Arranging and checking evaluations
and services
- Help in finding service providers and
programs to assist a person with access
to services in the community,
16
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
Priority Two – Persons assigned a priority two
are those whose condition will get worse
without placement.
Priority Three – Persons assigned a priority
three are those who could benefit from case
management but whose present condition is all
right.
COMMUNITY TRANSITION GOODS AND SERVICES
AND COMMUNITY RELOCATION SPECIALIST
SERVICES
Community Transition Goods and Services are
services a person may need to set up a basic
household when moving from a nursing facility
(long-term-care facility) setting into the
community.
Community Relocation Specialist Services are
services given:
While a person is a resident in a nursing facility
setting
During a person’s move into and while living in
the community
including:
 Setting up transportation
 Finding housing
 Locating providers to teach living
skills
 Finding vocational, educational, civic
or recreational services
- Arranging and taking part in setting up
and reviewing a plan of care, and
revising the plan when needed
- Assessing a person’s progress and
continued need for services
Community Transition Goods and Services
include:
Security deposits
Necessary household furnishings and
moving expenses required to live in the
community
Setup fees or deposits for utility or service
access
Services needed for a person’s health and
safety
Community Relocation Specialist Services
include:
Reviewing a person’s needs and helping to
arrange and get needed goods and services
for a move from a nursing facility setting to
the community
Setting up a person-centered, communitybased services and transition plan
Checking the first 60 days a person resides
in the community to make sure:
- He or she gets services based on the
transition plan
- The plan meets the person’s needs
Making sure a person has the chance to
teach and train his or her caregivers
Making sure the service plan is in place as
written
Making sure the person has access to the
right home- and community-based services
17
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
services.
DENTAL SERVICES
Amerigroup covers the following dental
services. Certain limits apply.
Emergency services – Covered services
include emergency care for all eligible
members.
Care
includes
operative
procedures needed to:
- Prevent abscess and the imminent loss
of teeth
- Treat injuries to the teeth or supporting
structures such as bone or soft tissue
next to the teeth
Diagnostic services –
- For members under 21, services
include one clinical oral exam every six
months and one added clinical oral
exam by a second dental provider
- For members 21 and over, coverage is
limited to one clinical oral exam per
year
Amerigroup covers emergency oral exams
performed as part of an emergency service
to relieve pain and suffering.
Radiology services – Amerigroup covers:
- One intra-oral complete series or
panoramic film every 60 months per
member recipient
- Bitewing X-rays once every 12 months
per member
Preventive services – Amerigroup covers
the following preventive services. Certain
limits apply.
- Prophylaxis
 One cleaning every six months for
members under 21
 One cleaning per year for members
21 and over
- Fluoride treatment
 One fluoride treatment every six
months for members under 21
 If medically needed, fluoride
treatments for members 21 and
older
- Molar sealants
18
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
 Sealants for permanent molars for
members under 21
 Each eligible member can get one
treatment per tooth every five years
- Space maintenance
Fixed unilateral and fixed bilateral space
maintainers (passive appliances)
- Restorative services
Certain restorative services are covered
- Endodontic services
Certain services for members under 21
are covered
- Periodontic services
Certain services are covered:
 Surgical
 Nonsurgical
 Other periodontic services, subject
to certain limits
- Removable prosthodontic services
 Two denture adjustments per
calendar year per member
 Repairs to complete and partial
dentures
- Fixed prosthodontic services
One recementation of a fixed bridge
- Oral surgery services
Amerigroup covers these services for all
members:
 Simple and surgical extractions
 Emergency palliative treatment of
dental pain
Amerigroup covers these services for
members with proof of medical need:
 General anesthesia
 Intravenous sedation
Prior approval is required for coverage of
certain services. Amerigroup covers
orthodontics for members under 21 if prior
approved.
These services must be:
Ordered by physicians or other licensed
providers
Performed or provided as follows:
- Performed by the ordering providers or
DIAGNOSTIC IMAGING AND THERAPEUTIC
RADIOLOGY SERVICES
Amerigroup covers:
Medically needed imaging
Blood flow measurement
19
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
under their direction in their office
Plethysmographic exams
Radiology services
-
Provided by a radiology lab that meets
state Medicaid guidelines
Other covered medically needed related
services include:
Treatment planning
Minor surgical procedures
Injections
Prior approval is required for any diagnostic
services given by non-network providers with
the exception of emergency-related care.
Prior approval is not required for certain
diagnostic tests given by network providers.
Amerigroup covers medically needed:
Dialysis supplies furnished to homedialyzed members
Renal dialysis services, including:
- All renal-related facility and home
dialysis services
- Supplies and equipment and routine lab
tests
DIALYSIS SERVICES
Prior approval is required if the facility is
hospital-based or the service is given by a nonnetwork provider.
Medically necessary durable medical
equipment and supplies are covered by
Amerigroup. This includes:
Repairs
Maintenance
Delivery, in some cases
DURABLE MEDICAL EQUIPMENT AND MEDICAL
SUPPLIES
Coverage for medical equipment and supplies
may be limited for members in:
Hospitals
Nursing homes
Other facilities expected to provide the
needed items
Prior approval is required for all DME rentals or
services given by non-network providers.
Prior approval is not required for certain
20
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
covered medical supplies that are purchased.
EMERGENCY RESPONSE SERVICES
This service provides an electronic device that
allows members to get help in an emergency.
Members may also wear a portable help button to
allow for mobility.
Testing and maintaining equipment
Training members, caregivers and first
responders on the use of equipment
Twenty-four-hour monitoring for alarms
Checking systems monthly or more often if
there is an electrical outage, severe
weather, etc.
Reporting member emergencies and
changes in the member’s condition that
may affect service delivery
Prior approval is required.
Covered services include inpatient and
outpatient services needed to review and
stabilize an emergency condition.
EMERGENCY SERVICES
See the section Emergency Care for more
details.
ENVIRONMENTAL MODIFICATIONS
Services include:
Purchasing and/or installing equipment
Making physical changes to a member’s
residence needed to:
- Help ensure the health, welfare and safety
of the member
- Enhance the member’s independence
Prior approval is not required.
Covered services include such changes as:
Installing ramps and grab bars
Widening doorways or hallways
Installing special electric and plumbing
systems to allow for medical equipment
and supplies
Installing lifts/elevators
All changes must be given as defined by federal
and state laws and local building codes.
For members under age 21, Amerigroup covers
EPSDT services. These services:
Improve health and prevent and treat
illness
Must be accessed through the Tot-to-Teen
HealthCheck program
EARLY AND PERIODIC SCREENING, DIAGNOSTIC,
AND TREATMENT (EPSDT) SERVICES
For information on the Tot-to-Teen
HealthCheck program, see the section
21
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
Wellness Care for Children.
Other Amerigroup-covered EPSDT services for
members under 21 include:
Case management
Personal care
Private duty nursing
Rehabilitation services
These services are covered if prescribed by the
member’s PCP and part of a treatment plan.
EPSDT Case Management Services –
Amerigroup covers case management services
for those who are medically at risk. Covered
services include:
A review of needs
Development and evaluation of a
treatment plan
Helping networks
EPSDT case management services for members
in institutions are covered only for the last 30
days of the stay. Some case management
services require prior approval to be covered.
EPSDT Personal Care Services – Amerigroup
covers medically needed services, such as:
Basic personal care
Help with eating and nutrition
Cognitive assistance
These services must be prior approved.
EPSDT Private Duty Nursing Services –
Medically needed EPSDT private duty nursing
services are covered by Amerigroup when the
services are given by a registered or licensed
practical nurse in a member’s home or school
setting. Services must be prior approved.
EPSDT Rehabilitation Services – Amerigroup
covers these therapies if medically needed and
given for diagnostic study or treatment:
22
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
EXPERIMENTAL TECHNOLOGY
Medicaid covers medically necessary services given
by Medicaid providers to eligible members.
HEALTH EDUCATION AND PREVENTIVE CARE
Speech
Physical
Occupational therapy
All therapy services except the initial evaluation
require prior approval to be covered.
Medicaid does not cover these experimental
procedures:
Medical
Surgical
Other health care procedures or
treatments, including the use of:
- Drugs
- Biological products
- Other products or devices, except for
routine patient care costs related to
certain Phase I, II, III and IV cancer
clinical trials
Amerigroup works to help keep you healthy.
You can get health information by:
Asking your PCP
Calling our Nurse HelpLine; our nurses are
available 24 hours a day, 7 days a week to
answer your health questions
Amerigroup also offers health education
programs. We can help you find classes near
your home.
Call Member Services to find out where and
when these classes are held.
See the section Special Amerigroup Services
For Healthy Living for more details.
All Amerigroup members need to have regular
wellness visits with their PCP.
When you become an Amerigroup
member, call your PCP and set up your first
visit within 90 days.
During a wellness visit, your PCP can see if
you have a problem before it is a bad
problem.
See the section Wellness Care for Children and
Adults for details. If you are eligible for
Medicare, see the section If You Have
23
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
Medicare Coverage for details on services you
get through the Medicare program. Your
service coordinator can answer your questions
about how to arrange for wellness visits with
your Medicare providers.
Amerigroup covers medically needed home
health care if it is recommended by the
member’s PCP or specialist. To get home
health services, you must meet at least one of
these requirements:
You cannot leave home without a
wheelchair, walker, crutches or help from
someone else
Your PCP or specialist tells you to avoid all
stressful physical activity because of a
severe illness or injury
You cannot leave home because of danger
caused by a mental condition
You just got home from the hospital after a
severe illness or surgery; your activities
have been limited by your PCP or specialist
because of pain, suffering, medical limits or
infection
You are at high risk (during a pregnancy,
infancy or childhood), and home health
care is appropriate for your needs
HOME HEALTH SERVICES
The following home health services are
covered if prescribed by the member’s PCP or
specialist and part of the plan of care:
Skilled nursing services
Home health aide services
Physical and occupational therapy services
Speech therapy services
Durable medical equipment and supplies
Maternal/child services
Coverage of all home health services after the
initial visits for evaluation require prior
approval.
24
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
HOSPICE SERVICES
Amerigroup covers hospice care for members
who choose it and have a terminal illness with
a life expectancy of six months or less. Hospice
care must be reasonable and necessary to
manage the member’s illness and conditions.
The following are covered as part of hospice
care:
Nursing services based on the treatment
plan that are given by registered nurses
Medical social services given by a social
worker at the direction of a PCP or
specialist
Physician services from a qualified provider
for a medical need not met by the
member’s attending physician
Counseling services to the member and his
or her family
Home health aide and homemaker services
Physical, occupational and speech-language
therapy if needed
Durable medical equipment and supplies,
and pharmacy services related to the
member’s illness and conditions
Short-term inpatient services for pain
control and symptom management
Short-term inpatient respite services
Continuous nursing care services for pain
control and symptom management
Prior approval is required for facility-based
hospice care. Prior approval may be required
for certain home health hospice care services
such as durable medical equipment.
Amerigroup covers inpatient hospital and
emergency services that are medically needed
for the diagnosis and/or treatment of an illness
or injury.
HOSPITAL SERVICES – INPATIENT
Items or services must be given through an
Amerigroup physician, podiatrist or dentist
who provides services in an Amerigroup
network hospital.
25
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
network and non-network providers except
emergency-related care.
HOSPITAL SERVICES – OUTPATIENT
Covered hospital outpatient care includes:
Use of minor surgery or cast rooms
Intravenous infusions
Catheter changes
First aid care of injuries
Lab and radiology services, and diagnostic
and therapeutic radiation, including
radioactive isotopes
Outpatient physical, occupational or speech
therapy services require prior approval.
Amerigroup covers services provided by
promotores and traditional healers in our
network. This service is available only to Native
American members.
INDIAN HEALTH SERVICES
LABORATORY SERVICES
Covered services include medically needed lab
services that are:
Ordered by physicians or other licensed
providers
Performed by ordering providers or under
their direction in an office lab or a clinical
lab that meets state Medicaid guidelines
Prior approval is required for certain services.
NURSING FACILITIES AND SWING BED HOSPITAL
SERVICES
Low- or high-level nursing facility and swing
bed hospital services are covered by
Amerigroup when medically needed for
diagnosis and/or treatment of an illness or
injury.
Amerigroup covers physical, occupational and
speech therapy services at these facilities in
accordance with allowable costs and New
Mexico Medicaid requirements.
26
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
Prior approval is required for these therapies
given to swing bed facility residents:
Physical
Occupational
Speech
Certain services in nursing facilities may also
require prior approval.
Amerigroup covers medically necessary
nutritional services for women who are
pregnant or for members under 21. Covered
services include:
Nutritional assessments for:
- Eligible pregnant women
- Members under 21 as part of the EPSDT
program
Nutrition counseling for members under 21
who have been referred for a nutritional
need
NUTRITIONAL SERVICES
Prior approval is not required.
Teaching of daily living skills
Developing perceptual motor skills
combined with sensory functions
Designing, building or changing of assistive
equipment or adaptive devices
Using specially designed crafts and exercise
to improve function
Consulting with other service providers or
family members as asked for by the
member
OCCUPATIONAL THERAPY SERVICES
These services:
Promote fine motor skills and coordination,
combined with sensory functions
Aid in the use of adaptive or other support
equipment
27
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
PERSONAL CARE OPTION SERVICES
Personal Care Option (PCO) services are for
members who:
Are age 21 and over
Qualify for nursing facility level of care but
want to live at home
Members work with their service coordinator
and primary care provider to help decide if
they are still eligible for PCO services.
Consumer-directed personal care lets
members, with the help of a service
coordinator, oversee their own personal care
delivery. Delegated personal care allows a
member to work with an agency to meet their
personal care needs. Talk with your service
coordinator or a case specialist to make sure
you know how to stay eligible for PCO services.
The extent and length of time of these services
are based on input from the member through a
thorough service assessment completed by the
service coordinator. This assessment takes into
account many parts such as:
The member’s health and daily needs
Natural supports or help the member gets
from friends or family
Your service coordinator will talk about your
assessment results with you in detail.
Amerigroup covers these personal care
services:
Hygiene and grooming
Bowel and bladder services
Meal preparation
Eating
Household support services such as:
- Light housekeeping
- Shopping
- Minor upkeep of medical equipment
(changing batteries, etc.)
Help with walking, transferring, or using a
wheelchair or walker
28
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
PHARMACY SERVICES
Most medically needed prescription drugs are
covered by Amerigroup when prescribed by a
licensed provider. Some over-the-counter
drugs are covered when prescribed by a
licensed provider.
Prior approval is required for certain drugs.
PHYSICAL HEALTH SERVICES
Covered services include primary and specialty
physical health services furnished by a licensed
provider within the provider’s scope and
practice as defined by state law.
Midwife Services – Amerigroup-covered
services given by certified or licensed
midwives include lab and diagnostic imaging
services related to normal pregnancies
Podiatry Services – Covered services include
routine foot care if certain conditions of the
foot, such as corns, warts, calluses and
conditions of the nails, pose a hazard to
members with a medical condition
Rural Health Clinic Services – Covered
services include:
- Medically needed diagnostic and
therapeutic services and supplies, and
treatment of medical conditions,
including medically needed family
planning services
- Lab and diagnostic imaging services for
diagnosis and treatment
- Surgical procedures, emergency room
physician services and inpatient hospital
visits given at a different facility when
performed by a physician under contract
to a rural health clinic
- Visiting nurse services with prior
approval
Federally Qualified Health Center Services
Amerigroup covers the following medically
needed services given by a Federally
Qualified Health Center (FQHC)
- Dental Services – See the Dental
Services listing
- Mid-level Practitioners – Covered
29
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
FQHC services include those provided
by a nurse practitioner, physician
assistant or nurse midwife
- Pharmacy Services – Prescription drugs
and some over-the-counter drugs and
medical supplies are covered when
ordered by a licensed provider
- Physician Services – Coverage includes
these services and supplies given by
FQHC physicians (including
psychiatrists):
 Radiology services
 Laboratory services
 Specimen collection for laboratory
services given by an off-site lab
Preventive Services – FQHCs may provide
these covered preventive services:
- Medical social services
- Nutritional assessment and referral
- Preventive health education
- Well-child care
- Prenatal and postpartum care
- Immunizations
- Family planning services
- Physical exams targeted to risk
- Visual acuity screening
- Hearing screening
- Cholesterol screening
- Stool testing for occult blood
- Dipstick urinalyses
- Risk assessment and initial risk
counseling
- Tuberculosis testing for those at risk
- Preventive dental services
- For women: Pap smears, clinical
breast exams, mammography
referral and thyroid function tests
services.
Services include:
Professional evaluations and monitoring
Physical therapy treatments and
interventions
PHYSICAL THERAPY SERVICES
These services:
Promote gross/fine motor skills
Aid in independent functioning
30
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
Prevent progressive disabilities
Training on physical therapy activities, use of
equipment or any other part of members’
physical therapy services
Designing, changing or monitoring use of
related activities that support members’
individual service plans
family members as asked for by the member
Amerigroup covers services to terminate a
pregnancy in accordance with New Mexico
state guidelines.
PREGNANCY TERMINATION SERVICES
Covered services for pregnant women include:
Surgical abortions
Psychological services
Medicines when given by a doctor or other
licensed provider according to New Mexico
law
Prior approval is required for all services except
Preventive health services include:
Immunizations (shots)
Screens
Tot-to-Teen HealthChecks
Counseling services
24-hour Nurse HelpLine
Family planning services
Prenatal care services
PREVENTIVE HEALTH SERVICES
See the sections Wellness Care for Children
and Adults, Special Kinds of Health Care, and
Special Amerigroup Services for Healthy Living
for more information.
31
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
PRIVATE DUTY NURSING SERVICES
Services include activities, procedures and care for
a physical condition, physical illness or chronic
disability.
Amerigroup covers services such as:
Medication management
Feeding tube and urinary catheter
management
Weight management
Bowel and bladder care
Wound and skin care
Infection control
Nutrition management
Oxygen management
Seizure management and safety
Behavior and self-care help
Medically needed prosthetics and orthotics are
covered by Amerigroup only under these
conditions:
The item has been ordered by a doctor or
other licensed provider
The need for the item is not met by a
device that the member already has
Prior approval requirements have been met
Coverage of compression stockings for
adults is limited to those that are custommade for the member’s needs
Coverage of orthopedic shoes for adults is
limited to the shoe that is attached to a leg
brace
Replacement of items is limited to one item
every three years, unless medically needed
sooner
Therapeutic shoes for diabetics is limited to
one of the following in one calendar year:
- No more than one pair of custommolded shoes and two added pairs of
inserts
- No more than one pair of depth shoes
and three pairs of inserts
PROSTHETICS AND ORTHOTICS
Prior approval is required for:
All prosthetics except for limbs attached
right after a surgery for traumatic injuries
while the member is a hospital inpatient
Orthotic items for the foot or for shoes
32
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
REHABILITATION SERVICES
Physical, occupational and speech therapy
services are covered by Amerigroup when:
Reasonable and necessary for the
treatment of a member’s condition
Ordered by the member’s PCP
Part of a treatment plan
Covered services can be given by the following
facilities:
Hospitals
Home health agencies
Outpatient hospitals
Rehabilitation hospitals
Licensed rehabilitation centers
All therapy services (except the initial
evaluation for physical or occupational
therapy) require prior approval to decide if
care is medically needed.
Amerigroup covers these medically needed
reproductive health services given by or under
the supervision of a licensed provider:
Sterilization services to mentally competent
and noninstitutionalized members 21 and
older who consent to the procedure
Hysterectomies not for the sole purpose of
sterilization
Methods, procedures and pharmaceutical
supplies to prevent unintended pregnancy
or contraception
REPRODUCTIVE HEALTH SERVICES
RESPITE SERVICES
Services provided to members who live in the
community and cannot care for themselves. These
services may be given in the member’s home or in
the community.
Prior approval is required for all services except
Helping with routine activities of daily living
Improving self-help skills
Assisting with getting access to fun and
leisure activities
33
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
SCHOOL-BASED SERVICES
For members under 21, Amerigroup covers
medically needed services given in a school
setting. The following services must be
approved by the child’s PCP and not be part of
an Individualized Education Plan or
Individualized Family Service Plan:
Therapy services (physical, occupational,
audiological and speech)
Nutritional assessment and counseling
Transportation if the member has to travel
from the school to get a covered service
Case management for medically at-risk
members
Nursing services
Amerigroup assists members in getting access
to services they need such as:
CoLTS waiver services
Medicaid state plan services
Medical, social and educational services
SERVICE COORDINATION
Service coordination gives members the support
and services needed to reach a desired quality of
life in a safe and healthy setting.
This is both a 1915(b) and 1915(c) waiver service.
SKILLED MAINTENANCE THERAPY SERVICES
For members age 21 and older, covered
services include occupational, physical therapy
and speech language therapy services.
SPECIAL REHABILITATION SERVICES
Medicaid pays for medically needed health services
given to eligible children. These services are paid as
part of early and periodic screening, diagnosis, and
treatment services. The need for special
rehabilitation services may be found in the:
Tot-to-Teen HealthCheck screen
Other assessment given through a health
check referral or by a PCP or specialist
Medically needed covered services include:
Speech, language and hearing services
Occupational therapy services
Physical therapy services
Psychological, counseling and social work
services
Developmental assessment and rehab
services
Nursing services
These services support and improve a child’s
development in one or more of the following areas: Prior approval is required.
Physical/motor
Communication
Adaptive
Cognitive
Social or emotional
Sensory development
34
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
SPEECH LANGUAGE THERAPY SERVICES
These services:
Preserve independent communication
Help with oral motor and swallowing function
Aid in the use of assistive equipment
Prevent progressive disabilities
Services include:
Identifying communicative disorders and
delays in developing communication skills
Preventing communicative disorders and
delays in developing communication skills
Developing eating and swallowing plans
and monitoring their success
Using specially designed equipment, tools
and exercises to improve function
Designing, building or changing of assistive
equipment or adaptive devices
Adjusting the member’s surroundings to
meet his or her needs
Offering speech language therapy training
family members as asked for by the
member
Amerigroup covers medically needed
transplant services that are not considered
unproven, new or experimental for the
condition for which they are meant or used.
Types of transplants include:
Heart
Lung
Heart-lung
Liver
Kidney
Autologous bone marrow
Allegoric bone marrow
Corneal transplants
TRANSPLANT SERVICES
Hospital
Doctor
Lab
Outpatient surgical
Other covered services needed to perform
the transplant
35
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
TRANSPORTATION SERVICES
If a member does not have access to free
transportation, Amerigroup will cover
emergency and nonemergency transportation.
We will cover the least costly transportation
that is fitting for a member’s health condition.
Ambulance services are covered for
emergencies or for nonemergencies if any
other transportation service would be a risk
to the member’s health.
As an added benefit (see the section Extra
Amerigroup Benefits), Amerigroup
reimburses volunteers for transportation
costs for a member’s office visits.
The following transportation-related services
are also covered by Amerigroup:
Long-distance transportation from common
carriers if the member must leave his or her
home community to get medical services
Air ambulance services in an emergency
and when medically needed
Lodging services for members who have to
travel more than four hours one way to get
medical services and need to stay overnight
Meal services for members who need to
leave their communities for more than
eight hours to get medical services
Transportation, meals and lodging for one
attendant, if the attendant is medically
needed or if the member who is getting
medical services is under 18 years of age;
the attendant for members under 18
should be the member’s parent or legal
guardian
Transportation to Medicaid waiver facilities
for Medicaid waiver members receiving
occupational, physical, speech and
behavioral therapy
All out-of-state transportation services require
prior approval. Other transportation services
may also need prior approval.
36
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
VISION SERVICES
Amerigroup covers services that are medically
needed to diagnose and treat eye diseases and
correct refractive errors, as required by the
condition of the member.
Routine eye exams – As an added benefit,
Amerigroup covers routine eye exams
every 12 months, instead of every 36
months as required by Medicaid. Exams for
an existing medical condition such as
diabetes will be covered for required
follow-up and treatment.
Corrective lenses – Amerigroup covers the
added benefit of one set of corrective
lenses every 12 months, instead of every 36
months as required by Medicaid. The
ophthalmologist or optometrist may
recommend lenses sooner if there is a
change in prescription due to a medical
condition that affects vision.
Bifocal lenses
Tinted lenses – Lenses with filtered or
photochromic lenses are covered by
Amerigroup for certain conditions.
Balance lenses – For members under 21,
these lenses are covered when used to
balance an aphakic eyeglass lens or if the
person is blind in one eye and the visual
acuity in the eye that requires correction
meets the correction standard.
Frames – As an added benefit, Amerigroup
covers one frame for corrective lenses
every 12 months instead of every 36
months as required by Medicaid.
Contact lenses – Amerigroup covers
contact lenses, either the original
prescription or replacement, only with prior
approval. Coverage for adults is limited to
one pair of contact lenses in a 24-month
period, unless an ophthalmologist or an
optometrist recommends a change in
prescription due to a medical condition that
affects vision.
37
NM-MHB-0004-12
NM MHB ENG 12/12
COVERED SERVICE
COVERAGE LIMITS
Replacement – Eyeglasses or contact lenses
that are lost, broken or have worsened to
the point that the examiner feels they can
no longer be useful to the member may be
replaced if:
- The member is under 21 years of age
- The member is 21 years of age or older
and has developmental disabilities
- Required documentation for
replacement has been reported
Prisms – All prisms are covered if medically
needed to prevent double vision.
Lens tempering – Amerigroup covers lens
tempering on new glass lenses only.
Lens edging – Amerigroup covers lens
edging and lens insertion.
Minor repairs – Amerigroup covers minor
repairs to eyeglasses.
Eye prosthesis – Amerigroup covers
artificial eyes.
Certain procedures or services may require
prior approval.
PRIOR AUTHORIZATIONS
Some Amerigroup services and benefits require prior approval. This means that your provider must ask
Amerigroup to approve those services or benefits before you get them. These services do not require
prior approval:
Emergency services
Poststabilization services
Urgent care
Affirmative Statement
Amerigroup follows the quality standards set forth by the National Committee for Quality Assurance
(NCQA). All Utilization Management (UM) decisions are based on:
Your medical needs
Benefits offered by Amerigroup
Our policies do not promote use of fewer services through our UM decision process. Practitioners and
others who take part in UM decision-making do not get any type of reward for denial of care or
coverage.
38
NM-MHB-0004-12
NM MHB ENG 12/12
EXTRA AMERIGROUP BENEFITS
Amerigroup covers some extra benefits members cannot get from fee-for-service Medicaid. These
extra benefits are also called value-added services. To get any of these services, you must call your
service coordinator first. Amerigroup offers the following:
Enhanced Adaptive Aids – Amerigroup covers adaptive aids or equipment not covered by fee-forservice Medicaid or the 1915(c) Home- and Community-based Services Waiver, up to $200 per
month. Prior approval for supplies or equipment is required from your service coordinator.
Respite Care – Amerigroup will offer up to 72 hours per year of respite care and services to families
and caregivers who live in the community.
Enhanced Transportation – Amerigroup will reimburse your caretakers, friends, non-household
family members and volunteers for transportation costs for office visits to your PCP. Caregivers
who are paid through the Personal Care Options program do not qualify to be reimbursed; this is
based on state law. See the section Transportation Services or call Member Services and ask to
speak with your service coordinator for details.
Enhanced Vision Care – Amerigroup covers exams, lenses and frames every 12 months instead of
every 36 months. See Eye Care in the Special Kinds of Health Care section for complete details.
Transitional Services – If you live in a nursing home, you may want to move back into the
community. Please talk to your service coordinator. He or she will:
-
Look at your health care needs
-
Work with you and your family to decide if a change would be best for you
If your health care needs can be better met in a home and community setting, you may qualify for
the Money Follows the Person program. Amerigroup will arrange the change. We will cover care
coordination and services up to $2,500 to help you move back into the community. We can help
with the following costs to set up your own household:
- Moving costs
- Security deposits
- Cost of basic household furnishings
- Setup fees or deposits for utility or service access
- Services you need for health and safety
Annual Physical for Adults – Amerigroup covers an annual physical exam for adults age 21 and
older given by their PCP
We give you these benefits to help keep you healthy and to thank you for choosing Amerigroup as your
health care plan.
SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID
Some services are covered by fee-for-service Medicaid instead of Amerigroup. You do not need a
referral from your Primary Care Provider (PCP) to get these services. But, if you think you need these
services, please call Member Services. We can help refer you to the right provider.
39
NM-MHB-0004-12
NM MHB ENG 12/12
Intermediate Care Facility Services for the Mentally Retarded – Medicaid pays for medically needed
health services provided by intermediate care facilities for the mentally retarded.
Emergency Services to Undocumented Aliens – Medicaid pays for needed emergency services given
to persons who are undocumented aliens, live in New Mexico and qualify for Medicaid.
Experimental or Investigational Procedures, Technologies or Nondrug Therapies – Medicaid covers
routine patient care costs related to certain Phase I, II, III and IV cancer clinical trials. These
services:
- Can only be performed in New Mexico
- Must be prior approved
Case Management Services for Children Provided by Child Protective Services and Juvenile
Probation and Parole Officers – Medicaid pays for medically needed case management services,
including behavioral health services given to persons under age 19 who qualify.
They must be:
- Supervised by a Juvenile Probation and Parole Officer
- Have a physical or mental status which will likely impair their cognitive, emotional, neurological,
social or physical growth
These services are offered through the Comprehensive Community Support Services (CCSS)
program, managed by the Children, Youth and Families Department (CYFD) and their Juvenile
Probation and Parole Officers. Amerigroup case managers will work with CYFD case managers to
arrange services members can get through the CoLTS and CCSS programs.
Adult Protective Services Case Management – Medicaid pays for these medically needed health
services for adults who have been abused, neglected or exploited:
- Supplying access to medical, social or other needed services
- Assessing persons’ medical and social needs
- Setting up a plan of care to help persons keep their greatest level of self-support
- Arranging natural helping networks such as family members, church members, community
groups and friends
- Setting up and monitoring the delivery of services; reviewing the value and quality of service;
and changing the plan of care if needed
School-based Services for Persons under Age 21 – Medicaid pays for medically needed services
given to those persons under age 21 who qualify for Medicaid when the services are part of a
person’s Individualized Education Plan or Individualized Family Service Plan to treat a known
medical condition.
Services given to the Home- and Community-based Waiver Services programs which include the
Mentally Fragile waiver, HIV/AIDS waiver and the Developmentally Disabled waiver.
SERVICES THAT DO NOT NEED A REFERRAL
If you qualify for Medicare, please see the section If You Have Medicare Coverage for details on
services you get through the Medicare program. Your service coordinator can answer your questions
about whether you need a referral for a service.
40
NM-MHB-0004-12
NM MHB ENG 12/12
It is always best to ask your PCP for a referral for any Amerigroup service. But you can get these
services without a referral from your PCP:
EPSDT services
Routine shots
Screening or testing for sexually transmitted diseases including HIV
Services given by a school health center
Yearly exams from an Amerigroup network OB/GYN
DIFFERENT TYPES OF HEALTH CARE
Routine, Urgent and Emergency Care: What Is the Difference?
Routine Care
In most cases when you need medical care, you call your Primary Care Provider (PCP) to make an
appointment. Then you go to see your PCP. This type of care is known as routine care. This will cover:
Most minor illnesses and injuries
Regular checkups
You should be able to see your PCP within 14-30 days for routine care. Your PCP is someone you see
when you are not feeling well, but that is only part of your PCP’s job. Your PCP also takes care of you
before you get sick. This is called wellness care. See the section in this handbook Wellness Care For
Children And Adults.
Urgent Care
The second type of care is urgent care. Some injuries and illnesses are not emergencies, but can turn
into emergencies if they are not treated within 24 hours. Some examples are:
Throwing up
Minor burns or cuts
Earaches
Headaches
Sore throat
Fever over 101 degrees
Muscle sprains/strains
If you need urgent care:
Call your PCP. Your PCP will tell you what to do.
Follow your PCP’s instructions. Your PCP may tell you to go to:
- His or her office right away
- Some other office to get immediate care
- The emergency room at a hospital for care; see the next section about emergency care for
more details
You can also call our 24-hour Nurse HelpLine at 1-800-600-4441 for advice about urgent care. You
should be able to see your PCP within 24 hours for an urgent care visit.
41
NM-MHB-0004-12
NM MHB ENG 12/12
Emergency Care
After routine and urgent care, the third type of care is emergency care. If you have an emergency, you
should call 911. Or you can go to the nearest Emergency Room (ER) right away. A listing of hospitals in
your area can be found on the inside back cover of your provider directory. If you want advice, call
your Primary Care Provider (PCP). Or call our 24-hour Nurse HelpLine at 1-800-600-4441. The most
important thing is to get medical care as soon as you can. You should be able to see your PCP at once
for emergency care.
If you must go to the ER, please remember to take the following information with you:
Your medical history
A list of medications you are taking
A list of your allergies
Your Amerigroup member ID card; and if you have Medicare, take your Medicare card, too
A list of emergency contacts
Any advance directives you may have
Your PCP’s name and phone number
Any other data that may help the emergency room provide the care you need
What is an emergency?
An emergency is when you need to get care right away. If you do not get it, it could cause your death.
It could cause very serious harm to your body. This means that someone with an average knowledge of
health and medicine can tell the problem may threaten your life, cause serious harm to your body or
harm your unborn child if you are pregnant.
Here are some examples of problems that are most likely emergencies:
Trouble breathing
Chest pains
Loss of consciousness
Very bad bleeding that does not stop
Very bad burns
Shakes called convulsions or seizures
What is poststabilization?
Poststabilization services are covered services that you get after emergency medical care. You get
these services to help keep your condition stable.
Medical emergencies and poststabilization care that have to do with your emergency do not need prior
approval by Amerigroup. After you visit the emergency room:
Call your PCP as soon as you can.
If you cannot call, have someone else call for you.
Your PCP will give or set up any follow-up care you need.
42
NM-MHB-0004-12
NM MHB ENG 12/12
How to Get Health Care When Your Primary Care Provider’s Office Is Closed
Except in the case of an emergency (see previous section) or when you need care that does not need a
referral (see the section Services That Do Not Need A Referral), you should always call your Primary
Care Provider (PCP) first before you get medical care. If you call your PCP’s office when it is closed,
leave a message. Give your name and a phone number where you can be reached. If it is not an
emergency, someone should call you back soon. He or she will tell you what to do. You may also call
our Nurse HelpLine 24 hours a day, 7 days a week for help.
If you think you need emergency care (see previous section), call 911 or go to the nearest emergency
room right away.
How to Get Health Care When You Are Out of Town
If you need emergency care when you are out of town or outside of New Mexico*, go to the
nearest hospital emergency room or call 911.
If you need urgent care:
- Call your Primary Care Provider (PCP)*. (See the section Urgent Care for more details.) If your
PCP’s office is closed, leave a phone number where you can be reached. Your PCP or someone
else should call you back soon.
- Follow the PCP’s instructions. You may be told to get care where you are if you need it very
quickly.
- Call our 24-hour Nurse HelpLine for help.
If you need routine care like a checkup or prescription refill:
- Call your PCP.
- Call our 24-hour Nurse HelpLine for help.
*If you are outside of the United States and get health care services, they will not be covered by
Amerigroup or fee-for-service Medicaid.
WELLNESS CARE FOR CHILDREN AND ADULTS
If you qualify for Medicare, please see the section If You Have Medicare Coverage for details on
services you get through the Medicare program. Your service coordinator will be able to answer
questions about how to arrange for well-care visits with your Medicare providers.
All Amerigroup members need to have regular wellness visits with their Primary Care Provider (PCP).
During a wellness visit, your PCP can see if you have a problem. If you do, your PCP can help you before
it is a bad problem.
When you become an Amerigroup member:
Call your PCP
Make your first appointment within 90 days
43
NM-MHB-0004-12
NM MHB ENG 12/12
Wellness Care for Children
Why Well-child Visits Are Important for Children
Children need more wellness visits than adults. These wellness visits for children are called Tot-to-Teen
HealthChecks. Tot-to-Teen HealthChecks is a program for anyone in Medicaid that is under 21 years
old. Babies need to:
See their PCP at least seven times by the time they are 12 months old
Go more often if they get sick
Your child may have special needs or an illness like asthma or diabetes. If so, one of our service
coordinators can help your child get his or her well-child checkups, tests and shots.
Your child can get Tot-to-Teen HealthChecks from any Amerigroup network provider. You do not need
a referral for these visits.
At these Tot-to-Teen HealthCheck visits, your child's PCP will:
Make sure your baby is growing well
Help you care for your baby, talk to you about what to feed your baby and how to help your baby
go to sleep
Answer questions you have about your baby
See if your baby has any problems that may need more health care
Give your baby shots that will help protect him or her from illnesses
When Your Child Should Get Tot-To-Teen Healthcheck Visits
The first well-child visit will be in the hospital. This happens right after the baby is born. For the next six
visits, you must take your baby to his or her PCP’s office. You must set up a well-child visit with the
doctor when the baby is:
Between 3-5 days old
1 month old
2 months old
4 months old
6 months old
9 months old
12 months old
Well-child care in your baby’s second year of life
In your baby’s second year of life, he or she should see the PCP at least four more times at:
15 months
18 months
24 months
30 months
Well-child care for children ages 3 through 20
Your child should see the doctor again at ages 3, 4 and 5. Be sure to set up these visits. Take your child
to his or her PCP when scheduled. From age 6 through age 20, your child should see his or her PCP at
least one time each year for a well-child checkup.
44
NM-MHB-0004-12
NM MHB ENG 12/12
Blood Lead Screening
Your child’s PCP will screen your child for lead poisoning if he or she is at risk of being exposed to lead.
Your child’s PCP will also give your child a blood test at:
12 months
24 months
Your child’s PCP will take a blood sample by pricking your child’s finger or taking blood from his or her
vein. This test will tell if your child has lead in his or her blood.
Eye Exams
Your child’s PCP will check your child’s vision at every well-child visit. Between the ages of 3 and 4, your
child’s doctor will screen him or her for visual problems. Please see Eye Care in the Special Kinds of
Health Care section for more details.
Hearing Exams
Your child’s PCP will check your child’s hearing at every well-child visit.
Dental Care
Your child’s PCP will check your child’s teeth and gums as part of each well-child visit. Please see Dental
Care in the Special Kinds of Health Care section for more details.
IMMUNIZATION (SHOT) SCHEDULE FOR CHILDREN
AGE
VACCINE
Birth
Hepatitis B
HepB
Rotavirus
1
mo
2
mo
4
mo
6
mo
HepB
1912 15 18
2-3 4-6 7-10
23
mo mo mo
years years years
mo
HepB
13-18
years
HepB Series if not given
Rota
Rota
Rota
DTaP
DTaP
DTaP
Hib
Hib
Hib if
needed
Hib
Pneumococcal
PCV
PCV
PCV
PCV
Inactivated
Poliovirus
IPV
IPV
Diphtheria,
Tetanus,
Pertussis
Haemophilus
influenzae
type b
11-12
years
DTaP
IPV
Influenza
Influenza (Yearly)
Measles,
Mumps,
Rubella
MMR
DTaP
PPSV if
high-risk
IPV
Tdap
Tdap if not
given
PPSV if high-risk
IPV Series if
not given
Influenza (Yearly)
MMR
MMR Series
if not given
45
NM-MHB-0004-12
NM MHB ENG 12/12
IMMUNIZATION (SHOT) SCHEDULE FOR CHILDREN
Varicella
Hepatitis A
Varicella
Varicella
HepA (2 doses)
Meningococcal
Varicella Series
if not given
HepA Series if high-risk
MCV4 if high-risk
Human
Papillomavirus
MCV4
MCV4
if not given
HPV Series
HPV
(3 doses) if not given
Wellness Care for Adults
Staying healthy means going to see your Primary Care Provider (PCP) for regular checkups. You should
see your PCP within six months of enrolling in Amerigroup to see if you are up-to-date with the
screenings shown in the chart below.
Your PCP will do these screenings as you need them. Use this chart to help make sure you stay up-todate with your yearly wellness visits.
WELLNESS VISITS SCHEDULE FOR ADULT MEMBERS
EXAM TYPE
WHO NEEDS IT?
Age 21-39
WELLNESS VISIT
Age 40 and over
Women: Under age 18 who are
PAP SMEAR AND PELVIC EXAM
sexually active
Age 18 and over
Women: Age 20-39
CLINICAL BREAST EXAM
Age 40 and over
Women: Age 20 and over
BREAST SELF-EXAM
MAMMOGRAMS (BREAST X-RAY)
Women: Age 21-65
CERVICAL CANCER SCREENING
FECAL BLOOD OCCULT TEST
SIGMOIDOSCOPY & DRE/PSA
OR COLONOSCOPY & DRE/PSA
BLOOD PRESSURE MEASUREMENT
SERUM CHOLESTOROL MEASUREMENT
At-risk members
Age 50 and over
Age 50 and over
OBESITY SCREENING
DIABETES SCREENING
TUBERCULOSIS SCREENING
Age 18 and over
Men: Age 35 and over
At-risk members age 20 and over
All members
All members
At-risk members
RUBELLA SCREENING
HEARING IMPAIRMENT SCREENING
Women of childbearing age
Age 50 and over
HOW OFTEN?
Every three years
Every year
Every year
Every year
Every three years
Every year
Once a month
Every one to two years
At least once by age 21;
every three years thereafter
Every year
Every year
Every five years
At least every two years
Every five years
At least once
Every year
At least once
As recommended by your
PCP
First visit with OB/GYN
Routine as recommended
by your PCP
46
NM-MHB-0004-12
NM MHB ENG 12/12
WELLNESS VISITS SCHEDULE FOR ADULT MEMBERS
EXAM TYPE
WHO NEEDS IT?
HOW OFTEN?
Adolescent and adult members At least once; added
PROBLEM DRINKING AND SUBSTANCE
screens will be based on
ABUSE SCREENING
results of first screen and
other clinical signs or
warnings
Women: Age 25 or younger who At least once
CHLAMYDIA SCREENING
are sexually active
Women: Over age 25 who are at
risk
Age 22 and over
First visit with PCP
BEHAVIORAL HEALTH SCREENING FOR
HIGH-RISK CONDITIONS
All pregnant members
As recommended by your
PRENATAL SCREENING
PCP or OB/GYN
47
NM-MHB-0004-12
NM MHB ENG 12/12
48
NM-MHB-0004-12
NM MHB ENG 12/12
49
NM-MHB-0004-12
NM MHB ENG 12/12
50
NM-MHB-0004-12
NM MHB ENG 12/12
When You Miss One of Your Wellness Visits
If you or your child does not get a wellness visit on time:
Set up a visit with the PCP as soon as you can
Call Member Services if you need help setting up the visit
If your child has not visited his or her PCP on time, Amerigroup will send you a postcard reminding you
to make your child’s Tot-to-Teen HealthCheck appointment.
SPECIAL KINDS OF HEALTH CARE
If you qualify for Medicare, please see the section If You Have Medicare Coverage. This is information
on services you get through the Medicare program. Your service coordinator can answer your
questions about how to get special kinds of health care from your Medicare doctors.
Eye Care
As an extra Amerigroup benefit, members age 21 and older get:
A vision exam every 12 months; this is instead of every 36 months as required by Medicaid
Coverage for required follow-up exams and treatment needed for an existing medical condition
such as diabetes; Amerigroup covers one pair of eyeglasses every 12 months, instead of every 36
months as required by Medicaid
See Vision Care Services in the Amerigroup Covered Services section for complete details.
Please see your provider directory for the vision center near you. You can also call Block Vision at
1-800-879-6901 for help finding an Amerigroup network eye doctor (optometrist) in your area.
Dental Care
We offer these dental services.
Members under age 21 get:
- One cleaning and one fluoride treatment every six months
- Medically necessary orthodontic services with prior approval
Members age 21 and older get:
- One cleaning every 12 months
All members get:
- Emergency care
- X-rays
- Fillings
- Simple extractions as needed
- Anesthesia when required
See Dental Services in the Amerigroup Covered Services section for complete details.
Please see your provider directory for a list of dentists near you. You can also call DentaQuest at
1-888-291-3765 for help finding an Amerigroup network dentist in your area.
51
NM-MHB-0004-12
NM MHB ENG 12/12
Behavioral Health (Mental Health Services)
Sometimes dealing with all the tasks of a home and family can lead to stress. Stress can lead to
depression and anxiety. It can also lead to marriage problems, family problems and parenting
problems. Stress can lead to alcohol and drug abuse, too.
If you or a family member is having these kinds of problems, you can get help. Call OptumHealth New
Mexico at 1-866-660-7185. You can also get the name of a provider who will see you if you need one.
All services and treatments are kept private. You do not need a referral from your PCP to get these
services.
Many medically necessary services are covered, such as:
Inpatient mental health treatment
Outpatient mental health treatment, including individual and family therapy
Alternative care, such as care in your home for members under 21 years of age
Substance abuse treatment
Family Planning Services
Amerigroup will arrange for counseling and education about planning a pregnancy. You can also learn
about preventing pregnancy. You can call your PCP and set up a time for a visit. You can also go to any
Medicaid family planning provider. You do not need a referral from your PCP.
Care for Individuals with Special Health Care Needs
Amerigroup will arrange for health care services for Individuals with Special Health Care Needs (ISHCN).
ISHCN include:
Persons who have or are at an increased risk for a chronic, physical, developmental, behavioral,
neurobiological or emotional condition
Those who have low to severe functional limits; these members may need certain types of health
and other related services that go beyond the service and care required by persons in general
If you or an Amerigroup family member needs this special care, we will give you the services and
support you need while helping you keep your greatest level of freedom.
Here’s How It Works
Within 30 days of enrolling in the Amerigroup CoLTS program, you will get a welcome call from a nurse
in our Early Case FindingSM Unit. During this call, you will be asked questions by the nurse so that we
can find out:
What kind of care you need
The long-term-care services you are getting now
Once you are identified as an ISHCN member, we will:
Help arrange health and social services for you
Work with you to find the best level of care for you
This way, you have the best chance of reaching your desired goals and outcomes.
52
NM-MHB-0004-12
NM MHB ENG 12/12
Amerigroup manages the service needs of ISHCN through a service coordinator. The service
coordinator will work with you and your family or caregiver to:
Assess your needs, including physical health, mental health, social and long-term support services
Develop an Individualized Service Plan (ISP) or treatment plan with and for you to meet your needs;
the ISP includes:
- Your history
- A summary of your current medical and social needs and concerns
- Short- and long-term care needs and goals
- A list of required services and how often these services are needed
- Details on who will provide these services
Inform and teach you about CoLTS 1915(b) and 1915(c) waiver services
Give you a list of specific waiver service network providers in your area from which you can choose
Help arrange timely access to a wide range of providers and services related to ISHCN, including:
- Direct access to CoLTS specialty providers as needed
- Rehabilitation therapy services
- Utilization management services
Help arrange other services given outside the ISP as needed
Amerigroup also provides service coordination to ISHCN, as needed through the Special Needs
Coordinator (SNC). The SNC will:
Review your care needs and help you with access to care, specialty referrals, durable equipment
and PCP changes
Contact you after your first health risk screen to find out if you have a PCP that can best serve you
based on your health care needs
Ensure a case manager is assigned to you at the time of the initial health screen if needed
Help set up PCP visits and referrals for ongoing case management as needed
Teach and allow you and your family or caregivers to make informed decisions based on your ISP or
treatment plan
Getting Started
The assessment
The process begins with an assessment. During the assessment, several people will help you plan your
care. They are called your planning team. The planning team includes:
You
Your family
Legal guardian or representative
Service coordinator
Others the service coordinator identifies to adequately plan the care you need
Your individual service plan
The planning team meets (as needed) when it is time to develop and begin your ISP. The ISP process
begins within 14 business days from the date your assessment is completed. You, together with your
planning team, create your ISP. That is why your input and information all through the process is very
important to us.
53
NM-MHB-0004-12
NM MHB ENG 12/12
We want you to:
Take an active part in creating your ISP. You are in control, to the extent possible, of all aspects of
your ISP, and you are the one who must agree to the ISP.
Hire and direct personal assistance services if you want them. You and your family or caregivers
take part in all aspects of care, including primary, acute and home care as fitting.
Your service coordinator can help arrange the care you need.
Medicines
Amerigroup has a list of commonly prescribed drugs. Your or your child’s Primary Care Provider (PCP)
or specialist can choose from this list of drugs to help you get well. This list is called a Preferred Drug
List (PDL). It is part of the Amerigroup formulary. The covered medicines on the PDL include:
Prescriptions
Certain over-the-counter medicines
Things to remember about the PDL
All Amerigroup network providers have access to this drug list.
Your or your child’s PCP or specialist should use this list when he or she writes a prescription.
Certain medicines on the PDL need prior approval.
All medicines that are not listed on the Amerigroup PDL need prior approval.
You can get prescriptions filled at Amerigroup network pharmacies. For a list of Amerigroup
pharmacies:
See the provider directory that came with your new member packet
Go to www.myamerigroup.com
If you do not know if a pharmacy is in the Amerigroup network, ask the pharmacist. You can also call
Member Services for help.
To get a prescription filled, follow these steps:
1. Take the written prescription from your provider to the pharmacy, or your provider can call in the
prescription to the pharmacy.
2. If you use a new pharmacy, tell the pharmacist about all of the medicines you are taking; include
over-the-counter medicines, too.
3. Show your Amerigroup member ID card and your Medicaid ID card to the pharmacy. If you are
enrolled in Medicare, you will also need to show the pharmacy your Medicare ID card. See the
section If You Have Medicare Coverage for details.
It is good to use the same pharmacy each time. This way your pharmacist:
Will know all the medicines you are taking
Can watch for problems that may occur when you are taking more than one prescription
You should always show your Amerigroup member ID card and your Medicaid ID card when you have a
prescription filled.
54
NM-MHB-0004-12
NM MHB ENG 12/12
Birthing Options Program
If you are pregnant and eligible for Medicaid, you have choices about who will provide care for you and
where your baby will be born.
Many health care practitioners offer pregnancy-related services, and many times they work together
to provide care for you and your baby.
These providers include:
Clinics
Doctor offices
Health centers
Hospitals
Indian Health Services health centers
Private practice offices
Women in New Mexico have many choices about where to give birth:
A birth center
A hospital
Your own home
If you choose to have out-of-hospital birthing services through a midwife, you must contact the New
Mexico Human Services Department, Medical Assistance Division and give them the following
information:
Your name, address and phone number
The name and phone number of the midwife you have chosen
You can call or mail this information to:
Pregnancy-Related Services – Benefits Bureau
New Mexico Human Services Department
Medical Assistance Division
P.O. Box 2348
Santa Fe, NM 87504-2348
1-888-997-2583
You will be sent a confirmation that will need to be completed in order for Medicaid to cover the outof-hospital service.
For more information and to choose a health care practitioner, you may call Amerigroup at
1-877-269-5660 or the New Mexico Medical Assistance Division at 1-888-997-2583.
For more information about the services provided by midwives, you may contact:
New Mexico Midwives Association at 1-888-332-4784 or 505-924-2169 in Albuquerque
American College of Nurse-Midwives New Mexico Chapter at: nmmidwives.org/practices.php
Maternal Health Program Department of Health at 505-476-8908
55
NM-MHB-0004-12
NM MHB ENG 12/12
Special Care for Pregnant Members
When You Become Pregnant
If you think you are pregnant:
Call your PCP or OB/GYN provider right away; you do not need a referral from your PCP to see an
OB/GYN doctor
Call Member Services if you need help finding an OB/GYN in the Amerigroup network
When you find out you are pregnant, you must also call Amerigroup Member Services.
While you are pregnant, you need to take good care of your health. You may be able to get healthy
food from the Women, Infants and Children Program (WIC). Member Services can give you the phone
number for the WIC program close to you. Just call us.
When you are pregnant, you must go to your PCP or OB/GYN at least:
Every four weeks for the first six months
Every two weeks for the seventh and eighth months
Every week during the last month
Your PCP or OB/GYN may want you to visit more than this based on your health needs.
Amerigroup also helps pregnant members with complex health care needs. Nurse case managers work
closely with these members to:
Help teach them about these needs
Give emotional support
Help them to follow their providers’ care plan
Our nurses also work with providers. They help with other services members may need. The goal is to
promote better health for members and the birth of healthy babies.
When You Have a New Baby
When you have your baby, you and your baby may stay in the hospital at least:
Forty-eight hours after a vaginal delivery
Ninety-six hours after a cesarean section (C-section)
You may stay in the hospital less time. If your PCP or OB/GYN and the baby’s doctor see that you and
your baby are doing well, you may go home earlier. If you do, your PCP or OB/GYN may ask you to have
an office or in-home nurse visit within 48 hours.
After you have your baby, you must:
Call Amerigroup Member Services as soon as you can to let your service coordinator know you had
your baby. We will need to get details about your baby.
Call your caseworker with the New Mexico Human Services Department to let him or her know you
had your baby.
56
NM-MHB-0004-12
NM MHB ENG 12/12
Guide to Prenatal Care
These guidelines are intended to help you know what to expect during pregnancy. You and your
physician will decide what is best for you while you are pregnant.
First Trimester
Visit frequency
Every four weeks
Your first visit to your PCP or OB/GYN while you are pregnant will cover many things:
Getting a complete health exam, including checking your weight and blood pressure and
taking a urine sample
Gathering facts about your health history, including information on former pregnancies,
any history of infections such as Chlamydia, Gonorrhea, Herpes, bacterial vaginosis, HPV,
RPR-VDRL (tests for syphilis), Hepatitis B and C, TB, and HIV testing
Getting lab work, including urine testing; genetic testing may also be included
Getting a prescription for prenatal vitamins
Getting a Pap smear of your cervix within the first six months of your pregnancy
You should also get a flu shot if you are pregnant during flu season.
Second Trimester
Visit frequency
Every four weeks
Visits to your PCP or OB/GYN during your second trimester will include:
Getting routine lab work, including screening for birth defects between 15-18 weeks
gestation
Listening to the baby’s heart; checking abdominal growth, fetal movement and the
position of the fetus during each visit
Third Trimester
Visit frequency
Every four weeks up to 28 weeks gestation
Every 2-3 weeks from 28-36 weeks gestation
Weekly from 36 weeks gestation until
delivery
Visits to your PCP or OB/GYN during your third trimester will include:
Getting lab work, including:
- Blood sugar and other blood count screenings between 24-28 weeks
- Group B Strep bacteria screening between 35-37 weeks
- Testing for sexually transmitted diseases
- Testing for markers on blood that could be a problem after delivery, called antibody
screen
- Listening to the baby’s heart; checking abdominal growth, fetal movement and the
position of the fetus during each visit
57
NM-MHB-0004-12
NM MHB ENG 12/12
Education
Amerigroup works to keep you healthy with our health education programs. We can help you
find classes near your home, including:
Learning about:
- How pregnancy affects a woman’s body and what to expect while you are pregnant
- How to avoid early delivery of your baby and what the warning signs are
- How your pregnancy can be affected due to:
 Alcohol, smoking and drug use
 Mental health problems, including depression
 The environment, including dangerous workplaces
- Sexual practices and how to prevent sexually transmitted diseases
- How to prevent injury to your body
Making healthy choices, such as:
- Eating healthy
- Getting proper exercise
- Keeping your mouth clean and healthy
Quitting cigarette smoking
Protecting yourself from violence
We can also help you find classes or information on:
Child birth
Labor and delivery, including ways to help with pain if you have anesthesia, a C-section or a
baby after you had a C-section
Breastfeeding
Postpartum care
Birth control counseling
Call your service coordinator to find out where and when these classes are held.
Adapted from the American College of Obstetricians and Gynecologists, Guidelines for Prenatal Care
Disease Management
Amerigroup has a Disease Management Centralized Care Unit (DMCCU) program. A team of licensed
nurses and social workers, called DMCCU care managers, educate you about your condition and help
you learn how to manage your care. Your Primary Care Provider or PCP and our team of DMCCU care
managers will help you with your health care needs.
DMCCU care managers work with you to create health goals and help you develop a plan to reach
these goals. As a member in the program, you will benefit from having a care manager who:
Listens to you and takes the time to understand your specific needs
Helps you create a care plan to reach your health care goals
Gives you the tools, support and community resources that can help you improve your quality of
life
Provides health information that can help you make better choices
Assists you in coordinating care with your providers
58
NM-MHB-0004-12
NM MHB ENG 12/12
Amerigroup has earned NCQA (National Committee for Quality Assurance) Patient and Practitioner
Oriented Accreditation for our disease management programs. Earning NCQA accreditation for disease
management represents our continued commitment to help you get quality health care coverage. Our
programs include:
Asthma
Chronic obstructive pulmonary disease
Coronary artery disease
Diabetes
As an Amerigroup member enrolled in the DMCCU program, you have certain rights and
responsibilities. You have the right to:
Have information about Amerigroup; this includes all Amerigroup programs and services, as well as
our staff’s education and work experience; it also includes contracts we have with other businesses
or agencies
Refuse to take part in or disenroll from programs and services we offer
Know which staff members arrange your health care services and who to ask for a change
Have Amerigroup help you to make choices with your providers about your health care
Learn about all DMCCU-related treatments; these include anything stated in the clinical guidelines,
whether covered by Amerigroup or not; you have the right to discuss all options with your
providers
Have personal and medical information kept private under HIPAA; know who has access to your
information; know what Amerigroup does to keep it private
Be treated with courtesy and respect by Amerigroup staff
File a complaint with Amerigroup and be told how to make a complaint; this includes knowing
about the Amerigroup standards of timely response to complaints and resolving issues of quality
Get information that you can understand
Have Amerigroup act as an advocate for you if needed
You are encouraged to:
Listen to and know the effects of taking or not taking health care advice
Provide Amerigroup with information needed to carry out our services
Tell Amerigroup and your providers if you decide to disenroll from the DMCCU program
If you have one of these conditions or would like to know more about our DMCCU, please call
1-888-830-4300 Monday through Friday from 8:00 a.m. to 5:00 p.m. Mountain time. Ask to speak with
a DMCCU care manager. You can also visit our website at www.myamerigroup.com. Log in with your
member information. Then, choose Programs and Info in Your Community. You can also call the
DMCCU if you would like a copy of DMCCU materials you find online.
SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING
Health Information
Learning more about health and healthy living can help you stay healthy. Here are some ways to get
health information:
Ask your Primary Care Provider (PCP).
59
NM-MHB-0004-12
NM MHB ENG 12/12
Call us. Our Nurse HelpLine is on hand 24 hours a day, 7 days a week. One of our nurses can tell
you:
- If you need to see your PCP
- How you can help take care of some health problems you may have
Health Education Classes
Amerigroup works to keep you healthy with our health education programs. We can help you find
classes near your home. You can call Member Services to find out where and when these classes are
held. Some of the classes include:
Our services and how to get them
Childbirth
Infant care
Parenting
Pregnancy
Quitting cigarette smoking
Protecting yourself from violence
Other health topics
Some of the larger medical offices in our network (like clinics) show health videos. The videos talk
about immunizations (shots) and prenatal care. They talk about other vital health topics. Please watch
these videos. Learn more about staying healthy.
We will also mail a member newsletter to you every year. This gives you health news about well care
and taking care of illnesses. It gives you tips on how to be a better parent and other topics.
Community Events
Amerigroup sponsors and takes part in special community events and family fun days. This is one way
you can get health news and have a good time. You can learn about topics like:
Healthy eating
Asthma
Stress
You and your family can play games, win prizes or take part in other fun community events.
Amerigroup representatives will be there to answer your questions about your benefits, too. Call
Member Services to find out when and where these events will be.
Domestic Violence
Domestic violence is abuse. Abuse is unhealthy and unsafe. It is never OK for someone to hit you. It is
never OK for someone to make you afraid. Domestic violence causes harm and hurt on purpose.
Domestic violence happens in the home. It can affect your children, and it can affect you. If you feel
you may be a victim of abuse, call or talk to your PCP.
60
NM-MHB-0004-12
NM MHB ENG 12/12
Safety tips for your protection:
If you are hurt, call your PCP.
Call 911 or go to the nearest hospital if you need emergency care. Please see the section
Emergency Services for more information.
Have a plan for how you can get to a safe place (like a women’s shelter or a friend’s or relative’s
home).
Pack a small bag and give it to a friend to keep for you until you need it.
If you have questions or need help:
Call our Nurse HelpLine at 1-800-600-4441.
Call the National Domestic Violence hotline number at 1-800-799-7233.
Abuse, Neglect and Exploitation
There are other types of abuse besides domestic violence. If you or someone you know is being hurt or
taken advantage of, you can report this.
Abuse means:
Hurting someone on purpose
Holding someone against his or her will
Threatening or punishing someone; causing pain or physical or mental harm
Neglect means not giving someone the things he or she needs to avoid physical or mental harm such
as:
Food
Shelter
Medical care
Exploitation means:
Stealing someone’s property or money
Using someone’s accounts or credit cards
Misplacing someone’s things on purpose without his or her permission
Abuse, neglect and exploitation can be reported to:
Your service coordinator
Amerigroup; call our Case Coordination Line at 1-877-269-5660
The member advocate
You can also call the state of New Mexico Adult Protective Services Department at 1-866-654-3219. If
you wish, you can keep your identity secret when you make a report.
Minors
For most Amerigroup members under age 18, Amerigroup network providers and hospitals cannot give
them care without their parent’s or legal guardian’s consent. This does not apply under the following
conditions:
If emergency care is needed
For pregnancy testing, delivery, and prenatal and postnatal care
61
NM-MHB-0004-12
NM MHB ENG 12/12
HIV-related services
Other reproductive health services such as testing and treatment for sexually transmitted diseases
These rules do not apply to emancipated minors. Members under age 18 may be emancipated minors
if they:
Are married
Are pregnant
Have a child
Have served in the armed forces
Are emancipated minors by court order
Emancipated minors may make their own decisions about their medical care. They also may make
decisions about the medical care of their children.
MAKING A LIVING WILL (ADVANCE DIRECTIVES)
Emancipated minors and members over 18 years old have rights under advance directive law. An
advance directive talks about making a living will. A living will says you may not want medical care if
you have a serious illness or injury and may not get better.
To make sure you get the kind of care you want if you are too sick to decide for yourself, you can sign a
living will. This is a type of advance directive. It is a paper that tells your provider and your family what
kinds of care you do not want if you are seriously ill or injured.
If you wish to sign a living will, you can:
Ask your PCP for a living will form or call Member Services to get one. A sample form is also in this
member handbook.
Fill out the form by yourself, or call us for help.
Take the form or mail it to your PCP or specialist. Your PCP or specialist will then know what kind of
care you want to get.
You can change your mind anytime after you have signed a living will.
Call your PCP or specialist to remove the living will from your medical record.
Fill out and sign a new form if you wish to make changes in your living will.
You can sign a paper called a durable power of attorney, too. This paper will let you name a person to
make decisions for you when you cannot make them yourself. Ask your doctor about these forms.
GRIEVANCES AND MEDICAL APPEALS
If you have any questions or concerns with your Amerigroup benefits, please call Member Services at
1-800-600-4441.
Grievances
If you have a problem with our services or network providers and would like to tell us about it, please
call Member Services.
62
NM-MHB-0004-12
NM MHB ENG 12/12
Filing a Grievance with Amerigroup
We will try to solve your problem on the phone. If we cannot take care of the problem when you call
us, you can file a grievance.
You can:
Call Member Services at 1-800-600-4441 and ask for help with writing a letter; include information
such as the date the problem happened and the people involved
File your grievance by fax or mail or in person within 90 calendar days of the date you were aware
of the problem
Send your letter to:
Quality Management
6565 Americas Parkway N.E., Suite 110
Albuquerque, NM 87110
When we get your call or letter, we will:
Send you a letter within five working days to let you know we got your grievance and when we
expect to have it resolved
Look into your grievance when we get it
Send you a letter within 30 calendar days from the date you first told us about your grievance; it
will tell you the decision made by Amerigroup and all the information that we reviewed
If we need more details, we may extend the grievance process for 14 calendar days. If we do this, we
will let you know the reason for the delay within two working days. You may also ask us to extend the
process if you have more details that we should see.
Filing a Grievance with the State
You can also file a grievance with the state if you are not pleased with our final decision. You can do
this at any time during the Amerigroup grievance process. To do this, contact:
Medical Assistance Division, Client Services Bureau
P.O. Box 2345
Santa Fe, NM 87504
1-888-997-2583 or 505-827-3100
OR
Aging and Long-Term Services Department (ALTSD)
2550 Cerrillos Road
Santa Fe, NM 87504
1-866-451-2901 or 505-476-4799
63
NM-MHB-0004-12
NM MHB ENG 12/12
Medical Appeals
There may be times when we say we will not pay for care that has been advised by your provider. This
may be all of the care or only part of the care. If we do this, you, a person acting on your behalf or your
provider (with your written OK) can appeal the decision.
A medical appeal is when you ask Amerigroup to look again at the care your provider asked for and we
said we would not pay for. You must file for an appeal within 90 calendar days from the date on the
letter that said we would not pay for a service.
You can appeal our decision in two ways:
Call Member Services. If you call us, you must still send us your appeal in writing unless it is an
emergency. We will send you an appeal form.
- Fill out the whole form.
- Mail it back to us at the address below within 10 calendar days of when you call us. If you do
not fill out and return the appeal form within 10 days, we will close your appeal. If you need
help, call Member Services.
Send us a letter or the appeal form to the address below:
Appeals Processing
6565 Americas Parkway, Suite 110
You can file your own appeal or have someone else do it for you. If someone else is going to file for
you, we must have your written OK that you want that person to file your appeal for you. You can do
this in two ways:
Call Amerigroup Member Services at the above number for a form that gives another person the
right to file an appeal for you (an agent).
Write your own letter.
Amerigroup will not take any action against you or your agent for filing an appeal. You can also ask
Amerigroup to see a copy of the file we have about your case.
When we get your letter or form, we will send you a letter saying we got your appeal. This will be sent
to you within five working days. This letter will also tell you:
When we expect to have it resolved
If we need more details to process your appeal; we will contact your doctor if we need medical
information about this service
After we receive your appeal:
A reviewer who has not seen your case before will look at your appeal. He or she will decide how
we should take care of your appeal.
We will send you a letter with the answer to your appeal. We will do this within 30 calendar days
from when we get your appeal.
64
NM-MHB-0004-12
NM MHB ENG 12/12
If we need more details about your appeal:
We may extend the appeals process for 14 calendar days.
We will let you know the reason for the delay. We will tell you within two working days from when
we decide to extend the process.
You may also ask us to extend the process if you have more information that we should consider.
To continue to get services that have already been approved and may be part of the reason for your
appeal, you must file the appeal within 13 calendar days from the date we mail the notice to you
saying that we will not pay for this care.
We must continue coverage of your benefits until:
You withdraw the appeal
Authorization expires or your service limits are met
Ten business days have passed since Amerigroup mailed a resolution letter; this applies only if the
decision is not in your favor and you have taken no further action
You may have to pay for the cost of any continued benefit if the final decision is not in your favor.
If a decision is made in your favor as a result of your appeal, Amerigroup will approve and pay for the
service we denied coverage of before.
Expedited Appeals
You or the person you ask to file an appeal for you can ask for an expedited appeal. You can ask for an
expedited appeal if you or your provider feels that taking the time for the standard appeals process
could seriously harm your life or your health.
You can ask for an expedited appeal in two ways:
You can call Member Services.
You can send us a letter to the address below. Call Member Services if you need help filing an
appeal.
Medical Management
6565 Americas Parkway N.E., Suite 110
If we agree your request for an appeal should be expedited, we will send you a letter with the answer
to your appeal. We will do this within three calendar days.
If we need more information from you or the person you asked to file the appeal for you:
We may extend the appeals process for 14 calendar days
We will let you know the reason for the delay; we will do this within two working days from when
we decide to extend the process
You may also ask us to extend the process if you have more details that we should review.
65
NM-MHB-0004-12
NM MHB ENG 12/12
If we do not agree that your request for an appeal should be expedited, we will:
Call you right away
Send you a letter within two working days to let you know how the decision was made and that
your appeal will be reviewed through the standard review process
If we do not agree to expedite your appeal, you can file a complaint about that, too. Even if you file a
complaint about Amerigroup denying your request to expedite your appeal, we will still continue to
review your appeal within the standard 30 calendar days. You can also fax your request toll free to
1-866-920-8354.
If the decision on your expedited appeal upholds our first decision and we will not pay for the care
your provider asked for, we will call you and send you a letter. This letter will:
Let you know how the decision was made
Tell you about your rights to request a state fair hearing
Auto-expedited Appeals
If we get an expedited request for approval of services and a decision is made to deny or limit these
services, Amerigroup will:
File an appeal on your behalf within 72 hours of getting the request for services
Call you to give you the appeal decision
Payment Appeals
If you get a service from a provider and we do not pay for that service, you may get a notice from
Amerigroup called an Explanation Of Benefits (EOB). This is not a bill. The EOB will tell you:
The date you got the service
The type of service
The reason we cannot pay for the service
The provider, health care place or person who gave you this service will get a notice called an
Explanation Of Payment (EOP).
If you get an EOB, you do not need to call or do anything at that time, unless you or your provider
wants to appeal the decision.
A payment appeal is when you ask Amerigroup to look again at the service we said we would not pay
for. Your provider must ask for an appeal within 90 calendar days of receiving the EOP. To appeal, your
provider can mail the request and medical information for the service to:
Central Appeals Processing
P.O. Box 61599
Virginia Beach, VA 23466-1599
Payment appeals must be submitted in writing by your provider.
66
NM-MHB-0004-12
NM MHB ENG 12/12
Fair Hearings
You have the right to ask for a fair hearing from the state. You may do this before, during, after or in
lieu of the appeal process. You must ask for a fair hearing within 90 days from the date you get our
Notice of Proposed Action letter denying coverage of services.
You can ask for a fair hearing by calling the New Mexico Human Services Department, Medical
Assistance Division at 1-800-432-6217; choose option 6 or by sending a letter to:
Fair Hearings Bureau
P.O. Box 2348
Santa Fe, NM 87504-2348
If you have any questions about your rights to appeal or request a fair hearing, call Member Services.
If you ask for a fair hearing, you will get a letter from the hearing officer. The letter will tell you:
The date and time of the hearing
What you need to know to get ready for the hearing
The hearing can be held by phone, and you can explain why you asked for this service. You can also ask
the hearing officer to review the information you send in and make a decision.
Continuation of Benefits
To continue to get services that have already been approved and may be part of the reason you are
filing for a fair hearing, you must call Member Services to request it within 13 calendar days from when
we mail the notice to you saying we will not pay for this care.
We must continue coverage of your benefits until:
You withdraw the request for a fair hearing
A fair hearing decision is reached and is not in your favor
Authorization expires or your service limits are met
You may have to pay for the cost of any continued benefit if the final decision is not in your favor.
If a decision is made in your favor as a result of your fair hearing, we will approve and pay for the
services we denied coverage of before.
OTHER INFORMATION
If You Move
You should contact your local Income Support Division (ISD) Office as soon as you move to report your
new address. If you get Social Security benefits, you should also contact your local Social Security office
to let them know you moved. Once you contact ISD and Social Security, you should then call
Amerigroup Member Services.
67
NM-MHB-0004-12
NM MHB ENG 12/12
You will continue to get health care services through us in your current area until the address is
changed. You must call Amerigroup before you can get any services in your new area unless it is an
emergency.
Renew Your Medicaid Benefits on Time
Keep the right care. Do not lose your health care benefits! You could lose your benefits even if you still
qualify. Every year, members enrolled in the CoLTS program with a nursing facility level of care will
need to renew their benefits. If you do not renew your eligibility, you will lose your health care
benefits.
Your local Income Support Division (ISD) office can answer your questions about renewing your
benefits. We want you to keep getting your health care benefits from us as long as you still qualify.
Your health is very important to us. You can look in your Amerigroup provider directory you got with
your enrollment package for an ISD office near you. You can also find the provider directory online at
www.myamerigroup.com.
If You Are No Longer Eligible for Medicaid
You will be disenrolled from Amerigroup if you no longer qualify for Medicaid. If you do not qualify for
Medicaid for six months or less and then become eligible again, you will be re-enrolled in Amerigroup
if:
You still qualify for nursing facility level of care
You have been in a nursing facility level of care setting while disenrolled
Your eligibility for Medicaid is confirmed back to the date you were disenrolled
How to Disenroll from Amerigroup
If you do not like something about Amerigroup, please call Member Services. We will work with you to
try to fix the problem.
Members enrolled in the CoLTS program may ask to be disenrolled from Amerigroup for cause at any
time during the lock-in period. You or your representative may call or submit your request in writing to
the state at:
Human Services Department
Medical Assistance Division, Client Services Bureau
P.O. Box 2348
Santa Fe, NM 87504-2348
1-888-997-2583
The change will take place no later than the first day of the second month following the month in
which you make the request.
68
NM-MHB-0004-12
NM MHB ENG 12/12
Reasons Why You Can Be Disenrolled from Amerigroup
Listed below are several reasons you could be disenrolled from Amerigroup. You can be disenrolled
without asking to be disenrolled. If you have done something that may cause you to lose your
enrollment, we will contact you. We will ask you to tell us what happened.
You could be disenrolled from Amerigroup if:
Amerigroup is no longer able to meet your health care or other medically necessary covered needs
Your conduct is such that it is not safe or wise to provide covered services
You have been made aware in writing and through other means of the chance to use the grievance
process
You try to hurt a provider, a staff person or an Amerigroup associate
If you have any questions about your enrollment, call Member Services.
If You Get a Bill
Always show your Amerigroup and Medicare ID cards when you:
See a provider
Go to the hospital
Go for tests
Even if your provider told you to go, you must show your ID cards to make sure you are not sent a bill
for services covered by Amerigroup.
If you do get a bill, send it to us with a letter saying that you have been sent a bill. Send the letter to
the address below:
Claims
P.O. Box 61010
Virginia Beach, VA 23466-1010
You can also call Member Services for help.
If You Have Other Health Insurance (Coordination of Benefits)
Please call Member Services if you or your children have other health insurance. Always show your
Amerigroup and other health insurance cards when you see a provider, go to the hospital or go for
tests. The other insurance plan needs to be billed for your health care services before Amerigroup can
be billed. Amerigroup will work with the other insurance plan on payment for these services.
Changes In Your Amerigroup Coverage
Sometimes Amerigroup may have to change the way we work, our covered services, or our network
providers and hospitals. We will mail you a letter when we make changes to the services that are
covered. Your Primary Care Provider’s (PCP’s) office may move, close or leave our network. If this
happens, we will call or send you a letter to tell you about this.
69
NM-MHB-0004-12
NM MHB ENG 12/12
We can also help you pick a new PCP. You can call Member Services if you have any questions.
Member Services can also send you a current list of our network PCPs.
How to Tell Amerigroup about Changes You Think We Should Make
We want to know what you like and do not like about Amerigroup. Your ideas will help us make
Amerigroup better. Please call Member Services to tell us your ideas. You can also send a letter to:
P.O. Box 62509
Virginia Beach, VA 23462
Amerigroup has a group of members who meet quarterly to give us their ideas; these meetings are
called Consumer Advisory Board meetings. This is a chance for you to find out more about us. You may
also ask questions and tell us ways we can improve. If you want to be part of this group, call Member
Services.
We also send surveys to some members. The surveys ask questions about how you like Amerigroup. If
we send you a survey, please fill it out and send it back. Our staff may also call to ask how you like
Amerigroup. Please tell them what you think. Your ideas can help us make Amerigroup better.
If you want to know more about the Amerigroup quality program, you can find the most up-to-date
information about our quality program in our annual quality report to members at
www.myamerigroup.com/NM.
Also, this information will include the results of our member surveys.
How Amerigroup Pays Providers
Different providers in our network have agreed to be paid in different ways by us. Your provider may
be paid each time he or she treats you (fee-for-service). Or your provider may be paid a set fee each
month for each member even if that member does not get services (capitation).
These kinds of pay may include ways to earn more money. This kind of pay is based on different things
like how happy a member is with the care or quality of care. It is also based on how easy it is to find
and get care.
If you want more details about how our contracted providers or any other providers in our network are
paid, please call the Amerigroup Member Services department or write to us at:
P.O. Box 62509
70
NM-MHB-0004-12
NM MHB ENG 12/12
YOUR AMERIGROUP MEMBER BILL OF RIGHTS
Your Rights
As an Amerigroup member, you have the right to:
Privacy
Be sure your medical record is private; be cared for with dignity and without discrimination; that
includes the right to:
Be treated fairly and with respect and get care in a non-discriminatory way
Know that your medical records and talks with your providers will be kept private and confidential
Not be harassed by Amerigroup or Amerigroup providers over contract problems
Choose your health plan and providers
Have the chance to choose a health care plan and Primary Care Provider or PCP, and change to another
health plan or provider in a reasonably easy manner; that includes the right to:
Choose a surrogate-decision maker to be involved in health care decisions as fitting
Be informed of how to choose your health plan or your PCP
Choose any health plan you want that is offered in your area
Choose your PCP or specialist from that plan’s network; this choice must be within the limits of the
referral and prior approval process
Change your PCP or specialist
Change your health plan for cause
Ask questions about your health care
Ask questions and get answers about anything you do not understand; that includes the right to
have your provider:
Explain your health care needs to you
Talk to you about ways your health care problems can be treated
Take part in decisions about your health care
Consent to or refuse treatment, and take part in treatment decisions; that includes the right to:
Work as part of a team with your provider or have someone that you choose work with your
provider to decide what health care is best for you
Say yes or no to the care your provider recommends
Get a second medical opinion at no cost to you
Make advance directives; tell your PCP how you wish to be treated if you become too ill to decide
for yourself
Use the grievance, appeal and fair hearing process
Use each complaint process on hand through Amerigroup and through Medicaid without penalty; get a
timely response to complaints; that includes the right to:
Make a complaint to Amerigroup or to the state Medicaid program about your health care, your
provider or your health plan
Ask for a fair hearing from the state Medicaid program about your complaint
Get a copy of your medical records
71
NM-MHB-0004-12
NM MHB ENG 12/12
Receive care in a timely manner
Get timely access to care that does not have any communication or physical access barriers; this
includes the right to:
Have phone access to a medical professional 24 hours a day, 7 days a week in order to get any
needed emergency or urgent care
Get medical care in a timely manner
Be able to get in and out of a health care provider's office; this includes barrier-free access for
persons with disabilities or other conditions that limit mobility, in accordance with the Americans
with Disabilities Act
Have interpreters, if needed, during times set up to see your providers and when you talk with your
health plan; interpreters include people who can speak in your language, assist with a disability or
help you understand the information
Get information in an alternate format in accord with the Americans with Disabilities Act
Have your health plan rules explained so that you know them; this includes the health care services
you can get and how to get them, and the providers who are in the Amerigroup network
Receive care without restraint
Not be restrained or secluded if doing so is:
For someone else’s convenience
Meant to force you to do something you do not want to do
To punish you
Your Responsibilities
As an Amerigroup member, you have the responsibility to:
Tell your providers about your health care needs
Share information that relates to your health status with your Primary Care Provider (PCP); become
fully informed about service and treatment options; this includes the responsibility to:
Tell your PCP about your health
Talk to your providers about your health care needs; ask questions about ways your health care
problems can be treated
Help your providers get your medical records
Give your providers the right information
Follow the prescribed treatment of care advised by your provider or let the provider know the
reasons the treatment cannot be followed as soon as possible
Make and keep doctor appointments and be on time; call the doctor’s office if you need to cancel
an appointment or will be late
Take part in making decisions about your health
Take part in decisions that relate to service and treatment options, make personal choices, and take
action to maintain your health; this includes the responsibility to:
Work as a team with your provider to decide what health care is best for you
Know how the things you do can affect your health
Do the best you can to stay healthy
Treat providers and staff with respect
72
NM-MHB-0004-12
NM MHB ENG 12/12
Call Member Services if you have a problem and need help.
Amerigroup provides health coverage to our members on a nondiscriminatory basis according to state
and federal law, regardless of gender, race, age, religion, national origin, physical or mental disability,
or type of illness or condition.
HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID PROGRAM
If you know someone who is misusing the Medicaid program, you can report him or her.
To report primary care providers, specialists, clinics, hospitals, nursing homes or Medicaid enrollees,
write or call Amerigroup at:
Corporate Investigations Department
4425 Corporation Lane
1-800-600-4441
Suspicions of fraud and abuse can be emailed directly to the Amerigroup Corporate Investigations
Department at [email protected].
Online: Suspicions of fraud and abuse can also be sent to the 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. This information is sent directly to the email address
above, which is checked every business day.
You can also call the Medicaid Fraud and Abuse Hotline at 1-800-228-4802 or the Inspector General’s
Fraud and Abuse Unit at 1-800-228-4802.
WE HOPE THIS BOOK HAS ANSWERED MOST OF YOUR QUESTIONS ABOUT AMERIGROUP. FOR MORE
INFORMATION, CALL THE AMERIGROUP MEMBER SERVICES DEPARTMENT AT 1-800-600-4441.
73
NM-MHB-0004-12
NM MHB ENG 12/12
NEW MEXICO ADVANCE HEALTH CARE DIRECTIVE
PART I
POWER OF ATTORNEY FOR HEALTH CARE
PART 1 of this form is a power of attorney for health care. PART 1 lets you name another individual as agent to
make health care decisions for you if you become incapable of making your own decisions or if you want
someone else to make those decisions for you now even though you are still capable. You may also name an
alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for
you. Unless related to you, your agent may not be an owner, operator or employee of a health care institution at
which you are receiving care. Unless the form you sign limits the authority of your agent, your agent may make
all health care decisions for you. This form has a place for you to limit the authority of your agent.
This part is the health care power-of-attorney form, which allows you to name an individual to act as your
agent to make health care decisions for you
(1) DESIGNATION OF AGENT: I, _______________________________, name the following individual as my
agent to make health care decisions for me:
______________________________________________________________________________________
Name
Phone Number
______________________________________________________________________________________
Address
City
State
ZIP Code
If I revoke my agent’s authority or if my agent is not willing, able or reasonably available to make a health
care decision for me, I designate as my first alternate agent:
______________________________________________________________________________________
Name
Phone Number
_______________________________________________________________________________________
Address
City
State
ZIP Code
If I revoke the authority of my agent and first alternate agent or if neither is willing, able or reasonably
available to make a health care decision for me, I designate as my second alternate agent:
______________________________________________________________________________________
Name
Phone Number
_______________________________________________________________________________________
Address
City
State
ZIP Code
If you give your agent unlimited authority, they will have the right to:
(a) Consent or refuse any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or
mental condition
(b) Select or discharge health care providers and institutions
(c) Approve or disapprove diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate
and
(d) Direct the provision, withholding or withdrawal of artificial nutrition and hydration and all other forms of health
care
74
NM-MHB-0004-12
NM MHB ENG 12/12
(2) AGENT’S AUTHORITY: My agent is authorized to obtain and review medical records, reports and
information about me and to make all health care decisions for me, including decisions to provide, withhold
or withdraw artificial nutrition, hydration and all other forms of health care to keep me alive, except as I
state here:
_______________________________________________________________________________________
_______________________________________________________________________________________
(3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority becomes effective when my
primary physician and one other qualified health care professional determine that I am unable to make my
own health care decisions. If I initial this box * +, my agent’s authority to make health care decisions for
me takes effect immediately.
(4) DURABILITY OF AGENT’S AUTHORITY: I intend for this Power of Attorney to be durable and to remain in
full force and effect during any period of time where I have been determined to be incapacitated pursuant
to Paragraph 3 above. Furthermore, I intend for this Power of Attorney to be effective notwithstanding any
lapse of time since its execution. The durability of this Power of Attorney does not in any way affect my
ability to revoke this instrument pursuant to Paragraph 14 below.
(5) AGENT’S OBLIGATIONS: My agent shall make health care decisions for me in accordance with this power
of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes, to the extent
known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me
in accordance with what my agent determines to be in my best interest. In determining my best interest, my
agent shall consider my personal values to the extent known to my agent.
(6) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, I
nominate the agent designated in this form. If that agent is not willing, able or reasonably available to act as
guardian, I nominate the alternate agents whom I have named, in the order designated.
PART 2 INSTRUCTIONS FOR HEALTH CARE
PART 2 of this form lets you give specific instructions about any aspect of your health care. Choices are provided
for you to express your wishes regarding life-sustaining treatment, including the provision of artificial nutrition
and hydration, as well as the provision of pain relief. Initial and check each choice that you want your health care
provider or agent to follow. In addition, you may express your wishes regarding whether you want to make an
anatomical gift of some or all of your organs and tissue. Space is also provided for you to add to the choices you
have made or for you to write out any additional wishes.
If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions,
you need not fill out this part of the form. If you do fill out this part of the form, you may cross out any
wording you do not want.
(7) END OF LIFE DECISIONS: If I am unable to make or communicate decisions regarding
my health care, and IF (i) I have an incurable or irreversible condition that will result in my death within a
relatively short time, OR (ii) I become unconscious and, to a reasonable degree of medical certainty, I will
not regain consciousness, OR (iii) the likely risks and burdens of treatment would outweigh the expected
benefits, THEN I direct that my health care providers and others involved in my care provide, withhold or
withdraw treatment in accordance with the choice I have initialed below in one of the following three
boxes:
75
NM-MHB-0004-12
NM MHB ENG 12/12
[
] (a) I CHOOSE NOT TO PROLONG LIFE
I do not want my life to be prolonged.
[
] (b) I CHOOSE TO PROLONG LIFE
I want my life to be prolonged as long as possible within the limits of generally accepted health care
standards.
[
] (c) I CHOOSE TO LET MY AGENT DECIDE
My agent under my power of attorney for health care may make life-sustaining treatment decisions
for me.
(8) ARTIFICIAL NUTRITION AND HYDRATION: If I have chosen above NOT to prolong life, I also specify by
marking my initials below:
[
]I DO NOT want artificial nutrition
OR
[
]I DO WANT artificial nutrition.
[
]I DO NOT want artificial hydration unless required for my comfort
OR
[
]I DO WANT artificial hydration.
(9) RELIEF FROM PAIN: Regardless of the choices I have made in this form and except as I state in the
following space, I direct that the best medical care possible be provided at all times to keep me clean,
comfortable and free of pain or discomfort so that my dignity is maintained, even if this care hastens my
death.
(10) ANATOMICAL GIFT DESIGNATION: Upon my death I specify as marked below whether I choose to
make an anatomical gift of all or some of my organs or tissue:
[
]I CHOOSE to make an anatomical gift of my organs or tissue to be determined by
medical suitability at the time of death, or by my wishes listed below, and artificial support may be
maintained long enough for organs to be removed. I wish to make ONLY the following donation:
_______________________________________________
[
]I REFUSE to make an anatomical gift of any of my organs or tissue.
[
]I CHOOSE to let my agent decide.
(11) OTHER WISHES: (If you wish to write your own instructions, or if you wish to add to the instructions
you have given above, you may do so here.) I direct that:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
PART 3 PRIMARY PHYSICIAN
PART 3 of this form lets you designate a physician to have primary responsibility for your health care, makes a
copy as effective as an original, and allows you to revoke at any time.
76
NM-MHB-0004-12
NM MHB ENG 12/12
(12) PRIMARY PHYSICIAN: I designate the following physician as my primary physician:
_______________________________________________________________________________________
(13) EFFECT OF COPY: A copy has the same effect as the original.
(14) REVOCATION: I understand that I may revoke this OPTIONAL ADVANCE HEALTH CARE DIRECTIVE at any
time, and that if I revoke it, I should promptly notify my supervising health care provider and any health
care institution where I am receiving care and any others to whom I have given copies of this power of
attorney. I understand that I may revoke the designation of an agent either by a signed writing or
personally informing the supervising health care provider.
SIGNATURE: Sign and date the form here:
_______________________________________________________________________________________
Your Signature
Address
_______________________________________________________________________________________
Today’s Date
Print Your Name
(Optional) SIGNATURE OF WITNESSES:
First Witness
______________________________________________________________________________________
Name
Address
______________________________________________________________________________________
Signature of Witness
Date
Second Witness
______________________________________________________________________________________
Name
Address
______________________________________________________________________________________
Signature of Witness
Date
(Optional) NOTARY PUBLIC
STATE OF NEW MEXICO )
) ss.
County of _______________________)
THE FOREGOING instrument was acknowledged before me this _____ day of ___________, 201___,
by the principal, ___________________________________.
__________________________________________________
NOTARY PUBLIC
(SEAL)
My Commission expires: ____________________________
77
NM-MHB-0004-12
NM MHB ENG 12/12
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed and how you
can get access to this information. Please review it carefully.
This notice is in effect April 14, 2003.
What Is this Notice?
This Notice tells you:
How Amerigroup handles your protected health information
How Amerigroup uses and gives out your protected health information
Your rights about your protected health information
The Amerigroup responsibilities in protecting your protected health information
This Notice follows what is known as the Health Insurance Portability and Accountability Act (HIPAA)
Privacy Regulations. These regulations were given out by the federal government. The federal
government requires companies such as Amerigroup to follow the terms of the regulations and of this
Notice.
This Notice is also available on the Amerigroup website at www.amerigroupcorp.com.
NOTE: You may also get a Notice of Privacy Practices from the state and other organizations.
What Is Protected Health Information?
Protected Health Information (PHI) - The HIPAA Privacy Regulations define PHI as:
Information that identifies you or can be used to identify you
Information that either comes from you or has been created or received by a health care provider,
a health plan, your employer or a health care clearinghouse
Information that has to do with your physical or mental health or condition, providing health care
to you, or paying for providing health care to you
In this Notice, protected health information will be written as PHI.
What are the Amerigroup Responsibilities to You about Your Protected Health
Information?
Your/your family’s PHI is private. We have rules to help keep it safe and private. These rules are meant
to follow state and federal laws. Amerigroup must:
Protect the privacy of the PHI that we have or keep about you through:
- Staff training
- Secure computer systems and offices
- Secure disposal of written material that includes PHI
- Other technical methods
Provide you with this Notice about how we get and keep PHI about you
Follow the terms of this Notice
78
NM-MHB-0004-12
NM MHB ENG 12/12
Follow state privacy laws that do not conflict with or are stricter than the HIPAA Privacy
Regulations
We will not use or give out your PHI without your consent, except as described in this Notice.
How Do We Use Your Protected Health Information?
The sections that follow tell some of the ways we can use and share PHI without your written
authorization.
For payment: We may use PHI about you so that the treatment services you get may be looked at for
payment. For example, a bill that your provider sends us may be paid using information that identifies
you, your diagnosis, the procedures or tests, and supplies that were used.
For health care operations: We may use PHI about you for health care operations. For example, we
may use the information in your record to review the care and results in your case and other cases like
it. This information will then be used to improve the quality and success of the health care you get.
Another example of this is using information to help enroll you for health care coverage.
We may use PHI about you to help provide coverage for medical treatment or services. For example,
information we get from a provider (nurse, doctor or other member of a health care team) will be
logged and used to help decide the coverage for the treatment you need. We may also use or share
your PHI to:
Send you information about one of our disease or case management programs
Send reminder cards that let you know that it is time to make an appointment or get services like
EPSDT or Child Health Checkup services
Answer a customer service request from you
Make decisions about claims requests and appeals for services you received
Look into any fraud or abuse cases and make sure required rules are followed
Other Uses of Protected Health Information
Business associates: We may contract with business associates that will provide services to
Amerigroup using your PHI. Services our business associates may provide include dental services for
members, a copy service that makes copies of your record and computer software vendors. They will
use your PHI to do the job we have asked them to do. The business associate must sign a contract to
agree to protect the privacy of your PHI.
People involved with your care or with payment for your care: We may make your PHI known to a
family member, other relative, close friend or other personal representative that you choose. This will
be based on how involved the person is in your care or payment that relates to your care. We may
share information with parents or guardians, if allowed by law.
Law enforcement: We may share PHI if law enforcement officials ask us to. We will share PHI about
you as required by law or in response to subpoenas, discovery requests, and other court or legal
orders.
79
NM-MHB-0004-12
NM MHB ENG 12/12
Other covered entities: We may use or share your PHI to help health care providers that relate to
health care treatment, payment or operations. For example, we may share your PHI with a health care
provider so that the provider can treat you.
Public health activities: We may use or share your PHI for public health activities allowed or required
by law. For example, we may use or share information to help prevent or control disease, injury, or
disability. We also may share information with a public health authority allowed to get reports of child
abuse, neglect or domestic violence.
Health oversight activities: We may share your PHI with a health oversight agency for activities
approved by law, such as audits; investigations; inspections; licensure or disciplinary actions; or civil,
administrative or criminal proceedings or actions. Oversight agencies include government agencies
that look after the health care system; benefit programs, including Medicaid, SCHIP or Healthy Kids;
and other government regulation programs.
Research: We may share your PHI with researchers when an institutional review board or privacy
board has followed the HIPAA information requirements.
Coroners, medical examiners, funeral directors and organ donation: We may share your PHI to
identify a deceased person, determine a cause of death, or do other coroner or medical examiner
duties allowed by law. We also may share information with funeral directors, as allowed by law. We
may also share PHI with organizations that handle organ, eye, or tissue donation and transplants.
To prevent a serious threat to health or safety: We may share your PHI if we feel it is needed to
prevent or reduce a serious and likely threat to the health or safety of a person or the public.
To prevent delays in treatment: We may share your PHI to prevent delays in treatment. For example,
if you switch health plans, we may share your PHI with your new health plan if we feel it is needed to
avoid delays in your treatment.
Military activity and national security: Under certain conditions, we may share your PHI if you are, or
were, in the Armed Forces. This may happen for activities believed necessary by appropriate military
command authorities.
Disclosures to the Secretary of the U.S. Department of Health and Human Services: We are required
to share your PHI with the Secretary of the U.S. Department of Health and Human Services. This
happens when the Secretary looks into or decides if we are in compliance with the HIPAA Privacy
Regulations.
What are Your Rights Regarding Your Protected Health Information?
We want you to know your rights about your PHI and your Amerigroup family members’ PHI.
80
NM-MHB-0004-12
NM MHB ENG 12/12
Right to get the Amerigroup Notice of Privacy Practices
We are required to send to each Amerigroup head of case or head of household a printed copy of this
Notice on or before April 14, 2003. After that, each head of case or head of household will get a
printed copy of the Notice in the New Member Welcome package.
We have the right to change this Notice. Once the change happens, it will apply to PHI that we have at
the time we make the change and to the PHI we had before we made the change. A new Notice that
includes the changes and the dates they are in effect will be mailed to you at the address we have for
you. The changes to our Notice will also be included on our website. You may ask for a paper copy of
the Notice of Privacy Practices at any time. Call Member Services toll free at 1-800-600-4441. If you are
deaf or hard of hearing and want to talk to Member Services, call the toll-free AT&T Relay Service at
1-800-855-2880.
Right to Request a Personal Representative
You have the right to request a personal representative to act on your behalf, and Amerigroup will
treat that person as if that person were you.
Unless you apply restrictions, your personal representative will have full access to all of your
Amerigroup records. If you would like someone to act as your personal representative, Amerigroup
requires your request in writing. A personal representative form must be completed and mailed back
to the Amerigroup Member Privacy Unit. To request a personal representative form, please contact
Member Services. We will send you a form to complete. The address and phone number are at the end
of this Notice.
Right to Access
You have the right to look at and get a copy of your enrollment, claims, payment and case
management information on file with Amerigroup. This file of information is called a designated record
set. We will provide the first copy to you in any 12-month period without charge.
If you would like a copy of your PHI, you must send a written request to the Amerigroup Member
Privacy Unit. The address is at the end of this Notice. We will answer your written request in 30
calendar days. We may ask for an extra 30 calendar days to process your request if needed. We will let
you know if we need the extra time.
We do not keep complete copies of your medical records. If you would like a copy of your medical
record, contact your doctor or other provider. Follow the doctor’s or provider’s instructions to get a
copy. Your doctor or other provider may charge a fee for the cost of copying and/or mailing the
record.
We have the right to keep you from having or seeing all or part of your PHI for certain reasons; for
example, if the release of the information could cause harm to you or other persons or the
information was gathered or created for research or as part of a civil or criminal proceeding. We
will tell you the reason in writing. We will also give you information about how you can file an
appeal if you do not agree with us.
81
NM-MHB-0004-12
NM MHB ENG 12/12
Right to Amend
You have the right to ask that information in your health record be changed if you think it is not
correct.
To ask for a change, send your request in writing to the Amerigroup Member Privacy Unit. We can send
you a form to complete. You can also call Member Services to request a form. The address and phone
number are at the end of this Notice.
State the reason why you are asking for a change.
If the change you ask for is in your medical record, get in touch with the doctor who wrote the
record. The doctor will tell you what you need to do to have the medical record changed.
We will answer your request within 30 calendar days of when we receive it. We may ask for an extra 30
calendar days to process your request if needed. We will let you know if we need the extra time.
We may deny the request for change. We will send you a written reason for the denial if:
The information was not created or entered by Amerigroup
The information is not kept by Amerigroup
You are not allowed, by law, to see and copy that information
The information is already correct and complete
Right to an Accounting of Certain Disclosures of Your Protected Health Information
You have the right to get an accounting of certain disclosures of your PHI. This is a list of times we
shared your information when it was not part of payment and health care operations.
Most disclosures of your PHI by our business associates or us will be for payment or health care
operations.
To ask for a list of disclosures, please send a request in writing to the Amerigroup Member Privacy
Unit. We can send you a form to complete. The address and phone number are at the end of this
Notice. Your request must give a time period that you want to know about. The time period may not
be longer than six years and may not include dates before April 14, 2003.
Right to Request Restrictions
You have the right to ask that your PHI not be used or shared. You do not have the right to ask for
limits when we share your PHI if we are asked to do so by law enforcement officials, court officials, or
state and federal agencies in keeping with the law. We have the right to deny a request for restriction
of your PHI.
To ask for a limit on the use of your PHI, send a written request to the Amerigroup Member Privacy
Unit. We can send you a form to fill out. The address and phone number are at the end of this Notice.
The request should include:
The information you want to limit and why you want to restrict access
Whether you want to limit when the information is used, when the information is given out or both
The person or persons that you want the limits to apply to
We will look at your request and decide if we will allow or deny the request within 30 calendar days. If
we deny the request, we will send you a letter and tell you why.
82
NM-MHB-0004-12
NM MHB ENG 12/12
Right to Cancel a Privacy Authorization for the Use or Disclosure of Protected Health Information
We must have your written permission (authorization) to use or give out your PHI for any reason other
than payment and health care operations, or other uses and disclosures listed under Other Uses of
Protected Health Information. If we need your authorization, we will send you an authorization form
explaining the use for that information.
You can cancel your authorization at any time by following the instructions below.
Send your request in writing to the Amerigroup Member Privacy Unit. We can send you a form to
complete. The address and phone number are at the end of this Notice. This cancellation will only
apply to requests to use and share information asked for after we get your Notice.
Right to Request Confidential Communications
You have the right to ask that we communicate with you about your PHI in a certain way or in a certain
location. For example, you may ask that we send mail to an address that is different from your home
address.
Requests to change how we communicate with you should be submitted in writing to the Amerigroup
Member Privacy Unit. We can send you a form to complete. For a copy of the form, contact Member
Services. The address and phone number are at the end of this Notice. Your request should state how
and where you want us to contact you.
What Should You Do If You Have a Complaint about the Way Your Protected Health Information Is
Handled by Amerigroup or Our Business Associates?
If you believe that your privacy rights have been violated, you may file a complaint with Amerigroup or
with the Secretary of Health and Human Services.
To file a complaint with Amerigroup or to appeal a decision about your PHI, send a written request to
the Amerigroup Member Privacy Unit or call Member Services. The address and phone number are at
the end of this Notice.
To file a complaint with the Secretary of Health and Human Services, send your written request to:
Office for Civil Rights
U.S. Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, TX 75202
You will not lose your Amerigroup membership or health care benefits if you file a complaint. Even if
you file a complaint, you will still get health care coverage from Amerigroup as long as you are a
member.
83
NM-MHB-0004-12
NM MHB ENG 12/12
Where Should You Call or Send Requests or Questions about Your PHI?
You may call us toll free at 1-800-600-4441. Or you may send questions or requests, such as the
examples listed in this Notice, to the address below:
Member Privacy Unit
P.O. Box 62509
Send your request to this address so that we can process it in a timely manner. Requests sent to
persons, offices or addresses other than the address listed above might be delayed.
If you are deaf or hard of hearing, you may call the toll-free AT&T Relay Service at 1-800-855-2880.
84
NM-MHB-0004-12
NM MHB ENG 12/12

What is AMERICAID Community Care?

Transcription

Similar documents

Candace [email protected] >

Point of sale - Close Motor Finance

Member HandbookAmerigroup Florida, Inc. Florida Healthy Kids

“Waianae Model of Integrative Healthcare”

STATEMENT OF PATIENT PRIVACY RIGHTS

Piecing it Together - The Arc of Spokane

flyer here

JPS HEALTH NETWORK • 537 bed hospital, Level 1 Trauma Center

Airgun World Magazine Article