Member HandbookAmerigroup Florida, Inc. Florida Healthy Kids

Member
Handbook
Amerigroup Florida, Inc.
FL-MHB-0043-15B FHK 01.16
Florida Healthy Kids Program
1-800-600-4441
www.myamerigroup.com/fl
www.myamerigroup.com
Dear Parent/Guardian:
Welcome to Amerigroup. Thank you for choosing us to help you get quality health care benefits
for your family.
Your child’s member handbook tells you how Amerigroup works and how to:
 Help keep your child healthy.
 Get health care, too.
You should have your child’s Amerigroup ID card by now. If not, you’ll get it soon. The ID card lists:
 When your child’s Amerigroup membership starts.
 Your child’s provider.
Check the ID card right away. If your child’s doctor or any other information is not right, please call
us at 1-800-600-4441 (TTY 711). We will send you a new ID card with the correct information.
AMERIGROUP BENEFITS
Here are some important Amerigroup benefits:
 No copay for well-child visits with a primary care provider
 $5 copay for office visits
 Free immunizations (shots)
 $10 a month to buy certain personal care items and over-the-counter (OTC) medicines
 $100 for hypoallergenic bedding (if medically needed)
 $5 copay for medicines (per monthly supply)
 Six months of free fitness and healthy behavior coaching for kids ages 7 to 13 years
 A free mouth guard for children who play contact sports
 Amerigroup On Call: A 24-hour nurse helpline to answer your medical questions day or night
Do you have questions about your child’s benefits? Please call Member Services at
1-800-600-4441 (TTY 711). You can also visit our website at www.myamerigroup.com/FL.
Do you have medical questions and want to talk to a nurse? Call Amerigroup On Call at
1-866-864-2544 24 hours a day, 7 days a week, 365 days a year. Our nurses can answer your
health questions and help you find the help your child needs.
Sincerely,
Amerigroup
We can translate this into another language at no cost. Call Member Services toll free at
1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
Podemos traducirle esta información a otro idioma sin costo. Llame a la línea gratuita de
Servicios al Miembro al 1-800-600-4441 (TTY 711) de lunes a viernes de 8 a.m. a 7 p.m. hora del
Este.
AMERITIPS: HEALTH TIPS THAT MAKE HEALTH HAPPEN
YOU NEED TO GO TO YOUR DOCTOR NOW!
WHEN IS IT TIME FOR A WELL-CARE VISIT?
All Amerigroup members need regular well-care visits. Your primary care provider (PCP) can
also see if you have any problems.
Children need more well-care visits than adults. Well-care visits are part of Florida’s Child
Health Check-Up program. Your child should have a well-child exam (physical) every year.
WHAT IF YOUR DAUGHTER BECOMES PREGNANT?
If you think your daughter is pregnant, call her PCP or OB/GYN right away. This can help her
have a healthy baby.
If you have any questions or need help making an appointment with the PCP or OB/GYN,
contact Member Services. Please call 1-800-600-4441 (TTY 711).
Alert! Keep the right care. Do not lose your child’s health care benefits. Renew your child’s
eligibility for Florida Healthy Kids program benefits on time.
AMERIGROUP
Florida Healthy Kids Member Handbook
4200 W. Cypress St., Suite 900 ● Tampa, FL 33607-4173
1-800-600-4441 ● TTY 711
www.myamerigroup.com/FL
Table of Contents
WELCOME TO THE AMERIGROUP HEALTHY KIDS PROGRAM .............................................................. 1
INFORMATION ABOUT YOUR CHILD’S NEW HEALTH PLAN ................................................................. 1
Important New Member Information.................................................................................................... 1
Member Handbook ........................................................................................................................... 1
Provider Directory ............................................................................................................................. 1
Identification Card ............................................................................................................................. 2
Eligibility ............................................................................................................................................ 2
HOW TO GET HELP ............................................................................................................................ 3
Amerigroup Member Services ............................................................................................................... 3
Online and Automated Self-service Features ........................................................................................ 4
Mobile Identification Card Application .................................................................................................. 4
Amerigroup On Call – A 24-hour Nurse Helpline ................................................................................... 4
Other Important Phone Numbers .......................................................................................................... 5
YOUR CHILD’S DOCTORS ................................................................................................................... 5
Choosing a Primary Care Provider ......................................................................................................... 5
If Your Child Had a Different Provider Before Joining Amerigroup .................................................. 6
If Your Child’s Primary Care Provider’s Office Moves, Closes or Leaves the Amerigroup Network . 6
How to Change Your Child’s Primary Care Provider .............................................................................. 6
If Your Child’s Primary Care Provider Asks for Your Child to Be Changed to a New Primary
Care Provider ................................................................................................................................ 7
If You Want Your Child to Go to a Provider Who Is Not the Primary Care Provider ........................ 7
Choosing an OB/GYN.............................................................................................................................. 7
Specialists ............................................................................................................................................... 7
GOING TO THE DOCTOR .................................................................................................................... 8
Your Child’s First Doctor Visit ................................................................................................................. 8
How to Make an Appointment .............................................................................................................. 8
Wait Times for Appointments ........................................................................................................... 9
What to Bring When Your Child Goes to a Provider Visit ................................................................. 9
How to Cancel a Visit ......................................................................................................................... 9
YOUR CHILD’S AMERIGROUP BENEFITS ........................................................................................... 10
What Is Covered by Amerigroup? ........................................................................................................ 10
Payment for Services............................................................................................................................ 10
Monthly Premiums............................................................................................................................... 10
Renewal ................................................................................................................................................ 11
AMERIGROUP AND HEALTHY KIDS BENEFITS ................................................................................... 11
Extra Amerigroup Benefits ................................................................................................................... 14
Utilization Management ...................................................................................................................... 14
Services That Don’t Need Prior Authorization ..................................................................................... 14
Dental Services ..................................................................................................................................... 15
Getting a Prescription Filled ................................................................................................................. 15
DIFFERENT TYPES OF HEALTH CARE ................................................................................................. 16
Routine, Urgent and Emergency Care: What is the Difference? ......................................................... 16
Routine Care .................................................................................................................................... 16
Urgent Care ..................................................................................................................................... 16
Emergency Care............................................................................................................................... 16
What Is an Emergency Medical Condition? ......................................................................................... 17
What Is an Emergency Behavioral Health Condition? ......................................................................... 17
What Is Post-stabilization?................................................................................................................... 17
WELLNESS CARE .............................................................................................................................. 18
Vision Screening ................................................................................................................................... 18
Hearing Screening ................................................................................................................................ 18
Dental Screening .................................................................................................................................. 18
Immunizations ...................................................................................................................................... 18
SPECIAL CARE FOR PREGNANT MEMBERS ........................................................................................ 21
When Your Child Becomes Pregnant ................................................................................................... 21
When Should Your Child Go to Her PCP or OB/GYN? .......................................................................... 22
When Your Child Has a New Baby ....................................................................................................... 22
DISEASE MANAGEMENT .................................................................................................................. 23
CASE MANAGEMENT....................................................................................................................... 24
SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING ................................................................... 25
Health Information ............................................................................................................................... 25
Amerigroup On Call .............................................................................................................................. 25
Health Education Classes ..................................................................................................................... 25
Bullying Resources ............................................................................................................................... 25
Smoking Cessation ............................................................................................................................... 27
Community Events ............................................................................................................................... 28
GRIEVANCES AND APPEALS ............................................................................................................. 28
Medical Appeals ................................................................................................................................... 30
Payment Appeals ................................................................................................................................. 32
Continuation of Benefits ...................................................................................................................... 33
OTHER INFORMATION .................................................................................................................... 34
If You Move .......................................................................................................................................... 34
Reasons Why You Can be Disenrolled from Amerigroup and Healthy Kids ........................................ 34
If You Get a Bill ..................................................................................................................................... 34
Changes in Your Child’s Amerigroup Coverage.................................................................................... 34
New Technology ................................................................................................................................... 34
How to Tell Amerigroup About Changes You Think We Should Make ................................................ 35
How Amerigroup Pays Providers ......................................................................................................... 35
SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES ................................... 36
You and Your Child’s Rights.................................................................................................................. 36
You and Your Child’s Responsibilities .................................................................................................. 37
HOW TO REPORT SOMEONE WHO IS MISUSING THE HEALTHY KIDS PROGRAM ................................... 37
IMPORTANT TERMS ........................................................................................................................ 38
HIPAA NOTICE OF PRIVACY PRACTICES ............................................................................................ 40
WELCOME TO THE AMERIGROUP HEALTHY KIDS PROGRAM
INFORMATION ABOUT YOUR CHILD’S NEW HEALTH PLAN
Welcome to Amerigroup Florida, Inc., doing business as Amerigroup. We are committed to helping
your child get quality care close to home.
The Healthy Kids program is offered through the Florida Healthy Kids Corporation. Healthy Kids has
contracted with Amerigroup to provide services in your county. Through this program, parents can get
health care for their children who are eligible for coverage. The Florida Healthy Kids Corporation is a
nonprofit organization created in 1990 by the state of Florida. It provides affordable health care
coverage for children from ages 5 to 18.
Your child’s primary care provider (PCP) will work together with you to keep your child healthy and
care for his or her health problems. This member handbook will help you understand your child’s
health plan.
Important New Member Information
There are three important items every new member needs:
1. Member handbook
2. Provider directory
3. Identification (ID) card
Member Handbook
To make it easy for busy FHK members, our member handbook is online and in print. You can view the
member handbook online at www.myamerigroup.com/FL. Go to Florida Healthy Kids.
To get a printed member handbook, call Member Services at 1-800-600-4441 (TTY 711). There is no
charge for the printed material.
This handbook will help you understand your child’s health plan. If you have questions or need help
with this member handbook, call Member Services. Amerigroup also has the member handbook in:
 A large print version
 An audio version
 A Braille version
The other side of this handbook is in Spanish.
Provider Directory
Is your child’s provider part of Amerigroup? Our provider directory is online and in print. You can see
this directory at www.myamerigroup.com/FL. Go to Florida Healthy Kids. Or use the interactive search
online at Find A Doctor.
To get a printed provider directory, call Member Services at 1-800-600-4441 (TTY 711). There is no
charge for the printed material.
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Identification Card
Your child’s Amerigroup ID card will be mailed. The ID card has:
 Primary care provider information:
- Name
- Address
- Office and after-hours phone number
 The date you became an Amerigroup member
 Your child’s date of birth
 Your subscriber (Amerigroup) identification number
 Other important numbers you need to know:
- Amerigroup Member Services
- Amerigroup On Call
- The number to find a network vision
care provider
- The number to report Medicaid Fraud and Abuse
 What to do if you have an emergency
If your child’s Amerigroup ID card is lost or stolen, call us right away at 1-800-600-4441
(TTY 711). We will send you a new one.
Eligibility
Your child is eligible for the Healthy Kids program if he or she is:
 5 to18 years old
 Uninsured
 Not eligible for Medicaid or the Children’s Medical Services Network
 Meet eligibility income levels
You may apply for Healthy Kids coverage at any time. If your child has lost Healthy Kids coverage,
please call 1-800-821-KIDS (5437) (TTY 1-877-427-9825) Monday through Friday from 7:30 a.m. to
7:30 p.m. They can answer any questions you have about your child’s eligibility or benefits with
Healthy Kids.
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HOW TO GET HELP
Amerigroup Member Services
You can call Member Services at 1-800-600-4441 (TTY 711) Monday through Friday 8 a.m. to 7 p.m.
Eastern time except for holidays.
Member Services can help you with:
 Understanding your member handbook
 Understanding your member ID card
 Using your health care benefits
 Getting to know your child’s doctor:
- Names
- Specialties
- Addresses
- Office and after-hours phone numbers








Making office visits
Understanding your health care
Understanding wellness care
Using healthy living benefits
Finding transportation
Getting health education
Filing grievances and appeals
Understanding your rights and
responsibilities
You can also call us:
 If you want to get a copy of the Amerigroup Notice of Privacy Practices (NOPP). It is also located in
this handbook. The NOPP describes:

How medical information about your child may be used and disclosed.

How you can get access to this information.
 If you move. We’ll need to know your new address and phone number. You should also call Healthy
Kids at 1-800-821-KIDS (5437) (TTY 1-877-427-9825) Monday through Friday from 7:30 a.m. to
7:30 p.m. Eastern time.
 If you want to get the member handbook in a different language.
For members who don’t speak English, we can:
 Help in many languages and dialects.
 Translate for you at provider visits at no cost to you.
For members who are deaf or hard of hearing:
 Call TTY 711.
 We’ll set up and pay for someone who knows sign language to help you during your
office visits.
Please let us know at least 24 hours before your appointment, if you need an interpreter. Call Member
Services to learn more.
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Online and Automated Self-service Features
These services are online at www.myamerigroup.com/FL or on our automated phone line 24 hours a
day, 7 days a week. You can:
 Choose or find a PCP in the Amerigroup network
 Ask to change your PCP
 Request an ID card
 Update your address or phone number
 Request a member handbook or provider directory
Mobile Identification Card Application
You can now access your child’s Amerigroup member Identification (ID) card from anywhere. Just
download the Amerigroup Mobile app to your iPhone®, iPad® or Android™ tablet
or smartphone.
With Amerigroup Mobile, you can show, email or fax your child’s member ID card to your doctor,
pharmacy or hospital. It’s fast. It’s free. And best of all, it’s safe. You just need your child’s ZIP code and
Amerigroup ID number, which is the subscriber number shown on your ID card, to use these services.
To download the app, go to the Apple iTunes® Store or the Android™ Market or visit our website at
www.myamerigroup.com/FL.
Amerigroup On Call – A 24-hour Nurse Helpline
When your child is sick, call Amerigroup On Call at 1-866-864-2544 (TTY 711). A registered nurse can
help you:
 Find a doctor after hours or on weekends.
 Get to an urgent care center or a walk-in clinic.
 Schedule an appointment with your doctor or a network doctor.
 Speak directly with a doctor about your health needs.
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
We want you to be happy with all the services your child gets from the Amerigroup network of doctors
and hospitals. Please call Member Services if you have any problems with your
child’s care.
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Other Important Phone Numbers
Service Needed
If you have an
emergency
Enrollment or
disenrollment
information
Behavioral health
care
Dental care
Disease
management
Who to Call
Local emergency services
Phone Number
911
Healthy Kids Customer Service
1-800-821-KIDS (5437) (TTY 1-877-4279825)
Amerigroup Member Services
1-800-600-4441 (TTY 711)
Healthy Kids Customer Service
Amerigroup Member Services
Vision care
eyeQuest
1-800-821-KIDS (5437)
1-800-600-4441 (TTY 711)(ask to speak
with a disease management care
manager)
1-888-696-9551 (TTY 1-800-466-7566)
YOUR CHILD’S DOCTORS
Choosing a Primary Care Provider
All Amerigroup members must have a family doctor. This doctor is known as a primary care provider
(PCP). Your child’s PCP must be in the Amerigroup network.
Your child’s PCP will:
 Get to know your child and his or her health history
 Help your child get quality care
 Give your child all the basic health services he or she needs
 Send your child to other doctors or hospitals when your child needs special care
When your child enrolled in Amerigroup, you should have picked a PCP for your child. If you did not,
we picked one for your child. We chose one whose office is close by you. This PCP’s name and phone
number are on your child’s Amerigroup ID card.
If we chose a PCP for your child, you can pick a new one. Just look in the provider directory online at
www.myamerigroup.com/FL. Click on Find A Doctor. Or we can also help you choose a PCP. Call
Member Services for help.
If your child is already seeing a PCP, you can look in the provider directory to see if that PCP is in our
network. If so, you can tell us you want to keep that doctor as your PCP.
PCPs can be any of the following, as long as they are in the Amerigroup network:
 Family practitioners
 Pediatricians
 Obstetrician/Gynecologists (OB/GYNs) for women if they are pregnant
 Advanced registered nurse practitioners
 Physician assistants
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You may choose the same PCP for all of your children. You can also choose a different PCP for each
child based on each child’s needs.
Second Opinion
Amerigroup members in the Healthy Kids program have the right to ask for a second opinion about the
use of any covered health care services. Your child can get a second opinion from a network provider.
Your child can also ask a non-network provider if a network provider is not available. If approved, this
will not cost any more than if the service came from an in-network provider. Ask your child’s PCP to ask
us for your child to get a second opinion.
Once approved, your child’s PCP will tell you the date and time of the appointment. Your child’s PCP
will also send all medical records to the doctor who will give the second opinion. Your child’s PCP will
let you and Amerigroup know the results of the second opinion.
If Your Child Had a Different Provider Before Joining Amerigroup
Your child may have been seeing a provider not in our network before he or she joined Amerigroup
and the Healthy Kids program. Your child may be able to keep seeing this provider for care while you
pick a new provider. Call Member Services to find out more about this. We will make a plan with you
and your child’s provider, so we all know when your child needs to start seeing his or her new provider.
If Your Child’s Primary Care Provider’s Office Moves, Closes or Leaves the Amerigroup Network
Your child’s PCP office may move, close or leave the Amerigroup network. If this happens, we will call
or send you a letter to tell you.
Sometimes, your child may be able to keep seeing his or her PCP for care for up to six months if he or she
is in a course of treatment. Call Member Services to find out more about this. Amerigroup will make a
plan with you and your child’s PCP, so we all know when your child needs to start seeing the new
Amerigroup network PCP.
We can also help you pick a new PCP for your child. Call Member Services for help. Once you have picked
a new PCP, we will send you a new ID card within 10 working days.
How to Change Your Child’s Primary Care Provider
If you need to change your PCP, you may pick another PCP from our network. Look in the Amerigroup
provider directory. You can view the provider directory online at www.myamerigroup.com/FL. Click on
Find A Doctor. Or call Member Services to ask for a printed version. There is no charge for the printed
material.
We can also help you pick a doctor. Call Member Services at 1-800-600-4441 (TTY 711). We can change
your PCP on the same day you ask for the change. The change will begin right away.
Call your provider if you want to make an appointment. If you need help, call Member Services. We can
help you make the appointment.
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If Your Child’s Primary Care Provider Asks for Your Child to Be Changed to a New Primary Care
Provider
Your child’s PCP may ask for your child to be changed to another PCP. Your child’s provider may do
this if:
 Your child’s PCP does not have the right experience to treat your child.
 The PCP your child was assigned to was by mistake (like a child assigned to an
adult’s provider).
 Your child doesn’t go to his or her appointments.
 Your child doesn’t follow the provider’s medical advice many times.
 Your child’s provider agrees this change is best for your child.
If You Want Your Child to Go to a Provider Who Is Not the Primary Care Provider
If you want your child to go to a provider who is not your child’s PCP, please talk to your child’s PCP
first. Usually, the PCP needs to give your child a referral. This is done when your child’s PCP can’t give
your child the care he or she needs. Please read the section Specialists to find out more. If your child
goes to a provider that the PCP has not referred him or her to, the care your child gets may not be paid
for by Amerigroup.
Choosing 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 doctor within the network
Your daughter does not need a referral from her PCP to see her OB/GYN. If she doesn’t want to go to
an OB/GYN, her PCP may be able to treat her OB/GYN health needs. Ask your daughter’s PCP if he or
she can give your daughter OB/GYN care. If not, your daughter will need to see an OB/GYN. You will
find a list of network OB/GYNs in the Amerigroup provider directory. The provider directory is also
online at www.myamerigroup.com/FL. Click on Find A Doctor.
While your daughter is pregnant, her OB/GYN can be her PCP. To speak with a registered nurse, call
Amerigroup On Call at 1-866-864-2544. If you need help picking an OB/GYN, you can:
 Refer to the online Amerigroup provider directory at www.myamerigroup.com/FL. Click on Find A
Doctor
 Call Member Services at 1-800-600-4441 (TTY 711).
Specialists
Your child’s PCP can take care of most of your child’s health care needs. But your child may also need
care from other kinds of doctors. Amerigroup offers services from many kinds of doctors. These
doctors provide other medically needed care. They are called specialists because they have training in
a special area of medicine.
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Examples of specialists are:
 Allergists (allergy doctors)
 Dermatologists (skin doctors)
 Cardiologists (heart doctors)
 Podiatrists (foot doctors)
Your child’s PCP will refer your child to a specialist in the network if your child’s PCP cannot give your
child the care he or she needs. In most cases, your child will need to have a referral from his or her PCP
to see another doctor. Your child’s PCP will give your child a referral form so he or she can see a
specialist. The referral form tells you and the specialist what kind of health care your child needs. Be
sure to take the referral form with you when you take your child to the specialist.
Members identified by Amerigroup to have special health care needs don’t need a referral to see a
specialist. This is done through a standing referral or an approved number of visits. Members with
special health care needs are children who face daily physical, mental or environmental challenges.
These challenges risk the member’s ability to fully function in society. If you believe your child has
special health care needs, please call Member Services.
Sometimes, we can’t get your child a needed and covered service from a doctor in our network. If that
happens, with approval, we’ll pay for this service from an out-of-network doctor. Amerigroup will do
this for as long as we can’t get this service from our network of doctors. Your child’s PCP will ask
Amerigroup to approve this change. You will not pay any more than if you were getting the service
from us.
GOING TO THE DOCTOR
Your Child’s First Doctor Visit
You can call your child’s provider to set up his or her first visit. Your child should see his or her primary
care provider (PCP) for a well-child visit (a general checkup) within 90 days of enrolling in Amerigroup.
By finding out more about your child’s health now, your child’s PCP can take better care of your child if
he or she gets sick. We can also help you set up your child’s first appointment. Call Member Services if
you want our help.
If your child has already been seeing the provider who is now your Amerigroup network provider, call
that office. You need to see if it‘s time for your child to get a checkup. Is it time for a checkup? Make an
appointment for your child to see the provider as soon as you can.
How to Make an Appointment
It’s easy to make an appointment with your child’s PCP. Just call the office. The phone number is on
your child’s Amerigroup ID card. If you need help, call Member Services. We will help you make the
appointment.
When you call to make an appointment, let the person you talk to know what your child needs (for
example, a checkup or a follow-up visit). Also, tell the office if your child is not feeling well. This will let
them know how soon your child needs to be seen.
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Wait Times for Appointments
We want your child to be able to get care at any time. When the office is closed, an answering service
will take your call. Your child’s provider should call you back within 30 minutes. Once you talk to your
child’s provider and set up an appointment, your child should be able to see the provider quickly. See
the chart below:
Urgent Care
Routine Sick Patient Care
Wellness Visit
Within one day
Within one week
Within one month
What to Bring When Your Child Goes to a Provider Visit
When you go to the provider visit, bring:
 Your child’s Amerigroup ID card
 Any medicines your child is taking
 Your child’s shot records
 A list of questions you might want to ask your child’s doctor
How to Cancel a Visit
If you make an appointment and then can’t go, call the PCP’s office. Tell the office to cancel the visit.
Make a new appointment when you call. Try to call at least 24 hours before the visit. This will let
someone else see the provider during that time. If you want us to cancel the appointment, call
Member Services. If you don’t call to cancel the visit, your child’s provider may ask for your child to go
to another provider.
How to Get Your Child to an Office Visit or to the Hospital
If your child has an emergency and needs transportation, call 911 for an ambulance. Be sure to tell
the hospital you’re an Amerigroup member. Call your child’s PCP as soon as you can. The PCP can
arrange treatment and help your child get needed hospital care.
Disability Access to Amerigroup Network Doctors and Hospitals
The Amerigroup network of doctors and hospitals help members with disabilities get needed care.
Members who use wheelchairs, walkers or other aids may need help getting into an office. If your child
needs help, make sure your child’s doctor knows this before you go. This way, they will be ready for your
child’s visit. If you want help talking to your child’s doctor about your child’s special needs, call
Member Services.
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What Does Medically Necessary Mean?
Your child’s PCP will help your child get the services he or she needs that are medically necessary.
Medically necessary health services are health services which are:
 Needed to treat your child’s injury or illness, or to prevent an injury or illness – for example, if your
child has a fever, is complaining of pain or has an injury that needs more than home treatment
 A treatment that most people would expect your child to get from a doctor, such as shots, or
medical care for a possible broken bone or ear infection
 A treatment or service that most doctors in your area would give to your child – for example, to
give stitches for a cut or medicine to treat a high temperature
 Given in the most correct place for your child’s health and safety – for example:
− You might need to take your child to the doctor for a small cut that is not bleeding a lot, but you
shouldn’t take him or her to the emergency room for that same cut.
− You might take your child to urgent care if your child has an illness or injury that can’t wait until
the next morning.
− You would bring your child to the emergency room if your child is injured badly or is so sick that
you fear for his or her life if he or she is not treated right away.
YOUR CHILD’S AMERIGROUP BENEFITS
When you enroll your child in the Healthy Kids program and Amerigroup, he or she becomes a member
of a Health Maintenance Organization (HMO). An HMO is a health plan that pays for most types of
medical care without large out-of-pocket costs for you. Amerigroup pays for treatment when your child
is sick or injured. We also pay for services that can help your child stay healthy. This includes annual
checkups and immunizations (shots).
What Is Covered by Amerigroup?
Payment for Services
Amerigroup is easy to use. We’re not like traditional health care plans, where you must file claim forms
and wait for your payment. When your child gets covered services, you pay a small copay, if needed.
Amerigroup pays for the rest without any paperwork. It’s very important for you to pay any copays for
nonemergency or nonurgent services so that your child is not denied (refused) care.
Monthly Premiums
In addition to small copays for certain services, a monthly premium (payment) is also needed to keep
your child’s coverage. Premium payments are due 30 days in advance to Healthy Kids. You will get a
coupon book to help remind you to make your payments. You can pay your premium online or by
phone with Healthy Kids. If a payment is not received in time, your child’s coverage will be cancelled.
To start your child’s coverage after it’s cancelled, you must call Healthy Kids at 1-800-821-KIDS (5437)
(TTY 1-877-427-9825). If your child’s coverage has been cancelled because you didn’t pay, you must wait
30 days to start coverage again. Services will not be paid for by Amerigroup during this time.
Monthly premiums can be paid by mail or phone or over the Internet. Checks by phone and payments
by debit or credit card are also OK.
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Mail monthly premiums to:
Florida Healthy Kids Corporation
P.O. Box 31105
Tampa, FL 33631-3105
Overnight payments aren’t accepted at this address.
Call 1-800-821-KIDS (5437) (TTY 1-877-427-9825) to pay by phone. Payments by phone can be made 24
hours a day, 7 days a week. Payments can also be made online at www.healthykids.org. A small fee will
be charged for payments made over the phone and online.
Renewal
Every family must renew Healthy Kids coverage once a year. You will get a letter from Florida Healthy
Kids about two months before your child’s renewal date. It will have a form with most of your current
information already filled in. You may also review your information online at www.healthykids.org.
It’s very important for you to return this renewal letter. If you have any questions, please contact
Florida Healthy Kids. The toll-free number for the Customer Service department is
1-800-821-5437 (TTY 1-877-427-9825) Monday through Friday from 7:30 a.m. to 7:30 p.m.
AMERIGROUP AND HEALTHY KIDS BENEFITS
This is a list of the health care services that the Healthy Kids program and Amerigroup will cover when
your child needs them. Your child’s primary care provider (PCP) will give your child the care he or she
needs or refer him or her to a provider who can.
For some special benefits, members have to be a certain age or have a certain kind of health problem.
Sometimes, your child’s doctor may need to get prior authorization (approval) from Amerigroup before
your child can get a benefit. Your child’s doctor will work with Amerigroup to get approval. If you have
a question or are not sure whether we offer a certain benefit, call Member Services.
COVERED SERVICES
COVERAGE LIMITS
COPAYS
Well-child care, including
Hearing and vision screenings and immunizations No copay
must be provided by your child’s PCP
preventive care visits,
immunizations (shots), and
routine hearing and vision
screenings
Primary care provider (PCP)  Must use an Amerigroup network provider
$5 copay
office visits
Specialist office visits
$5 per visit
 Must use an Amerigroup network provider
 Must be referred by your child’s PCP
Diagnostic testing
No copay
 Must use an Amerigroup network provider
(laboratory, X-rays)
 Must meet medical necessity
Prescription drugs (generic
$5 per prescription
 Must use Amerigroup network pharmacy
drugs, unless brand name is
(up to a 31-day
 Must be prescribed by your child’s PCP or an
medically necessary)
supply)
Amerigroup-approved specialist or doctor
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COVERED SERVICES
Inpatient hospital stays
(semiprivate room)
Chiropractic services
Podiatric services
Maternity services and
newborn care, including
prenatal and postpartum
care, and the initial inpatient
care of the newborn
Family planning services
Emergency services,
including visits to an
emergency room (see
Emergency Care
COVERAGE LIMITS
 Stays must be approved by Amerigroup
 Limited to 15 days per year for rehabilitation
and physical therapy stays
Limited to one visit per day for up to 24 visits per
calendar year
Limited to one visit per day for up to two visits
per month for certain foot disorders
Coverage for the newborn limited to three days
or until transferred
COPAYS
No copay
Limited to one visit per year and one supply visit
every 90 days
Must use an Amerigroup network hospital or
provider for emergency care, unless the time to
reach a network provider would risk permanent
damage to your child’s health
$5 per visit
Emergency transportation
services
Must be for an emergency (see Emergency Care).
If you have an emergency, call 911 or go to the
nearest hospital emergency room right away. If
you want advice, call your PCP or Amerigroup On
Call at 1-866-864-2544.
Your child will get a new pair of eyeglasses:
Vision services
Your child’s PCP will test his
 After a failed vision screening
or her eyesight; if the tests
 Every two years or when head size or
show problems, your child
prescription changes
will be referred to a specialist Limited to Medicaid frames and certain kinds of
lenses
Behavioral health services,
Limits are similar to those of physical illnesses:
including inpatient and
 Duration of services
outpatient care for
 Number of visits
evaluation, diagnosis and
 Number of days for hospitalization or
treatment
residential services
Some services may need precertification before
you can get them. Please have your doctor call
Member Services at 1-800-600-4441.
$5 per visit
$5 per visit
No copay
$10 per visit (no
copay if admitted
or if visit approved
by your child’s
PCP)
$10 per trip
$5 per visit with
specialist
$10 for corrective
lenses
No inpatient copay
$5 per outpatient
visit
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COVERED SERVICES
Substance abuse services,
including inpatient and
outpatient care for drug and
alcohol abuse (such as
counseling and help with
placement)
Outpatient services include
evaluation, diagnosis and
treatment
Nursing facility services,
including regular nursing
services, rehabilitation
services, semiprivate room
Therapy services, including
physical, occupational,
respiratory and speech
therapies for short-term
rehabilitation where your
child’s condition will
significantly improve
Home health services,
including prescribed home
visits by registered and
licensed practical nurses to
provide skilled nursing
services on a part-time,
short-term basis
Hospice services, including
reasonable and necessary
services to manage a
terminal illness
Durable Medical Equipment
(DME) and prosthetic
devices if prescribed by your
child’s Amerigroup doctor as
medically necessary
COVERAGE LIMITS
Limits are similar to those of physical illnesses:
 Duration of services
 Number of visits
 Number of days for hospitalization or
residential services
COPAYS
No inpatient copay
$5 per outpatient
visit
Some services may need precertification before
you can get them. Please have your doctor call
Member Services at 1-800-600-4441.
 Must be approved by Amerigroup and
provided by a network facility
 Limited to 100 days per year (rehabilitation
and physical therapy stays are limited to 15
days per year)
 Excludes private duty nurses, television,
custodial care, specialized treatment centers
and independent kidney disease treatment
centers
 Must be provided by an Amerigroup network
provider or upon approved referral
 Limited to 24 sessions in a 60-day period per
incident (begins with first visit)
No copay
 Must be approved by Amerigroup
 Limited to skilled nursing services
 Excludes meals, housekeeping and personal
comfort items
 Private duty nursing is covered, if
medically necessary
$5 per visit
If you want your child to get hospice care,
services which do not treat the terminal
condition will not be covered
$5 per visit
 Must be approved by Amerigroup and
provided by an Amerigroup supplier
 Covered prosthetics include artificial eyes and
limbs, braces
 Hearing aids covered only when medically
necessary
No copay
$5 per visit
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COVERED SERVICES
Organ transplant services,
including care before, during
and after the transplant, and
treatment of complications
after the transplant
COVERAGE LIMITS
Must be deemed necessary and appropriate
within guidelines of the Organ Transplant
Advisory Council or the Bone Marrow Transplant
Advisory Council
COPAYS
No copay
Extra Amerigroup Benefits
To better meet all your needs, Amerigroup offers extra benefits called value-added services. These
extra benefits include:
 $10 a month to buy certain personal care items and over-the-counter (OTC) medicines
 $100 for hypoallergenic bedding (if medically needed)
 Six months of free fitness and healthy behavior coaching for kids ages 7 to 13 years
 A free mouth guard for children who play contact sports
 Amerigroup On Call: A 24-hour nurse helpline to answer your medical questions day or night. Call
toll free at 1-866-864-2544 (TTY 711)
We give you these benefits to help keep your family healthy.
Making Decisions on Care and Services
Sometimes, we need to make decisions about how we pay for care and services. This is called
Utilization Management (UM). Our UM process is based on the standards of the National Committee
for Quality Assurance (NCQA). All UM decisions are based on medical needs and current benefits only.
We do this for the best possible health results for our members. We don’t tell or ask providers to not
use these services. We don’t create issues to getting health care. Providers don’t get rewards for
limiting or denying care.
Utilization Management
Some services and benefits need prior authorization (approval). This means your provider must ask
Amerigroup to approve the services first. Amerigroup has a utilization review team that looks at
approval requests. You or your doctor can ask for a review if Amerigroup says it won’t pay for the care.
Amerigroup will let you and your doctor know after we get the request.
Services That Don’t Need Prior Authorization
Some services don’t need prior authorization (approval) from Amerigroup or your child’s PCP. These
services include:
 Outpatient behavioral health care services
 Emergency behavioral health care services
 Outpatient substance abuse and rehabilitation treatments
 Emergency room visits
 Well-child care
 Family planning services
 PCP office visits
 Chiropractic care services
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If you have questions about these covered services or how to access care, call Member Services.
Dental Services
If you get dental benefits, they are provided through a different company. Please contact Healthy Kids
Customer Service at 1-800-821-KIDS (5437) (TTY 1-877-427-9825) to find out about your child’s
dental plan.
Getting a Prescription Filled
You’ll get covered prescription drugs when written by a licensed prescriber. You can pick from several
local pharmacies (drugstores) and major drugstore chains to get the drugs. Look in the provider
directory for a list of network drugstores.
There is a $5 copay for prescription drugs.
Your $5 copay covers up to a 31-day supply of a formulary medication. The formulary is a list of drugs
we pay for. Certain drugs may require approval before they are covered as a benefit. When this
happens, it is called a prior authorization (approval).
An Amerigroup network pharmacist may need to get information from your doctor to make sure the
medicine is the best one for you. Amerigroup will talk with your doctor about prior treatments to help
make these decisions.
The pharmacist will use a generic (instead of brand-name) drug if one is available. A brand-name drug
is only covered if a generic drug is not available or when your physician says a brand name is
medically necessary.
Along with the over-the-counter (OTC) items covered on our formulary, your child also has an OTC drug
benefit. Your household can get up to $10 worth of certain OTC items per month. You must get the
item at an Amerigroup network drugstore that takes part in this benefit. Choose the item. Show the
pharmacist your Amerigroup ID card. The pharmacist will let you know when your household has
reached the $10 limit for the month.
Some types of OTC items you can get are:
 Vitamins and minerals
 Pain relievers
 First aid supplies
 Cough, cold and allergy medicine
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DIFFERENT TYPES OF HEALTH CARE
Routine, Urgent and Emergency Care: What is the Difference?
Routine Care
In most cases when your child needs medical care, you call your child’s doctor to make an
appointment. Your child will go to see the doctor. This will be good for most minor illnesses, injuries
and regular checkups. This care is called routine care. Your child’s primary care provider is someone
your child sees when he or she is not feeling well. But that is only part of the PCP’s job. Your child’s PCP
also takes care of your child before he or she gets sick. This is called wellness care.
See the Wellness Services in this handbook. Your child should be able to see his or her PCP within one
week for routine care.
Urgent Care
The second type of care is urgent care. There are some injuries and illnesses that aren’t emergencies.
But they can turn into an emergency if not treated within 24 hours.
Some examples are:
 High fever
 Animal bites
 Fractures
 Severe pain
 Infectious or respiratory illnesses
 Flu
For urgent care, call your child’s PCP. Your child’s PCP will tell you what to do. Your child’s PCP may tell
you to come to the office right away. You may be told to go to another office for your child to get care
right away. You need to follow what your child’s PCP says. Sometimes, your child’s PCP may tell you to
go to the emergency room at a hospital. See the next section about emergency care to find out more.
You can also call Amerigroup On Call, our 24-hour nurse helpline, at 1-866-864-2544 (TTY 711) for
questions about urgent care. Your child should be able to see his or her PCP within one day for an
urgent care appointment.
Emergency Care
The third type of care is emergency care. If your child has an emergency, you should call 911. Or take
your child to the nearest hospital emergency room right away. If you want advice, call your child’s PCP.
You can also call Amerigroup On Call at 1-866-864-2544 (TTY 711).
The most important part is to get medical care as soon as you can. Your child should be able to see a
physician right away for emergency care. When your child goes to the hospital, he or she will get a
medical screening. After the screening, you will need to show your child’s Amerigroup ID card. Ask the
hospital to call Amerigroup. The steps for providers to follow are on your ID card.
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What Is an Emergency Medical Condition?
An emergency medical condition is when not seeing a doctor for care right away could cause death or
very bad harm to your child’s body. The problem is so bad that a person with an average knowledge of
health and medicine can tell the problem may cause death. Or it may cause harm to any organ or part
of the body. Or in the case of a pregnant child, it may cause harm to the health of the child or her
unborn baby.
In the case of a pregnant child, an emergency medical condition is when:
 There is not enough time to safely move her to a new hospital before delivery.
 A transfer may threaten the health and safety of the patient or her unborn baby.
 There is proof of prolonged uterine contractions or rupture of the membranes
Here are examples of problems that are most likely emergencies:
 Trouble breathing
 Chest pains
 Loss of consciousness
 Very bad bleeding that does not stop
 Very bad burns
 Shakes called convulsions or seizures
What Is an Emergency Behavioral Health Condition?
An emergency behavioral health condition meets the standard above. Examples of an emergency
behavioral health condition include:
 Likely danger to self and/or others
 So much functional harm that the person is not able to carry out actions of daily life
 Functional harm that will likely cause death or serious harm to the body
What Is Post-stabilization?
Post-stabilization services are covered services your child gets after emergency medical care. Your child
gets these services to help keep his or her condition stable.
Medical emergencies and post-stabilization care that are because of your child’s emergency don’t need
prior approval by Amerigroup. Call your child’s PCP as soon as you can after the emergency room visit.
If you can’t call, have someone else call for you. Your child’s PCP will give or arrange any follow-up care
your child needs.
How to Get Health Care When Your Child’s PCP’s Office Is Closed
Except in the case of an emergency (see previous section) or when your child needs care that does ‘t
need a referral, always call your child’s PCP first before your child gets medical care. If you call your
child’s PCP’s office when it’s closed, leave a message with your name and a phone number where you
can be reached. If it’s not an emergency, someone should call you back soon to tell you what to do.
You can also call Amerigroup On Call 24 hours a day, seven days a week for help.
If you think your child needs emergency services (see previous section), call 911. Or go to the nearest
emergency room right away.
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How to Get Health Care When Your Child Is Out of Town
If your child needs emergency services when out of town or outside of Florida,* go to the nearest
hospital emergency room. Or call 911. You must get in touch with your child’s PCP as soon as you can.
You need to tell the PCP about your child’s out-of-area emergency care. This will help your child’s PCP
to set up follow-up care. If your child is placed in the hospital, have the hospital call Amerigroup. This
call should be made within 24 hours of admission or as soon as possible to confirm coverage.
Any nonemergency care your child gets outside the service area is not covered unless your child gets
prior approval from Amerigroup. Follow the doctor’s orders. You may be told to get care for your child
where he or she is if he or she needs it very quickly.
You can also call Amerigroup On Call 24 hours a day, seven days a week for help. If your child needs
routine care like a checkup or a prescription refill when he or she is out of town, call the PCP. If your
child’s PCP directs you to get care while you are out of town, then Amerigroup will pay for the care.
*If your child is outside of the United States and gets health care services, he or she will not be covered
by Amerigroup.
How to Get Care When Your Child Can’t Leave Your Home
Amerigroup will find a way to help take care of your child. Call Member Services right away if your child
can’t leave your home. We will put you in touch with a case manager who will help your child get the
medical care he or she needs.
WELLNESS CARE
Your child needs to have routine wellness visits with his or her primary care provider (PCP). During a
wellness visit, your child’s PCP will check his or her overall health. Many health problems can be
treated and handled, if found early. Your child’s PCP can also answer your medical questions and help
your child stay healthy. When your child becomes an Amerigroup member, call your child’s PCP. You
need to make his or her first appointment within 90 days.
You must set up a well-child visit with the doctor once per year from age two through the month your
child turns 19. Be sure to make these appointments. Take your child to his or her PCP when scheduled.
Vision Screening
Your child’s PCP should check your child’s vision at every well-child visit. Please see the section Vision
Services under Amerigroup Covered Services for more information.
Hearing Screening
Your child’s PCP should check your child’s hearing at every well-child visit.
Dental Screening
Your child should have his or her teeth and gums checked by the PCP as a part of the routine well-child
visits. Please see Dental Services under Amerigroup Covered Services to learn more.
Immunizations
It is important for your child to get immunizations (shots) on time. Take your child to the provider
when the PCP says a shot is needed. Use the chart that follows to help keep track of the shots your
child needs.
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When Your Child Misses a Wellness Visit
If your child does not get a wellness care visit on time, make an appointment with his or her PCP as
soon as you can. If you need help to set up the appointment, call Member Services. If your child has
not visited the PCP on time, Amerigroup will send you a postcard to remind you.
SPECIAL CARE FOR PREGNANT MEMBERS
Taking Care of Baby and Me® is the Amerigroup program for pregnant members. It’s very important to
see your child’s primary care provider (PCP) or OB/GYN for care when your child is pregnant. This kind of
care is called prenatal care. It can help your child have a healthy baby. Prenatal care is always important
even if your child has already had a baby. With our program, members receive health information and
baby gifts for getting prenatal care and postpartum care.
Our program also helps pregnant members with complex health care needs. Nurse case managers
work closely with these members to help teach them about these needs. They give emotional support.
They help members follow their provider’s 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 Your Child Becomes Pregnant
If you think your child is pregnant, call her PCP or OB/GYN provider right away. You don’t need a
referral from her PCP to see an OB/GYN. Her OB/GYN should see her within 14 days. We can help you
find an OB/GYN in the Amerigroup network.
You must also call Amerigroup Member Services when you find out your child is pregnant. If she is a
new Amerigroup member who is pregnant and has been seen by a non-Amerigroup provider for at
least one complete prenatal checkup before she joined Amerigroup, then she may be able to keep
seeing that provider throughout her pregnancy. She may also keep seeing the provider through the
delivery and up to two months after her baby is born.
When your child is pregnant, Amerigroup will send her a pregnancy education package. It will include
a:
 Letter welcoming her to the Taking Care of Baby and Me program
 Self-care book
 Taking Care of Baby and Me reward program brochure
 Amerigroup On Call (nurse helpline) Ameritips fact sheet
The self-care book gives her information about her pregnancy. She can also use the book to write down
things that happen during her pregnancy. The Taking Care of Baby and Me brochure tells your child
how to get her gift for getting prenatal care.
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When Should Your Child Go to Her PCP or OB/GYN?
Stages of Her Pregnancy
Less than 13 weeks pregnant (or sooner if she
thinks she is pregnant)
14-28 weeks pregnant
29-36 weeks pregnant
37-40 weeks pregnant
After she delivers her baby
When to Go to Her Doctor
Get her first prenatal visit as soon as possible
Every 4 weeks
Every 2 weeks
Every week
Get her postpartum checkup between 21-56
days after she has her baby, even if she sees
her doctor before three weeks have passed
Your child’s PCP or OB/GYN may want her to visit more than this based on her health needs.
While your child is pregnant, she needs to take good care of her health. She may be able to get healthy
food from the Women, Infants, and Children program (WIC). Call Member Services to get the phone
number for the WIC program close to you.
When Your Child Has a New Baby
When your child delivers her baby, she and her baby may stay in the hospital at least:
 Two days (not including the day of delivery) after a vaginal delivery
 Four days (not including the day of delivery) after a cesarean section (C-section)
She may stay in the hospital less time if her PCP or OB/GYN and the baby’s provider see that she and
her baby are doing well. She and her baby should stay in the hospital until her provider says they can
leave. They can leave the hospital before the provider releases them. But it is best not to do this. If she
and her baby leave the hospital early, the provider may ask her to have an office or in-home nurse visit
within 48 hours.
After your child has her baby, you must call Amerigroup Member Services as soon as you can. You need
to call us to let us know she had her baby. When your child has had her baby, Amerigroup will send her
the Taking Care of Baby and Me postpartum education package.
It will include a:
 Letter welcoming you to the postpartum part of Taking Care of Baby and Me program
 Babycare book
 Taking Care of Baby and Me reward program brochure about going to your postpartum visit
 Brochure about postpartum depression
 Amerigroup On Call (nurse helpline) Ameritips fact sheet
She can use the baby-care book to write down things that happen during her baby’s first year. This
book will give her information about her baby’s growth.
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DISEASE MANAGEMENT
Amerigroup has a Disease Management Centralized Care Unit (DMCCU) program. A team of licensed
nurses and social workers, called DMCCU care managers, educates you about your child’s condition
and helps you learn how to manage your child’s care. Your PCP and our team of DMCCU care managers
will help your child with his or her health care needs.
DMCCU care managers provide support over the phone for members with:
 Diabetes
 HIV/AIDS
 Heart conditions
− Coronary artery disease
− Congestive heart failure
− Hypertension
 Lung conditions
− Asthma
− Chronic obstructive pulmonary disease
 Behavioral health conditions
− Bipolar disorder
− Major depressive disorder
− Schizophrenia
DMCCU care managers work with your child to create health goals. They help develop a plan to reach
these goals. As a member in the program, your child will benefit from having a care manager who:
 Listens and takes the time to understand your child’s specific needs
 Helps create a care plan to reach your child’s health care goals
 Gives your child the tools, support and community resources that can help your child improve his
or her quality of life
 Provides health information that can help your child make better choices
 Helps you coordinate care with your child’s providers
As part of your child’s enrollment in the DMCCU, you and your child have certain rights
and responsibilities.
You and your child have the right to:
 Have information about Amerigroup. This includes all Amerigroup programs and services, our
staff’s education and work experience, and 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 and your child make choices with your doctors about your
health care
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





Learn about all DMCCU-related treatments, including anything stated in the clinical guidelines,
whether covered by Amerigroup or not; you and your child have the right to discuss all options
with your doctors
Have personal and medical information kept confidential under HIPAA, know who has access to
your information, and know what Amerigroup does to keep it private and confidential
Be treated with courtesy and respect by Amerigroup staff
File a complaint with Amerigroup and be told how to make a complaint, including knowing about
Amerigroup standards of timely response to complaints and resolving issues of quality
Get information that you can understand
Have Amerigroup act as an advocate for you and your child if needed
We have the responsibility to:
 Listen and know the effects of accepting or rejecting health care advice
 Provide Amerigroup with information needed to carry out our services
 Tell Amerigroup and your child’s doctors if you decide to disenroll from the
DMCCU program
If your child has one of these conditions or if you would like to know more about our DMCCU program,
please call 1-888-830-4300 Monday through Friday from 8:30 a.m. to 5:30 p.m. Eastern time. Ask to
speak with a DMCCU care manager. You can also visit our website at www.myamerigroup.com/FL.
CASE MANAGEMENT
Amerigroup has case managers to help you understand and care for your child’s condition. Your PCP
will help you with your child’s special condition, but it’s also important you learn to care
for child.
When your child joins Amerigroup, we will call you to get to know you. During this welcome call, we’ll
ask if your child needs case management services. If yes, we’ll refer you to a case manager. Your child’s
case manager will work with you and your child’s PCP to set up a plan of care. If you think your child
needs case management services, please call Member Services at 1-800-600-4441 (TTY 711). We’ll
refer you to the Case Management department.
Our case managers may also call you if:
 Your child’s PCP believes your child would be helped by this program.
 Your child is discharged from the hospital and needs follow-up coordination of care.
 Amerigroup finds your child is going to the emergency room (ER) too often for nonurgent care. This
is care that could be handled by your PCP.
 You call Amerigroup On Call and your child needs additional follow-up for ongoing care.
Your case manager can help with:
 Setting up health care services
 Referrals and prior authorizations (approvals)
 Reviewing your child’s plan of care, as needed
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We may also call you to be part of our Complex Case Management program. Complex case
management is for members with serious physical or mental health conditions that need more care
coordination. We use data to determine which members might be a good fit for this program.
If you are called, a nurse or social worker will:
 Ask if you’d like your child to be part of our case management program.
 Teach you about what we offer within the program.
 Talk to you about your child’s health and how you’re handling other parts of your
child’s life.
SPECIAL AMERIGROUP SERVICES FOR HEALTHY LIVING
Health Information
Learning more about health and healthy living can help your child stay healthy. One way to get health
information is to ask your child’s primary care provider (PCP). Another way is to call us.
Amerigroup On Call
When your child is sick, you can call Amerigroup On Call at 1-866-864-2544 (TTY 711). A registered
nurse can help you:
 Find a doctor after hours or on weekends
 Get to an urgent care center or a walk-in clinic
 Schedule an appointment with your PCP or a network doctor
 Speak directly with a doctor about your health needs
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
 Correct any problems you may have with your care
Health Education Classes
Amerigroup works to keep your child healthy with its 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:
 Amerigroup services and how to get them  Pregnancy
 Protecting yourself from violence
 Childbirth
 Children’s programs
 Quitting cigarette smoking
 Infant care
 Substance abuse programs
 Parenting
 Other classes about health topics
Some of the larger medical offices (like clinics) in our network show health videos. These videos help
you learn about immunizations (shots), prenatal care and other important health topics. We hope you
will learn more about keeping your child healthy.
Bullying Resources
Bullying is a big problem and happens face-to-face, on text messages or the web. It can happen at any
age, boy or girl, or school level. Bullying can cause real harm.
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Amerigroup wants you to know the warning signs that someone is bullying others or by being bullied.
These warning signs may show other problems as well. To learn more about bullying, visit
www.stopbullying.gov.
These may be signs of someone being bullied if he or she:
 Comes home with damaged or missing clothing or items
 Loses things like books, electronics, clothing or jewelry
 Has unexplained injuries
 Complains often of headaches, stomachaches or feeling sick
 Has trouble sleeping or has frequent bad dreams
 Has changes in eating habits
 Hurts himself or herself
 Is very hungry after school from not eating lunch
 Runs away from home
 Loses interest in visiting or talking with friends
 Is afraid of going to school or other activities with peers
 Loses interest in school work or begins to do poorly
 Appears sad, moody, angry, anxious or depressed when he or she comes home
 Talks about suicide
 Feels helpless
 Often feels like he or she is not good enough
 Suddenly has fewer friends
 Avoids certain places
 Acts differently than usual
These may be signs of someone bullying others:
 Becomes violent with others
 Gets into physical or verbal fights with others
 Gets sent to the principal’s office or detention a lot
 Has extra money or new belongings that cannot be explained
 Is quick to blame others
 Will not accept responsibility for his or her actions
 Has friends who bully others
 Needs to win or be best at everything
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If you believe your child is being bullied:
Action
Response
Someone in immediate risk of harm because Call 911
of bullying
Your child is feeling suicidal because of
bullying
Call the suicide prevention hotline toll free
at 1-800-273-TALK (8255)
Your child’s teacher is not keeping your child Contact local school leaders (principal or
safe from being bullied
superintendent)
Your school is not keeping your child safe
from being bullied
Contact the state school department
Your child is sick, stressed, not sleeping or is
having other problems because of bullying
Contact your counselor or other health
professional
Your child is bullied because of his or her
race, ethnicity or disability, and local help is
not helping to solve the problem
Contact the U.S. Department of
Education’s Office on Civil Rights
Smoking Cessation
The smoking cessation program is designed to help your child find a way to quit smoking and stay
smoke free. Amerigroup offers many services at no cost, including:
 Community classes – A listing of classes taught in the community
 Phone counseling –Trained health coaches work with your child to find a program that looks at how
your child acts and lives
 Prescription benefits
 Additional resources and tools
- Phone counseling for stopping tobacco use
o The Florida Quitline: The Florida Quitline is a toll-free, phone-based tobacco use cessation
service. Any person living in Florida who wants to try to quit smoking can use the Quitline.
The following services are available:
 Counseling sessions
 Self-help materials
 Counseling and materials in English and Spanish
 Translation service for other languages
 Pharmacotherapy assistance
 TDD service for deaf and hard of hearing
- Online resources
o www.smokefree.gov
o www.quitnet.com
o www.quitsmokingsupport.com
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- Printed Resources
o You Can Quit Smoking Flier
o Tobacco Use – Breaking the Habit Ameritip
o Tobacco Use – Reasons To Quit Ameritip
Community Events
Amerigroup sponsors and takes part in special community events and family fun days. You and your
child can learn more about health and have a good time. You can learn about topics like healthy living,
asthma and stress. People from Amerigroup will be there to answer your questions about your child’s
benefits, too. Call Member Services to find out when and where these events will be.
Minors
Amerigroup network doctors and hospitals cannot give most Amerigroup members younger than age
18 care without a parent’s or legal guardian’s consent. This does not apply if emergency care
is needed.
Parents or legal guardians also have the right to know what is in their child’s medical records. Members
under age 18 can ask their doctor not to tell their parents about their medical records. But the parents
can still ask the doctor to see the medical records.
These rules do not apply to emancipated minors. Members younger than age 18 may be emancipated
minors if they:
 Are married
 Are pregnant or
 Have a child
Emancipated minors may make their own decisions about their medical care and the medical care of
their children. Parents no longer have the right to see the medical records of emancipated minors.
GRIEVANCES AND APPEALS
You have the right to tell us if you are not happy with your care or the coverage of your health care
needs. These are called grievances and appeals.
An appeal is when you feel you should be getting a service covered and you are not, or that service has
been discontinued or stopped.
A grievance is when you are unhappy about something besides your benefits – like your doctor’s
behavior or you didn’t receive information you should have.
If you should have any problems with your services, please call Member Services at
1-800-600-4441 (TTY 711).
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I have a concern I would like to report
Amerigroup has a process to solve complaints and grievances. If you have a concern that is easy to
solve and can be resolved within 24 hours, Member Services will help you.
If it can’t be fixed in 24 hours and needs to be looked at by our grievance coordinator, it will be sent to
the grievance coordinator.
How do I let Amerigroup know about my concern?
A complaint or grievance must be given verbally or in writing within one year of the occurrence.
To file a complaint or grievance, you can:
1. Call Member Services at 1-800-600-4441 (TTY 711).
2. Write us a letter regarding your concern and mail it to:
Grievance Coordinator
Amerigroup
4200 W. Cypress St., Suite 900
Tampa, FL 33607-4173
You may also have someone else help you file the complaint or grievance. This person can be:
 A family member
 A friend
 Your doctor
 A lawyer
Write this person’s name on the grievance form.
If you need help filing the complaint, Amerigroup can help. Call Member Services at
1-800-600-4441 (TTY 711).
If you want to talk with the grievance coordinator to give more information, tell Member Services
when you file the complaint or put it in your letter.
Once Amerigroup gets your grievance (verbal or written), we will send you a letter within five calendar
days telling you the date we received your grievance.
What happens next?
The grievance coordinator will look at your concern. If more information is needed or you have asked
to talk to the coordinator, the coordinator will call you. If you have more information to give us, you
can bring it to us in person or write to us at:
Grievance Coordinator
Amerigroup
4200 W. Cypress St. Suite 1000
Tampa, FL 33607-4173
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Medical concerns are looked at by medical staff.
Amerigroup will tell you the decision of your grievance within 60 calendar days from the date we get
your grievance.
If you have any questions or need help anytime, please call the Member Services department toll free
at 1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 5 p.m. Eastern time.
Medical Appeals
There may be times when Amerigroup says it will not pay, in whole or in part, for care that your doctor
asked for. If we do this, you (or your doctor for you and with your written approval) can appeal the
decision. A medical appeal is when you ask Amerigroup to look again at the care your doctor asked for,
and we said we will not pay for. You must file for an appeal within 30 days from the date on the letter
that says we will not pay for a service. Amerigroup will not hold it against you or your doctor for
helping you file an appeal or for filing an appeal for you.
Amerigroup said it would not pay for care I need. What can I do about this?
You can file an appeal. An appeal is when you ask Amerigroup to look again at the care we said we
would not pay for. You can ask for an expedited (rushed) appeal if you or your doctor thinks you need
the services for an emergency or life-threatening illness.
If coverage of the service you asked for has been denied, limited, reduced, suspended or terminated,
you must ask for an appeal within 30 days of the date on the letter that said we would not pay for the
service.
You can have someone else help you with the appeal process. This person can be a family member, a
friend, your doctor or a lawyer. Write this person’s name on the appeal form. Fill out a Request to
Designate a Personal Representative form.
You can ask us to send you more information to help you understand why we would not pay for the
service you requested.
I want to ask for an appeal. How do I do it?
An appeal may be filed (verbally or in writing) within 30 calendar days of when you get the notice of
action. Except when an expedited (rushed) ruling is required, verbal notice must be followed with a
written notice within 10 calendar days of the verbal filing. The date of the verbal notice will be the date
of the notice.
There are two ways to file an appeal:
1. Write us a letter and ask to appeal.
2. Call Member Services at 1-800-600-4441 (TTY 711).
What else do I need to know?
If you call us, we will send you an appeal form; if you want to have someone else help you with the
appeal process, let us know, and we will send you a form for that. Fill out the form. Mail it back to us.
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You must mail it back to us within 10 days of your call. To continue with the appeal, we must have the
request in writing. We can also help you fill out the form when we talk to you on the phone.
When we get your letter or appeal form, we will send you a letter within five business days to tell you
we got your appeal.
You may talk to the doctor who looks at your case. We can arrange for you to meet with or talk to
this person.
You may ask for a free copy of the guidelines, records or other information used to make this decision.
We will tell you what the doctor decides within 45 calendar days of getting your appeal request.
If we reduce coverage for a service you are receiving right now and you want to continue to get the
service during your appeal, you can call us to ask for it. You must call within 10 days of the date of the
letter mailed to you that tells you we will not pay for the service.
If you have more information to give us, you can bring it to us in person or mail it to:
Medical Appeals
Amerigroup
P.O. Box 62429
Virginia Beach, VA 23466-2429
Also, you can look at your medical records and information on this decision before and during the
appeal process.
The time frame for a grievance or appeal may be extended up to 14 calendar days if:
 You ask for an extension
 Amerigroup finds that additional information is needed and the delay is in your interest
If the time frame is extended other than at your request, Amerigroup will notify you in writing within
five business days of when the decision is made.
If you have a special need, we will give you additional help to file your appeal. Please call
1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m.
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How do I ask for an appeals review?
After receiving a final determination from Amerigroup, you can call or write the Subscriber Assistance
Program (SAP):
Agency for Health Care Administration (AHCA)
Subscriber Assistance Program
Building 3, MS #45
2727 Mahan Drive
Tallahassee, FL 32308
Toll free: 1-888-419-3456
850-412-4502
Before filing with the SAP, you must complete the Amerigroup appeal process.
You must submit the appeal to the SAP within one year after receipt of the final decision letter
from Amerigroup.
The SAP will not consider an appeal that has already been to a Medicaid fair hearing.
The SAP will complete its review and make a decision.
What can I do if I think I need an urgent or expedited appeal?
You can ask for an urgent or expedited (rush) appeal if you think the time for a standard appeal process
could seriously harm your life or health, or ability to attain, maintain, or regain maximum function.
You can also call Member Services toll free at 1-800-600-4441 (TTY 711), Monday through Friday from
8 a.m. to 7 p.m. Eastern time.
You can ask for an expedited appeal. We must respond to you within 72 hours after we receive the
appeal request, whether the appeal was made verbally or in writing.
If the request for expedited appeal is denied, the appeal will be transferred to the time frame for
standard resolution, and you will be notified within 72 hours.
If you have any questions or need help anytime, please call Member Services toll free at
1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
Payment Appeals
If your child gets a service from a provider and Amerigroup does not pay for that service, you may get a
notice from Amerigroup. This notice is called an Explanation Of Benefits (EOB). This is not a bill. The
EOB will tell you the date your child got the service, the type of service and the reason we can’t pay.
The provider, health care place or person who gave you this service will get a notice called an
Explanation Of Payment (EOP).
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If you receive an EOB, you do not need to call or do anything at that time, unless you or your child’s
provider wants to appeal the decision. An appeal is when you ask Amerigroup to look again at the
service we said we would not pay for. You must ask for an appeal within 30 days of getting the EOB. To
appeal, you or your child’s doctor can call Member Services at 1-800-600-4441 (TTY 711).
You can also mail your request and medical information to:
Payment Appeals
Amerigroup
P.O. Box 61599
Virginia Beach, VA 23466-1599
If you call us, we will send you a letter to let you know we got your request for an appeal. We will
include an appeal form for you to fill out and mail back to us. We can accept your appeal by phone. But
you must follow up in writing within 15 days of calling us.
There may be times when we need more information from you or the person you asked to file the
appeal for you. If we need more information, and it is in your child’s best interest that we have this
information, we may extend the appeal process for 14 days. If we extend the appeal process, we will
let you know in writing the reason for the delay. You may also ask us to extend the process if you know
more information that we should consider. You or your child’s doctor should send us this information
right away in the case of an expedited appeal.
If we do not approve your request for an expedited appeal, we will also let you know by phone and in
writing within two days. We will then resolve your appeal within 45 days. This is the normal appeal
time frame.
Continuation of Benefits
You may ask Amerigroup to continue to cover your benefits during the appeal process. If coverage of a
service you are getting is reduced and you want to keep getting that service during your appeal, you
can call Member Services to request it.
We must continue coverage of your benefits until:
 You withdraw the appeal
 Ten days from the date of our first decision
 Authorization expires or your service limits are met
If a decision is made in your favor as a result of your appeal, Amerigroup will approve and pay for the
services we denied coverage of before. If the decision is not made in your favor, you may be
responsible for payment of services you received during the appeal process.
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OTHER INFORMATION
If You Move
Report your new address as soon as possible if you move. Call 1-800-821-KIDS (5437)
(TTY 1-877-427-9825) and Amerigroup Member Services at 1-800-600-4441 (TTY 711). If you move out
of our service area, you will be disenrolled.
Reasons Why You Can be Disenrolled from Amerigroup and Healthy Kids
Disenrollment from the program is determined only by Healthy Kids. Your child’s coverage may end:
 At the end of the month in which your child turns 19
 If your child has other health insurance
 If your child becomes eligible for Medicaid
 If your child moves out of the Amerigroup service area
If you have any questions about your enrollment, call Member Services.
If You Get a Bill
Always show your child’s Amerigroup ID card when you see a doctor, go to the hospital or go for tests.
Even if your child’s doctor told your child to go, you must show your child’s Amerigroup ID card. This
will help 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 you have been sent a bill. Send the letter to:
Claims
Amerigroup
P.O. Box 61010
Virginia Beach, VA 23466-1010
You can also call Member Services for help.
Changes in Your Child’s Amerigroup Coverage
Sometimes, Amerigroup may have to make changes in the way it works, its covered services or its
network doctors and hospitals. We will mail you a letter when we make changes in the services that
are covered. Your child’s PCP office may move, close or leave our network. If this happens, we will call
or send you a letter to tell you about this.
We can also help you pick a new doctor for your child. You can call Member Services if you have any
questions. Member Services can also send you a current list of our network doctors.
New Technology
The Amerigroup medical director and our providers look at new medical advances (or changes to
existing technology) in:
 Medical procedures
 Behavioral health procedures
 Pharmaceuticals
 Devices
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They also look at scientific research. They consider whether these new medical advances and
treatments:
- Are believed to be safe and helpful by the government
- Give equal or better outcomes than the treatments or therapies that are paid for now
They do this to see if these advances should be benefits that will be paid for.
How to Tell Amerigroup About Changes You Think We Should Make
We want to know what you like and do not like about Amerigroup. Your ideas will help us make
Amerigroup better. Please call Member Services to tell us your ideas. You can also send a
letter to:
Amerigroup
P.O. Box 62509
Virginia Beach, VA 23466-2509
Amerigroup has a group of members who meet quarterly to give us their ideas. These meetings are
called Member Advisory meetings. This is a chance for you to find out more about us, ask questions
and give us ideas for improvement. If you would like 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.
How Amerigroup Pays Providers
Different providers in our network have agreed to be paid in different ways by us. Your child’s provider
may be paid each time he or she treats your child (fee for service). Or your child’s provider may be paid
a set fee each month for each member whether or not the member gets services (capitation).
These kinds of pay may include ways to earn more money. This kind of pay is based on different things
like member satisfaction, quality of care, accessibility and availability.
You can contact Amerigroup to get any other information you want. This includes the structure and
operation of Amerigroup and how we pay providers (the amount of these payments are private).
Please call Member Services at 1-800-600-4441 (TTY 711).
Write us at:
Member Services
Amerigroup
P.O. Box 62509
Virginia Beach, VA 23466-2509
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SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES
The Patient's Bill of Rights and Responsibilities was created to promote the interests and well-being of
patients and to promote better communication between the patient and the health care provider.
Florida law requires that your health care provider or health care facility recognize your rights while
you are receiving medical care and that you respect the health care provider’s or health care facility’s
right to expect certain behavior on the part of patients. See Section 381.026, Florida Statutes.
You and Your Child’s Rights
You and your child have the right to:
 Be treated with courtesy and respect, with appreciation for your dignity and with protection of
privacy
 Get a timely and reasonable response to questions and requests
 Know who is providing medical services and who is responsible for your care
 Know what member support services are available, including whether an interpreter is available if
you do not speak English
 Know what rules and regulations apply to your action
 Be given health care provider information such as evaluation, diagnosis, planned course of
treatment, alternatives, risks and prognosis
 Be given the opportunity to participate in decisions involving your health care, except when such
participation goes against medical reasons
 Refuse any treatment, except as otherwise provided by law
 Be given full information and necessary counseling on the availability of known financial resources
for care
 Know in advance of treatment, whether your PCP or health care facility accepts the Medicare
assignment rate if you are covered by Medicare
 Receive a reasonable estimate of charges for medical care before treatment
 Receive a copy of an easy-to-understand itemized bill and, upon request, to have the charges
explained
 Get medical treatment or accommodations, regardless of race, national origin, religion, physical
handicap or source of payment
 Get treatment for any emergency medical condition that will deteriorate from failure to provide
treatment
 Know if medical treatment is for experimental research and to agree or refuse to participate
 Express complaints about any violation of your rights
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You and Your Child’s Responsibilities
You and your child are responsible for:
 Giving your PCP accurate and complete information about present complaints, past illnesses,
hospitalizations, medications and other matters relating to your health
 Reporting unexpected changes in your condition to your PCP
 Telling your PCP whether you understand a possible treatment and what is expected of you
 Following the treatment plan recommended by your PCP
 Keeping appointments or notifying your PCP or health care facility when you can’t keep an
appointment
 Your actions if you refuse treatment or do not follow the PCP’s instructions
 Making sure the financial responsibilities are completed
 Following health care facility rules and regulations
Amerigroup members also have these additional rights and responsibilities. You have the right to:
 An honest talk about appropriate or medically necessary treatment choices for your conditions, no
matter what the cost or benefit coverage
 Tell us your grievance (complaint) or appeals about Amerigroup, our services, practitioners and
providers or the care we give.
 Get information about Amerigroup, our services, practitioners and providers, and member rights
and responsibilities
 Make suggestions about our member rights and responsibilities policy
 Understand your health problems and be part of creating a treatment goal with your providers, as
is possible.
We can translate this into another language at no cost. Call Member Services toll free at
1-800-600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
HOW TO REPORT SOMEONE WHO IS MISUSING THE HEALTHY KIDS PROGRAM
If you know someone who is misusing (through fraud, abuse and/or overpayment) the Healthy Kids
program, you can report him or her.
To report doctors, clinics, hospitals, nursing homes or Healthy Kids enrollees, write to:
Corporate Investigations Department
Amerigroup
4425 Corporation Lane
Virginia Beach, VA 23462
1-800-600-4441
1-800-821-KIDS (5437) (TTY 1-877-427-9825)
Suspicions of fraud and abuse can be emailed directly to the Amerigroup Corporate Investigations
Department at [email protected].
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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.
IMPORTANT TERMS
Here are some of the most important words used in this handbook. We hope the terms and definitions
below will help you get a better understanding of how your child’s health care coverage works.
Child — Your natural-born child or a legally adopted child who has been placed in your home
Contract year (or year) — October 1 through September 30 - the covered benefit period from one
contract year to the next
Copayment (copay) — An out-of-pocket payment (usually a few dollars) that you pay to the doctor or
other health care provider when your covered child gets care
Elective surgical procedure — a surgical operation that isn’t an emergency and doesn’t have to be
done right away
Hospital — An institution that:
− Provides medical care and treatment to sick and injured patients on an inpatient basis for a fee
− Provides or operates medical, diagnostic and major surgical facilities, either at its location or in
facilities with which it has an arrangement
− Provides care and treatment given and managed by doctors
− Provides nursing services on a 24-hour basis, given or managed by
registered nurses
− Is licensed and runs as a hospital according to the laws of the local area
− Is not primarily a convalescent, rest or nursing home, or a facility providing custodial care or
educational services
Intensive care unit — A special part of a hospital that:
− Treats patients with serious injuries
− Uses special lifesaving methods and equipment
− Admits patients no matter what their expected outcome
− Provides constant close watch of patients by a specially trained nursing staff
Medically necessary services — Services or supplies covered by the plan must be considered medically
necessary. This means these supplies or services must:
− Be consistent with the symptoms or diagnosis and treatment of the child’s injury or sickness
− Be considered proper according to standards of good medical practice
− Not be provided just for the convenience of your child, the physician, or the hospital or outpatient
care facility
− Provide the proper level of care or the right supply of medicine or equipment that can be safely
offered to the sick or injured child (for inpatient care, this means that the treatment your child gets
must be a treatment that cannot be given safely on an outpatient basis)
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Member (or plan member) — Your child or children who are covered by Amerigroup and the Healthy
Kids program
Nonparticipating provider — Hospitals and providers who have not signed an agreement with us to
provide services to members
Open enrollment period — A period of time each year when anyone who is eligible can enroll in
the plan
Outpatient — A person who gets care at a hospital or other facility for no longer than 23 hours
Participating provider — A hospital, physician or other provider of health care that has signed an
agreement with us to provide services for Amerigroup members
Physician — A person who is licensed to practice medicine or osteopathy and does so within the scope
of his or her license, and whose services must be covered under group health care plans according to
state laws; includes podiatrists, osteopaths and chiropractors
Preadmission tests — Lab tests or X-ray exams done on an outpatient basis in a hospital or other
facility no more than seven days before your child goes into the hospital or has outpatient surgery
Primary care provider (PCP) — A person who is licensed to practice medicine or osteopathy in the local
area where your child gets care and provides, prescribes, authorizes and helps manage all care and
treatment for your child
Psychiatric treatment program — Services offered by programs licensed for the treatment of mental
and nervous disorders or substance abuse rehabilitation
Room and board — Services provided by a hospital that include room, meals and all general services
and activities needed for the care of patients
Service or services — Medical services or supplies provided to Amerigroup members
Sickness — A physical illness or disease (includes any problems during pregnancy)
Skilled nursing facility — A licensed institution (other than a hospital) that:
− Maintains all services needed for medical care and treatment at its location
− Provides medical services managed by physicians
− Provides nursing services given or managed by a Registered Nurse
Total disability or totally disabled — A disability that keeps your child from going to school or taking
part in the normal activities of other children in his or her age group
We, us, our — Amerigroup
You, your — Amerigroup Healthy Kids member
We hope this handbook has answered most of your questions about Amerigroup. For more
information, you can call the Amerigroup Member Services department at 1-800-600-4441 (TTY 711).
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www.myamerigroup.com
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION WITH REGARD TO YOUR HEALTH BENEFITS.
PLEASE REVIEW IT CAREFULLY.
HIPAA NOTICE OF PRIVACY PRACTICES
The original effective date of this notice was April 14, 2003. The most recent revision date is shown at
the end of this notice.
Please read this notice carefully. This tells you who can see your protected health information (PHI).
It tells you when we have to ask for your OK before we share it. It tells you when we can share it
without your OK. It also tells you what rights you have to see and change your information.
Information about your health and money is private. The law says we must keep this kind of
information, called PHI, safe for our members. That means if you’re a member right now or if you used
to be, your information is safe.
We get information about you from state agencies for Medicaid and the Children’s Health Insurance
Program after you become eligible and sign up for our health plan. We also get it from your doctors,
clinics, labs and hospitals so we can OK and pay for your health care.
Federal law says we must tell you what the law says we have to do to protect PHI that’s told to us, in
writing or saved on a computer. We also have to tell you how we keep it safe. To protect PHI:
 On paper (called physical), we:
– Lock our offices and files
– Destroy paper with health information so others can’t get it
 Saved on a computer (called technical), we:
– Use passwords so only the right people can get in
– Use special programs to watch our systems
 Used or shared by people who work for us, doctors or the state, we:
– Make rules for keeping information safe (called policies and procedures)
– Teach people who work for us to follow the rules
When is it OK for us to use and share your PHI?
We can share your PHI with your family or a person you choose who helps with or pays for your health
care if you tell us it’s OK. Sometimes, we can use and share it without your OK:
 For your medical care
– To help doctors, hospitals and others get you the care you need
 For payment, health care operations and treatment
– To share information with the doctors, clinics and others who bill us for your care
– When we say we’ll pay for health care or services before you get them
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To find ways to make our programs better, as well as giving your PHI to health information
exchanges for payment, health care operations and treatment. If you don’t want this, please
visit www.myamerigroup.com/pages/privacy.aspx for more information.
For health care business reasons
– To help with audits, fraud and abuse prevention programs, planning, and everyday work
– To find ways to make our programs better
For public health reasons
– To help public health officials keep people from getting sick or hurt
With others who help with or pay for your care
– With your family or a person you choose who helps with or pays for your health care,
if you tell us it’s OK
– With someone who helps with or pays for your health care, if you can’t speak for yourself and
it’s best for you
We must get your OK in writing before we use or share your PHI for all but your care, payment,
everyday business, research or other things listed below. We have to get your written OK before we
share psychotherapy notes from your doctor about you.
You may tell us in writing that you want to take back your written OK. We can’t take back what we
used or shared when we had your OK. But we will stop using or sharing your PHI in the future.
Other ways we can — or the law says we have to — use your PHI:
 To help the police and other people who make sure others follow laws
 To report abuse and neglect
 To help the court when we’re asked
 To answer legal documents
 To give information to health oversight agencies for things like audits or exams
 To help coroners, medical examiners or funeral directors find out your name and cause of death
 To help when you’ve asked to give your body parts to science
 For research
 To keep you or others from getting sick or badly hurt
 To help people who work for the government with certain jobs
 To give information to workers’ compensation if you get sick or hurt at work
What are your rights?
 You can ask to look at your PHI and get a copy of it. We don’t have your whole medical record,
though. If you want a copy of your whole medical record, ask your doctor or health clinic.
 You can ask us to change the medical record we have for you if you think something is wrong or
missing.
 Sometimes, you can ask us not to share your PHI. But we don’t have to agree to your request.
 You can ask us to send PHI to a different address than the one we have for you or in some other
way. We can do this if sending it to the address we have for you may put you in danger.
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You can ask us to tell you all the times over the past six years we’ve shared your PHI with someone
else. This won’t list the times we’ve shared it because of health care, payment, everyday health
care business or some other reasons we didn’t list here.
You can ask for a paper copy of this notice at any time, even if you asked for this one by email.
If you pay the whole bill for a service, you can ask your doctor not to share the information about
that service with us.
What do we have to do?
 The law says we must keep your PHI private except as we’ve said in this notice.
 We must tell you what the law says we have to do about privacy.
 We must do what we say we’ll do in this notice.
 We must send your PHI to some other address or in a way other than regular mail if you ask for
reasons that make sense, like if you’re in danger.
 We must tell you if we have to share your PHI after you’ve asked us not to.
 If state laws say we have to do more than what we’ve said here, we’ll follow those laws.
 We have to let you know if we think your PHI has been breached.
We may contact you
You agree that we, along with our affiliates and/or vendors, may call or text any phone numbers you
give us, including a wireless phone number, using an automatic telephone dialing system and/or a
prerecorded message. Without limit, these calls or texts may be about treatment options, other
health-related benefits and services, enrollment, payment, or billing.
What if you have questions?
If you have questions about our privacy rules or want to use your rights, please call Member Services at
1-800-600-4441. If you’re deaf or hard of hearing, call 711.
What if you have a complaint?
We’re here to help. If you feel your PHI hasn’t been kept safe, you may call Member Services or
contact the Department of Health and Human Services. Nothing bad will happen to you if you
complain.
Write to or call the Department of Health and Human Services:
Office for Civil Rights
U.S. Department of Health and Human Services
Sam Nunn Atlanta Federal Center, Suite 16T70
61 Forsyth St. SW
Atlanta, GA 30303-8909
Phone: 1-800-368-1019
TDD: 1-800-537-7697
Fax: 404-562-7881
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We reserve the right to change this Health Insurance Portability and Accountability Act (HIPAA) notice and
the ways we keep your PHI safe. If that happens, we’ll tell you about the changes in a newsletter. We’ll also
post them on the Web at www.myamerigroup.com/pages/privacy.aspx.
Your personal information
We may ask for, use and share personal information (PI) as we talked about in this notice. Your PI is not
public and tells us who you are. It’s often taken for insurance reasons.
 We may use your PI to make decisions about your:
– Health
– Habits
– Hobbies
 We may get PI about you from other people or groups like:
– Doctors
– Hospitals
– Other insurance companies
 We may share PI with people or groups outside of our company without your OK in some cases.
 We’ll let you know before we do anything where we have to give you a chance to say no.
 We’ll tell you how to let us know if you don’t want us to use or share your PI.
 You have the right to see and change your PI.
 We make sure your PI is kept safe.
Revised May 1, 2015
We can translate this into another language at no cost. Call Member Services toll free at
1-800 600-4441 (TTY 711) Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
Podemos traducir esta información a otro idioma sin costo. Llame a la línea gratuita de Servicios al
Miembro al 1-800-600-4441 (TTY 711) de lunes a viernes de 8 a.m. a 7 p.m. hora del Este.
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