If you, as a member of the health plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 90 days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 90 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at:
Fair Hearing Coordinator Amerigroup
3800 Buffalo Speedway, Suite 400 Houston, TX 77098
Or you can call Member Services at 1-800-600-4441. We can help you with this request.
You have the right to keep getting any service the health plan denied or reduced, at least until the final hearing decision is made, if you ask for a fair hearing by the later of:
10 calendar days following the Amerigroup mailing of the notice of the action or
The day the health plan’s letter says your service will be reduced or end.
If you do not request a fair hearing by this date, the service the health plan denied will be stopped.
If you ask for a fair hearing, you will get a packet of information letting you know the date, time, and location of the hearing. Most fair hearings are held by telephone. At that time, you or your
representative can tell why you need the service the health plan denied.
HHSC will give you a final decision within 90 days from the date you asked for the hearing.
Can I Ask for a Fair Hearing for Long-term Services and Supports ?
Yes, you can ask for a fair hearing from the state for long-term services and supports. To request one, see the instructions in the Can I Ask for a State Fair Hearing? section above.
www.myamerigroup.com
Dear Member:
Welcome to Amerigroup. We are pleased that you chose us to arrange for your Amerigroup benefits.
The member handbook tells you how Amerigroup works and how to help you take good care of your health. It also tells you how to get health care when you need it.
You will get your Amerigroup ID card and more information from us in a few days. Your ID card will tell you when your Amerigroup membership starts.
We want to hear from you. Call 1-800-600-4441. You can talk to a Member Services representative about your benefits. You can also talk to a nurse on our Nurse HelpLine.
Thank you for picking us as your health plan.
Sincerely,
LeAnn Behrens
Chief Executive Officer Amerigroup
Texas Health Plans
Amerigroup is a diverse company and welcomes all eligible people. We do not base membership on health status. If you have questions or concerns, please call 1-800-600-4441 and ask for extension 34925.
Or visit www.myamerigroup.com.
AMERIGROUP STAR+PLUS PROGRAM
MEMBER HANDBOOK FOR MEMBERS WITH BOTH MEDICARE AND MEDICAID COVERAGE
Bexar Service Area El Paso Service Area Harris and Jefferson Service Areas 12500 San Pedro Avenue 7430 Remcon Circle 3800 Buffalo Speedway
Suite 400 Building C, Suite 120 Suite 400
San Antonio, TX 78216 El Paso, TX 79912 Houston, TX 77098
Lubbock Service Area Tarrant Service Area Travis Service Area
3223 S. Loop 289 2505 N. Highway 360 823 Congress Ave.
Suite 110 Suite 300 Suite 400
Lubbock, TX 79423 Grand Prairie, TX 75050 Austin, TX 78701
1-800-600-4441
www.myamerigroup.com/TX Welcome to Amerigroup!
This member handbook will tell you how to use Amerigroup to get the long-term care you need.
Table of Contents
WELCOME TO AMERIGROUP! ... 1
INFORMATION ABOUT YOUR NEW HEALTH PLAN ...1
YOUR AMERIGROUP MEMBER HANDBOOK ...1
IMPORTANT PHONE NUMBERS ... 1
AMERIGROUP MEMBER SERVICES DEPARTMENT ...1
AMERIGROUP 24-HOUR NURSE HELPLINE ...2
OTHER IMPORTANT PHONE NUMBERS ...2
YOUR AMERIGROUP ID CARD ... 3
WHAT INFORMATION IS ON MY AMERIGROUP ID CARD? ...3
How Do I Read My Amerigroup ID Card? ... 3
How Do I Replace My Amerigroup ID Card If It Is Lost or Stolen? ... 3
YOUR TEXAS BENEFITS MEDICAID CARD ...3
WHAT IF I NEED A TEMPORARY ID MEDICAID CARD? ...4
PRIMARY CARE PROVIDERS ... 5
WHAT IS A PRIMARY CARE PROVIDER? ...5
WHAT DO I NEED TO BRING WITH ME TO MY DOCTOR’S APPOINTMENT? ...5
PHYSICIAN INCENTIVE PLANS ... 5
CHANGING HEALTH PLANS ... 5
WHAT IF I WANT TO CHANGE HEALTH PLANS?...5
WHO DO I CALL? ...5
HOW MANY TIMES CAN I CHANGE HEALTH PLANS? ...6
WHEN WILL MY HEALTH PLAN CHANGE BECOME EFFECTIVE? ...6
CAN AMERIGROUP ASK THAT I BE DROPPED FROM THEIR HEALTH PLAN (FOR NONCOMPLIANCE, ETC.)? ...6
MY BENEFITS ... 6
WHAT ARE MY HEALTH-CARE BENEFITS? ...6
How Do I Get These Services? ... 6
What If Amerigroup Doesn’t Have a Provider For One of My Covered Benefits? ... 6
Are There Any Limits to Any Covered Services? ... 7
WHAT ARE MY ACUTE CARE BENEFITS? ...7
WHAT SERVICES ARE COVERED BY MEDICAID? ...7
How Do I Get These Services? ... 7
What Number Do I Call to Find Out about These Services? ... 7
WHAT ARE MY LONG-TERM SERVICES AND SUPPORTS BENEFITS? ...7
How Do I Get These Services? ... 7
What Number Do I Call to Find Out about These Services? ... 8
WHAT IS SERVICE COORDINATION? ...8
YOUR AMERIGROUP SERVICE PLAN ...8
WHAT IS A SERVICE PLAN? ...9
HOW DO I CHANGE MY AMERIGROUP SERVICE PLAN? ...9
What Will a Service Coordinator Do for Me? ... 9
How Can I Talk with a Service Coordinator? ... 9
HOW CAN I MAKE SURE I KEEP GETTING THE COMMUNITY CARE FOR THE AGED AND DISABLED, COMMUNITY BASED ALTERNATIVE WAIVER, OR NURSING HOME SERVICES I AM GETTING NOW? ...9
WHAT SERVICES ARE NOT COVERED? ... 10
WHAT ARE MY PRESCRIPTION DRUG BENEFITS? ... 10
What if I Also Have Medicare? ... 10
How Do I Find a Network Drugstore? ... 10
What If I Go to a Drugstore Not in the Network? ... 10
What Do I Bring With Me to the Drugstore? ... 10
What if I Need My Medications Delivered to Me? ... 10
Who Do I Call If I Have Problems Getting My Medications? ... 10
What If I Can’t Get the Medication My Doctor Ordered Approved? ... 10
What If I Lose My Medication(s)?... 10
What If I Need Durable Medical Equipment or Other Products Normally Found In a Pharmacy? ... 11
CALL 1-800-600-4441 FOR MORE INFORMATION ABOUT THESE BENEFITS. ... 11
WHAT EXTRA BENEFITS DO I GET AS A MEMBER OF AMERIGROUP? ... 11
How Can I Get These Extra Benefits? ... 12
WHAT HEALTH EDUCATION CLASSES DOES AMERIGROUP OFFER? ... 12
WHAT OTHER SERVICES CAN AMERIGROUP HELP ME GET?... 12
Community Events ... 12
Domestic Violence ... 12
Minors ... 13
HEALTH-CARE AND OTHER SERVICES ... 13
WHAT DOES MEDICALLY NECESSARY MEAN? ... 13
HOW IS NEW TECHNOLOGY EVALUATED? ... 14
WHAT IS ROUTINE MEDICAL CARE? ... 14
How Soon Can I Expect to Be Seen? ... 14
WHAT IS URGENT MEDICAL CARE? ... 15
How Soon Can I Expect to Be Seen? ... 15
WHAT IS EMERGENCY MEDICAL CARE? ... 15
When Can I Expect to Be Seen?... 16
HOW SOON CAN I SEE MY DOCTOR? ... 16
WHAT IS POSTSTABILIZATION? ... 17
What If I Am out of the Country? ... 17
HOW CAN I ASK FOR A SECOND OPINION? ... 17
CAN SOMEONE INTERPRET FOR ME WHEN I TALK WITH MY LONG-TERM SERVICES AND SUPPORTS? ... 17
Who Do I Call for an Interpreter? ... 17
How Far in Advance Do I Need to Call? ... 17
How Can I Get a Face-to-Face Interpreter in the Provider’s Office? ... 17
IF I DO NOT HAVE A CAR, HOW CAN I GET A RIDE TO A DOCTOR’S OFFICE? WHO DO I CALL? ... 17
How Far in Advance Do I Need to Call? ... 17
How Can Someone I Know Give Me a Ride to My Appointment and Get Money for Mileage? ... 17
What Are the Hours of Operation and Limits for Transportation Services? ... 18
Who Do I Call if I Have a Complaint about the Service or Staff? ... 18
WHAT IF I AM PREGNANT? ... 18
How Do I Sign Up My Newborn Baby? ... 18
HOW AND WHEN DO I TELL AMERIGROUP? ... 18
HOW AND WHEN DO I TELL MY CASEWORKER? ... 18
WHO DO I CALL IF I HAVE SPECIAL HEALTH-CARE NEEDS AND NEED SOMEONE TO HELP ME? ... 18
WHAT IF I AM TOO SICK TO MAKE A DECISION ABOUT MY MEDICAL CARE? ... 19
What Are Advance Directives? ... 19
How Do I Get an Advance Directive?... 19
WHAT HAPPENS IF I LOSE MY MEDICAID COVERAGE? ... 19
WHAT IF I GET A BILL FROM MY DOCTOR? WHO DO I CALL? ... 19
CAN MY MEDICARE PROVIDER BILL ME FOR SERVICES OR SUPPLIES IF I AM IN BOTH MEDICARE AND MEDICAID? ... 19
WHAT INFORMATION WILL THEY NEED? ... 19
WHAT DO I HAVE TO DO IF I MOVE? ... 20
WHAT IF I HAVE OTHER HEALTH INSURANCE IN ADDITION TO MEDICAID? ... 20
Medicaid and Private Insurance ... 20
WHAT ARE MY RIGHTS AND RESPONSIBILITIES AS AN AMERIGROUP MEMBER? ... 20
QUALITY MANAGEMENT ... 22
WHAT IS THE AMERIGROUP QUALITY MANAGEMENT PROGRAM? ... 22
WHAT ARE CLINICAL PRACTICE GUIDELINES? ... 22
COMPLAINTS PROCESS ... 22
WHAT SHOULD I DO IF I HAVE A COMPLAINT? WHO DO I CALL? ... 22
Can Someone from Amerigroup Help Me File a Complaint? ... 22
How Long Will It Take to Process My Complaint? ... 22
What Are the Requirements and Time Frames for Filing a Complaint? ... 22
How Do I File a Complaint with the Health and Human Services Commission Once I Have Gone through the Amerigroup Complaint Process? ... 23
APPEALS PROCESS ... 23
WHAT CAN I DO IF MY DOCTOR ASKS FOR A SERVICE FOR ME THAT’S COVERED BUT AMERIGROUP DENIES IT OR LIMITS IT? ... 23
HOW WILL I FIND OUT IF SERVICES ARE DENIED? ... 23
What Are the Time Frames for the Appeals Process? ... 24
Can Someone from Amerigroup Help Me File an Appeal? ... 24
Can Members Request a State Fair Hearing? ... 24
EXPEDITED APPEALS ... 25
WHAT IS AN EXPEDITED APPEAL? ... 25
HOW DO I ASK FOR AN EXPEDITED APPEAL? DOES MY REQUEST HAVE TO BE IN WRITING? ... 25
WHAT ARE THE TIME FRAMES FOR AN EXPEDITED APPEAL? ... 25
WHAT HAPPENS IF THE HEALTH PLAN DENIES THE REQUEST FOR AN EXPEDITED APPEAL? ... 25
WHO CAN HELP ME FILE AN EXPEDITED APPEAL? ... 25
STATE FAIR HEARING ... 25
CAN I ASK FOR A STATE FAIR HEARING? ... 25
CAN I ASK FOR AN APPEAL FOR LONG-TERM SERVICES AND SUPPORTS? ... 26
FRAUD AND ABUSE ... 26
DO YOU WANT TO REPORT WASTE, ABUSE, OR FRAUD? ... 26
INFORMATION THAT MUST BE AVAILABLE ON AN ANNUAL BASIS ... 27
NOTICE OF PRIVACY PRACTICES ... 28
WELCOME TO AMERIGROUP!
Information about Your New Health Plan
Welcome to Amerigroup. Amerigroup is a managed care organization committed to helping you get the right care close to home. You have enrolled in Amerigroup to get STAR+PLUS long-term services and supports through the Texas Medicaid program. To find out about providers in your area, visit www.myamerigroup.com/TX or contact Member Services at 1-800-600-4441.
Our records show you get your acute health care from your primary care provider through original Medicare and a Prescription Drug Plan or a Medicare Advantage Plan that includes Part D coverage. If you live in Bexar,
Brazoria, Denton, Fort Bend, Harris, Montgomery, or Tarrant counties, you may have picked the Amerigroup Amerivantage Plan, a Medicare Advantage Plan, for your Medicare benefits. If you are enrolled in the Amerivantage Plan, please also refer to the Amerivantage evidence of coverage and member handbook for complete details on your Medicare and prescription drug benefits and how they work together with the benefits you receive through Medicaid. If you are enrolled with another Medicare insurer, refer to the handbook and information they send you.
Your Amerigroup Member Handbook
This handbook will help you understand your Amerigroup health plan. If you have questions, call our Member Services department. Amerigroup also has the member handbook in a large print version, an audio-taped version, and a Braille version. The other side of this handbook is in Spanish.
IMPORTANT PHONE NUMBERS
Amerigroup Member Services Department
If you have any questions about your Amerigroup health plan benefits, you can call our Member Services department at 1-800-600-4441. You can call us Monday through Friday from 8 a.m. to 5 p.m. local time, except for holidays. If you call after 5 p.m. or on a holiday, you can leave a voice mail message. A Member Services representative will call you back the next business day. Member Services can help you with:
This member handbook Member ID cards
Your Amerigroup Service Coordination team
What to do if you think you need long-term services and supports Special kinds of health care
Healthy living
Complaints and appeals Rights and responsibilities
For members who do not speak English, we are able to help in many different languages and dialects, including Spanish. This service is also available for visits with your doctor at no cost to you. Please let us know if you need an interpreter at least 24 hours before your appointment. Call Member Services for more information.
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TX-MHB-0055-12 TX STAR+PLUS Dual MHB 02.13
For members who are deaf or hard of hearing, call the toll-free AT&T Relay Service at 1-800-855-2880.
Amerigroup will set up and pay for you to have a person who knows sign language help you during your doctor visits. Please let us know if you need an interpreter at least 24 hours before your appointment.
Amerigroup 24-hour Nurse HelpLine
The Nurse HelpLine is available to all members 24 hours a day, 7 days a week. You can call the Nurse HelpLine at 1-866-864-2544 if you need advice on:
How soon you need care for an illness What kind of health care is needed How you can get the care that is needed
We want you to be happy with all the services you get through Amerigroup. Please call Member Services if you have any problems. We want to help you correct any problems you may have with your care.
If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away.
Other Important Phone Numbers
Texas Client Notification Line 1-800-414-3406
STAR+PLUS Program Help Line 1-800-964-2777
Medicaid Managed Care Helpline 1-866-566-8989
(TDD 1-866-222-4306)
Medical Transportation Program 1-877-633-8747
Monday through Friday 8 a.m. to 5 p.m.
Dental Care for members age 20 and under DentaQuest
MCNA Dental
Dental Care for members age 21 and older (not for members in Tarrant)
1-800-516-0165 1-800-494-6262
1-800-365-3527
Member Services
Regular business hours are 8 a.m. to 5 p.m. local time for your service area, Monday through Friday, excluding state-approved holidays
Member Services is available 24 hours a day, 7 days a week
−
Information is available in English and Spanish−
Interpreter services are also available−
TDD Line for hearing impaired is 1-800-855-2880 For information on the availability of Service Coordination To set up transportation to your medical visitsFor behavioral health and substance abuse care
For information about our disease management programs
1-800-600-4441
YOUR AMERIGROUP ID CARD
What Information Is on My Amerigroup ID Card?
If you do not have your Amerigroup ID card yet, you will get it soon. Please carry it with you at all times.
If you are enrolled in Amerigroup to get long-term care services only, show your ID card to any long-term care provider you receive services from. The card tells providers you are a member of Amerigroup for your long-term care benefits and how we pay for your care. It also tells them they should not ask you to pay for the benefits covered by Amerigroup. No primary care doctor will be listed on the card since this is covered through your Medicare insurer.
If you are enrolled in the Amerivantage Plan offered by Amerigroup, you will have 1 ID card to present to providers. You must use your Amerivantage ID card to get covered services. Your Amerivantage ID card will tell providers that you have Medicare, Medicaid, and Medicare Part D prescription drug coverage through
Amerivantage. If your Medicare coverage is with another Medicare insurer, you will have a card from them.
Your Amerigroup ID card has the date you became an Amerigroup member on it. Your ID card lists many of the important phone numbers you need to know, like our Member Services department and Nurse HelpLine.
How Do I Read My Amerigroup ID Card?
The card tells providers and hospitals you are a member of Amerigroup. It also says that Amerigroup will pay for the benefits listed in the My Benefits section.
Your Amerigroup ID card shows the date you became an Amerigroup member. It also lists many of the important phone numbers you need to know, like our Member Services department and Nurse HelpLine.
How Do I Replace My Amerigroup ID Card If It Is Lost or Stolen?
If your ID card is lost or stolen, call us right away. We will send you a new one.
Your Texas Benefits Medicaid Card
When you are approved for Medicaid, you will get a Your Texas Benefits Medicaid card. This plastic card will be your everyday Medicaid ID card. You should carry and protect it just like your driver’s license or a credit card.
The card has a magnetic stripe that holds your Medicaid ID number. Your doctor can use the card to find out if you have Medicaid benefits when you go for a visit.
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TX-MHB-0055-12 TX STAR+PLUS Dual MHB 02.13
You will get a new Your Texas Benefits Medicaid card every time you change your health plan.
If you are not sure if you are covered by Medicaid, you can find out by calling toll-free at 1-800-252-8263. You can also call 2-1-1. First pick a language and then pick option 2.
Your health history is a list of medical services and drugs that you have gotten through Medicaid. We share it with Medicaid doctors to help them decide what health care you need. If you don’t want your doctors to see your health history through the secure online network, call toll-free at 1-800-252-8263.
The Your Texas Benefits Medicaid card has these facts printed on the front:
Your name and Medicaid ID number
The name of the Medicaid program you’re in if you get your Medicaid services through a health plan; this would be STAR, STAR Health, or STAR+PLUS
The date HHSC made the card for you
Facts your drugstore will need to bill Medicaid
The name of the health plan you’re in and the plan’s phone number
The name of your doctor and drugstore if you’re in the Medicaid Limited program
The back of the Your Texas Benefits Medicaid card has a website you can visit (www.yourtexasbenefits.com) and a phone number you can call (1-800-252-8263) if you have questions about the new card.
If you forget your card, your doctor, dentist, or drugstore can use the phone or the Internet to make sure you get Medicaid benefits.
If you lose the Your Texas Benefits Medicaid card, you can get a new one by calling toll-free at 1-855-827-3748.
What If I Need a Temporary ID Medicaid Card?
If you have lost or do not have access to Your Texas Benefits Medicaid card and need a temporary ID Medicaid card, you can get the Temporary ID Card (Form 1027-A) at your local HHSC benefits office. Present this form as proof of your eligibility for Medicaid in the same way you would present your Texas Benefits Medicaid card as described above. Your provider will accept this form as proof of Medicaid eligibility.
PRIMARY CARE PROVIDERS
What Is a Primary Care Provider?
A primary care provider is a family doctor who will provide you with most of your routine care. Your doctor will give you a medical home. That means that he or she will get to know you and your health history and be able to help you get the best possible care. He or she will also send you to other doctors or hospitals when you need
A primary care provider is a family doctor who will provide you with most of your routine care. Your doctor will give you a medical home. That means that he or she will get to know you and your health history and be able to help you get the best possible care. He or she will also send you to other doctors or hospitals when you need