«Member Handbook: Integrated Health Services For Physical and Behavioral Health Services Amerigroup Louisiana LA-MHB-0018-16 05.16 1-800-600-4441 (TTY ...»
and Family Services
Region 9 East Carroll, Franklin, Lincoln, Madison, 318-654-4245 Monroe area Morehouse, Ouachita, Richland, Tensas, Wraparound Services of Union and West Carroll Parishes Northeast Louisiana
SERVICES COVERED UNDER THE LOUISIANA STATE PLAN OR FEE-FORSERVICE MEDICAIDSome services are covered by the Louisiana State Plan or fee-for-service Medicaid instead of Amerigroup. These services are called carved-out services.
Even though we do not cover these services, your Amerigroup PCP or specialist will:
Provide all required referrals Assist in setting up these services These services will be paid for by the Louisiana Department of Health and Hospitals (DHH) on a
fee-for-service basis. Carved-out benefits include:
Services given through the DHH Early Steps program School-based Individualized Education Plan services given by a school district Health services for a member to help them stay in their home of community Targeted case management services, including nurse family partnership For details on how and where to access these services, call the Louisiana DHH at 1-888-342-6207.
Copays may apply for certain services.
Amerigroup screens children to decide if they need these services. If your child meets one of the three criteria listed below then we will refer you to the CSOC program managed by Magellan.
Has your child done things that put him or her in danger? Run away from home? Done reckless things like riding on top of a car?
Has your child ever threatened to hurt someone? Been in fights at school or home? Ever seriously hurt someone else?
Does your child break school rules or been in trouble with the law?
The system of care helps families and children:
Have a stronger voice in their care Become a partner in the treatment process Return or stay at home
Services available through the Coordinated System of Care include:
A care plan for members Support and training for youth, parents and caregivers Respite care Crisis support If you or your child is eligible for the services, it’s your choice to be in the program.
To find about eligibility for Coordinated System of Care services, call Member Services at 1-800-600-4441 (TTY 711). We can help arrange a screening.
If you’re enrolled in the program, Magellan Health Services will help you get services. If you need help getting services, call Magellan directly at 1-800-424-4489 (TTY 1-800-424-4416) or visit www.magellanoflouisiana.com.
PRIOR AUTHORIZATIONSSome Amerigroup services and benefits require prior approval. This means that your provider and/or you must ask Amerigroup to approve those services or benefits before you get them.
These services do not require prior approval:
Emergency services Post-stabilization services Urgent care Family planning services Early and Periodic Screening, Diagnosis and Treatment (EPSDT) 40 LA-MHB-0018-16 Updated 05/16
CASE MANAGEMENTAmerigroup covers free case management nursing services for members. Through this process, a nurse case manager will work with you and your family (or a representative) to review your strengths and
needs. The review should result in a service plan that:
You, your family or representative, and case manager agree on Meets your medical, functional, social and behavioral health needs in the most unified setting
The case manager can help with:
Assessing your health care needs Developing a plan of care Giving you and your family the information and training needed to make informed decisions and choices Giving providers the information they need about any changes in your health to help them in planning, delivering and monitoring services Will follow up with you within 72 hours of discharge for a behavioral health-related diagnosis Provides aftercare planning for members prior to discharge from a 24-hour facility for behavioral health care To collect and assess this information, your case manager will conduct phone interviews or home visits with you or your representatives. To complete the assessment, the case manager will also get information from your primary care provider (PCP) and specialists and other sources to set up and decide your current medical and nonmedical service needs.
You can also call Member Services if you think you need case management services. We will refer you to our Case Management department.
NEW TECHNOLOGYThe Amerigroup medical director and our participating providers assess new medical advances (or
changes to existing technology) in:
Medical procedures Behavioral health procedures Pharmaceuticals Devices
They also look at scientific literature and whether these new medical advances and treatments:
Are considered safe and effective by the government Give equal or better outcomes than the covered treatment or therapy that exists now They do this to see if these advances are suited as covered benefits.
You should be able to see your PCP within six weeks for routine care. For behavioral health care, you should be able to see your behavioral health provider within 14 days for routine care.
ut this is only part of your WW’s ũob. Your WW also takes care of you before you get sick. This is called wellness care. See the Wellness care for children and adults section in this handbook.
If you need urgent care:
Call your PCP. Your PCP will tell you what to do.
&ollow your WW’s instructions. Your WW may tell you to go to:
- His or her office right away
- Some other office to get immediate care
- The emergency room at a hospital for care; see the next section about emergency care for more details You can also call Amerigroup On Call at 1-866-864-2544 if you need advice about urgent care. You should be able to see your PCP within 24 hours for an urgent care appointment.
Emergency care If you have an emergency, call 911 or go to the nearest hospital emergency room. You can go to any hospital for emergency care even if it’s in a different city or state.
What is an emergency? An emergency is when you need to get care right away. /f you don’t get it͕ it could cause your death. It could cause very serious harm to your body.
You should be able to see a physician right away. The emergency provider who will be treating you will decide whether you are well enough to transfer or be discharged from the hospital. Amerigroup will cover this expense based on what the provider decides.
If there is a question of whether you are stable, the doctor treating you will make the final decision about your condition. Amerigroup will agree with this decision.
If you want advice about emergency care, such as where to go for care, call your PCP or Amerigroup On Call at 1-866-864-2544. Medical emergencies do not need prior approval by Amerigroup.
After you visit the emergency room:
Call your PCP as soon as you can.
If you cannot call, have someone else call for you.
Your PCP will give or set up any follow-up care you need. This is called post-stabilization care. You get these services to help keep your condition stable. These services do not need prior approval by Amerigroup.
How to get health care when your primary care provider’s office is closed Except in the case of an emergency (see previous section), you should always call your primary care provider (PCP) first before you get medical care. /f you call your WW’s office when it is closed͕ leave a message with your name and a phone number where you can be reached. If it is not an emergency, someone should call you back within 30 minutes to tell you what to do. You may also call Amerigroup On Call 24 hours a day, 7 days a week for help at 1-866-864-2544.
If you think you need emergency services (see previous section), call 911 or go to the nearest emergency room right away.
How to get health care when you are out of town If you need emergency services when you are out of town or outside of Louisiana,* go to the nearest hospital emergency room or call 911. You have the right to use any hospital or other medical emergency care facility. This is called out-of-area care.
*If you are outside of the United States and get health care services, the services will not be covered by Amerigroup or fee-for-service Medicaid.
How to get health care when you cannot leave your home If you cannot leave your home, we will find a way to help take care of you. Call Member Services right away. We will put you in touch with a case manager who will help you get the medical care you need.
WELLNESS CARE FOR CHILDREN AND ADULTSAll Amerigroup members need to have regular wellness visits with their primary care provider (PCP).
During a wellness visit, your PCP can see if you have a problem. If you do, your PCP can help you before it is a bad problem.
When you become an Amerigroup member:
Call your PCP.
Make your first appointment within 90 days.
Wellness care for children Why well-child visits are important for children Children need more wellness visits than adults. These wellness visits for children are for anyone in
Medicaid that is under 21 years old. Babies need to:
See their PCP at least seven times by the time they are 12 months old Go more times if they get sick Your child may have special needs or an illness like asthma or diabetes. If so, one of our case managers can help your child get checkups, tests and shots.
Your child can get checkups from his or her PCP or any Amerigroup network provider. You do not need a referral for these visits.
At these wellness visits͕ your child’s WW will:
Make sure your baby is growing well Help you care for your baby, talk to you about what to feed your baby and how to help your baby go to sleep
Well-child care for children ages 3 through 20 Your child should see the doctor again at ages 3, 4 and 5. Be sure to set up these visits. It is important to take your child to his or her PCP when scheduled. From ages 6 through 20, your child should see his or her PCP at least one time each year for a well-child checkup.
Blood lead screening Your child’s WW will begin to screen your child for lead poisoning at every well-child visit. Your child’s PCP will give your child a blood lead test at 12 and 24 months unless your child’s PCP decides it should be done at other times. Your child’s WW will also give your child blood lead tests between ϯ and ϲ years of age if he or she has not been tested before.
Your child’s WW will take a blood sample by pricking your child’s finger or taking blood from his or her vein. The test will tell if your child has lead in his or her blood.
Vision screening Your child’s WW should check your child’s vision at every well-child visit.
Hearing screening Your child’s WW should check your child’s hearing at every well-child visit.
Dental screening Your child’s WW should check your child’s teeth and gums as part of each well-child visit. Children should start seeing a dentist when they get their first tooth or before their first birthday. Your child should then keep seeing a dentist every six months.
When you or your child misses one of your wellness visits
If you or your child does not get a wellness visit on time:
Set up a visit with the PCP as soon as you can.
Call Member Services if you need help setting up the visit.
If your child has not visited his or her PCP on time, Amerigroup will send you a postcard reminding you to make your child’s wellness appointment.
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SPECIAL KINDS OF HEALTH CARESpecial care for pregnant members Taking Care of Baby and Me® is the Amerigroup program for all pregnant members. It is very important to see your primary care provider (PCP) or OB-GYN for care when you are pregnant. This kind of care is called prenatal care. It can help you have a healthy baby. Prenatal care is always important even if you have already had a baby. With our program, members receive health information and up to $75 in gift cards for getting prenatal and postpartum care.
Our program also helps pregnant members with complicated health care needs. You’ll get a call to complete a pregnancy risk screening. This may be by a live person or from a program called Warm Health. We’ll use your responses to determine your level of risk and provide case management or care coordination support for your specific pregnancy needs. Nurse case managers work closely with these
members to provide:
Education Emotional support Help following the doctor’s care plan Our nurses also work with doctors and help with other services members may need. The goal is to promote better health for members and the delivery of healthy babies.
When you become pregnant
If you think you are pregnant:
Call your PCP or OB-GYN doctor right away. You don’t need a referral from your PCP to see an OB-GYN doctor.
Call Member Services if you need help finding an OB-GYN in the Amerigroup network.
When you find out you’re pregnant, you must also call Amerigroup Member Services.
We’ll send you a pregnancy education package. It’ll include: