«Member Handbook: Integrated Health Services For Physical and Behavioral Health Services Amerigroup Louisiana LA-MHB-0018-16 05.16 1-800-600-4441 (TTY ...»
Claims Amerigroup Louisiana, Inc.
P.O. Box 61010 Virginia Beach, VA 23466-1010 You can also call Member Services for help.
If you have other health insurance (coordination of benefits) Please call Amerigroup Member Services if you or your children have other insurance, including employer-sponsored insurance. Amerigroup will be secondary to that insurance.
Because you already have other insurance, we will not assign you a primary care provider (PCP) from our network. Ask your primary insurance carrier for a WW if you don’t already have one. Kr you can call Member Services to ask for an Amerigroup PCP. See your PCP for all of your routine health care needs and checkups.
Always show your Amerigroup and other health insurance cards when you see a provider, go to the hospital or go for tests. The other insurance plan needs to be billed for your health care services before Amerigroup can be billed. Amerigroup will work with the other insurance plan on payment for these services.
You should also call Amerigroup Member Services right away if you have:
A Worker’s Compensation claim A pending personal injury or medical malpractice law suit Been involved in an auto accident Changes in your Amerigroup coverage Sometimes, Amerigroup may have to change the way we work, your covered services or our network providers and hospitals. DHH may also change the covered services that we arrange for you. We will
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 Louisiana, Inc.
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 suggestions 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 provider may be paid each time he or she treats you (fee-for-service). Or your provider may be paid a set fee each month for each member whether or not the member actually gets services (capitation).
These kinds of pay may include ways to earn more money. This kind of pay is based on different things like how happy a member is with the care or quality of care. It is also based on how easy it is to find and get care.
If you want more details about how our contracted providers or any other providers in our network are
paid, please call the Amerigroup Member Services department or write to us at:
Amerigroup Louisiana, Inc.
P.O. Box 62509 Virginia Beach, VA 23466-2509
YOUR RIGHTS AND RESPONSIILITIES AS AN AMERIGROUP MEMERYour rights
As an Amerigroup member, you have the right to:
Privacy Be sure your medical record is private; be cared for with dignity and without discrimination.
That includes the right to:
62 LA-MHB-0018-16 Updated 05/16 ʹ Be treated fairly and with respect ʹ Know your medical records and discussions with your providers will be kept private and confidential ʹ The right to receive a copy of your medical records (one copy free of charge); the right to request that the records be amended or corrected Take part in making decisions about your health care Consent to or refuse treatment and actively take part in treatment decisions. You can refuse medical service, treatment or diagnoses at any time on religious grounds. In the case of a child, the parent or guardian may refuse treatment for the child.
Receive counseling or referral services that are not covered by Amerigroup
- If you need counseling or referral services that are not covered by Amerigroup due to moral or religious objections, call the Enrollment Broker. For information on how to get these services, call 1-855-229-6848 (TTY 1-855-526-3346).
Receive care without restraint
Not be restrained or secluded if doing so is:
ʹ &or someone else’s convenience ʹ Meant to force you to do something you do not want to do ʹ To get back at you or punish you Have access to health care services Get health care services that are similar in amount and scope to those given under fee-for-service
Medicaid. That includes the right to:
ʹ Get health care services that will achieve the purpose for which the services are given
ʹ Get services that are fitting and are not denied or reduced due to:
Diagnosis Type of illness Medical condition Receive all information in a manner that may be easily understood
Be given information in a manner and format you can understand. That includes:
ʹ Enrollment notices ʹ Information about your health plan rules, including the health care services you can get and how to get them ʹ Treatment options and alternatives, regardless of cost or whether it is part of your covered benefits ʹ A complete description of disenrollment rights at least annually ʹ Notice of any key changes in your benefits package at least 30 days before the effective date of the change ʹ Information on the grievance, appeal and state fair hearing procedures ʹ A list of your member rights and responsibilities You have a right to receive a member welcome packet at least once a year if you need it. The packet will include another copy of the member handbook which may be updated from time to time.
63 LA-MHB-0018-16 Updated 05/16 Get information about the Amerigroup health plan prior to joining Amerigroup Receive information about Healthy Louisiana offered through Amerigroup so that you can make an
informed choice. That includes:
ʹ Basic features of Healthy Louisiana ʹ The populations that may or may not enroll in the program ʹ The responsibility of Amerigroup to arrange care in a timely manner Receive information on Amerigroup services
Receive information on Healthy Louisiana services offered through Amerigroup. That includes:
ʹ Covered benefits ʹ Procedure for getting benefits, including any prior approval requirements ʹ Any copay requirements ʹ Service area ʹ Names, locations and phone numbers of, and non-English languages spoken by current
contracted providers, including, at a minimum:
Primary care providers Specialists Hospitals ʹ Any restriction on your freedom of choice of network providers ʹ Names of providers who are not accepting new patients ʹ Benefits not offered by Amerigroup but that members can obtain and how to get them; this includes how transportation is offered ʹ Service utilization policies Get information on emergency and after-hours coverage
Receive detailed information on this coverage. That includes:
ʹ What constitutes an emergency medical condition, emergency services and post-stabilization services (Post-stabilization care services are Medicaid covered services that you receive after emergency medical care. You get these services to help keep your condition stable.) ʹ Post-stabilization rules ʹ Notice that emergency services do not require prior approval ʹ The process and procedures for getting emergency services ʹ The locations of any emergency settings and other sites where providers and hospitals furnish emergency and post-stabilization covered services ʹ Your right to use any hospital or other setting for emergency care Get the Amerigroup policy on referrals Receive the Amerigroup policy on referrals for specialty care and other benefits not given by your primary care provider (PCP) Get help from DHH and the Enrollment Broker Know the requirements and benefits of the Louisiana Medicaid CCN program Get oral interpretation services
Receive oral interpretation services. That includes the right to:
ʹ Receive these services free of charge for all non-English languages, not just those known to be common ʹ Be told these services are offered and how to access them 64 LA-MHB-0018-16 Updated 05/16 Exercise your rights without adverse effects Exercise your rights without adverse effects on the way Amerigroup, our providers or DHH treats
you. That includes the right to:
ʹ Tell us your complaint or file an appeal about Amerigroup or the care or services you receive from our providers ʹ Make recommendations regarding your rights and responsibilities as an Amerigroup member Your responsibilities
As an Amerigroup member, you have the responsibility to:
Learn about your rights Learn and understand each right you have under the Medicaid program. That includes the
ʹ Ask questions if you do not understand your rights ʹ Learn what choices of health plans are available in your area Learn and follow your health plan and Medicaid rules
Abide by the health plan Medicaid policies and procedures. That includes the responsibility to:
ʹ Carry your ID card at all times when getting health care services ʹ Let your health plan know if your ID card is lost or stolen ʹ Never loan, sell or give your ID card to anyone else ʹ doing so could result in loss of eligibility or legal action ʹ Let your health plan know right away if you have a Worker’s Compensation claim or a pending personal injury or medical malpractice law suit or been involved in an auto accident ʹ Learn and follow your health plan and Medicaid rules ʹ Make any changes in your health plan and PCP in the ways established by Medicaid and by the health plan ʹ Keep scheduled appointments ʹ Cancel appointments in advance when you cannot keep them ʹ Always contact your PCP first for your nonemergency medical needs ʹ Be sure you have approval from your PCP before going to a specialist ʹ Understand when you should and should not go to the emergency room Tell your providers about your health care needs Share information relating to your health status with your PCP and become fully informed about
service and treatment options. That includes the responsibility to:
ʹ Tell your PCP about your health ʹ Talk to your providers about your health care needs and ask questions about the different ways health care problems can be treated ʹ Help your providers get your medical records ʹ Provide your providers with the right information ʹ Follow the prescribed treatment of care recommended by the provider or let the provider know the reasons the treatment cannot be followed as soon as possible Take part in making decisions about your health Actively participate in decisions relating to service and treatment options, make personal choices
and take action to maintain your health. That includes the responsibility to:
ʹ Work as a team with your provider in deciding what health care is best for you ʹ Understand how the things you do can affect your health
Amerigroup provides health coverage to our members on a nondiscriminatory basis, according to state and federal law, regardless of gender, race, age, religion, national origin, physical or mental disability or type of illness or condition.
HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID OR LACHIPPROGRAM If you know someone who is misusing (through fraud, abuse and/or overpayment) the Medicaid or LaCHIP program, you can report him or her.
To report doctors, clinics, hospitals, nursing homes, or Medicaid or LaCHIP enrollees, write or call
Corporate Investigations Department Amerigroup Louisiana, Inc.
P.O. Box 62509 Virginia Beach, VA 23466-2509 1-800-600-4441 If you wish to remain anonymous, you can call the External Compliance Hotline at 1-877-660-7890. Or go to the external reporting website at amerigroup.silentwhistle.com.
Suspicions of fraud and abuse can be emailed directly to the Amerigroup Corporate Investigations department at firstname.lastname@example.org. Or go online at www.myamerigroup.com/LA. Choose your state from the map and click State Programs. Then choose Report Waste, Fraud & Abuse to report details about a possible issue. This information is sent directly to the email address above, which is checked every business day.
You can also call the Louisiana Medicaid Fraud and Abuse Hotline at 1-800-488-2917.
HOW TO REPORT SOMEONE WHO HAS NOT FOLLOWED REQUIRED
DKs in ouisiana must follow certain marketing guidelines. DKs can’t do things such as:
Market directly to a potential member Say anything negative about the other MCOs Help a member enroll in Medicaid If you know someone who has done any of these things, you must report the incident to the Louisiana Medicaid Department of Health and Hospitals (DHH) by completing the DHH Healthy Louisiana Marketing Complaint form.
To request a form, contact DHH at 1-888-342-6207.
We hope this handbook/evidence of coverage has answered most of your questions about Amerigroup. For more information, call the Amerigroup Member Services department at 1-800-600-4441.