Your personal guide to good health
Member Handbook www.amerihealthcaritasia.com
Contact information — List of helpful numbers My AmeriHealth Caritas Iowa ID number (fill in your number): Other family members’ AmeriHealth Caritas Iowa ID numbers:
My primary care provider (PCP)/medical home: My child’s PCP/medical home: My dentist: My child’s dentist: My AmeriHealth Caritas Iowa care manager: My child’s AmeriHealth Caritas Iowa care manager: Iowa Medicaid Enterprise Member Services..................... 1-800-338-8366 Healthy and Well Kids in Iowa (hawk-i) Member Services.................................................................... 1-800-257-8563 Iowa Medicaid Eligibility Line............................................. 1-800-338-8366 Department of Human Services (DHS) customer service center (income maintenance call center):
1-877-347-5678 Local DHS office: Please see the DHS map at http://dhs.iowa.gov/dhs_office_locator
AmeriHealth Caritas Iowa Member Services.................... 1-855-332-2440 Call for: TTY 1-844-214-2471 Available 24 hours a day, 7 days a week. • Behavioral health and substance use disorder services. • Pharmacy services. • Non-emergency transportation services (routine reservations and Where’s My Ride). You can also reach routine reservations at 1-855-346-9760 and Where’s My Ride at 1-855-212-2213. AmeriHealth Caritas Iowa 24-hour Nurse Call Line....... 1-855-216-6065 AmeriHealth Caritas Iowa Fraud, Waste and Abuse Hotline: ................................................... 1-800-831-1394 You can write AmeriHealth Caritas Iowa Member Services at............................................................... AmeriHealth Caritas Iowa P.O. Box 1516 Des Moines, Iowa 50305 Get information from the web! AmeriHealth Caritas Iowa also communicates through our website and member portal. Sign up. Log on. Stay connected at www.amerihealthcaritasia.com. This member handbook is also available in Spanish.
Your personal guide to good health
Member Handbook For questions about your care and services, call: AmeriHealth Caritas Iowa Member Services 1-855-332-2440/TTY 1-844-214-2471 24 hours a day, 7 days a week
Table of contents Welcome to AmeriHealth Caritas Iowa..................................1 About us...................................................................................1
Federally qualified health centers and rural health clinics......................................................................... 23
Our mission.............................................................................1
Home health care................................................................. 23
How we can help you.............................................................1
Behavioral health services.................................................. 23
How you can help us..................................................................2
Covered services................................................................... 24
We need you to help us..........................................................2
Community-based services................................................ 24
Getting information...................................................................3
Other services....................................................................... 26
On the Web..............................................................................3
Finding a behavioral health and/or substance use disorder provider.................................................................. 26
Other languages and formats...............................................3 Getting started............................................................................4 Enrolling...................................................................................4 Completing the new member welcome kit .......................4 Your ID cards...........................................................................4 AmeriHealth Caritas Iowa ID card...................................4 Iowa Department of Human Services (DHS) Medical Assistance Eligibility Card..................................4
DME and medical supplies................................................. 26 Nursing facility services...................................................... 26 Eye care.................................................................................. 27 Eye care benefits for children (younger than age 21)... 27 Eye care benefits for adults (age 21 and older)............ 27 Access to women’s health specialists................................ 28 Family planning services..................................................... 28
Things to know about your ID cards...................................4
Integrated Health Care Management.............................. 28
AmeriHealth Caritas Iowa ID card for hawk-i...................4
Health homes in Medicaid................................................. 28
Example of what your ID cards will look like.................5
Getting care for your family................................................... 31
Benefits, services and limitations.............................................6
If you are pregnant.............................................................. 31
Getting care, staying well................................................... 17
Bright Start program for pregnant members.................. 31
Getting in touch with your PCP........................................ 18
Childbirth classes................................................................. 31
Getting care from specialists.............................................. 19
Postpartum care................................................................... 32
Specialist office visits........................................................... 19
Care for your children......................................................... 32
Out-of-network providers.................................................. 19
AmeriHealth Caritas Iowa’s special programs.................... 33
Out-of-network care for dual eligibles............................. 19
Disease management programs........................................ 33
Chiropractic services........................................................... 19
Breast cancer screening...................................................... 33
Nurse Call Line..................................................................... 19
Quitting tobacco.................................................................. 34
Urgent care............................................................................ 20
Getting care away from home........................................... 34
Transportation..................................................................... 20
Dedication to quality care...................................................... 35
Pharmacy services................................................................ 20
Medically necessary services and benefits........................... 35
Prescriptions ........................................................................ 20
Prior authorization.................................................................. 36
Preferred drug list (list of medicines) ........................... 20
Prior authorization process................................................ 36
Over-the-counter medicines.......................................... 21
Services needing prior authorization............................... 36
Prior authorization for medicine.................................. 21
Getting other benefits and services...................................... 37
Emergency supply ........................................................... 21
Dental services..................................................................... 37
15-day initial supply........................................................ 21
Other insurance and bills....................................................... 37
Copays ............................................................................... 21
If you have other health insurance................................... 37
Participating pharmacies ............................................... 21
If you get a bill or statement.............................................. 37
Emergency services.............................................................. 22
Help with insurance premiums......................................... 37
Follow-up care after an ER visit (post-stabilization care)....................................................... 22
Loss of benefits (disenrollment)............................................ 38
Non-emergency use of the ER (Iowa Health and Wellness and hawk-i members)......................................... 23
Your rights............................................................................. 40
Hospital care......................................................................... 23
Our uses and disclosures.................................................... 41
Your information. Your rights. Our responsibilities.......... 39 Your choices.......................................................................... 41
Table of contents Our responsibilities............................................................. 43
What are long-term services and supports?.................... 53
Changes to the terms of this notice.................................. 43
Long-term services and supports eligibility.................... 53
Advance directives................................................................... 44
Long-term services and supports referrals...................... 53
Notice of action........................................................................ 44
Community-based case management and the role of the case manager...................................... 53
Important Information for You and Your Family Members About the Estate Recovery Program .................................... 45
Changing case managers.................................................... 54
Notice of significant change.................................................. 45
Freedom of choice............................................................... 54
Member grievances/complaints, appeals and state fair hearings.............................................................................. 46
Home- and community-based services............................ 54
Grievance system................................................................. 46
Waiver benefits..................................................................... 57
Grievances............................................................................. 46
Consumer Choices Option................................................ 58
What is a grievance?........................................................ 46
Required service components....................................... 58
Filing a grievance............................................................. 46
Self-directed care............................................................ 59
How do you file a grievance?.......................................... 47
Hiring and training your employee............................. 59
Appeals................................................................................... 47
Supervising your employee........................................... 59
What is an appeal?........................................................... 47 Expedited appeals................................................................ 47
Overseeing your employee’s pay and service notes............................................................. 59
How to file an expedited appeal.................................... 47
If you can’t perform some or all of these duties......... 59
State fair hearing.................................................................. 48
Enrolling in self-directed care....................................... 59
How do you request a state fair hearing?..................... 48
Excluded services............................................................ 60
Continuing benefits during an appeal or state fair hearing............................................................................ 48
Facility-based services.................................................... 60
Eligibility............................................................................... 56
Fraud and abuse....................................................................... 49
When you may have to pay for long-term services and supports.......................................................... 60
Reporting abuse, neglect and exploitation...................... 49
Money Follows the Person (MFP)................................. 60
Special situations..................................................................... 50
Hospice Benefits.................................................................. 61
Continued care..................................................................... 50
Role of the Long-Term Care Ombudsman...................... 61
Changing your PCP............................................................. 51 If your PCP is leaving the AmeriHealth Caritas Iowa network........................................................................ 51 Long-Term Services and Supports........................................ 52
AmeriHealth Caritas Iowa may not cover all of your expenses. Not all services listed in this member handbook are available for all member types. Read your member handbook carefully so you will know which health care services are covered. You have the right to ask for, and get, the information in this member handbook each year.
Welcome to AmeriHealth Caritas Iowa About us AmeriHealth Caritas Iowa is a managed care organization, or health plan, that makes sure you and covered family members get the care that’s right for you. We help you and your family members stay healthy. We work to make sure you and your family are treated with the dignity and respect you deserve. Also, we work to make sure your health care services are provided in a way that is private and confidential. AmeriHealth Caritas Iowa is dedicated to you. Our mission Our mission at AmeriHealth Caritas Iowa is to help people: • Get care. • Stay well. • Build healthy communities. How we can help you The AmeriHealth Caritas Iowa Member Services team is available to help you 24 hours a day, 7 days a week. We can help you with the following questions: • How do I get medical care? • How do I choose my PCP and find a medical home? • How do I get my medical records? • How do I get a list of AmeriHealth Caritas Iowa providers? • What services and benefits are covered? • How do I find out about special needs services? • What do I do if I get a bill? • How do I file a grievance or an appeal? Call us at 1-855-332-2440/TTY 1-844-214-2471 to talk to a Member Services representative 24 hours a day, 7 days a week. Or go to www.amerihealthcaritasia.com. It is important to understand all you can about how your new health plan works. Please keep reading this handbook.
1 | Member Handbook
How you can help us We need you to help us We are committed to you. To support your needs, we need you to help us. Please remember to: • Let the Iowa Medicaid Enterprise (IME), AmeriHealth Caritas Iowa and your health care providers know of any changes that may affect your membership, health care needs or benefits. Some examples include, but are not limited to, the following: ͞͞ You are pregnant. ͞͞ You have a new baby. ͞͞ Your address or phone number changes. ͞͞ You or one of your children has other health insurance. ͞͞ You have a special medical condition. ͞͞ Your family size changes. ͞͞ You move out of the county or state. • To keep your benefits, make sure your information is up-to-date with the Medicaid eligibility, call Iowa Medicaid Enterprise Member Services 1-800-338-8366 or 1-515-256-4606 (if calling from Des Moines). • Work with AmeriHealth Caritas Iowa and our health care providers. This means following the guidelines we give you about AmeriHealth Caritas Iowa and following your health care provider’s instructions about your care. This includes: ͞͞ Making appointments with your health care provider. ͞͞ Canceling appointments when you cannot make your appointment. ͞͞ Calling AmeriHealth Caritas Iowa when you have questions. • Treat your health care providers and their staff with respect and dignity. • Talk with your health care provider to agree on goals for your treatment, to the degree you are able to do so. • Talk with your health care provider so you can understand your health problems, to the degree you are able to do so. If you have any questions about your responsibilities, or for more information, please call Member Services at 1-855-332-2440/TTY 1-844-214-2471. Remember: You must always call Iowa Medicaid Enterprise Member Services at 1-800-338-8366 or 1-515-256-4606 (if calling from Des Moines), or call Healthy and Well Kids in Iowa (hawk-i) Member Services at 1-800-257-8563, to let them know of your changes. Representatives are available Monday through Friday, 8:00 a.m. to 5:00 p.m.
AmeriHealth Caritas Iowa | 2
Getting information On the Web
Other languages and formats
We have made it easy for you to find what you are looking for on our website. Go to www.amerihealthcaritasia.com for the following information:
AmeriHealth Caritas Iowa can provide you written member materials in languages other than English and in other formats for the visually impaired. These materials do not cost you any money. Please call AmeriHealth Caritas Iowa Member Services at 1-855-332-2440/ TTY 1-844-214-2471 to ask for member materials in another language or format.
• Help finding a provider. Search our online provider directory to find a provider near you. • Benefits and services. • Preventive health guidelines and screening recommendations. • Health Insurance Portability and Accountability Act (HIPAA) notice of privacy practices. • Member rights and responsibilities. • Grievances, appeals and fair hearings. • Community services. • Contact information. • Your member portal. If you do not have access to the Internet, most of the information above is included in this handbook. If you have questions, please call Member Services at 1-855-332-2440/ TTY 1-844-214-2471. Our member handbook is available in English and Spanish. To request other formats, call Member Services at 1-855-332-2440/TTY 1-844-214-2471.
3 | Member Handbook
If you do not speak English, we can help you. Our language line service has representatives who speak languages other than English. If your PCP or specialist cannot provide an interpreter for your appointments, AmeriHealth Caritas Iowa will also provide an interpreter to help you. Interpreter services do not cost you any money. Call us at 1-855-332-2440/ TTY 1-844-214-2471 to be connected to the language line for interpreter services. If you are deaf or hard of hearing, our TTY number is 1-844-214-2471. You can also call the Iowa Relay service at 1-800-735-2942.
Getting started It is easy to get care with AmeriHealth Caritas Iowa. Enrolling If you are currently eligible for and receiving Medicaid, the Iowa Medicaid Enterprise will temporarily assign you and your family to a managed care organization. Medicaid Choice Counselors will help if you: • Decide to keep your health plan. • Decide to change health plans. • Have questions about your choice of health plans. You can talk to a Medicaid Choice Counselor by calling Iowa Medicaid Member Services at 1-800-338-8366. In Des Moines, call 1-515-256-4606. Representatives will be available 8:00 a.m. to 5:00 p.m., Monday through Friday. You may select a health plan through the voice system option 24 hours a day, 7 days a week. Also, you may email the Iowa Medicaid Member Services team at
[email protected]. For hawk-i members, you can call hawk-i Member Services at 1-800-257-8563. Representatives will be available 8 a.m. to 6 p.m., Monday through Friday. Completing the new member welcome kit Once you are enrolled in AmeriHealth Caritas Iowa, you will get a welcome kit. The handbook you’re reading is a part of that welcome kit. It contains information about all of your benefits and services. The kit also includes a personal health assessment. Please read and answer each question as best you can. Mail the assessment to us in the self-addressed envelope found in your welcome kit. When we receive your assessment, you’ll receive a $10 reward. When you are enrolled in a health plan, you have 90 days to change plans. You are allowed to change your plan each year. Also, you may change your health plan at any time throughout the year for “good cause.” Please see page 38 for more information on cause and disenrollment.
Your ID cards AmeriHealth Caritas Iowa ID card
After you are enrolled in AmeriHealth Caritas Iowa, you will get an AmeriHealth Caritas Iowa ID card. If you have not received your card, or if you have lost it, please call Member Services for a new card. Your AmeriHealth Caritas Iowa ID card is very important; keep it with you at all times. Iowa Department of Human Services (DHS) Medical Assistance Eligibility Card
You will also get a Medicaid ID card from DHS. If you lose your Medicaid ID card, call Iowa Medicaid Enterprise at 1-800-338-8366. Please keep all cards. If you need help or if you have questions about your cards, call AmeriHealth Caritas Iowa Member Services at 1-855-332-2440/ TTY 1-844-214-2471. Things to know about your ID cards You may need to show your medical insurance cards at every provider and pharmacy visit, including behavioral health appointments. You may need to show your: • AmeriHealth Caritas Iowa ID card. • Medicaid ID card. • Any other health insurance cards you have. It is important to carry all of your cards with you at all times. AmeriHealth Caritas Iowa ID card for hawk-i After you are enrolled in AmeriHealth Caritas Iowa for hawk-i, you will get an AmeriHealth Caritas Iowa ID/hawk-i ID card. If you have not received your card, or if you have lost it, please call Member Services for a new card. Your ID card is very important; keep it with you at all times. You may need to show your medical insurance cards at every provider and pharmacy visit, including behavioral health appointments. If you need help or if you have questions about your cards, call AmeriHealth Caritas Iowa Member Services at 1-855-332-2440/TTY 1-844-214-2471.
AmeriHealth Caritas Iowa | 4
Getting started Example of what your ID card will look like Medicaid PO Box 1516, Des Moines, IA 50305 www.amerihealthcaritasia.com
Member name Doe, John
Primary Care Provider (PCP) PCP Last Name, PCP First Name Group Name
AmeriHealth Caritas Iowa ID 123456789
PCP phone number 1-555-555-1234
Sex: M
*Copayment applies for non-emergent visits to the ER.
Out-of-area care: Report out-of-area care to AmeriHealth Caritas Iowa and your PCP within 48 hours. Mental health, drug, and alcohol services: Call Member Services at 1-855-332-2440.
Effective: 00/00/0000
DOB: MM/DD/YYYY State ID: 1234567890123 Copays ER*
PCP
SPEC
RX(G)
AmeriHealth Caritas Iowa Claims Processing P.O. Box 7113, London, KY 40742
RX(B)
Limits may apply to some services.
Always carry your AmeriHealth Caritas Iowa card. You’ll need it to get your benefits. Go to your AmeriHealth Caritas Iowa Primary Care Provider (PCP) for medical care. Emergency room: Go to an emergency room near you when you believe your medical condition may be an emergency. If you get emergency care, please notify your PCP.
Not transferable.
Member Services and filing grievances 1-855-332-2440 or TTY 1-844-214-2471 Provider Services and prior authorization 1-844-411-0579 Report Medicaid fraud 1-800-831-1394 To speak with a nurse anytime 1-855-216-6065 Pharmacy Member Services 1-855-332-2440 or TTY 1-844-214-2471 Pharmacy RxBIN #600428 Pharmacy RxPCN #07390000 Pharmacy Provider Services: 1-855-328-1612
All other insurance payors must be billed before AmeriHealth Caritas Iowa, payor of last resort.
hawk-i PO Box 1516, Des Moines, IA 50305 www.amerihealthcaritasia.com
Member name Doe, John AmeriHealth Caritas Iowa hawk-i ID 123456789 Sex: M
Primary Care Provider (PCP) PCP Last Name, PCP First Name Group Name PCP phone number 1-555-555-1234 Effective: 00/00/0000
DOB: MM/DD/YYYY State ID: 1234567890123 Copays ER* PCP
SPEC
RX(G)
Limits may apply to some services.
5 | Member Handbook
Always carry your AmeriHealth Caritas Iowa hawk-i card. You’ll need it to get your benefits. Go to your AmeriHealth Caritas Iowa hawk-i Primary Care Provider (PCP) for medical care. Emergency room: Go to an emergency room near you when you believe your medical condition may be an emergency. If you get emergency care, please notify your PCP. *$25 copayment applies for non-emergent visits to the ER. Out-of-area care: Report out-of-area care to AmeriHealth Caritas Iowa hawk-i and your PCP within 48 hours. Mental health, drug, and alcohol services: Call Member Services at 1-855-332-2440. AmeriHealth Caritas Iowa Claims Processing P.O. Box 7113, London, KY 40742
RX(B) Not transferable.
Member Services and filing grievances 1-855-332-2440 or TTY 1-844-214-2471 Provider Services and prior authorization 1-844-411-0579 Report Medicaid fraud 1-800-831-1394 To speak with a nurse anytime 1-855-216-6065 Pharmacy Member Services 1-855-332-2440 or TTY 1-844-214-2471 Pharmacy RxBIN #600428 Pharmacy RxPCN #07390000 Pharmacy Provider Services: 1-855-328-1612
All other insurance payors must be billed before AmeriHealth Caritas Iowa, payor of last resort.
Benefits, services and limitations The Iowa Medicaid Enterprise determines the covered benefits and services you receive. You must use an AmeriHealth Caritas Iowa network provider to get these benefits and services, unless: • The services are emergency services. • The services are family planning services. You have the freedom to choose any family planning provider, including those not in the AmeriHealth Caritas Iowa network. • You get prior authorization (prior approval) to use a provider who is not in AmeriHealth Caritas Iowa’s network. The following is a list of covered benefits, services and limitations. Please call Member Services at 1-855-332-2440/TTY 1-844-214-2417 for complete information.
Services
Medicaid
Iowa Wellness Plan
Family planning
Covered
Covered
Covered
ü 1915(C) home- and community-based services
Must meet level of care.
ü 1915(I) habilitation services
Must meet the needs based criteria.
ü Abortions
Allergy testing and injections
ü
Certain circumstances Certain circumstances must apply. Contact must apply. Contact Member Services. Member Services.
ü
ü ü
Anesthesia
ü
(b)(3) services (intensive psychiatric rehabilitation, community support services, peer support, residential substance use treatment), respite and integrated services and supports.
ü
Bariatric surgery for morbid obesity
ü
Behavioral health intervention services (including applied behavior analysis)
ü ü ü
Breast reconstruction Cardiac rehabilitation
ü
Anesthesia is only covered where indicated and appropriate, for covered Family Planning and Family Planning Related Services only.
Residential treatment not covered.
ü
Following breast cancer Following breast cancer and mastectomy. and mastectomy.
ü
ü AmeriHealth Caritas Iowa | 6
Benefits, services and limitations
Medicaid
Iowa Wellness Plan
Family planning
Covered
Covered
Covered
Certified nurse midwife services
ü
ü
Chemotherapy
ü
ü
Child care medical services
ü
Chiropractic care (limitations apply)
ü
ü
Colorectal cancer screening
ü
ü
Community-based neurobehavioral rehabilitation services
ü
Diabetes equipment and supplies
ü
ü
Diabetic self-management training
ü
ü
ü
ü
Services
Diagnostic genetic testing
Prior authorization needed.
Prior authorization needed.
Dialysis
ü
ü
Durable medical equipment (DME) and supplies (limitations may apply; contact Member Services)
ü
ü
ü
ü
Emergency room (ER) services
Non-emergent visits will be subject to copay.
Non-emergent visits will be subject to copay.
ü
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
ü
EPSDT home care benefit (private duty nursing/personal cares)
ü
ü
ü
ü
Emergency medical transportation
Emergency transportation is subject to review for medical necessity.
Covered for ages 19 – 20.
Emergency transportation is subject to review for medical necessity.
Family planning-related services and supplies Pregnant women and children (value-added) • Bright Start maternity program. • Community baby showers. • 4 Your Kids Care education program.
7 | Member Handbook
ü
ü
ü
Benefits, services and limitations
Services
Foot care (podiatry)
Medicaid
Iowa Wellness Plan
Family planning
Covered
Covered
Covered
ü
ü
Must be related to medical condition of the foot and/or ankle. Routine foot care services are not covered.
ü Genetic counseling
Covered with prior authorization.
Must be related to medical condition of the foot and/or ankle. Routine foot care services are not covered.
ü Covered with prior authorization.
ü Includes an annual women’s health wellness exam in addition to any other medically necessary gynecological exam for a specific medical condition which requires diagnosis and/or treatment.
Gynecological exam
ü
Healthy incentives (value-added) • AmeriHealth Caritas Iowa Visa® Rewards CARE Card.
ü
ü
Healthy resources and services (value-added) • Telehealth and telemonitoring. • Mobile health units. • Healthy Hoops® asthma management program. • Wellness centers.
ü
ü
Health and wellness (value-added) • Weight management program. • Lose to Win program. • Focus on Fitness gym membership. • Family Food program. • Health Empowerment Tour health and wellness program. • Community health fairs.
ü
ü
ü
ü Hearing aids
ü ü
Hearing exams
1 hearing exam per year covered.
Covered for ages 19 – 20. ü 1 hearing exam per year covered. AmeriHealth Caritas Iowa | 8
Benefits, services and limitations
Services HiSET program (value-added) (high school diploma equivalency)
Medicaid
Iowa Wellness Plan
Family planning
Covered
Covered
Covered
ü
ü ü The following limitations apply: Skilled nursing — 5 visits per week
Home health services (skilled nursing, home health aide, physical therapy [PT], occupational therapy [OT], speech-language therapy [ST])
Home health aide — Total visits that do not exceed 28 hours per week.
ü
Physical, occupational and speech therapies — Visits that do not exceed the authorization in a physician approved home health plan of care. Private duty nursing and personal cares are not covered.
Hospice • Daily categories: routine care, facility respite or inpatient hospital. • Hourly category: continuous care (in home). • Nursing facility room and board: 95% of nursing facility.
ü
ü
Immunizations (shots) Vaccines for Children covers shots for children up to age 21.
ü
ü ü
Injections (provider’s office and hospital)
Intermediate care facility for individuals with intellectual disabilities (ICF/ID)
ü
ü
Limited to injections for family planning or family planningrelated purpose.
ü Level of care must be met.
ü Lab tests
9 | Member Handbook
ü
ü
Covered for family planning or family planning-related purpose.
Benefits, services and limitations
Services
Medicaid
Iowa Wellness Plan
Family planning
Covered
Covered
Covered
ü Maternity and pregnancy services
ü
Medical equipment and supplies (value-added) • Free cell phone and service program.
ü
Member is required to report pregnancy and eligibility for consideration of benefits under the Medicaid state plan.
ü ü
Mental/behavioral health inpatient treatment
ü
Residential treatment is not covered.
Mental/behavioral health outpatient treatment
ü
ü
Newborn child coverage
ü
ü
Non-emergency medical transportation
ü
Nursing facility
ü
Organ/bone marrow transplants (with limitations)
ü
ü
Orthotics (some limitations may apply)
ü
ü
Outpatient surgery
ü
ü
ü
ü
Prior authorization is required after 12 visits.
Prior authorization is required after 12 visits.
Outpatient therapy (physical, occupational, speech, cardiac, pulmonary)
ü Oxygen therapy (inhalation therapy)
ü
Limited to 60 visits in a 12-month period.
Pap smears
ü
ü
ü ü
Pathology
ü
ü
Pelvic exams
ü
ü
Covered for family planning or family planning related purpose.
ü AmeriHealth Caritas Iowa | 10
Benefits, services and limitations
Services
Medicaid
Iowa Wellness Plan
Family planning
Covered
Covered
Covered ü
Pharmacy
ü
ü
Prior authorization is required as specified in the preferred drug list. Exclusions may apply.
Prior authorization is required as specified in the preferred drug list. Exclusions may apply.
Prescription drugs, supplies and devices for women's health, treatment of sexually transmitted infections (STIs)/sexually transmitted diseases (STDs) (except AIDS/ HIV and hepatitis).
ü
Physician services (office visits, ER visits, inpatient hospital visits and consultations)
ü
ü
Limited to physician office services only, where that physician is a Family Planning (FP) Waiver provider and where only FP or FP-related services are being provided.
ü Psychiatric medical institutions for children
Must meet the needs-based criteria.
ü ü Preventive services are covered the same as under Medicaid.
Preventive care
ü
Prostate cancer screening
ü
ü
Prosthetics
ü
ü
Radiation therapy
ü
ü
Reconstructive surgery (non-cosmetic)
ü
ü
Second surgical option
ü
ü
STI and STD testing
ü
ü
ü Skilled nursing facility
11 | Member Handbook
Level of care must be met.
ü Limited to 120 days.
Limited to covered family planning and family planning related services, such as Pap smear, pelvic exam, sexually transmitted disease testing and related education.
ü
Benefits, services and limitations
Services Sleep apnea treatment
Medicaid
Iowa Wellness Plan
Family planning
Covered
Covered
Covered
ü
ü ü
Sleep study testing
ü
Treatment for snoring, without a diagnosis of sleep apnea, is not covered. Claims for sleep study testing must be for a diagnosis of sleep apnea.
ü AmeriHealth Caritas Iowa prior authorization is required for this out of state benefit.
Special population nursing facility (skilled pre-approval)
ü
Substance use disorder inpatient treatment
ü
ü
Substance use disorder outpatient treatment
ü
ü
Temporomandibular joint (TMJ) treatment
ü
Tobacco cessation
ü
ü
Urgent care centers/facilities and emergency clinics (non-hospital based)
ü
ü
ü
ü
Vision services
1 visit per year covered. 1 visit per year covered.
ü ü Vision frames and lenses
X-rays (procedures such as magnetic resonance imaging (MRI), computerized axial tomography (CAT) scans and positron emission tomography (PET) scans require prior authorization)
Limitations may apply. Contact Member Services for more information.
ü
Frames and lenses are covered only following cataract surgery. Frames and lenses are covered for individuals between the ages of 19 and 20.
ü
ü
AmeriHealth Caritas Iowa | 12
Benefits, services and limitations
hawk-i Services
Covered
1915(C) home- and community-based services 1915(I) habilitation services
ü Abortions Allergy testing and injections
Certain circumstances must apply. Contact Member Services.
ü
(b)(3) services (intensive psychiatric rehabilitation, community support services, peer support, residential substance use treatment) Bariatric surgery for morbid obesity
ü
Behavioral health intervention services (including applied behavior analysis) Breast reconstruction Certified nurse midwife services
ü
Chemotherapy
ü
Chiropractic care (limitations apply)
ü
Colorectal cancer screening Contraceptives
ü
Diabetes equipment and supplies
ü
Diabetic self-management training
ü
Diagnostic genetic testing
ü
Dialysis
ü
DME and supplies (limitations may apply; contact Member Services)
ü ü
ER services
Emergency services for nonemergent conditions are subject to a $25 copay if the family pays a premium for the hawk-i program.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Emergency medical transportation
ü
Family planning-related services and supplies
ü
Foot care (podiatry)
13 | Member Handbook
ü Limitations may apply.
Benefits, services and limitations
hawk-i Services Genetic counseling
Covered ü Requires prior authorization.
Healthy incentives (value-added) • AmeriHealth Caritas Iowa Visa® Rewards CARE Card.
ü
Healthy resources and services (value-added) • Telehealth and telemonitoring. • Mobile health units. • Healthy Hoops asthma management program. • Wellness centers.
ü
Health and wellness (value-added) • Weight management program. • Lose to Win program. • Focus on Fitness gym membership. • Family Food program. • Health Empowerment Tour health and wellness program. • Community health fairs.
ü
Hearing aids
ü
Hearing exams
ü
HiSET program (value-added) (high school diploma equivalency)
ü
Home health services (home health agency care, including skilled nursing, home health aide and therapies [ PT, OT, ST ] are covered benefits.)
ü
Hospice
ü
Hospital inpatient services • Room and board (semi-private). • Miscellaneous.
ü
Immunizations (shots)
ü
Injections (provider’s office and hospital)
ü
ICF/ID Lab tests
ü
Maternity and pregnancy services
ü
AmeriHealth Caritas Iowa | 14
Benefits, services and limitations
hawk-i Services
Covered
Medical equipment and supplies (value-added) • Free cell phone and service program.
ü
Mental/behavioral health inpatient treatment
ü
Mental/behavioral health outpatient treatment
ü
Newborn child coverage
ü
Non-emergency medical transportation Organ/bone marrow transplants (with limitations) Orthotics (some limitations may apply) Outpatient surgery Outpatient therapy (physical, occupational, speech, cardiac, pulmonary)
Oxygen therapy (inhalation therapy)
ü Prior authorization is required.
ü ü Limitations may apply.
ü Limitations may apply.
Pap smears
ü
Pathology
ü
Pelvic exams
ü
Pharmacy
ü
Provider services (office visits, ER visits, inpatient hospital visits and consultations)
ü
Psychiatric medical institutions for children
ü Preventive care
Routine preventive physical exams, including well-child care and gynecological exams.
Prostate cancer screening Prosthetics
15 | Member Handbook
ü
Benefits, services and limitations
hawk-i Services Radiation therapy
Covered ü ü
Reconstructive surgery (non-cosmetic)
To restore function lost or impaired as the result of illness, injury or a birth defect (even if there is an incidental improvement in physical appearance).
Second surgical option
ü
STI and STD testing
ü
Skilled nursing facility
ü
Sleep apnea treatment
ü
Sleep study testing
ü ü
Special population nursing facility (skilled pre-approval)
AmeriHealth Caritas Iowa prior authorization is required for this out of state benefit.
Substance use disorder inpatient treatment
ü
Substance use disorder outpatient treatment
ü ü
Temporomandibular joint (TMJ) treatment
Services that are medically necessary; osteotomy not covered.
Tobacco cessation Urgent care centers/facilities and emergency clinics (non-hospital based) Vision services
ü ü 1 visit per year covered.
ü Vision frames and lenses X-rays (procedures such as MRIs, CAT scans and PET scans require prior authorization)
Limitations may apply. Contact Member Services for more information.
ü
* The list provided may not show all your covered benefits. For more information, please contact AmeriHealth Caritas Iowa Member Services at 1-855-332-2440/TTY 1-844-214-2471. AmeriHealth Caritas Iowa | 16
Benefits, services and limitations Getting care, staying well When you join AmeriHealth Caritas Iowa, you choose a PCP. Your PCP is the doctor, nurse practitioner or physician assistant you regularly see. Your PCP’s office is your medical home. Your medical home will provide medical services and advice on health matters. Your PCP will also keep other providers you see informed of your medical records and advise whenever these records are needed.
As your medical home provider, your PCP will help you stay healthy. By having regular visits with you, your PCP will be able to: • Learn your health history and keep your records up to date. • Answer questions about your health. • Give you information about healthy eating and diet. • Give you the shots and screenings you need.
If you did not pick a PCP when you enrolled, you will have 10 days from the date you enrolled to pick a PCP. If you do not pick a PCP within 10 days, AmeriHealth Caritas Iowa will assign a PCP for you and your family.
You can choose the same PCP for your whole family or you can have a different PCP for each family member. There are different kinds of practitioners who can be PCPs, including: • Family practice and general practice PCPs, who treat adults and children. • Internal medicine providers, or internists, who treat members older than age 18. • Pediatricians, who treat children from birth to age 21. • Physician assistants. • Nurse practitioners. Some providers have trained health care assistants whom you may see during an appointment, such as: • Medical residents. • Nurse midwives. For questions about changing your PCP, see the section “Changing your PCP” on page 51 of this handbook. You can change your PCP at any time and for any reason. In some cases, if you have health needs that require specialized care, you may be able to choose a specialist as your PCP. For more information, please call Member Services at 1-855-332-2440/ TTY 1-844-214-2471. 17 | Member Handbook
• Help you get care from other providers, if needed. • Find problems before they become serious. • Provide EPSDT services for members 20 years old and younger. See the “Care for your children” section on page 32 for more information. • Provide preventive treatment for conditions like diabetes, high blood pressure, asthma and heart disease. Remember to: üü Make an appointment with your PCP right away — your PCP’s phone number is on your AmeriHealth Caritas Iowa ID card. üü Have your medical records sent from your old PCP to your new PCP, if you have picked a new PCP. üü Get regular checkups.
Benefits, services and limitations Getting in touch with your PCP You can call your PCP for medical problems 24 hours a day, 7 days a week. There is no limit to how many times you can visit your PCP. It is important to be on time for your appointment. If you are going to be late or need to cancel your appointment, call the PCP’s office ahead of time and let the office know. If you need to change your appointment, try to let the PCP’s office know at least 24 hours before the appointment. The Nurse Call Line is there for you 24 hours a day, 7 days a week. Call 1-855-216-6065. Please remember the Nurse Call Line does not take the place of your PCP. Always follow up with your PCP if you have questions about your health care.
It may be time for a checkup if:
You should:
Your child is under 13 years old.
See your child’s PCP regularly for shots and screenings.
You (or your child) are 11 to 20 years old.
See your (or your child’s) PCP once every year.
You are a woman 21 years or older, or are sexually active.
See your gynecologist (GYN) for a Pap test every year, or as directed by your PCP.
You have learned you are pregnant.
See your obstetrician (OB) or OB/GYN right away and make regular appointments. See page 31 for more information.
You are a woman 40 years old or older.
Get your mammogram once every year or as directed by your PCP.
You are a man 50 years old or older.
Talk to your PCP about screenings for prostate cancer.
You are 50 years old or older.
Talk to your PCP about screenings for colon and rectal cancers.
AmeriHealth Caritas Iowa | 18
Benefits, services and limitations Getting care from specialists If you have health needs that require specialized care, your PCP might send you to a specialist. A specialist is a doctor trained to treat certain health problems. Specialists can include: • Heart doctors (cardiologists). • Skin doctors (dermatologists). • Doctors for women’s health (gynecologists). • Doctors for pregnant women (obstetricians). • Doctors for blood problems (hematologists). • Foot doctors (podiatrists). • Eye doctors (ophthalmologists). • Cancer doctors (oncologists). • Behavioral health doctors (psychiatrists). • Surgeons. Your PCP can help you choose a specialist and make an appointment. You can get a list of AmeriHealth Caritas Iowa specialists by going to www.amerihealthcaritasia.com and clicking on “Find a Provider,” or by calling Member Services at 1-855-332-2440/TTY 1-844-214-2471. Specialist office visits AmeriHealth Caritas Iowa covers your visits to specialists in our network. There is no limit to how many times you may see the specialist. If the specialist thinks you need surgery or other special treatment, you can ask to see another specialist. This is called a “second opinion.” If you want a second opinion, ask your PCP for a specialist in a different practice within the AmeriHealth Caritas Iowa network.
AmeriHealth Caritas Iowa network. You can talk to your PCP about this. Out-of-network care for dual eligibles If you are dually eligible for Medicaid and Medicare and receive an order from an out-of-network Medicare provider for services we cover, but Medicare doesn’t, you must use a provider who is in-network. If you have questions about out-of-network providers, please call Member Services at 1-855-332-2440/TTY 1-844-214-2471. Chiropractic services AmeriHealth Caritas Iowa covers chiropractic care. Chiropractic prior authorization will not be required, but there is a limit on the number of visits. Please call Member Services at 1-855-332-2440/ TTY 1-844-214-2471. Nurse Call Line Our Nurse Call Line is a confidential service that you can call 24 hours a day, 7 days a week. Trained nurses can answer questions about your health and give you information when your PCP is not available. They can help you decide which kind of care you need. When you call the toll-free Nurse Call Line, the nurse will: • Ask you questions about your health. • Give you information on how to care for yourself at home, when appropriate. • Give you information to help you decide what other care you need.
Out-of-network providers
The Nurse Call Line has an audio library where you can listen to information about health topics.
Visits to providers who are not in the AmeriHealth Caritas Iowa network will need prior authorization from AmeriHealth Caritas Iowa. Your provider will help you get prior authorization. Please see the “Prior Authorization” section on page 36 for more information.
The Nurse Call Line is available 24 hours a day, 7 days a week. Call 1-855-216-6065. Please remember that the Nurse Call Line does not take the place of your PCP. Always follow up with your PCP if you have questions about your health care.
If AmeriHealth Caritas Iowa does not have a provider who can treat your health problem, you have the right to ask to see a provider who is not in the 19 | Member Handbook
Benefits, services and limitations Urgent care Urgent care is for conditions that are serious, but are not emergencies. This is when you need immediate attention from a provider, but not in the ER. If you need urgent care but are not sure if it is an emergency, call your PCP first. If you cannot reach your PCP, call the AmeriHealth Caritas Iowa Nurse Call Line. Your PCP or the nurse will help you decide if you need to go to the ER, the PCP’s office or to an urgent care center near you. If you go to an urgent care center or the ER, be sure to call your PCP the next day to make an appointment. Your PCP must schedule an appointment for you within 2 calendar days of your request for an urgent care appointment. Examples of urgent care conditions: • Coughing. • Colds. • Vomiting. • Pink eye.
• You will need to know the street address, city and ZIP code for the location of your appointment. • You must have your Medicaid ID number when you call to schedule your ride. • Medicaid members who are eligible for full Medicaid benefits and need transportation services so that they can receive Medicaidcovered services from providers enrolled with the AmeriHealth Caritas Iowa program may obtain transportation services Pharmacy services AmeriHealth Caritas Iowa members are eligible for pharmacy benefits. If you need medicine, your provider will write you a prescription to take to a participating pharmacy. You will find a list of participating pharmacies on our website at www.amerihealthcaritasia.com. If you can’t find your regular pharmacy on this list, you can call Pharmacy Member Services at 1-855-332-2440/ TTY 1-844-214-2471 for more information on pharmacies in our network.
• Diarrhea.
Prescriptions
• Stomachache.
Your provider will write a prescription for medicine to be filled by your pharmacist.
• Earache. • Rashes. • Sore throat. • Lacerations.
AmeriHealth Caritas Iowa covers medicines that are: • Medically necessary. • Approved by the Food and Drug Administration (FDA). • Prescribed by a provider.
Transportation
Preferred drug list (list of medicines)
If you have an emergency, please call 911 right away.
Your preferred drug list is the list of medicines AmeriHealth Caritas Iowa covers. This list helps your health care provider prescribe medicines for you. Brand-name and generic medicines are on the preferred drug list. If a certain medicine is nonpreferred on the preferred drug list or requires a prior authorization, your doctor may ask for it through AmeriHealth Caritas Iowa’s prior authorization process. For the preferred drug list, go to our website at www.amerihealthcaritasia.com. Please call Pharmacy Member Services at 1-855-332-2440/TTY 1-844-214-2471 to see what medicines are covered.
For non-emergency medical transportation, call our reservation line at 1-855-346-9760. You can check the status of your ride by calling 1-855-212-2213. Please remember: • You must call at least 2 business days before your appointment to schedule your ride. You can schedule as early as 30 days before your appointment.
AmeriHealth Caritas Iowa | 20
Benefits, services and limitations Over-the-counter medicines
Some generic over-the-counter medicines are covered by AmeriHealth Caritas Iowa. You must have a prescription from a health care provider for your over-the-counter medicine. Some examples of over-the-counter medicines covered by AmeriHealth Caritas Iowa are:
Copays
Health and Wellness $0.00
• Sinus and allergy medicines.
Maintenance prescriptions
• Pain medicine, such as acetaminophen or ibuprofen.
$0.00
Some medicines on the AmeriHealth Caritas Iowa preferred drug list and all medicines not on the AmeriHealth Caritas Iowa preferred drug list require prior authorization by AmeriHealth Caritas Iowa. If your provider writes a prescription for a medicine that requires prior authorization, your provider will need to send us a prior authorization request form. We will review it and let your provider know our decision. AmeriHealth Caritas Iowa will cover the medicine if it is medically necessary. If it is not medically necessary, we will send you a letter that will tell you why. The letter will explain how to make an appeal if you want to do so. Emergency supply
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Generic prescriptions $0.00
Prior authorization for medicine
hawk-i
Brand-name prescriptions
• Cough and cold medicines.
• Nicotine replacement products for smoking cessation.
Medicaid
There will be no prescription copay for members who are: • Under age 21. • Receiving family planning benefits. • Pregnant. • Receiving care or residing in an institution. ͞͞ Inpatient hospital. ͞͞ Skilled nursing facility. ͞͞ ICF. ͞͞ ICF/ID. ͞͞ State mental health institutes — except transferred resources. • American Indians (AI) and Alaska Natives (AN) who have received a service in an Indian Health Services (IHS) facility or clinic.
If your medicine requires prior authorization and you need to start it right away, your pharmacy can give you a one-time three-day emergency supply. Exclusions to the three day supply may apply.
Show your AmeriHealth Caritas Iowa member ID card when you get your prescriptions. If you have questions, call Pharmacy Member Services at 1-855-332-2440/ TTY 1-844-214-2471.
15-day initial supply
Participating pharmacies
Not all medicines work the same for everyone. To reduce waste, you may only get a 15-day supply of some medicines. This will help you and your provider make sure the medicine works for you. If it does, you may get up to a 31-day supply on your refills.
You can get pharmacy services at any participating AmeriHealth Caritas Iowa pharmacy. If you need a list of participating AmeriHealth Caritas Iowa pharmacies, call Pharmacy Member Services at 1-855-332-2440/TTY 1-844-214-2471. You can also go to our website at www.amerihealthcaritasia.com. Go to Pharmacy and then to Find a Pharmacy. Pharmacy Member Services
If you have questions, please call Pharmacy Member Services at 1-855-332-2440. TTY users, please call 1-844-214-2471. 21 | Member Handbook
Benefits, services and limitations Emergency services
Follow-up care after an ER visit
An emergency is a serious or life-threatening condition that: • Requires immediate medical care. • Places the health of the person at risk. • Causes serious harm to the body and its functions.
(post-stabilization care)
If you have an emergency, call 911 for an ambulance or go directly to the nearest hospital ER. If you need care, but are not sure if it is an emergency, call your PCP or behavioral health specialist first. If you cannot reach your PCP, call the AmeriHealth Caritas Iowa Nurse Call Line at 1-855-216-6065. Your PCP or the nurse will help you find the best care available for you at that time.
After an emergency, you may need care to help your medical issue get better or go away. This is called post-stabilization care. Post-stabilization services are covered services related to an emergency medical condition. They are provided after your immediate medical or behavioral health problems are stabilized. AmeriHealth Caritas Iowa requires pre-approval for post-stabilization care you get in or out of network. We will cover the post-stabilization care you receive within the first hour of the hospital submitting the pre-approval request. AmeriHealth Caritas Iowa will also cover post-stabilization care if your hospital requests pre-approval and AmeriHealth Caritas Iowa:
Emergency services are those (inpatient and outpatient) you receive from a qualified provider to evaluate or stabilize an emergency medical condition.
• Doesn’t provide pre-approval within an hour of the request.
You do not need approval from AmeriHealth Caritas Iowa to receive care in an emergency. You have the right to get the care you need. You also have the right to say no to treatment and to ask for, or say no to, a transfer to another hospital. The care you get during and after an emergency is meant to improve your medical issue or to make it go away.
• Can’t reach an agreement with your treating provider about your care, and a provider in the AmeriHealth Caritas Iowa network is not available.
Examples of emergencies: • • • • • • • • • •
Chest pain. Choking. Severe wound or heavy bleeding. Breathing problems. Severe spasms/convulsions. Loss of speech. Broken bones. Severe burns. Drug overdose. Sudden loss of feeling or not being able to move. • Severe dizzy spells, fainting or blackout.
• Can’t be contacted.
AmeriHealth Caritas Iowa’s coverage of unapproved post-stabilization care will end when: • A provider in the AmeriHealth Caritas Iowa network, with privileges at the treating hospital, assumes responsibility for your care. • A provider in the AmeriHealth Caritas Iowa network assumes responsibility for your care through transfer. • AmeriHealth Caritas Iowa and your treating provider reach an agreement about your care. • You are discharged. You don’t have to pay for emergency care even if you go to a facility that’s not in the AmeriHealth Caritas Iowa network. To find a hospital near you, log on to our online provider directory at www.amerihealthcaritasia.com or call Member Services at 1-855-332-2440/TTY 1-844-214-2471.
AmeriHealth Caritas Iowa | 22
Benefits, services and limitations Non-emergency use of the ER
Federally qualified health centers
(Iowa Health and Wellness and
and rural health clinics
hawk-i members)
AmeriHealth Caritas Iowa covers care at federally qualified health centers (FQHCs) and rural health clinics (RHCs) that are in the AmeriHealth Caritas Iowa network. Please see our online provider directory at www.amerihealthcaritasia.com or call Member Services to find a center near you.
If you’re an Iowa Health and Wellness or hawk-i member and you get care in the ER for a condition that is not considered an emergency, you will be charged a copay. The copay is $8 for Health and Wellness members and $25 for hawk-i members. Before charging you the copay, the hospital is required to do the following: • Conduct a medical screening to determine that you don’t need emergency care. • Tell you how much you’re required to pay to receive non-emergency care in the ER. • Provide you with the name and location of a nearby non-emergency care provider. • Determine if the non-emergency provider can address your needs in a timely manner. • Provide a referral to the non-emergency provider. If you’re subject to the copay and can’t pay it, tell the hospital. They cannot refuse to give you care. If they do, call Member Services at 1-855-332-2440/ TTY 1-844-214-2471. Call your PCP to make an appointment for care after your emergency. Do not go back to the ER where you were treated unless your PCP tells you to do so. Hospital care AmeriHealth Caritas Iowa covers medically necessary hospital services, including outpatient services like X-rays and laboratory tests, when they are medically necessary. Your PCP or specialist can help you get hospital services in the AmeriHealth Caritas Iowa network. Go to www.amerihealthcaritasia.com or call Member Services to find out if a particular hospital is in the AmeriHealth Caritas Iowa network.
23 | Member Handbook
Home health care If your PCP or specialist thinks you need care at home, he or she will ask that a home health agency provide an assessment and write a home health plan of care (POC) for you that your PCP or specialist will sign. The POC will list what home health services you will need and how often. PLEASE NOTE: Private duty nursing and personal cares are NOT included under the home health care benefit. These services are covered under the EPSDT authority for children up to 21. Private duty nursing and personal cares both need prior authorization. Your PCP or specialist will ask AmeriHealth Caritas Iowa for prior authorization before you get the service. Behavioral health services AmeriHealth Caritas Iowa works with behavioral health and substance use disorder providers and community resources. This is to help provide you the best care using proven methods. When you see “behavioral health,” think mental health and substance use disorders. AmeriHealth Caritas Iowa members who think they need behavioral health or substance use disorder services can talk to their PCPs — that’s the best place to start. Members can tell their PCPs how they are feeling and ask about behavioral health providers who can help. Members can also find behavioral health and substance use disorder providers by calling Member Services at 1-855-332-2440. For TTY, call 1-844-214-2471. Or visit our website at www.amerihealthcaritasia.com.
Benefits, services and limitations Below are lists of services covered under your Iowa Medicaid plan. Please keep in mind the covered services have to be medically necessary (needed to improve your health) for AmeriHealth Caritas Iowa to pay for them. Covered services Below are descriptions of behavioral health services that AmeriHealth Caritas Iowa covers for the IA Health Link program. Behavioral health services help members with difficulties with mental illness, drug use or alcohol use (substance use disorder/addictive disorders/drug and alcohol use disorders). Your mental health and substance use disorder benefits and services depend on your age and the Medicaid plan you are in. The services described below are part of the AmeriHealth Caritas Iowa behavioral health program. Addiction services — These services help members deal with challenges due to drug and alcohol use. These services may or may not be done in a hospital and are designed to help members stop using alcohol and/or drugs. If members use these services, they may or may not stay at the program overnight. Behavioral health outpatient services — These services are planned, regularly scheduled visits to a provider, counselor or therapist to talk about your behavioral health issues. These can include individual, family and group therapy, as well as psychological and/or neuropsychological testing. Inpatient hospitalization for mental health and substance use disorders — These services are the most intensive services available. Hospitalization usually occurs when you are at risk of harming yourself or others, when you are experiencing a behavioral health crisis, when medications need close and continual checking, or when other services tried in the community have not helped to solve the problems that brought you in for service.
Psychiatric medical institute for children — This service provides long-term behavioral health and substance use disorder care in a 24-hour group living facility for members under the age of 21. Community-based services Clearly focused services provided in the community. Assertive community treatment (ACT) — This service is provided for adults with serious mental illness. A team of providers will work with the members where they live. Services can include counseling, substance use disorder therapy, housing assistance and medication management. Autism services — · Applied behavioral analysis (ABA). · Family counseling and behavior management. · Parent training. · Physical/speech/occupational therapy. Behavioral health intervention services (BHIS) — Members ages 18 and above can get training to learn new skills. Members ages 20 and younger can get help with health, behavior and family issues, as well as for crisis situations. The services help to improve or even stop behaviors caused by the members’ behavioral health issues, so the members can function as well as possible in the community. The idea is to improve the members’ health and wellbeing using mental, behavioral or social interventions designed to meet the members’ specific needs. Community support services — Provided by a community support service provider accredited by the state of Iowa. These services help members live and work in their community. They are designed to help members better manage symptoms that keep them from functioning as best they can. These services include checking mental health symptoms and providing transportation. The idea is to offer a supportive relationship to the member.
AmeriHealth Caritas Iowa | 24
Benefits, services and limitations Crisis intervention/stabilization — Services you can use any time of day or night to help you when you are in a crisis. This is to assist members in a crisis to help you not go to an ER or a hospital. Our goal is to include the family in all of the member’s ongoing behavioral health needs during this time. Transportation is available for eligible members. If you are in a crisis, call Member Services at 1-855-332-2440/TTY 1-844-214-2471. Habilitation services — A program to provide homeand community-based services (HCBS) for Iowans with the functional injuries usually related to chronic mental illnesses. The federal Deficit Reduction Act of 2005 allowed states to offer HCBS as a state plan option effective January 1, 2007. Using this option, the Department worked with the Centers for Medicare & Medicaid Services to design a program to meet the service needs of Iowans with the functional limitations usually related to chronic mental illness. Habilitation services are designed to assist participants in getting, keeping and improving the self-help, socialization and adaptive skills necessary to live successfully in home and communitybased settings. Services available include: • Home-based habilitation Services provided in the person’s home and community. Typical examples would be help with medication management, budgeting, grocery shopping, personal hygiene skills, etc. • Day habilitation Services that are usually provided in a day program setting outside the home. Focuses on areas such as social skills, communication skills, behavior management, etc. • Prevocational services Can be provided in a variety of settings, and focus on developing generalized skills that prepare a person for employment. Typical examples include attendance, safety skills, following directions and staying on task.
25 | Member Handbook
• Supported employment Assists in getting and keeping a job in the community. Assists in placing the individual in a job in a regular work setting with persons without disabilities at minimum wage or higher, and provides support to maintain the job. Typical examples include skills assessments, consultation with the employer, job coaching and behavior management. Home- and community-based services Provides members who are older or have disabilities with individualized benefits that allow them to live in their own home or community who would otherwise require care in a nursing facility or other institution. This gives you more choices about how and where you receive services. These services may allow you to stay in your home. You must be eligible for Medicaid and also meet the requirements for the waiver you are applying for and/or receiving. You will need to meet certain requirements that show you are in need of nursing facility, skilled nursing facility or hospital care or care in an intermediate care facility for individuals with intellectual disabilities. Intensive psychiatric rehabilitation (IPR) — This service is for members that live within the community and is designed to help you achieve your goals and be able to continue to work and live in your community with family and friends. Members receive assistance in day-to-day life skills and related goals. Peer support services (PSS) — Provided by a peer support specialist (PSS). The PSS helps the member in the home or community and speaks up for the member’s needs. The PSS provides support for the member during emergency, outpatient and inpatient care. The PSS can also help the member transition from a 24-hour level of care.
Benefits, services and limitations Other services There are other services and community supports that may be available through the county or department of public health programs in your area. AmeriHealth Caritas Iowa can help you to access those services and we can help explore any costs that may apply to you. We can help you find possible ways of covering those costs. AmeriHealth Caritas Iowa staff works with other agencies, such as your PCP and other state organizations and agencies, to help organize your treatment and support. For more information, contact Member Services at 1-855-332-2440. For TTY, call 1-844-214-2471. Finding a behavioral health and/or substance use disorder provider If you need to find a behavioral health provider, you can go to www.amerihealthcaritasia.com and click on Find a Provider. This will take you to the online provider directory where you can find a list of all providers in the AmeriHealth Caritas Iowa network. Go to the behavioral health section for this list. You can also call Member Services at 1-855-332-2440/ TTY 1-844-214-2471 if you would like to receive a paper copy of the provider directory at no cost, or they can help you find a provider over the phone. DME and medical supplies Members living in or getting services from a licensed health care facility may choose to get certain DME from the provider. In some cases the equipment may be provided by the provider to the member during the inpatient stay. Or, it may be provided on a permanent basis. The equipment provided must be medically necessary and may require prior authorization. Your provider will help you get needed DME. For more information, members may contact Member Services at 1-855-332-2440/TTY 1-844-214-2471.
This does not include: • Personal care items (such as deodorant, talcum powder, bath powder, soap, toothpaste, eye wash or contact solution). • Oral or injectable over-the-counter drugs and medicines. DME is generally an item and/or device that: • Can be used again and again. • Is primarily used for a medical purpose. • Is used in the home. Some examples of DME are oxygen tanks, special medical beds, walkers and wheelchairs. Examples of supplies are diapers, catheters and diabetes testing supplies. Some DME will need prior authorization. Your PCP or specialist will ask AmeriHealth Caritas Iowa for prior authorization before you get the DME. Please see the “Prior Authorization” section on page 36 of this handbook for more information. Please call the Rapid Response and Outreach Team for assistance at 1-855-332-2440/TTY 1-844-214-2471. Nursing facility services AmeriHealth Caritas Iowa covers short-term skilled care in a nursing facility when the plan is for the member to return home. This type of care needs prior authorization by AmeriHealth Caritas Iowa. Your PCP or specialist will ask for prior authorization for you before you go to the nursing facility. AmeriHealth Caritas Iowa covers long-term care in a nursing facility when DHS confirms that a member qualifies for that level of care. We also cover longterm care in a nursing facility when DHS determines that institutional services are best for meeting the needs of a member. See “Long-Term Services and Supports” starting on page 52 for more details.
Medical supplies are generally:
• Disposable. • Required for care of a medical condition. • Used at home.
AmeriHealth Caritas Iowa | 26
Benefits, services and limitations Eye care Eye care benefits for children (younger than age 21)
Children are eligible for routine eye exams 1 time every 12 months. They are also eligible for unlimited replacements for glasses that are lost or damaged. Safety frames are allowed for children through age 7. Call your/your child’s eye doctor to schedule a routine eye exam. Additional child eye care benefits are listed below: Age
Up to 1 year old
1 to 3 year old
4 to 7 year old
8 years and older
Benefits
Frequency
Frame services
3 times each year
Single vision multi-focal lens
Up to 3 times each year
Contact lens (gas permeable)
Up to 16 lenses
Frame services
4 times each year
Single vision multi-focal lens
Up to 4 times each year
Contact lens (gas permeable)
Up to 8 lenses every 12 months
Frame services
1 frame every 12 months
Single vision multi-focal lens
1 time every 12 months
Contact lens (gas permeable)
Up to 6 lenses every 12 months
Frame services
1 frame every 24 months
Single vision multi-focal lens
1 time every 24 months
Contact lens (gas permeable)
2 lenses every 24 months
Eye care benefits for adults (age 21 and older)
Adults are eligible for routine eye exams once every 12 months. They are also eligible for replacement glasses once every 12 months for those that are lost or damaged beyond repair.
27 | Member Handbook
Benefits, services and limitations Access to women’s health specialists Female members can access care from any women’s health provider within the AmeriHealth Caritas Iowa network for: • Routine GYN care, such as physical, breast and pelvic exams; Pap smears; and education. • Preventive health services. • GYN problems for diagnosis, evaluation, treatment and follow-up care. • Maternity care, including all visits. Family planning services You can go to any AmeriHealth Caritas Iowa or Medicaid provider or clinic you choose for family planning services. You can choose providers and clinics not in the AmeriHealth Caritas Iowa network. You do not need a referral from your PCP for routine family planning services. Please call Member Services at 1-855-332-2440/TTY 1-844-214-2471, with any questions. Integrated Health Care Management Our care managers can help you to manage your physical and/or behavioral health care needs. Here are some things that we can help you with: • Getting to your medical and/or behavioral health appointments. • Getting the medical and/or behavioral health support services you need. • Learning more about your health conditions. • Getting the medicine your provider has ordered for you. • Finding helpful resources. If you have any questions about the Integrated Health Care Management program, please contact AmeriHealth Caritas Iowa Member Services at 1-855-332-2440/TTY 1-844-214-2471 and ask to speak with the Rapid Response and Outreach Team. Health homes in Medicaid A health home is a team of professionals working together to provide members with care that is: • Patient-centered. We partner with you, providers and your family to ensure your needs are met and that you have the support you need to make decisions about your own care. • Comprehensive. We work with providers who focus on your physical and mental health care needs, including prevention and wellness, as well as acute and chronic care. • Coordinated. We organize your care across the health care system, including specialty care, hospitals, home health care and community services and supports.
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Benefits, services and limitations • Accessible. We work with you to access services with shorter waiting times, “after hours” care, and 24/7 electronic or telephone access. • Committed to quality and safety. We are committed to constant improvement by using the latest technology and tools to make sure you can make informed decisions about your health. Chronic condition health homes AmeriHealth Caritas Iowa will identify eligible members for enrollment into a chronic condition health home if they have: • Two or more chronic conditions from the list below: ͞͞ Mental health condition. ͞͞ Substance use disorder. ͞͞ Asthma. ͞͞ Diabetes. ͞͞ Heart disease. ͞͞ Body mass index (BMI) over 25. ͞͞ Hypertension. ͞͞ BMI over 85th percentile for pediatric (child) population. or • One chronic condition and the risk of developing another from the list below: ͞͞ ͞͞ ͞͞ ͞͞ ͞͞ ͞͞ ͞͞ ͞͞
Mental health condition. Substance use disorder. Asthma. Diabetes. Heart disease. BMI over 25. Hypertension. BMI over 85th percentile for pediatric (child) population.
If you are an eligible member, you may agree to opt in or participate in the chronic condition health home after talking with a provider in a health home practice about the benefits of doing so. If you agree to participate, you have a free choice of chronic condition health home providers. AmeriHealth Caritas Iowa and the Iowa Medicaid Enterprise may also enroll members in a health home. Affected members will have the option to opt out at any time.
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Benefits, services and limitations Integrated health home (IHH) An integrated health home (IHH) is a team of professionals working together to provide whole-person, patient-centered, coordinated care for adults with a serious mental illness (SMI) and children with a serious emotional disturbance (SED). AmeriHealth Caritas Iowa will identify eligible members for enrollment and will offer integrated health home services to: • Adult members with a SMI. SMI includes a diagnosis of: ͞͞ Schizophrenia. ͞͞ Schizoaffective disorder. ͞͞ Bipolar disorder. ͞͞ Major depression. ͞͞ Psychotic disorders. ͞͞ Delusional disorder. ͞͞ Obsessive-compulsive disorder. ͞͞ Other serious mental health conditions that cause significant impairment in daily functioning. • Child members with a SED. SED includes a diagnosable mental, behavioral or emotional disorder of sufficient duration to meet diagnostic criteria specified in the most current Diagnostic and Statistical Manual of Mental Disorders (DSM) that results in a functional impairment. SED may co-occur with substance use disorders, learning disorders, or intellectual disorders that may be a focus of clinical attention. If you are an eligible member or guardian, you may agree to opt in or participate in an IHH after talking with a provider in an IHH practice about the benefits of doing so. Members enrolled in the Children’s Mental Health Waiver must be enrolled in an IHH. Members enrolled in Habilitation must be enrolled in an IHH unless they are also enrolled in a waiver. A community-based case manager will coordinate services for members enrolled in both Habilitation and a waiver. If you agree to participate, you have a free choice of IHH providers. AmeriHealth Caritas Iowa and the Iowa Medicaid Enterprise may also enroll members in an Integrated Health Home. Affected members will have the option to opt out at any time. For more information on health homes, call Member Services at 1-855-332-2440/TTY 1-844-214-2471.
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Getting care for your family If you are pregnant
Bright Start program
It is important to see your provider regularly while you are pregnant and to keep all your appointments. This will help you and your baby stay healthy. Your provider must schedule an appointment for you within a certain number of days from when he or she learns you are pregnant. Your appointment must be made within:
for pregnant members
• 14 working days when you are in your first 3 months of pregnancy (first trimester). • 7 working days when you are in your second 3 months of pregnancy (second trimester). • 3 working days when you are in your last 3 months of pregnancy (third trimester). In an emergency, call 911 or go to the nearest ER.
The Bright Start program helps you stay healthy when you are pregnant and also helps you have a healthy baby. The Bright Start program gives you information about the importance of: • Eating right. • Taking your prenatal vitamins. • Receiving medical care in a timely manner. • Staying away from drugs, alcohol and smoking. • Visiting your dentist so you can keep your gums healthy. AmeriHealth Caritas Iowa will work with your providers to make sure you get the care you need. AmeriHealth Caritas Iowa also has information to help with other services, like:
It is important to stay with the same health insurance company while you are pregnant.
• Food and clothes.
If you are pregnant, remember to:
• The Women, Infants, and Children (WIC) program.
• Transportation.
• Call Iowa Medicaid Enterprise at 1-800-338-8366 to update your information.
• Domestic abuse.
• Make an appointment with your provider and be sure to keep all your appointments while you are pregnant.
• Home care.
• Make an appointment with your dentist. • If you smoke, quit. • Choose a PCP for your baby before your baby is born. • Join our Bright Start program by calling 1-855-332-2440/TTY 1-844-214-2471.
• Breast-feeding. • Helping you understand your emotions. Call Bright Start for more information toll free at 1-855-332-2440/TTY 1-844-214-2471. Care managers are available to answer questions, provide educational materials and work with you during your pregnancy. You can access health and wellness advice from a nurse 24 hours a day, 7 days a week. Childbirth classes AmeriHealth Caritas Iowa offers birthing classes to all pregnant members. There are no limits to the number of classes you attend. Please call Bright Start at 1-855-332-2440/TTY 1-844-214-2471 for more information and to find a class near you.
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Getting care for your family Postpartum care
Care for your children
Postpartum is the time just after you have had your baby. During this time:
AmeriHealth Caritas Iowa helps make sure your children get the medical care they need to prevent and find out about childhood diseases and illnesses early. Our Medicaid members under 21 years old will receive EPSDT services. Our hawk-i members age 19 and under will receive care through Healthy and Well Kids of Iowa.
• Call your OB or PCP to make an appointment for your postpartum checkup. Try to get an appointment for 4 to 6 weeks after your baby is born, unless your provider wants to see you sooner. • Call Iowa Medicaid Enterprise at 1-800-338-8366 or hawk-i Member Services at 1-800-257-8563. Tell them about your new baby. This is very important. They will make sure you get the benefits and services your baby needs. • Call the baby’s provider to make an appointment for your baby. Your baby should see the provider at 2 to 4 weeks of age, unless the provider wants to see your baby sooner. Do you have the “baby blues?” Sometimes women feel down or sad after having a baby. This is normal. Please ask yourself these 2 questions: üü During the past month, have I often felt down, depressed or hopeless? üü During the past month, have I often had little interest or pleasure in doing things? If you answer “yes” to one or both of these questions, please call our Bright Start program toll free at 1-855-332-2440/TTY 1-844-214-2471. We can help you.
Your child can see a pediatrician, a family practice provider, a nurse practitioner or a physician assistant. The provider you choose for your child will be your child’s PCP. To keep your children healthy, you need to make regular appointments with your child’s PCP. These are called well-child visits and they are important at every age. They are different from visits to the PCP when your child is sick. At a well-child visit, the PCP will examine your child. What the PCP does during the exam depends on the age of your child. The PCP will ask questions, order tests and check your child’s growth based on your child’s age. If you have questions or want to find out more about this program, call Member Services at 1-855-332-2440/TTY 1-844-214-2471. My “to do” list: üü Make an appointment for my baby’s first PCP visit. üü Have my child see the PCP for his or her shots and screenings. üü Make sure my teenager sees the PCP every year for a checkup. üü Make appointments for the whole family to see the dentist every 6 months. üü Have my child’s eyes checked. üü Get my checkup so I can stay healthy for my children!
* Not all services are available for all member types. AmeriHealth Caritas Iowa | 32
AmeriHealth Caritas Iowa’s special programs Disease management programs AmeriHealth Caritas Iowa offers disease management programs for members. You can get help managing your chronic conditions such as asthma, diabetes, chronic obstructive pulmonary disease (COPD), heart disease, high blood pressure and obesity, as well as behavioral health conditions such as depression, autism, attention-deficit hyperactivity disorder (ADHD) and bipolar disorder. AmeriHealth Caritas Iowa’s disease management programs can help you make a plan to improve your health. You will learn how to: • Self-manage your condition. • Take your medications. • Eat well. • Exercise. • Stay healthy. For more information, call 1-855-332-2440/ TTY 1-844-214-2471. AmeriHealth Caritas Iowa has special programs to help you stay healthy. You do not need a referral from your PCP to be in any of these programs. If you have one of the health care conditions listed below, you could become a part of one of our special programs. • Asthma. • COPD. • Diabetes. • Heart disease, including high blood pressure. • Obesity. • Depression. • Autism. These programs can help you better understand your condition. A care manager helps coordinate your health care and then sends information to you about your condition. If you have extra needs, your care manager will work with you and your PCP. You will set personal goals and work to improve your health and quality of life.
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If you have any questions about our special programs, or you do not want to be a part of these programs, call the Care Coordination program at 1-855-332-2440/TTY 1-844-214-2471 or write to: Care Coordination Program AmeriHealth Caritas Iowa P.O. Box 7135 London, KY 40742 Breast cancer screening AmeriHealth Caritas Iowa encourages women to do a breast self-exam every month. We also want you to get a mammogram every year after age 40. Your PCP may want you to get a mammogram earlier. You do not need a referral from your provider to get a mammogram, but you do need a prescription from your provider. Talk to your provider. A mammogram is an X-ray of your breasts. A mammogram and monthly self-exams can find breast cancer early. A mammogram can show a lump before you or your provider can feel it. Breast cancer found early is easier to treat, and this can save your life. Make sure you: • Talk to your provider about when to get your mammogram. • Talk to your provider or call Member Services at 1-855-332-2440/TTY 1-844-214-2471 about where to get your mammogram. • Get a prescription from your provider to have your mammogram. You do not need a referral from your provider or prior authorization to get a mammogram.
AmeriHealth Caritas Iowa’s special programs Quitting tobacco AmeriHealth Caritas Iowa can help you quit smoking cigarettes and using any other tobacco products, like cigars, pipes and chewing tobacco. If you smoke or if you are affected by someone who smokes, we can help support you. Call the Rapid Response and Outreach Team at 1-855-332-2440/ TTY 1-844-214-2471 to get information about the Iowa Medicaid Tobacco Cessation Program. Another resource is the Quitline at 1-800-QUITNOW (1-800-784-8669). You may also be eligible for tobacco cessation products through the Iowa Medicaid pharmacy benefit. Please call the Iowa Medicaid Inquiry Line at 1-800-338-8366 for more information.
We pay attention to your care Getting care away from home There are times when you will need care while you are away from home. If you are sick or need urgent or emergency care in the United States while you are away from home, here is what you should do: • If you think you have an emergency, call 911 or go to the nearest hospital ER. • If you are sick and you are not sure if it is urgent or an emergency, call your PCP. Your PCP can help you decide if you need to go to the nearest ER or urgent care center. • If you get care in the ER and you are admitted to the hospital while you are away from home, have the hospital call AmeriHealth Caritas Iowa at 1-855-332-2440. The phone number is also listed on the back of your ID card.
AmeriHealth Caritas Iowa’s licensed providers and nurses monitor the services given to all members. They also make decisions about medically necessary care and services. They make these decisions using: • Nationally accepted guidelines. • Medical information, including your Medicaid benefits and your personal medical needs. AmeriHealth Caritas Iowa does not reward health care providers for denying, limiting or delaying benefits or health care services. We also do not give incentives to our staff for making decisions about medically necessary services or benefits that result in more or less health care coverage and services. Contact the Nurse Call Line when you cannot reach your provider or are away from home. The Nurse Call Line is there for you toll free 24 hours a day, 7 days a week, at 1-855-216-6065. When you call the toll-free Nurse Call Line, the nurse will: • Ask you questions about your health. • Give you information on how to care for yourself at home, when appropriate. • Give you information to help you decide what other care you need. Please remember the Nurse Call Line does not take the place of your PCP. Always follow up with your PCP if you have questions about your health care.
Remember, Member Services is here to help you 24 hours a day, 7 days a week.
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Dedication to quality care AmeriHealth Caritas Iowa expects all network providers to give quality care to you and your family. We monitor to make sure the health care and services are being used in the right way and that they are appropriate and necessary. We conduct member satisfaction surveys each year and give member education on health-related issues. If you believe you or your family got care that was not appropriate, please call Member Services. AmeriHealth Caritas Iowa will review the issue. If you would like more information about our quality improvement goals, activities or outcomes, call Member Services at 1-855-332-2440/TTY 1-844-214-2471.
Medically necessary services and benefits Care and services provided to our members must be medically necessary. This means you should receive the right care, at the right time, in the right place, from the right provider. For more information on medically necessary care and services, call Member Services at 1-855-332-2440/TTY 1-844-214-2471.
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Prior authorization Some services need to be approved as “medically necessary” by AmeriHealth Caritas Iowa before your PCP or other health care provider can help you get these services. This process is called “prior authorization.” AmeriHealth Caritas Iowa will honor your existing prior authorizations (pre-approvals) for benefits and services for the first 90 days at the time of your enrollment. If you have questions about prior authorization, please call Member Services at 1-855-332-2440 (TTY 1-844-214-2471). Prior authorization process 1. Your provider gives AmeriHealth Caritas Iowa information to show us the service is medically necessary. 2. AmeriHealth Caritas Iowa nurses and doctors review the information. They use rules approved by DHS to see if the service is medically necessary. 3. If the request is approved, we will let you and your health care provider know it was approved. 4. If the request is not approved, a letter will be sent to you and your health care provider telling you the reason for the decision. You can appeal any decision AmeriHealth Caritas Iowa makes. If you receive a denial and would like to appeal it, talk to your provider. He or she will work with AmeriHealth Caritas Iowa to determine if there were any problems with the information that was submitted. You may also file a grievance or request a state fair hearing. For more information, see page 46. Services needing prior authorization Some of the services that need prior authorization are: • All services you get out of the network (except for emergency care, post-stabilization and some family planning services). • Air ambulance for non-emergency needs. • Cardiac rehabilitation. • Pulmonary rehabilitation. • Cosmetic surgery. • Pull on diapers* (ages 3 and up): If quantity exceeds the individual maximum allowed or any
combination of maximum allowed for members over 3 years old as outlined by Iowa Medicaid. * Diapers, briefs, panty liners and disposable underpads (e.g., Chux) are covered when: ͝͝ They are prescribed and determined to be appropriate for a member who has lost control over bowel or bladder function. ͝͝ A bowel or bladder training program was not successful. ͝͝ The member is 3 years old or older. (Coverage differs from Medicare.) Incontinence products are not covered for stress, urge or overflow. • DME — all rentals. • DME — purchases $750 and over. • Inpatient hospital care. • Home health care (after 6 visits). • Hyperbaric oxygen. • MRI, magnetic resonance angiogram (MRA), magnetic resonance stimulation (MRS), CT scan, nuclear cardiac imaging, PET scan and single-photon emission computerized tomography (SPECT) scan. • Special population nursing facility (skilled pre-approval). • Therapy and related services after 12 visits for: ͞͞ ST. ͞͞ OT. ͞͞ PT. (Per calendar year.) • Waiver services. This is not a complete list, just some examples. If you have questions, please call Member Services at 1-855-332-2440/TTY 1-844-214-2471 or talk to your provider. As an AmeriHealth Caritas Iowa member, you are not responsible to pay for medically necessary, covered services provided by Iowa Medicaid providers. However, you may have to pay when the service provided is not covered by AmeriHealth Caritas Iowa. Your provider will ask you to sign an agreement to pay for the noncovered service. AmeriHealth Caritas Iowa | 36
Getting other benefits and services The following benefits and services are available to AmeriHealth Caritas Iowa members. AmeriHealth Caritas Iowa does not provide these services, but can help you get them. If you have questions or need help, please call Member Services at 1-855-332-2440/TTY 1-844-214-2471. Dental services Dental services are not covered by AmeriHealth Caritas Iowa. If you need these services, please call Iowa Medicaid Member Services at 1-800-338-8366 or hawk-i Member Services at 1-800-257-8563.
Other insurance and bills If you have other health insurance If you have other medical insurance, give that information to your health care providers. Iowa Medicaid Enterprise also needs your other medical insurance information. You can reach Iowa Medicaid Enterprise at 1-800-338-8366. Medicaid is the payer of last resort. If you have other medical insurance, your other medical insurance must be billed first. You are required to show all of your medical cards at each provider’s office and pharmacy visit. This helps make sure your health care bills get paid. If you get a bill or statement As an AmeriHealth Caritas Iowa member, you are not responsible to pay for medically necessary covered services supplied by an Iowa Medicaid provider. If you receive a bill or statement, notify AmeriHealth Caritas Iowa Member Services at 1-855-332-2440/TTY 1-844-214-2471 right away. Remember to ask your health care provider: • Are you an AmeriHealth Caritas Iowa provider? • Does this service need prior authorization? These questions can save you from getting a bill.
Help with insurance premiums The Health Insurance Premium Payment (HIPP) program is a service for people who receive Medicaid. The HIPP program helps people get or keep health insurance through their employer. They do this by reimbursing the member for the cost of the health insurance premium. To complete an application over the phone or for questions, call 1-888-346-9562. For a paper application, please visit www.dhs.ia.us/hipp. Applications may be returned by fax at 1-515-725-0725 or email at
[email protected].
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Loss of benefits (disenrollment) You will lose your AmeriHealth Caritas Iowa benefits (be disenrolled from AmeriHealth Caritas Iowa) if: • You are no longer eligible for Medicaid or hawk-i. • You move out of the state of Iowa service area. • Your condition or illness could be better cared for by another plan. • There is evidence you have engaged in fraud, forgery or unauthorized use or abuse of medical services. • You reached the effective date of your requested disenrollment (see below for when you can ask to disenroll). • You enroll in a program that is not eligible for Iowa Health Link, like Medically Needy, PACE or HIPP. You will not lose your AmeriHealth Caritas Iowa benefits if: • You have changes to the state of your health. • You are using more medical services. • You are uncooperative or disruptive because of your special needs or condition, except when your continued enrollment in the plan seriously impairs its ability to furnish services to you or other members.
• Your application and approval for the Program of All-Inclusive Care for the Elderly (PACE). • Without cause, once every 12 months and within 90 days of your enrollment or of the date the state sends you notice of the enrollment, whichever is later. You also have 90 days to disenroll after being re-enrolled after a temporary loss of Medicaid. ͞͞ You can disenroll at any time if you are unable to get all related services you are requesting at one time, within the AmeriHealth Caritas Iowa network, to avoid unnecessary risk to you. ͞͞ You can disenroll at any time if the state sanctions the plan, resulting in temporary management or the plan having to pay a financial penalty. Disenrollment from AmeriHealth Caritas Iowa is effective on the first day of the following month or no later than the first day of the second month. Please contact the Iowa Medicaid Enterprise Customer Service with questions about Medicaid at 1-800-338-8366. Please contact the hawk-i Member Services with questions about hawk-i at 1-800-257-8563.
You can ask to be disenrolled from AmeriHealth Caritas Iowa: • For cause, at any time. A cause includes, but is not limited to: ͞͞ You move out of the state of Iowa service area. ͞͞ You receive poor-quality care. ͞͞ You are not able to access covered services or providers. ͞͞ You request service that AmeriHealth Caritas Iowa does not cover because of moral or religious objections.
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Your information. Your rights. Our responsibilities. This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. AmeriHealth Caritas Iowa and its network of PCPs and other providers of services does not discriminate against members based on race, national origin, sex, religion, disability, age, sexual orientation or any other basis prohibited by law. AmeriHealth Caritas Iowa is committed to complying with all applicable requirements under federal and state law and regulations pertaining to member privacy and confidentiality rights. As a member, you have the right to: • Get information about: ͞͞ AmeriHealth Caritas Iowa and its health care providers. ͞͞ Your rights and responsibilities.
• Ask that any AmeriHealth Caritas Iowa communication that contains protected health information be sent to you by alternative means or to an alternative address.
͞͞ Your benefits and services.
• Receive health care services consistent with applicable state and federal law.
͞͞ The cost of health care services and any required cost sharing.
• Talk with your health care provider about:
• Have AmeriHealth Caritas Iowa and its health care providers treat you with dignity and respect. • Get materials or help in languages and formats other than written English, such as braille, audio or sign language, as indicated, at no cost to you. • Receive help with interpretation services, as indicated, at no cost to you. • Receive materials that are written in a manner and format that are easily understood and culturally sensitive. • Have personal and health information and medical records kept private and confidential. • Expect that AmeriHealth Caritas Iowa will give you a copy of its Notice of Privacy Practices without your request, and: ͞͞ Approve or deny the release of identifiable medical or personal information, except when the release is required by law. • Request a list of disclosures of protected health information. • Request and receive a copy of your medical records as allowed by applicable state and federal law. • Ask that AmeriHealth Caritas Iowa amend certain protected health information.
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͞͞ Treatment plans. ͞͞ Information on available treatment options and alternatives, given in a way you understand. ͞͞ The kinds of care you can choose to meet your medical needs, regardless of cost or benefit coverage. • Be a part of decisions about your health care, including the right to refuse treatment. Your decision to do so will not negatively affect the way AmeriHealth Caritas Iowa, its health care providers or DHS treats you. • Voice complaints about and/or appeal decisions made by AmeriHealth Caritas Iowa and its health care providers. • File a state fair hearing with DHS. • Make an advance directive. • Be given an opportunity to provide suggestions for changes to AmeriHealth Caritas Iowa’s policies and procedures. • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. • Be free from discrimination prohibited by state and federal law.
Your information. Your rights. Our responsibilities. Your rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. You have the right to: • Get a copy of your health and claims records. ͞͞ You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. ͞͞ We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. • Ask us to correct health and claims records. ͞͞ You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. ͞͞ We may say “no” to your request, but we’ll tell you why in writing within 60 days. • Request confidential communication. ͞͞ You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. ͞͞ We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not. • Ask us to limit the information we share. ͞͞ You can ask us not to use or share certain health information for treatment, payment or our operations. ͞͞ We are not required to agree to your request, and we may say “no” if it would affect your care.
• Get a list of those with whom we’ve shared your information. ͞͞ You can ask for a list (called an “accounting”) of the times we’ve shared your health information for 6 years prior to the date you ask, who we shared it with and why. ͞͞ We will include all the disclosures except for those about treatment, payment and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. • Get a copy of this privacy notice. ͞͞ You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. • Choose someone to act for you. ͞͞ If you have given someone medical power of attorney or if someone is your legal guardian, that person can act for you and your rights and make choices about your health information. ͞͞ We will make sure the person has this authority and can act for you before we take any action. • File a complaint if you believe your privacy rights have been violated. ͞͞ You can complain if you feel we have violated your rights by contacting us at 1-855-332-2440/TTY 1-844-214-2471. ͞͞ You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1‑877-696-6775, or visiting www.hhs.gov/ocr/ privacy/hipaa/complaints/. ͞͞ We will not retaliate against you for filing a complaint.
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Your information. Your rights. Our responsibilities. Your choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. You have some choices in the way that we use and share information as we: • Answer coverage questions from your family and friends. • Provide disaster relief.
• The use of mobile and digital technologies (such as text message, email or mobile app) has a number of risks that you should consider. Text messages and emails may be read by a third party if your mobile or digital device is stolen, hacked or unsecured. Message and data rates may apply. In these cases, we never share your information unless you give us written permission: • Marketing purposes. • Sale of your information. Our uses and disclosures
• Communicate through mobile and digital technologies.
How do we typically use or share your health information?
• Market our services and sell your information.
We typically use or share your health information in the following ways.
In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends or others involved in payment for your care. • Share information in a disaster relief situation. • Share information with you through mobile and digital technologies (such as sending information to your email address or to your cell phone by text message or through a mobile app). • If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information with others (such as to your family or to a disaster relief organization) if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. However, we will not use mobile and digital technologies to send you health information unless you agree to let us do so.
We may use and share your information as we: • Help manage the health care treatment you receive. ͞͞ We can use your health information and share it with professionals who are treating you. ͝͝ Example: A provider sends us information about your diagnosis and treatment plan so we can arrange additional services. • Run our organization. ͞͞ We can use and disclose your information to run our organization and contact you when necessary. We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long-term care plans. ͝͝ Example: We use health information about you to develop better services for you. • Pay for your health services. ͞͞ We can use and disclose your health information as we pay for your health services. ͝͝ Example: We share information about you to coordinate payment for your health services.
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Your information. Your rights. Our responsibilities. • Administer your health plan. ͞͞ We may disclose your health plan information for plan administration. ͝͝ Example: We share health information with others who we contract with for administrative services. • Coordinate your care among various health care providers. ͞͞ Our contracts with various programs require that we participate in certain electronic health information networks (HINs) and health information exchanges (HIEs) so we are able to more efficiently coordinate the care you are receiving from various health care providers. ͞͞ If you are enrolled/enrolling in a government-sponsored program, such as Medicaid or Medicare, please review the information provided to you by that program to determine your rights with respect to participating in an HIN or HIE. ͝͝ Example: We share health information through an HIN or HIE to provide timely information to providers delivering services to you. • Help with public health and safety issues. We can share health information about you for certain situations such as: ͞͞ Preventing disease. ͞͞ Helping with product recalls. ͞͞ Reporting adverse reactions to medications. ͞͞ Reporting suspected abuse, neglect or domestic violence. ͞͞ Preventing or reducing a serious threat to anyone’s health or safety. • Do research. ͞͞ We can use or share your information for health research.
• Comply with the law. ͞͞ We will share information about you if state or federal laws require it, including with the U.S. Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. • Respond to organ and tissue donation requests and work with a medical examiner or funeral director. ͞͞ We can share health information about you with organ procurement organizations. ͞͞ We can share health information with a coroner, medical examiner or funeral director when an individual dies. • Address workers’ compensation, law enforcement and other government requests. We can use or share health information about you: ͞͞ For workers’ compensation claims. ͞͞ For law enforcement purposes or with a law enforcement official. ͞͞ With health oversight agencies for activities authorized by law. ͞͞ For special government functions such as military, national security and presidential protective services. • Respond to lawsuits and legal actions. ͞͞ We can share health information about you in response to a court or administrative order, or in response to a subpoena. • Additional restrictions on use and disclosure. ͞͞ Certain federal and state laws may require greater privacy protections. Where applicable, we will follow more stringent federal and state privacy laws that relate to uses and disclosures of health information concerning AIDS/HIV, cancer, behavioral health, alcohol and/or substance use, genetic testing, sexually transmitted diseases, and reproductive health.
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Your information. Your rights. Our responsibilities. How else can we use or share your health information?
We are allowed or required to share your information in other ways — usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/ consumers/index.html. Our responsibilities AmeriHealth Caritas Iowa takes our members’ right to privacy seriously. To provide you with your benefits, AmeriHealth Caritas Iowa creates and receives personal information about your health. This information comes from you, your PCPs, hospitals and other health care services providers. This information — called protected health information — can be oral, written or electronic. We are required by law to maintain the privacy and security of your protected health information. We are required by law to ensure third parties who assist with your treatment, our payment of claims or health care operations maintain the privacy and security of your protected health information in the same way that we protect your information. We are also required by law to ensure that third parties who assist us with treatment, payment and operations abide by the instructions outlined in our Business Associate Agreement. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
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For more information, see: www.hhs.gov/ocr/privacy/hipaa/ understanding/consumers/noticepp.html. Changes to the terms of this notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request and on our website, and we will mail a copy to you.
Advance directives The Patient Self-Determination Act is a federal law. It says you have the right to choose the medical care and treatment you receive. You have the right to make these wishes known to your PCP or other health care provider through an advance directive. An advance directive is a decision you make ahead of time about the medical care you do or do not want if you are unable to make a decision about medical care at the time it is needed. Advance directives are used only if you are unable to speak or make decisions for yourself. Your advance directive would be used if you were determined by a provider to be in a terminal or vegetative state. AmeriHealth Caritas Iowa will honor your advance directive to the fullest extent allowed by law. There are two kinds of documents that can serve as an advance directive in Iowa: • Living will — This a written record of how you wish your medical care to be handled if you are no longer able to decide and speak for yourself. This document should say what type of medical treatments you would or would not want to have.
• Durable power of attorney for health care — This is a legal document that gives the name of the person you want to make medical treatment decisions for you in case you cannot make them for yourself. This person does not have to be a lawyer.
To make sure your wishes are met if you cannot speak or make a decision about your care, you should write an advance directive and give a copy to your PCP, as well as to family members. If you have any questions about advance directives, please call Member Services at 1-855-332-2440/TTY 1-844-214-2471.
Notice of action A notice of action is provided to the member and/or provider in writing at least 10 days before the termination, suspension or reduction of previously authorized services. The notice of action is shortened to 5 days if probable member fraud is verified. Written notification will be sent for all approvals, terminations, suspensions or reductions of previously authorized services, or denial of a new request. AmeriHealth Caritas Iowa will give this notice for the following situations: • Death of a member. • A signed statement from you requesting that AmeriHealth Caritas Iowa end your services. You provide information requiring termination or reduction of services and know the result of your action. • You are admitted to a health care facility that makes you ineligible for authorized service. • Your address is unknown and returned mail has no forwarding address.
• An unfavorable decision was made for admission to a nursing facility. • Other reasons for notice are: ͞͞ Your health or safety would be in danger. ͞͞ Your health improves, allowing for transfer. ͞͞ You are discharged due to more urgent needs. ͞͞ You have not been a resident in a nursing facility for 30 days (applies to nursing facility transfer unfavorable actions).
• Your provider orders a change in your level of care.
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Important Information for You and Your Family Members About the Estate Recovery Program Estate Recovery legal reference: 441 IAC 75.28(7)
If you received Medicaid benefits, which includes capitation fees paid to a managed care organization (MCO), the state of Iowa has the right to ask for money back from your estate after your death. Members affected by the estate recovery policy are those who are either: • 55 years of age or older, regardless of where they are living. • Under age 55 and: ͞͞ Reside in a nursing facility, an intermediate care facility for persons with an intellectually disability, or a mental health institute. ͞͞ Cannot reasonably be expected to be discharged and return home. For more information, please call IME Member Services: 1-800-338-8366 toll free 1-515-256-4606 (Des Moines area) 8 a.m. to 5 p.m., Monday through Friday.
Notice of significant change In addition to notifying you about changes in our operations that will affect you, we will also provide written notice of any change that impacts your access to services and benefits. This is a material change that you would think is significant. AmeriHealth Caritas Iowa shall provide you written notice when there is a significant change. A significant change is any change that may impact your access to services and benefits, including: • Restrictions on your freedom of choice among network providers.
• The extent to which, and how, enrollees may get benefits from out-of-network providers.
• Your rights and protections.
• The extent to which, and how, after-hours and emergency coverage are provided.
• Grievance and fair hearing procedures. • Amount, duration and scope of benefits available. • Procedures for getting benefits, including authorization (approval) requirements.
• Policy on referrals for specialty care and for other benefits not provided by the member’s primary care provider. • Cost sharing.
All material changes shall be communicated to you or your providers at least 30 days prior to the effective date of the change.
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Member grievances/complaints, appeals and state fair hearings We hope you are satisfied with AmeriHealth Caritas Iowa and our health care providers. If you have questions or concerns about your AmeriHealth Caritas Iowa benefits or services, please call Member Services. We can help you with most questions and concerns. If we cannot immediately resolve your questions or concerns, we will investigate the issue and respond to you within 30 days. If you are still not satisfied, you have the right to file a grievance/complaint or appeal or request a fair hearing with the state of Iowa. Grievance system AmeriHealth Caritas Iowa’s grievance system includes: • A grievance process where you can submit a grievance or complaint. • An appeal process where you can appeal a decision AmeriHealth Caritas Iowa has made to deny or limit services.
your medical care, you would file an appeal and not a grievance. Filing a grievance
• You should file a grievance as soon as possible and no later than 90 days after the event that caused you to be unhappy. • You can file a grievance in writing or by phone.
• A fair hearing process, where you can submit your grievance or appeal before the state in a fair hearing.
• AmeriHealth Caritas Iowa will send you a letter within 3 business days to let you know we received your grievance.
Each of these processes is explained in this section.
• After we finish our research and within 30 business days of getting your grievance, we will send you another letter with the outcome. AmeriHealth Caritas Iowa may extend the review time frame by an additional 14 business days. If we do so, we will send you a letter that explains the delay.
Grievances What is a grievance?
A grievance is a way for you to tell AmeriHealth Caritas Iowa you are not happy with the way your care has been handled. If you are not happy with a decision AmeriHealth Caritas Iowa has made about
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Member grievances/complaints, appeals and state fair hearings How do you file a grievance?
• You can file a grievance in writing or by phone. • To file a grievance by phone, you can call Member Services at 1-855-332-2440. TTY users may call 1-844-214-2471. You can call 24 hours a day, 7 days a week. To file a written grievance, send your grievance to: Complaints and Grievances Department P.O. Box 7116 London, KY 40742 ATTN: Complaints and Grievances • Your grievance can be filed by your provider for you, but you must give written consent. • You, or your representative, should file your grievance with AmeriHealth Caritas Iowa first. We will try to address your concern. If you are dissatisfied with the outcome of our decision, we will direct you to the Iowa Medicaid Enterprise enrollment broker to request disenrollment. Appeals What is an appeal?
An appeal is a request for AmeriHealth Caritas Iowa to review an action taken by AmeriHealth Caritas Iowa. You may file an appeal if you are not satisfied with any of the following decisions: • A denial of services that your provider requested. • A reduction or limitation of health care services you are getting. • A suspension of or end to a health care service you are getting. If AmeriHealth Caritas Iowa denies, reduces, limits, suspends or ends health care services, a written notice of action will be sent to you about this decision. If you receive a notice of action and do not agree with the AmeriHealth Caritas Iowa decisions, you may file an appeal*. • You can file the appeal by telephone or in writing. If you file your appeal by telephone, you will also need to send a letter afterward. If you would like your provider to submit an appeal for you and he *411 Iowa Administrative Code Chapter 7. 47 | Member Handbook
or she agrees to do so, you must give your written consent. You may also choose someone else besides your provider to represent you and make a request for an appeal. However, if the appeal is expedited, you do not need to take this step. • AmeriHealth Caritas Iowa members, someone you choose to represent you, or a provider who has your written consent may file a grievance or appeal. • The appeal must be filed within 30 days after the date on the notice of action. • To file an appeal, you can call Member Services at 1-855-332-2440. TTY users may call 1-844-214-2471. You can call 24 hours a day, 7 days a week. • To file an appeal in writing, you or your authorized representative can send the letter to: AmeriHealth Caritas Iowa Attention: Member Appeals Coordinator Member Appeals Department 601 Locust Street Suite 900 Des Moines, IA 50309 • AmeriHealth Caritas Iowa will start to review your appeal request the day we get it. A decision will be made within 30 calendar days, unless additional information is needed. AmeriHealth Caritas Iowa may extend the time frame up to 14 calendar days. If the time frame extension is not requested by you, AmeriHealth Caritas Iowa will send you a letter explaining the reason for the delay. • AmeriHealth Caritas Iowa will send you or your authorized representative a letter with the decision about the appeal. The letter will explain how the decision was made. Expedited appeals Appeals are expedited when a decision needs to be made in less than 30 days. AmeriHealth Caritas Iowa will expedite an appeal when your life or health is at risk. Expedited appeals are for health care services, not for denied claims. How to file an expedited appeal
You may file an expedited appeal by sending an Appeal for Request and Hearing form, or you may do so by phone. For more information about the appeal process,
Member grievances/complaints, appeals and state fair hearings please call Member Services at 1-855-332-2440. TTY users may call 1-844-214-2471. AmeriHealth Caritas Iowa will start to review your expedited appeal request the day it is received. We will make a decision within 3 business days of receiving your request. We will attempt to notify you of the decision by phone, first. We will also mail you a notice about the decision. AmeriHealth Caritas Iowa may extend the 72-hour time period by up to 14 calendar days if you request an extension, or if AmeriHealth Caritas Iowa shows a need for more information and how the delay is in your interest. If you ask for an appeal to be expedited and AmeriHealth Caritas Iowa does not believe the appeal needs a faster decision, the appeal will be reviewed within the standard appeal time frame. You will be informed in writing and by phone within 2 calendar days if the time frame for your appeal has changed. AmeriHealth Caritas Iowa members or their representatives will be allowed to present facts and evidence to support their expedited appeals. Limited time is available for doing so. This information can be presented in person or in writing. The members or their representatives will be informed how long they have to submit information for an expedited review. State fair hearing If you’ve completed the appeals process and you’re not satisfied with the outcome, you may request a state fair hearing within 90 days of the date on the AmeriHealth Caritas Iowa appeal decision. How do you request a state fair hearing?
You may request a state fair hearing with DHS in person, by phone or in writing. To file a request in writing, do one of the following: • Complete a state fair hearing request electronically at http://dhs.iowa.gov/node/966. • Write a letter telling us why you think AmeriHealth Caritas Iowa’s decision is wrong. Call DHS at 1-515-281-3094 if you want to appeal by phone.
Or mail, fax or take your appeal to: Department of Human Services Appeals Section 1305 E. Walnut Street, 5th Floor Des Moines, IA 50319 Fax: 1-515-564-4044 Email:
[email protected] Continuing benefits during an appeal or state fair hearing You can keep getting covered services while you wait for AmeriHealth Caritas Iowa to decide on an appeal or while a state fair hearing is pending, if all of the following apply: • The appeal is filed on or before the later of: ͞͞ 10 days from the date AmeriHealth Caritas Iowa mailed the notice of action. ͞͞ Before the effective date on the notice of action. • The appeal is related to reduced or suspended services or to services that were previously authorized for you. • The services were ordered by an authorized provider. • The authorization period for the services has not ended. • You asked that the services continue. If AmeriHealth Caritas Iowa continues your benefits while deciding an appeal or while a state fair hearing is pending, the services must be continued until one of the following happens: • You decide not to continue the appeal. • You do not request a state fair hearing within 10 days from the date AmeriHealth Caritas Iowa mails the notice of action. • The authorization for services expires or authorization service limits are met. • A hearing decision is issued in the state fair hearing that is adverse to the member. If the state fair hearing officer agrees with you, AmeriHealth Caritas Iowa will pay for the services you got while you waited for the decision. However, if the state supports the original appeal decision and rules against you, you will have to pay for the service you received during the waiting period. AmeriHealth Caritas Iowa | 48
Fraud and abuse Unfortunately, there may be times when you see fraud or abuse relating to Medicaid services. Some examples of fraud and abuse by a health care provider are: • Billing or charging you for services that AmeriHealth Caritas Iowa covers. • Offering you gifts or money to get treatment or services you do not need. • Offering you free services, equipment or supplies in exchange for using your AmeriHealth Caritas Iowa member number. • Giving you treatment or services you do not need. • Physical, mental or sexual abuse by medical staff. Some examples of fraud and abuse by a member are: • Members selling their ID cards to other people. • Members lending their ID cards to other people. • Members abusing their benefits by seeking drugs or services that are not medically necessary. You can report fraud and abuse by calling the AmeriHealth Caritas Iowa Hotline number at 1-866-833-9718. You can also report fraud and abuse to DHS. • To report member or provider fraud and abuse, call toll free at 1-800-831-1394, Monday through Friday, from 7 a.m. to 6 p.m. CST. • To report member or provider fraud and abuse, go to the website of the U.S. Department of Health and Human Services at the Office of Inspector General at https://forms.oig.hhs.gov/ hotlineoperations/nothhsemployeeen.aspx. You do not have to give your name, but if you do, the provider or member will not be told it was you who made the report. Reporting abuse, neglect and exploitation AmeriHealth Caritas Iowa members have the right to be free from abuse, neglect and exploitation. It is important that you understand how to identify these situations and how to report them.
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Abuse can be: • Physical abuse. • Emotional abuse. • Sexual abuse. It includes pain, injury, mental suffering, being locked up or held in a place against your will, or other cruel treatment. Neglect can be: • When you can’t take care of yourself or get the care your need, placing your life at risk. This is “self-neglect.” • When your caregiver is not taking care of your basic needs, putting you at risk for harm to your health or safety. The neglect may be unintended due to the caregiver’s inability to provide or arrange for your care. Neglect also may be due to the carelessness of the caregiver to meet your needs. Exploitation (made to do something you don’t want to do or were asked to do without knowing the real reason for doing so) can include: • Fraud or bullying. • Forgery. • Unauthorized use of banking accounts or credit cards. Financial exploitation occurs when a caregiver improperly uses funds intended for your care. These are funds paid to you or the caregiver by a governmental agency. If you think you or another AmeriHealth Caritas Iowa member is a victim of these situations, please notify your care manager by calling 1-855-332-2440/ TTY 1-844-214-2471 or contact one of the agencies below: • Iowa Department of Human Services Centralized Unit for Reports of Child, Dependent and Adult Abuse: 1-800-362-2178. • Nursing Home Abuse and Complaint Hotline: 1-877-686-0027. Or in writing to: Iowa Department of Inspections and Appeals Health Facilities Division/Complaint Unit Lucas State Office Building 321 East 12th Street, 3rd Floor Des Moines, IA 50319-0083
Special situations Continued care If you are getting ongoing treatment from a provider who is not in the AmeriHealth Caritas Iowa network, you may be able to continue that treatment. Treatment or services are “ongoing” if you were treated during the past 12 months for a condition where you need to get follow-up care or additional treatment. Services are also considered ongoing if they have already been approved. You are allowed to continue ongoing treatment with a health care provider who is not in the AmeriHealth Caritas Iowa network when any of the following happens: • You are a new AmeriHealth Caritas Iowa member and you are getting ongoing treatment from a health care provider who is not in the AmeriHealth Caritas Iowa network. • You are a current AmeriHealth Caritas Iowa member and you are getting ongoing treatment from a health care provider whose contract has ended with AmeriHealth Caritas Iowa for reasons that are “not-for-cause.” Reasons that are “not-for-cause” means the provider’s contract did not end because of the quality of the provider’s care or because the provider did not meet other contract or regulatory requirements.
If you are...
AmeriHealth Caritas Iowa will allow you to...
A new AmeriHealth Caritas Iowa member
Keep getting treatment from a health care provider who is not in the AmeriHealth Caritas Iowa network. You can continue treatment for up to 90 days from the date you were enrolled in AmeriHealth Caritas Iowa.
A new AmeriHealth Caritas Iowa member and you are pregnant as of the date you enroll in AmeriHealth Caritas Iowa
Keep getting treatment from an OB or midwife who is not in the AmeriHealth Caritas Iowa network until the end of your postpartum care related to your delivery.
A current AmeriHealth Caritas Iowa member and your health care provider (provider, midwife or certified registered nurse practitioner ) stops participating with AmeriHealth Caritas Iowa and you need to keep getting health care
Continue going to the provider for treatment for up to 90 days from the date AmeriHealth Caritas Iowa tells you that the health care provider stops participating in the AmeriHealth Caritas Iowa network or for up to 60 days from the date the provider’s contract with AmeriHealth Caritas Iowa ends — whichever is longer.
A current AmeriHealth Caritas Iowa member in your second or third trimester of pregnancy and the OB or midwife whom you see stops participating with AmeriHealth Caritas Iowa
Continue going to the provider for treatment from that OB or midwife until you deliver your baby and receive postpartum care related to the delivery.
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Special situations Requests for ongoing treatment or services are reviewed case-by-case. If you want to keep getting treatment or services with a health care provider who is not in the AmeriHealth Caritas Iowa network, you must either: • Call Member Services for help with continuing care. • Ask your health care provider to call AmeriHealth Caritas Iowa’s Utilization Management department at 1-844-411-0604. Once we have the request to continue care, we will review your case. We will notify you and your health care provider by telephone if continued services have been authorized. If for some reason we do not approve continued care, you and your health care provider will get a telephone call and a letter that includes our decision and information about your right to appeal the decision. You must get approval from AmeriHealth Caritas Iowa to continue care. AmeriHealth Caritas Iowa will not cover continuing care when: • The provider’s contract has ended because of quality-of-care issues. • The provider is not an Iowa Medicaid provider. • The provider did not comply with regulations or other contract requirements. • The services are not ongoing. Changing your PCP If you move or want to change your PCP for any reason, we will help you choose another PCP in your area. You can change your PCP at any time and for any reason. How to change your PCP
If you have access to the Internet: • Go to www.amerihealthcaritasia.com and click on Find a Provider to choose a provider in your area. If you do not have access to the Internet: • We can send you a provider directory.
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Once you change your PCP: • We will ask why you want to change your PCP. This will help us learn about any possible problems with the services given by PCPs in our network. • You will get a new AmeriHealth Caritas Iowa ID card. When your new card arrives, destroy your old card at once. If your PCP is leaving the AmeriHealth Caritas Iowa network There are times when a PCP will leave the AmeriHealth Caritas Iowa network. If your PCP leaves the health plan, we will let you know within 15 days after we receive a termination notice so you can choose a new PCP. If you do not choose a new PCP by the date we give you, we will choose a PCP for you. We will send a letter to you with the name of your new PCP. You will also get a new ID card in a separate mailing. When your new card arrives, destroy your old card. If you do not want the PCP we have chosen for you, you can change your PCP at any time by calling Member Services at 1-855-332-2440/ TTY 1-844-214-2471.
Your personal guide to good health
Long-Term Services and Supports For questions about your care and services, call: AmeriHealth Caritas Iowa Member Services 1-855-332-2440/TTY 1-844-214-2471 24 hours a day, 7 days a week
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Long-Term Services and Supports What are long-term services and supports? Long-term services and supports are just what they sound like — special services to help members who need extra help. You must apply for these benefits. AmeriHealth Caritas Iowa will try to assist members in this process. Long-term services and supports eligibility DHS decides eligibility for long-term services and supports provided through: • A waiver. • In facilities. • Habilitation. AmeriHealth Caritas Iowa will help enrolled members apply for a level of care determination when their condition shows possible eligibility. Long-term services and supports referrals AmeriHealth Caritas Iowa wants you to get the care you need. Changes in your health might make you eligible to receive additional services. This includes medical, habilitation, rehabilitation, home care or social services that people need over months or years to improve or maintain their health. These services may be provided in your home or a community-based setting. Facilitybased long-term services and supports are services provided in a nursing facility or other residential care setting. As an AmeriHealth Caritas Iowa member, you will be the center of the planning process. This is called person-centered planning. You will receive a comprehensive assessment of your needs, including your need for community-based or facility-based longterm services and supports. During this assessment, your case manager will ask you questions over the phone or in person at your home. This assessment could also involve your caregivers or personal representatives. As part of the assessment, your care manager will also obtain information from your PCP, specialists and other sources. This will help complete the picture of your current medical and support needs. All of the needs identified in your assessment will be included in your care plan. In addition, your care plan will outline which services you need, how often you will need them and the providers who will address these needs. 53 | Member Handbook
If you, a friend or a family member notice a change in your condition or health status at any time, you can contact your case manager at 1-855-332-2440/TTY 1-844-214-2471. This will help us to make sure your care plan meets your needs. Community-based case management and the role of the case manager AmeriHealth Caritas Iowa is responsible for managing all of your physical, behavioral and long-term services and supports. We do this through community-based case management and person-centered planning. You will be assigned to a case manager. Your case manager is your primary contact and the person you should call if you have questions about your services. We will send you a letter with the name and phone number of your case manager. Write down your case manager’s name and phone number in this member handbook. Contact your case manager anytime you have a question or concern about your health care. You do not need to wait until your case manager comes to your home or calls you. Your case manager will: • Give you information about AmeriHealth Caritas Iowa and answer your questions. • Work with you to make sure you have all the information you need to make good choices about your health care. • Help you get the right kind of long-term services and supports in the right setting. • Coordinate all of your physical, mental and longterm services and supports needs. • Help solve issues that you have about your care. • Make sure that your care plan is carried out and is working for you. • Be aware of your needs as they change and update your care plan to make sure the services you get are right for your changing needs. • Talk with your providers to make sure they are informed about your health care and to coordinate your services.
Long-Term Services and Supports If you receive nursing facility care, your case manager will: • Be part of the person centered planning process with the nursing facility where you live. • Perform any additional needs assessment that may be helpful in managing your health. • Add to the nursing facility’s care plan if there are things AmeriHealth Caritas Iowa can do to help manage health problems or coordinate other kinds of physical and mental health care you need. • Coordinate with the nursing facility when you need services the nursing facility isn’t responsible for providing. • Conduct face-to-face visits at least every 6 months. • Check at least 1 time a year to make sure that you continue to need the level of care provided in a nursing facility. Changing case managers You may ask for a new case manager if you are unhappy with your current case manager. AmeriHealth Caritas Iowa will assign a new case manager if one is available and will assign someone who best fits your needs. If we cannot assign a new case manager, we will tell you why, and we will address any problems or concerns you have with your case manager. There may be times when AmeriHealth Caritas Iowa has to change your case manager. This may happen if your case manager is no longer with AmeriHealth Caritas Iowa, is temporarily not working or has a workload that is too large to manage. If this happens, AmeriHealth Caritas Iowa will send you a letter with the name and telephone number of your new case manager. Freedom of choice If you qualify for nursing facility care, you have the right to select care: • In your home.
You have a right to choose between a nursing facility and home- and community-based services if: • You qualify for nursing facility care. • Your needs can be safely and effectively met at home or in the community. Talk with your case manager to discuss your options to move between a nursing facility and care in your home or community. You may change your choice at any time as long as you qualify, and we can arrange for you to receive care in the setting you want. With AmeriHealth Caritas Iowa, you may choose providers from our network. Services may include nursing facility care, assisted living or care at home. You also may be in charge and hire or train your own caregiver (called self-directed attendant care). See the “Consumer Choices Option” section for more detail. The provider you choose must be contracted with AmeriHealth Caritas Iowa to be in our provider network and must be willing and able to provide the care you need. Your case manager will help you to find the right providers. Home- and community-based services The Iowa HCBS Waiver Program provides members who are older or have disabilities with individualized benefits that allow them to live in their own home or community who would otherwise require care in a nursing facility or other institution. This gives you more choices about how and where you receive services. These services may allow you to stay in your home. You must be eligible for Medicaid and also meet the requirements for the waiver you are applying for and/or receiving. You will need to meet certain requirements that show you are in need of nursing facility, skilled nursing facility or hospital care or care in an intermediate care facility for individuals with intellectual disabilities. Before a member can access waiver services, the member must be awarded a funding slot. If no funding slot is available, then the member will be placed on a waiting list.
• In another place in the community (such as an assisted living or critical adult care home). • In a nursing facility. AmeriHealth Caritas Iowa | 54
Long-Term Services and Supports Iowa currently has the following Medicaid HCBS waivers: • Health and Disability Waiver. • AIDS/HIV Waiver. • Elderly Waiver. • Intellectual Disability Waiver.
• Brain Injury Waiver. • Physical Disability Waiver. • Children’s Mental Health Waiver.
Iowa currently has a 1915(i) State Plan HCBS Program for habilitation services. Services provided under the State’s 1915(i) program must be provided to members who have incomes at or below 150 percent of the federal poverty level and meet the needs based eligibility criteria for the Habilitation program by DHS. Services available include: • Home-based habilitation ͞͞ Services and supports that help the member gain, keep or improve skills needed to live in the community. These services are provided in the member’s home or community. These services help the member to live in the setting that best fits his or her needs. The services focus on the member’s daily living needs, and they can be provided at any time of day or night. • Day habilitation ͞͞ Regularly scheduled activities that take place outside of the member’s private residence or other living arrangement. These services and activities help the member gain, keep or improve: ͝͝ Self-help abilities. ͝͝ Social interaction skills. ͝͝ Adaptive skills to support activities of daily life and community living. Activities and environments are designed to encourage the member to develop skills, build positive social behavior, and gain more independence and confidence making personal choices. The services fit with the member’s person-centered plan. The goal is to help the member get to or stay at his or her maximum potential.
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The services may include physical, occupational or speech therapy, and be provided along with any other needed therapies in the member’s person-centered services and supports plan. • Prevocational habilitation ͞͞ Provides learning and work experiences. This may include volunteer work, where the member can work on building basic strengths and skills for integrated community-based jobs. Services may take place over a certain period of time and have specific goals. This is decided by the member and the member’s service and supports planning team through an ongoing person-centered planning process. Members must have employment-related goals in their person-centered services and supports plan. The activities must be designed to support employment goals. Competitive, integrated employment in the community for which a member is compensated at or above the minimum wage — but not less than the employer would offer for the same or similar work done by a person without disabilities — is the best outcome from prevocational services. These services should help the member to reach the highest level of work in the most integrated setting and with the job matched to the member’s interests, strengths, priorities, abilities, and capabilities while following federal wage guidelines. • Supported employment individual employment (SEIE) habilitation ͞͞ SEIE supports may be provided to any member who needs and chooses them through a person-centered planning process. They are not limited to persons with intellectual or developmental disabilities. The services are for members who need intensive, ongoing support because of their disabilities so they can get and keep employment. Supports are provided to members employed in a competitive or customized job, or to members who are self-employed. Members should be integrated into the general workforce and compensated
Long-Term Services and Supports at or above the minimum wage, but not less than the employer would offer for the same or similar work done by a person without disabilities. The goal is continued paid employment in a job that meets personal and career goals. • Supported employment small group (enclave) ͞͞ Services and training activities provided in regular business, industry, and community settings for groups of 2 to 8 workers with disabilities. Examples include mobile crews and other business-based workgroups employing small groups of workers with disabilities in community-based jobs. The support must be provided in a way that promotes integration into the workplace and interaction between members and people without disabilities in those workplaces. The goal is continued paid employment and work experience leading to more career development and individual integrated community-based employment for which a member is compensated at or above the minimum wage, but not less than the employer would offer for the same or similar work done by a person without disabilities. Small group employment support does not include vocational services provided in facilitybased work settings. Eligibility The federal law that the program will operate under bans targeting a specific population group to be served. However, the program provides the type of services typically needed by adults with a chronic mental illness. Anyone seeking services through this program must be eligible for Medicaid and have a need for these services which will be demonstrated by meeting the following needs-based criteria: The individual meets at least one of the following risk factors:
• Has a history of psychiatric illness resulting in at least one episode of continuous, professional supportive care other than hospitalization. In addition, the person has a need for assistance usually shown by meeting at least 2 of the following criteria on a continuing or intermittent basis for at least 2 years: • Is unemployed, or employed in a sheltered setting, or have noticeably limited skills and a poor work history. • Requires financial assistance for out-of-hospital maintenance and may not be able to procure this assistance without help. • Shows severe inability to establish or maintain a personal social support system. • Requires help in basic living skills such as self-care, money management, housekeeping, cooking, or medication management. • Shows inappropriate social behavior that results in demand for intervention. There is no age restriction on the receipt of habilitation services; anyone who meets all eligibility requirements for the program can receive the service. However, the needs-based criteria are functional criteria that most likely would not be applicable to most younger children regardless of disability. Adolescents who are transitioning from children’s services to adult services would likely benefit from the program without the need to make an abrupt transition at the age of 18. Federal law restricts eligibility to individuals whose household income does not exceed 150 percent of the federal poverty level. Services may be provided to a member regardless of Waiver enrollment; however, a person must still meet all eligibility criteria for both programs, and services may not be duplicative between the 2 programs.
• Has received or is currently receiving psychiatric treatment more intensive than outpatient care, more than once in a lifetime (e.g., emergency services, alternative home care, partial hospitalization or inpatient hospitalization).
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Long-Term Services and Supports Waiver benefits Waiver
AIDS/HIV
Benefits • Adult day care.
• Home health aide.
• Consumer-directed attendant care.
• Homemaker services.
• Counseling services. • Home-delivered meals. • Adult day care. • Behavioral programming. • Consumer-directed attendant care.
Brain injury
• Nursing care. • Respite. • Consumer Choices Option. • Personal emergency response system. • Prevocational services. • Respite.
• Family counseling and training.
• Specialized medical equipment.
• Home and vehicle modifications.
• Supported community living.
• Interim medical monitoring and treatment.
• Supported employment. • Transportation. • Consumer Choices Option.
Children’s mental health
Elderly
• Environmental modifications and adaptive devices.
• Respite.
• Family and community support services. • Adult day care.
• Home health aide.
• Assistive devices.
• Homemaker services.
• Assisted living.
• Mental health outreach.
• Chore services.
• Nursing care.
• Consumer-directed attendant care.
• Nutritional counseling.
• Personal emergency response system. • Home and vehicle modifications. • Home-delivered meals.
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• In-home family therapy.
• Respite. • Senior companions. • Transportation. • Consumer Choices Option.
Long-Term Services and Supports
Waiver
Benefits • Adult day care. • Consumer-directed attendant care.
Health and disability waiver
• Nursing.
• Counseling.
• Nutritional counseling.
• Home and vehicle modification.
• Personal emergency response system.
• Home-delivered meals.
• Respite.
• Home health aide. • Homemaker services. • Adult day care. • Consumer-directed attendant care.
Intellectual disability waiver
• Interim medical monitoring and treatment.
• Consumer Choices Option. • Personal emergency response system. • Prevocational services.
• Day habilitation.
• Respite.
• Home and vehicle modifications.
• Supported community living.
• Home health aide.
• Supported community living — residential-based.
• Interim medical monitoring and treatments.
• Supported employment. • Transportation.
• Nursing.
• Consumer Choices Option.
Physical disability waiver
• Consumer-directed attendant care.
• Specialized medical equipment.
• Home and vehicle modification.
• Consumer Choices Option.
• Transportation.
• Personal emergency response system.
For more information on the benefits and benefit limits for each waiver program, please call AmeriHealth Caritas Iowa Member Services at 1-855-332-2440/TTY 1-844-214-2471. Consumer Choices Option The Consumer Choices Option is an option that is available under the Brain Injury, Elderly, Health and Disability, Intellectual Disability, AIDS/HIV, and Physical Disability waivers. This option will give you more control over a targeted amount of Medicaid dollars. You will use these dollars to develop an individual budget plan to meet your needs by directly hiring employees and/or purchasing other goods and services. Enrollment in this program is voluntary. The Consumer Choices Option offers more choice, control and flexibility over your services, as well as more responsibility. Additional assistance is available if you choose this option. You will choose an
independent support broker who will help you develop your individual budget and help you recruit employees. You will also work with a financial management service that will help you carry out your responsibilities as an employer and will pay your workers on your behalf. Required service components To participate in the consumer choices option, a member must: • Hire an independent support broker. • Work with a financial management service provider that is enrolled as a Medicaid HCBS waiver service provider. AmeriHealth Caritas Iowa | 58
Long-Term Services and Supports Self-directed care
If you can’t perform some or all of these duties:
Self-direction gives you more choice and control over who provides your services and how your care is given. If you choose to self-direct your services, you employ the employee who will provide your services. You are the employer of the caregivers who work for you. You must be able to do the things that an employer would do, such as:
Choose a family member, friend or someone close to you to act as an employer. This person is called an “employer representative.” Select someone who knows you very well and is dependable. Your employer representative cannot get paid for performing these duties and must: • Be at least 18 years old.
Hiring and training your employee: • Develop a job description for your employee. • Find, interview and hire an employee to provide care for you. • Define your employee’s job duties. • Train your employee to deliver your care based on your needs and likes. • Set and manage your employee’s schedule: ͞͞ Set a work schedule in advance of when your employee should start and end the work day. ͞͞ Make sure your employee documents each time he or she starts and ends the work day. ͞͞ Make sure your employee does not work beyond approved work hours. ͝͝ If you think your employees are working more hours than they are budgeted for, contact your case manager or AmeriHealth Caritas Iowa Member Services. Supervising your employee: • Observe your employee. • Evaluate how your employee performs job duties. • Address problems or concerns with how your employee performs job duties. • Discontinue working with an employee when needed. Overseeing your employee’s pay and service notes: • Make sure your employee starts and ends the day based on the work schedule. • Keep good notes in your home about how well your employee provides care. • Develop a back-up plan to address times that a scheduled employee is not available or doesn’t show up. You must plan ahead since you cannot be without services. • Activate your back-up plan when needed. 59 | Member Handbook
• Know you very well. • Understand the kinds of care you need and how you want care to be given. • Know your schedule and routine. • Know your health care needs and the medicine you take. • Be willing and able to do all of the things that are required to be in self-direction. You can pay a family member or friend to provide self-directed care but you cannot pay your employer representative to provide your care. Enrolling in self-directed care Services and the care you need are listed in your care plan. You receive the same services whether you choose self-directed care or not. You receive only the services you need that are listed in your care plan. You may choose to split care between a self-directed employee and home care from providers in our network that you do not employ. Talk with your case manager about self-directed care if you are interested. Your case manager will have you complete an assessment, determine if you are eligible and work with you to enroll in self-directed care if you want. You will continue with your current plan of care until self-directed care is set up. You must have support in place to give you the care you need until self-directed care is set up. You may start or stop self-directed care at any time. You will still receive services if you stop self-directed care. The only change is you will receive the services you need from a provider in the AmeriHealth Caritas Iowa network. Please contact your case manager or AmeriHealth Caritas Iowa Member Services if you wish to stop self-directed care.
Long-Term Services and Supports Excluded services Costs of the following items and services cannot be included in your individual budget and cannot be self-directed: • Child care services. • Clothing not related to an assessed medical need. • Conference, meeting or similar venue expenses other than the costs of approved services needed while attending the conference, meeting or similar venue. • Costs associated with shipping items. • Experimental and non-FDA-approved medications, therapies or treatments. • Goods or services covered by other Medicaid programs. • Home furnishings such as comforters, linens or drapes. • Home repairs or home maintenance. • Homeopathic treatments. • Insurance premiums or copayments of any kind, including home insurance, vehicle insurance, etc. • Items purchased on installment payments. • Motorized vehicles. • Nutritional supplements, such as vitamins or herbal supplements. • Personal entertainment items. • Repairs and maintenance of motor vehicles. • Room and board, including rent or mortgage payments. • School tuition. • Service animals. • Services covered by third parties or services that are the responsibility of a non-Medicaid program. • Sheltered workshop services. • Social or recreational purchases not related to an assessed need or goal identified in the member’s service plan. • Vacation expenses, other than the costs of approved services needed while on vacation. Facility-based services • If you qualify for certain levels of care, you may choose to receive that care in a facility. The facility you choose must be contracted with AmeriHealth Caritas Iowa to be in our provider
network and must be willing and able to provide the care you need. AmeriHealth Caritas Iowa will pay for: ͞͞ Intermediate care or skilled care in a nursing facility. ͞͞ Services in an intermediate care facility for persons with intellectual disabilities. ͞͞ Services in a nursing facility for persons with mental illness for members who have been determined to be eligible by DHS. • In general, facilities provide all the services a qualifying member needs. When you may have to pay for long-term services and supports You may have to pay a part of the cost of your care. This is called client participation. The amount of client participation depends on your income and is calculated by DHS. You must pay the client participation amount to the facility service provider if you live in: • A nursing facility for intermediate or skilled care. • An intermediate care facility for persons with intellectual disability. • A nursing facility for persons with mental illness. If you have client participation and receive services through a waiver, your case manager will determine the providers to whom you must pay the client participation amount. If you have questions about client participation, contact your case manager at 1-855-332-2440/ TTY 1-844-214-2471. Money Follows the Person (MFP) DHS has a federal grant to provide 1 year of funding to certain people who are in institutions and want to move into community-based settings. These enhanced services are coordinated by DHS. AmeriHealth Caritas Iowa will assign communitybased case managers to work with DHS transition specialists who manage services paid through the MFP grant. This will ensure a smooth transition to the home- and community-based waiver when the grant funding ends.
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Long-Term Services and Supports Hospice Benefits Hospice benefits are provided to care for terminally ill members. Hospice provides care and support for members that are determined by their provider to have 6 months or less to live due to a medical condition. Members may choose to stay in their home to receive care or in a nursing facility. Either way the member will receive appropriate care during this difficult time. Some of the covered services include the following: • Nursing care. • Medical social services. • Physician services. • Counseling services. • Medical devices and supplies, including medications as needed for the palliation and management of the member’s terminal diagnosis.
Role of the Long-Term Care Ombudsman The Long-Term Care Ombudsman Program is an Iowa state government program that protects and promotes the rights and quality of life for people who live in nursing facilities and those who receive home- and community-based services. An ombudsman, or public advocate, has hands-on working relationships with the residents and staff of the facilities in their areas. They inform nursing facility residents, people with disabilities and their families of their rights. If you need assistance and receive long-term care services or HCBS waiver services, independent advocacy services are available to assist you with education and information; advocacy; outreach; complaint resolution and grievances, appeals and state fair hearings. Contacting your local Long-Term Care Ombudsman
The Long-Term Care Ombudsman Program is available to all current residents and facility residents. The state contact information is listed below. Contacting Iowa’s Long-Term Care Ombudsman Program
Call: 1-515-725-3333 Toll free: 1-866-236-1430 Fax: 1-515-725-3313
Write: Office of the State Long-Term Care Ombudsman 510 E 12th St., Ste. 2, Des Moines, Iowa 50319-9025 Website: www.state.ia.us/elderaffairs/advocacy/ ombudsman.html
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Notes
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Our mission We help people get care, stay well and build healthy communities. Our values • Advocacy. • Compassion. • Competence. • Dignity. • Diversity. • Hospitality. • Stewardship.
Call Member Services at 1 -855-332-2440 or TTY 1-844-214-2471. www.amerihealthcaritasia.com This handbook may be updated with additional text provided by DHS, or other information we feel is important for you to know. Revision date: October 2015 © 2015 AmeriHealth Caritas Iowa
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