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Solutions

Member Handbook

Medicaid Advantage Plus Plan Kings, New York, Queens and Richmond Counties HPAQMHB-0006-11 7.12

1-866-805-4589 n TTY 1-800-855-2880 8:00 a.m. to 8:00 p.m. Monday through Friday

healthplus.amerigroup.com

HEALTHPLUS, AN AMERIGROUP COMPANY MEDICAID ADVANTAGE PLUS MEMBER HANDBOOK 21 Penn Plaza 360 W. 31st St. Fifth Floor New York, NY 10001 1-866-805-4589 TTY 1-800-855-2880 healthplus.amerigroup.com

TABLE OF CONTENTS WELCOME TO THE HEALTHPLUS AMERIGROUP MEDICAID ADVANTAGE PLUS PLAN ............... 2 HELP FROM MEMBER SERVICES ............................................................................................. 2 YOUR HEALTHPLUS AMERIGROUP MEMBER HANDBOOK ....................................................... 2 ENROLLMENT IN THE MEDICAID AVANTAGE PLUS PROGRAM ................................................ 2 SERVICES COVERED BY THE HEALTHPLUS AMERIGROUP MEDICAID ADVANTAGE PLUS PROGRAM ............................................................................................................................. 3 SERVICE AUTHORIZATIONS AND ACTIONS.............................................................................. 9 MEDICAID SERVICES NOT COVERED BY OUR PLAN ………………………………………………………………12 FAMILY PLANNING .............................................................................................................. 13 SERVICES NOT COVERED BY THE MEDICAID ADVANTAGE PLUS PROGRAM ........................... 13 DISENROLLMENT FROM THE MEDICAID ADVANTAGE PLUS PROGRAM................................. 13 WHAT TO DO IF YOU HAVE A COMPLAINT ABOUT OUR PLAN OR WANT TO APPEAL A DECISION ABOUT YOUR CARE ............................................................................................. 14 MEDICAID RULES FOR APPEALS AND COMPLAINTS .............................................................. 15 MEMBER RIGHTS AND RESPONSIBILITIES ............................................................................. 22 ADVANCE DIRECTIVES ......................................................................................................... 22 HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID ADVANTAGE PLUS PROGRAM ........................................................................................................................... 23 NOTICE OF PRIVACY PRACTICES ........................................................................................... 24

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WELCOME TO THE HEALTHPLUS AMERIGROUP MEDICAID ADVANTAGE PLUS PLAN Welcome to the HealthPlus Amerigroup Medicaid Advantage Plus Plan. The Medicaid Advantage Plus program is especially designed for people who have Medicare and Medicaid and who need health and long-term care services like home care and personal care to stay in their homes and communities as long as possible. This handbook tells you about the added benefits HealthPlus Amerigroup covers since you are enrolled in the HealthPlus Amerigroup Medicaid Advantage Plus Plan. It also tells you how to request a service, file a complaint or grievance or disenroll from this plan. The benefits described in this handbook are in addition to the Medicare benefits described in the HealthPlus Amerigroup Amerivantage Specialty + Rx Medicare Evidence of Coverage. Keep this handbook with your Amerivantage Specialty + Rx Medicare Evidence of Coverage. You need both to learn what services are covered and how to get them. HELP FROM MEMBER SERVICES There is someone to help you in Member Services: Monday through Friday 8:00 a.m. to 8:00 p.m. local time Call 1-866-805-4589 (TTY/TDD 1-800-855-2880) If you need help at other times, you may leave a voicemail message or speak with our 24-hour Nurse HelpLine by calling the Member Services number listed above. YOUR HEALTHPLUS AMERIGROUP MEMBER HANDBOOK This handbook will help you understand your Medicaid Advantage Plus health plan. If you have questions or need help understanding your member handbook, call Member Services. HealthPlus Amerigroup also has the member handbook available upon request in a large print version, an audio-taped version and a Braille version. The other side of this handbook is in Spanish. ENROLLMENT IN THE MEDICAID ADVANTAGE PLUS PROGRAM Eligibility Medicaid Advantage Plus is a program for people who have both Medicare and Medicaid. You are eligible to join the Medicaid Advantage Plus Plan if you are also enrolled in the Amerivantage Specialty + Rx Plan for Medicare coverage and: Are age 18 and older Reside in the plan’s service area – Kings, New York, Queens or Richmond County

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Have a chronic illness or disability that makes you eligible for services usually provided in a nursing home Are able to stay safely at home at the time you join the plan Are expected to need one or more of the following services for at least 120 days from the date you join our plan: − Nursing services in the home − Therapies in the home − Home health aide services − Personal care services in the home − Adult day health care − Social day care if used instead of in-home personal care services The coverage explained in this handbook becomes effective on the date of your enrollment in the HealthPlus Amerigroup Medicaid Advantage Plus Plan. Enrollment in the Medicaid Advantage Plus Plan is voluntary. Re-enrollment If you are disenrolled from the HealthPlus Amerigroup Medicaid Advantage Plus Plan because you are no longer eligible but become eligible again within 3 months, you will be re-enrolled in the plan if you remain enrolled in the HealthPlus Amerigroup Amerivantage Specialty + Rx Plan unless: The HealthPlus Amerigroup Medicaid Advantage Plus Plan is no longer offered where you live You let us know in writing that you wish to enroll in another managed care plan’s Medicaid and Medicare Advantage plans If You Are Pregnant Call HealthPlus Amerigroup Member Services when you find out you are pregnant and after your baby is born. We will need to get information about the birth of your child. We will notify the LDSS of your child’s birth within 5 days from when you contact HealthPlus Amerigroup. SERVICES COVERED BY THE HEALTHPLUS AMERIGROUP MEDICAID ADVANTAGE PLUS PROGRAM Deductibles and Copayments on Medicare Covered Services Many of the services you receive, including inpatient and outpatient hospital services, doctor visits, emergency services and laboratory tests, are covered by Medicare and are described in the Amerivantage Specialty + Rx Medicare Evidence of Coverage. Chapter 3 of the Amerivantage Specialty + Rx Medicare Evidence of Coverage explain the rules for using plan providers and getting care in a medical emergency or if urgent care is needed. Some services have deductibles and copayments. These amounts are shown in the Benefit Chart in Chapter 4 of the Amerivantage Specialty + Rx Medicare Evidence of Coverage under the column What You Must Pay When You Get These Covered Services.

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Because you have joined the Medicaid Advantage Plus Plan and you have Medicaid, Medicaid Advantage Plus will pay these amounts. You do not have to pay these deductibles and copayments except for those that apply to pharmacy items. If there is a monthly premium for benefits (see Chapter 4 of the Amerivantage Specialty + Rx Medicare Evidence of Coverage), you will not have to pay that premium since you have Medicaid. We will also cover many services that are not covered by Medicare but are covered by Medicaid. The sections below explain what is covered. Care Management Services As a member of our plan, you will get care management services. Our plan will provide you with a Care Manager who is a health care professional – usually a nurse or a social worker. Your Care Manager will work with you and your doctor to decide the services you need and develop a care plan. Your Care Manager will also arrange appointments for any services you need and arrange transportation to get those services. Your Care Manager is an employee of HealthPlus Amerigroup and is the individual you speak with when you call HealthPlus Amerigroup about your long-term care needs. Your Care Manager is responsible for seeking and coordinating creative solutions to help meet your health and long-term care needs while ensuring quality outcomes with the goal of ensuring functionality and quality of life. Your Care Manager will: Create a care plan considering your wishes, health and long-term care needs Obtain authorization for your services Make your access to needed services as easy as possible by coordinating and integrating covered and non-covered acute and long-term care services A Registered Nurse with expertise in community-based home care will also make periodic visits to your home to reassess your condition. Your Care Manager will speak with you, the registered nurse reassessing your condition and your physician(s) to authorize and order the services outlined in the plan of care that is personally designed for you. Your Care Manager will work cooperatively with you, your primary care physician and other health care professionals (such as your home health care provider, nurses and physical therapists) to coordinate all of your health-care needs, both covered and non-covered services. Your Care Manager is matched, based upon availability, to best meet your individual language and cultural needs. Additional Covered Services Because you have Medicaid and qualify for the Medicaid Advantage Plus program, our plan will arrange and pay for the extra health and social services described below. You may get these services as long as they are medically necessary; this means they are needed to prevent or treat your illness or disability. Your Care Manager will help identify the services and providers you need. In some cases, you may need a referral or an order from your doctor to get these services. You must get these services from providers who are in the HealthPlus Amerigroup Medicaid Advantage Plus network. If you cannot find a provider in our network with appropriate training or experience to meet your needs, you may obtain a referral to a healthCall HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -4-

care provider outside our network. In the event you require an out-of-network provider, please contact your Care Manager to assist you in obtaining an approval. If you do not get the required approval, the provider will not be paid for services. If you have questions regarding this process, please contact our Member Services department at 1-866-805-4589. Personal Care These services include help with personal hygiene, dressing and eating, walking, preparing meals and housekeeping. Services must be needed to maintain your health and safety in your own home. Personal care must be medically needed and ordered by your physician and provided by a qualified person according to your plan of care. Prior approval from HealthPlus Amerigroup is required. Call Member Services. A Member Services representative will assist you with your needs or transfer your request to your Care Manager. Home Health Care Services Not Covered by Medicare These services covered by Medicaid include nursing, home health aide and occupational, physical and speech therapies. The services must be ordered by your physician. Prior approval from HealthPlus Amerigroup is required. Contact Member Services. A Member Services representative will assist you with your needs or transfer your request to your Care Manager. Durable Medical Equipment Not Covered by Medicare These services covered by Medicaid include things such as tub stools and grab bars. These services must be ordered by your physician. Prior approval from HealthPlus Amerigroup is required. Call Member Services. A Member Services representative will assist you with your needs or transfer your request to your Care Manager. Hearing Services and Products These services covered by Medicaid are in excess of the Amerivantage Specialty + Rx Plan annual benefit limit. They include hearing services and products when medically needed to ease disability caused by the loss or damage of hearing. Services include hearing aid selecting, fitting and dispensing; hearing aid checks after dispensing, conformity evaluations and hearing aid repairs; audiology services including exams and testing; hearing aid evaluations and hearing aid prescriptions; and hearing aid products such as hearing aids, earmolds, special fittings and replacement parts. You may access these services directly. No approval is needed.

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Vision Services These include services given by vision care professionals and coverage of glasses, contact lenses and low vision aids and services. They are in excess of the services covered under your Amerivantage Specialty + Rx Plan. Replacements of glasses that are lost, damaged or destroyed are also covered. You may access these services directly. Medical and Surgical Supplies, Enteral and Parenteral Formula and Hearing Aid Batteries These items are generally considered to be one-time only use, consumable items routinely paid for under the durable medical equipment category of fee-for-service Medicaid. No approval is needed for hearing aid batteries. Medical and surgical supplies and enteral and parenteral formula supplements must be ordered by your physician. Your provider must also request prior approval from HealthPlus Amerigroup for these items. Call Member Services. A Member Services representative will assist you with your needs or transfer your request to your Care Manager. Nutritional Counseling Nutrition services include: − Assessing your nutrition needs and food patterns − Setting up a plan for having foods and drink that suit your physical and medical needs − Offering classes on nutrition and counseling to meet normal and therapeutic needs These services may also include assessing your nutrition status and the foods you prefer, planning the right diet intake within your home and setting up a treatment plan. These services must be ordered by your physician and given by a qualified nutritionist. Medical Social Services These services include assessing the need for services, arranging for them and providing aid for social problems related to caring for a patient in the home. These services must be performed by a qualified social worker and given based on a plan of care. Prior approval from HealthPlus Amerigroup is required. Call Member Services. A Member Services representative will assist you with your needs or transfer your request to your Care Manager. Home Delivered Meals and/or Meals in a Group Setting Such as a Day Care Facility Home-delivered meals and meals offered in a group setting are meals provided to persons who cannot prepare meals or have them prepared. No approval is needed for meals offered in a group setting. Prior approval from HealthPlus Amerigroup is required for home delivered meals. Call Member Services. A Member Services representative will assist you with your needs or transfer your request to your Care Manager. Call HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -6-

Social Day Care Social day care is a complete program which provides functionally impaired individuals with socialization; supervision and monitoring; personal care; and nutrition in a protective setting during any part of the day, but for less than a 24-hour period. Services may include and are not limited to maintaining and improving daily living skills, transportation and caregiver help. Prior approval from HealthPlus Amerigroup is required. Call Member Services. A Member Services representative will assist you with your needs or transfer your request to your Care Manager. Nonemergency Transportation These services are covered when needed to get necessary medical care and services covered under the plan’s benefits or Medicaid fee-for-service. Services include transport by ambulance, invalid coach, taxicab, livery, public transportation or other means fitting to an enrollee’s medical condition. These services also include transportation for an attendant to accompany the enrollee, if needed. For members with disabilities, the method of transport will provide for the member’s needs and take into account the nature of the disability. Call Member Services to schedule nonemergency transportation. Private Duty Nursing Private duty nursing services are provided by a registered professional nurse or licensed practical nurse. Private duty nursing can be provided through an approved certified home health agency, a licensed home care agency or a private practitioner. These services may be given in a facility under certain conditions but are commonly given in the member’s home. Services are covered when the attending physician decides these services are medically needed. Nursing services may be given part-time or ongoing according to the written treatment plan of the ordering physician, registered physician assistant or certified nurse practitioner. Prior approval from HealthPlus Amerigroup is required. Call Member Services. A Member Services representative will assist you with your needs or transfer your request to your Care Manager. Dental Covered dental services include needed preventive, prophylactic and other routine dental care, services and supplies to lessen a serious health condition. Ambulatory or inpatient surgical dental services are covered when not covered by Medicare.

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HealthPlus Amerigroup has chosen Healthplex to arrange for your dental care. If you have questions about your dental benefits, call Healthplex toll free at 1-800-468-9868 (TTY 1-800662-1220). No approval is needed for routine dental care. Procedures requiring anesthesia and ambulatory or inpatient surgical dental services must first be approved by Healthplex. If approved, your provider must also request prior approval from HealthPlus Amerigroup by calling 1-866-805-4589.

Social and Environmental Supports These services and items support the medical needs of the member and are part of the member’s plan of care. They include but are not limited to: − Home maintenance tasks − Homemaker/chore services − Housing improvement − Respite care Prior approval from HealthPlus Amerigroup is required. Call Member Services. A Member Services representative will assist you with your needs or transfer your request to your Care Manager. Personal Emergency Response System Personal Emergency Response System (PERS) is an electronic device which allows certain high-risk patients to get help in case of a physical, emotional or environmental emergency. The PERS is linked to the patient’s phone and signals a response center once a help button is set off. If there is an emergency, the signal is received and acted on by a response center. Prior approval from HealthPlus Amerigroup is required. Call Member Services. A Member Services Representative will assist you with your needs or transfer your request to your Care Manager. Adult Day Health Care Adult day health-care is care and services given in a residential health care site or other approved extension site under the medical direction of a physician. The care is given to a person who is functionally impaired and not homebound and needs certain preventive diagnostic, therapeutic and rehabilitative care or services. Services include: medical, nursing, food and nutrition, social services, rehab therapy, a planned program of diverse leisure time events, dental, pharmacy and other services. These services must be ordered by your physician.

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Prior approval from HealthPlus Amerigroup is required. Call Member Services. A Member Services Representative will assist you with your needs or transfer your request to your Care Manager. Nursing Home Care not covered by Medicare (provided you are eligible for institutional Medicaid) Skilled nursing facility days given by a licensed facility are covered for Medicaid Advantage Plus members in excess of the first 100 days in the Medicare Advantage benefit period. These services must be ordered by your physician. Prior approval from HealthPlus Amerigroup is required. Call Member Services. A Member Services Representative will assist you with your needs or transfer your request to your Care Manager. Inpatient Mental Health Care Over the 190-day Lifetime Medicare Limit SERVICE AUTHORIZATIONS AND ACTIONS When HealthPlus Amerigroup determines that services are covered solely by Medicaid, we will make decisions about your care following these rules: Prior Authorization Some covered services require prior authorization (approval in advance) from your physician, HealthPlus Amerigroup or both before you receive them or in order to be able to continue receiving them. You or someone you trust can ask for this. The following treatments and services must be approved for coverage before you get them: HealthPlus Amerigroup Medicaid Advantage Plus Benefit

Physician Order Required

HealthPlus Amerigroup Authorization Required

Personal Care

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Home Health Care Services

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Durable Medical Equipment

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Nutritional Counseling

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Medical Social Services

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Home Delivered Meals

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Social Day Care

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Nonemergency Transportation

Call Member Services

Private Duty Nursing

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Dental Care (no approval is needed for routine dental care) Social and Environmental Supports

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Personal Emergency Response System Adult Day Health care

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Nursing Home Care

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When you ask for approval of a treatment or service, it is called a service authorization request. To get a service authorization request, you or your doctor must call our Member Services department toll free at 1-866-805-4589. The Member Services representative will assist you with your needs or transfer your request to your Care Manager. You may also send your request in writing to: Medicaid Advantage Plus HealthPlus, an Amerigroup Company 21 Penn Plaza 360 W. 31st St., Fifth Floor New York, New York 10001 Services will be authorized in a certain amount and for a specific period of time. This is called an authorization period. You will also need to get prior authorization if you are getting one of these services now, but need to get more of the care during an authorization period. This is called concurrent review. What happens after we get your service authorization request? The health plan has a review team to be sure you get the services we promise. Doctors and nurses are on the review team. Their job is to be sure the treatment or service you asked for is medically needed and right for you. They do this by checking your treatment plan against accepted medical standards. Any decision to deny coverage of a service authorization request or to approve it for an amount that is less than requested is called an action. These decisions will be made by a qualified health care professional. If we decide that the requested service is not medically necessary, the decision will be made by a clinical peer reviewer who may be a doctor, nurse or health care professional who typically provides the care you requested. You can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity. After we get your request, we will review it under a standard or fast track process. You or your doctor can ask for a fast track review if it is believed that a delay will cause serious harm to your health. If your request for a fast track review is denied, we will tell you; and your request will be handled under the standard review process. In all cases, we will review your request as fast as your medical condition requires us to do so, but no later than mentioned below.

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We will tell you and your provider both by phone and in writing if your request is approved or denied. We will also tell you the reason for the decision. We will explain what options for appeals or fair hearings you will have if you don’t agree with our decision. Time frames for prior authorization requests: Standard review: We will make a decision about your request within 3 working days of when we have all the information we need, but you will hear from us no later than 14 days after we receive your request; we will tell you by the 14th day if we need more information Fast track review: We will make a decision, and you will hear from us within 3 working days; we will tell you by the third working day if we need more information Time frames for concurrent review requests: Standard review: We will make a decision within 1 working day of when we have all the information we need, but you will hear from us no later than 14 days after we receive your request Fast track review: We will make a decision within 1 working day of when we have all the information we need, but you will hear from us no later than 3 working days after we receive your request If we need more information to make either a standard or fast track decision about your service request, the time frames above can be extended up to 14 days. We will: Write and tell you what information is needed; if your request is in a fast track review, we will call you right away and send a written notice later Tell you why the delay is in your best interest Make a decision as quickly as we can when we receive the necessary information, but you will hear from us no later than 14 days from the end of the original time frame If you are not satisfied with our answer, you have the right to file an action appeal with us. See the Action Appeal section later in this handbook. You, your provider or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the plan to help decide your case. This can be done by calling 1-866-805-4589 or writing to: Medicaid Advantage Plus HealthPlus, an Amerigroup Company 21 Penn Plaza 360 W. 31st St., Fifth Floor New York, New York 10001 You or someone you trust can file a complaint with the plan if you don’t agree with our decision to take more time to review your request. You or someone you trust can also file a complaint about the review time with the New York State Department of Health by calling 1-866-712-7197. Call HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -11-

Other Decisions About Your Care Sometimes, we will do a concurrent review on the care you are receiving to see if you still need the care. We may also review other treatments and services you have already received. This is called retrospective review. We will tell you if we take these other actions. Time frames for notice of other actions: In most cases, if we make a decision to reduce, suspend or terminate coverage of a service we have already approved and you are now getting within an authorization period, we must tell you at least 10 days before we change the service If we are checking care that has been given in the past, we will make a decision about paying for it within 30 days of receiving necessary information for the retrospective review; if we deny payment for a service, we will send a notice to you and your provider the day the payment is denied; you will not have to pay for any care you received that was covered by the plan or by Medicaid even if we later deny payment to the provider MEDICAID SERVICES NOT COVERED BY OUR PLAN There are some Medicaid services that Medicaid Advantage Plus does not cover. You can get these services from any provider who takes Medicaid by using your Medicaid benefit card. Call Member Services at 1-866-805-4589 if you have a question about whether a benefit is covered by Medicaid Advantage Plus or Medicaid. Some of the services covered by Medicaid using your Medicaid benefit card include: Pharmacy Most prescription drugs are covered by Amerivantage Specialty + Rx Plan Medicare Part D as described in Chapter 5 of the Amerivantage Specialty + Rx Medicare Evidence of Coverage. Regular Medicaid will cover some drugs not covered by the Amerivantage Specialty + Rx Plan or Medicare. Medicaid may also cover drugs that we deny coverage under Medicaid Advantage Plus. Certain Mental Health Services, including: Intensive psychiatric rehabilitation treatment Day treatment Case management for seriously and persistently mentally ill (sponsored by state or local mental health units) Partial hospital care not covered by Medicare Rehabilitation services to those in community homes or in family-based treatment Continuing day treatment Assertive community treatment Personalized recovery-oriented services Certain Mental Retardation and Developmental Disabilities Services, including: Long-term therapies Day treatment Call HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -12-

Medicaid service coordination Services received under the Home and Community Based Services Waiver Other Medicaid Services Methadone treatment Comprehensive Medicaid case management Directly observed therapy for TB (Tuberculosis) Adult day treatment for persons with HIV/AIDS HIV COBRA case management FAMILY PLANNING Members may go to any Medicaid doctor or clinic that provides family planning care. You do not need a referral from your primary care provider. SERVICES NOT COVERED BY THE MEDICAID ADVANTAGE PLUS PROGRAM You must pay for services that are not covered by the HealthPlus Amerigroup Medicaid Advantage Plus Plan or by Medicaid if your provider tells you in advance that these services are not covered and you agree to pay for them. Examples of services not covered by Medicaid Advantage Plus or Medicaid are: Cosmetic surgery if not medically needed Personal and comfort items Fertility treatment and services Services from a provider who is not part of the plan (unless Medicaid Advantage Plus sends you to that provider) If you have any questions, call Member Services at 1-866-805-4589. DISENROLLMENT FROM THE MEDICAID ADVANTAGE PLUS PROGRAM You Can Choose to Disenroll You can ask to leave the Medicaid Advantage Plus Plan at any time for any reason by oral or written notice to the HealthPlus Amerigroup Medicaid Advantage Plus Plan. To request disenrollment, call Member Services toll free at 1-866-805-4589 for help or to get the right forms. The Member Services representative will assist you with your needs or transfer your request to your Care Manager. You may also send your disenrollment request in writing to: Medicaid Advantage Plus HealthPlus, an Amerigroup Company 21 Penn Plaza 360 W. 31st St., Fifth Floor New York, New York, 10001

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It could take up to 6 weeks to process, depending on when your request is received. You may disenroll to regular Medicaid or join another health plan as long as you qualify. You Will Have to Leave the Medicaid Advantage Plus Program if you: No longer are in the Amerivantage Specialty + Rx Plan for your Medicare coverage Need nursing home care, but are not eligible for institutional Medicaid because of a transfer of assets Are out of the plan’s service area for more than 90 consecutive days Permanently move out of the Medicaid Advantage Plus service area No longer require a nursing home level of care Join a long-term home health care program or a home and community-based services waiver program or are enrolled in a program or become a resident in a facility that is under the auspices of the Offices of Mental Health, Mental Retardation and Developmental Disabilities or Alcoholism and Substance Abuse Services We Can Ask You to Leave the Plan We will ask that you leave our Medicaid Advantage Plus Plan if: You are asked to leave our Medicare Amerivantage Plan (see Chapter 10 of the Amerivantage Specialty + Rx Plan Medicare Evidence of Coverage for reasons when Amerivantage must end your membership in our plan) You, a family member or an informal caregiver behaves in a way that prevents the plan from providing the care you need You provide fraudulent information on an enrollment form or permit abuse of care in the Medicaid Advantage Plus Plan You fail to pay money owed to the plan You knowingly fail to complete and submit any necessary consent or release WHAT TO DO IF YOU HAVE A COMPLAINT ABOUT OUR PLAN OR WANT TO APPEAL A DECISION ABOUT YOUR CARE As a dually-eligible member of our plan, you may make complaints and appeals about your services based on whether HealthPlus Amerigroup determines the services are covered by Medicare or Medicaid. For complaints and appeals about a service that is covered only by Medicare (e.g., chiropractic services), you will follow the rules outlined in Chapter 9 of the HealthPlus HealthPlus Amerigroup Amerivantage Specialty + Rx Plan Medicare Evidence of Coverage For complaints and appeals about a service that is covered only by Medicaid (e.g., personal care services, private duty nursing, nonemergency transportation, dental services, etc.), you will follow the Medicaid rules listed below For complaints and appeals about all other services covered by Medicaid Advantage Plus, you may choose to follow either the Medicare rules outlined in Chapter 9 of the Amerivantage Specialty + Rx Plan Evidence of Coverage or the Medicaid rules described below

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If you choose to follow the Medicare rules, you cannot use your Medicaid complaint and appeal rights, including the right to a state fair hearing regarding the complaint or appeal. But if you choose to follow the Medicaid rules, you will have up to 60 days from the day of the HealthPlus Amerigroup Medicaid Advantage Plus notice of denial of coverage to use your Medicare complaint and appeal rights. HealthPlus Amerigroup will explain the complaints and appeals processes available to you, depending on the complaint you have. Call Member Services at 1-866-805-4589 to get more information on your rights and the options available to you. MEDICAID RULES FOR APPEALS AND COMPLAINTS Action Appeals If you are not satisfied with our decisions about your Medicaid care, there are steps you can take. Your provider can ask for reconsideration: If we made a decision about your service authorization request without talking to your doctor, your doctor may ask to speak with the plan’s Medical Director. The Medical Director will talk to your doctor within 1 working day. You can file an action appeal: If you are not satisfied with an action we took or what we decide about your service authorization request, you have 45 business days after hearing from us to file an appeal You can do this yourself or ask someone you trust to file the appeal for you; you can call Member Services at 1-866-805-4589 if you need help filing an appeal We will not treat you any differently or act badly toward you because you file an appeal The appeal can be made by phone or in writing; if you make an appeal by phone, it must be followed up in writing Your action appeal will be reviewed under the fast track process if: You or your doctor asks to have your appeal reviewed under the fast track process; your doctor would have to explain how a delay will cause harm to your health; if your request for fast track is denied, we will tell you; and your appeal will be reviewed under the standard process Your request was denied when you asked to continue receiving care that you are now getting or need to extend a service that has been provided Fast track appeals can be made by phone and do not have to be followed up in writing. What happens after we get your appeal? Within 15 days, we will send you a letter to let you know we are working on your appeal. We will let you know if we need additional information to make our decision Action appeals of clinical matters will be decided by qualified health care professionals who did not make the first decision; at least one person will be a clinical peer reviewer

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Non-clinical decisions will be handled by persons who work at a higher level than the people who worked on your first decision Before and during the appeal, you or your designee can see your case file, including medical records and any other documents and records being used to make a decision on your case You can also provide information to be used in making the decision in person or in writing You will be given the reasons for our decision and our clinical rationale, if it applies; if you are still not satisfied, you will be informed of any further appeal rights you have; or you or someone you trust can file a complaint with the New York State Department of Health at 1-866-712-7197 Time frames for action appeals: Standard appeals: If we have all the information we need, we will tell you our decision within 30 days from when we receive your appeal; a written notice of our decision will be sent within 2 working days from when we make the decision Fast track appeals: If we have all the information we need, we will make fast track appeal decisions within 2 working days from when we receive the necessary information; we will tell you within 3 working days after you give us your appeal if we need more information; we will tell you our decision by phone and send a written notice later If we need more information to make either a standard or fast track decision about your action appeal within the above time frames, we will: Write you and tell you we need more time to collect the information; if your request is in a fast track review, we will call you right away and send a written notice later Tell you why the delay is in your best interest Make a decision no later than 14 days from the day we asked for more information You, your provider or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the plan to help decide your case. This can be done by calling Member Services at 1-866-805-4589 or writing to: Medicaid Advantage Plus HealthPlus, an Amerigroup Company 21 Penn Plaza 360 W. 31st St., Fifth Floor New York, New York 10001 You or someone you trust can file a complaint with the plan if you don’t agree with our decision to take more time to review your action appeal. You or someone you trust can also file a complaint about the review time with the New York State Department of Health by calling 1-866-712-7197. If your original denial was because we said the service was not medically necessary or was experimental or investigational and we do not tell you our decision about your appeal, the Call HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -16-

original denial against you will be reversed. This means your service authorization request will be approved. Aid to continue while appealing a decision about your care: In some cases you may be able to continue receiving the services while you wait for your appeal to be decided. You may be able to continue the services that are scheduled to end or be reduced if you ask for an appeal: Within 10 days from being told that your request is denied or care is changing By the date the change in services is scheduled to occur If your appeal results in another denial, you may have to pay for the cost of any continued benefits that you received. If we deny your appeal and you are not satisfied, you can appeal further using the external appeals process or fair hearing process described below. External Appeals If the plan decides to deny coverage for a medical service you and your doctor asked for because it is not medically needed or because it is experimental or investigational, you can ask New York State for an independent external appeal. This is called an external appeal, because it is decided by reviewers who do not work for the health plan or the State. These reviewers are qualified people approved by New York State. The service must be in the plan’s benefit package or be an experimental treatment. You do not have to pay for an external appeal. Before you appeal to the State, you must file an action appeal with the plan and get the plan’s final adverse determination, or: If you had a fast track action appeal and are not satisfied with the plan’s decision, you can choose to file a standard action appeal with the plan or go directly to an external appeal, or You and the plan may agree to skip the plan’s appeals process and go directly to an external appeal You have 45 days after you receive the plan’s final adverse determination to ask for an external appeal. If you and the plan agreed to skip the plan’s appeals process, then you must ask for the external appeal within 45 days of when you made that agreement. Additional appeals to your health plan may be available to you if you want to use them. However, if you want an external appeal, you must still file the application with the State Department of Insurance within 45 days from the time the plan gives you the notice of final adverse determination or when you and the plan agreed to waive the plan’s appeal process. You will lose your right to an external appeal if you do not file an application for an external appeal on time.

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To ask for an external appeal, fill out an application and send it to the State Insurance Department. You can call Member Services at 1-866-805-4589 if you need help filing an appeal. You and your doctors will have to give information about your medical problem. Here are some ways to get an application: Call the State Insurance Department, 1-800-400-8882 Go to the State Insurance Department’s web site at www.ins.state.ny.us Contact the health plan at 1-866-805-4589 Your external appeal will be decided in 30 days. More time (up to 5 working days) may be needed if the external appeal reviewer asks for more information. You and the plan will be told the final decision within 2 days after the decision is made. You can get a faster decision if your doctor says that a delay will cause serious harm to your health. This is called an expedited external appeal. The external appeal reviewer will decide an expedited appeal in 3 days or less. The reviewer will tell you and the plan the decision right away by phone or fax. Later, a letter will be sent that tells you the decision. You may also ask for a fair hearing if the plan decided to deny, reduce or end coverage for a medical service. You may request a fair hearing and ask for an external appeal. If you ask for a fair hearing and an external appeal, the decision of the fair hearing officer will be the one that counts. Complaints We hope our plan serves you well. If you have a problem with the care or treatment you receive from our staff or providers or you do not like the quality of care or services your receive from us, call Member Services at 1-866-805-4589. Please remember that complaints about services that are only a benefit under Medicare should be handled through the Amerivantage Specialty + Rx Plan Medicare complaint process. Complaints about services only covered by Medicaid should be handled through the HealthPlus Amerigroup Medicaid Advantage Plus complaint process. You can choose to use either the Medicare or Medicaid complaints process for complaints about services that HealthPlus Amerigroup determines are a benefit under both Medicare and Medicaid. If you file a complaint under the Medicare process, you will not be eligible to file a complaint appeal under the Medicaid process. Most problems can be solved right away. Problems that are not solved over the phone and relate to benefits under both Medicare and Medicaid services will be handled according to the procedures described below. You can ask someone you trust to file the complaint for you. If you need our help because you are deaf or hard of hearing or have low vision, or if you need translation services, we can help you. We will not make things hard for you or take any action against you for filing a complaint. How to file a complaint with the plan:

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To file by phone, call Member Services at 1-866-805-4589, Monday through Friday, 8:00 a.m. to 8:00 p.m. local time. If you call us after hours, leave a message. We will call you back the next working day. If we need more information to make a decision, we will tell you. You can send your complaint in writing to: Member Complaints, Appeals and Grievances HealthPlus, an Amerigroup Company P. O. Box 61116 Virginia Beach, VA 23466 What happens next? If we don’t solve the problem right away over the phone or after we get your written complaint, we will send you a letter within 15 working days. The letter will tell you: Who is working on your complaint How to contact this person If we need more information Your complaint will be reviewed by one or more qualified people. If your complaint involves clinical matters, your case will be reviewed by one or more qualified health care professionals. After we review your complaint: We will let you know our decision in 45 days of when we have all the information we need to answer your complaint, but you will hear from us in no more than 60 days from the day we get your complaint; we may need more information from you or the person you asked to file the complaint for you; if we do, we may extend the process for 14 days; if we extend the process, we will let you know in writing the reason for the delay; you may also ask us to extend the process if you have more details that we should review; we will write you and will tell you the reasons for our decision When a delay would risk your health, we will let you know our decision in 48 hours of when we have all the information we need to answer your complaint, but you will hear from us in no more than 7 days from the day we get your complaint; we will call you with our decision or try to reach you to tell you; you will get a letter to follow up our communication in 3 working days You will be told how to appeal our decision if you are not satisfied If we are unable to make a decision about your complaint because we don’t have enough information, we will send a letter and let you know Complaint Appeals If you disagree with a decision we made about your complaint, you or someone you trust can file a complaint appeal with the plan. Complaint appeals are only available through the Medicaid complaint and appeal process. How to make a complaint appeal: Call HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -19-

If you are not satisfied with what we decide, you have 60 business days after hearing from us to file an appeal You can do this yourself or ask someone you trust to file the appeal for you The appeal must be made in writing or by phone; if you make an appeal by phone, it must be followed up in writing What happens after we get your complaint appeal? After we get your complaint appeal, we will send you a letter within 15 working days. The letter will tell you: Who is working on your complaint appeal How to contact this person If we need more information Your complaint appeal will be reviewed by one or more qualified people at a higher level than those who made the first decision about your complaint. If your complaint appeal involves clinical matters, your case will be reviewed by one or more qualified health professionals who were not involved in making the first decision about your complaint. At least one person reviewing your case will be a clinical peer reviewer. We will let you know our decision within 30 working days from when we have all the information we need. If a delay would risk your health, you will get our decision in 2 working days of when we have all the information we need to decide the appeal. You will be given the reasons for our decision and our clinical rationale, if it applies. If you are still not satisfied, you or someone on your behalf can file a complaint at any time with the New York State Department of Health at 1-866-712-7197. Fair Hearings In some cases you may ask for a Fair Hearing from New York State. You may ask for a fair hearing within 60 days of receiving the notice of adverse determination if: You are not happy with a decision your local department of social services or the New York State Department of Health made about your staying or leaving the Medicaid Advantage Plus Program You are not happy with a decision that HealthPlus Amerigroup made about one of the services that you were getting; you feel the decision limits your Medicaid benefits or that the plan did not make the decision in a reasonable amount of time You are not happy with a decision that HealthPlus Amerigroup made that denied services; you feel that the decision limits your Medicaid benefits or that HealthPlus Amerigroup did not make the decision in a reasonable amount of time You are not happy with a decision that your doctor would not order one of the Medicaid services listed above that you wanted, and you feel the doctor’s decision stops or limits your Medicaid benefits; you must file a complaint and an appeal with HealthPlus Amerigroup, and if HealthPlus Amerigroup agrees with your doctor, you may ask for a state fair hearing. Call HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -20-

In some cases, you may be able to keep getting care the same way while waiting for your fair hearing. If you filed a complaint or appeal under Medicare rules, you may not request a state fair hearing about the same complaint or appeal. You are only eligible for a fair hearing if you file the complaint or appeal under Medicaid. You can use one of the following ways to request a fair hearing: By phone; call toll free 1-800-342-3334 By fax at 518-473-6735 By Internet at www.otda.state.ny.us/oah/forms.asp By mail: Fair Hearing Section NYS Office of Temporary and Disability Assistance P.O. Box 1930 Albany, NY 12201 Remember, you can file a complaint anytime to the New York State Department of Health by calling 1-866-712-7197. Call Member Services at 1-866-805-4589 if you have any questions.

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MEMBER RIGHTS AND RESPONSIBILITIES Your Rights As a member of HealthPlus Amerigroup Medicaid Advantage Plus, you have the right to: Receive information about HealthPlus Amerigroup and managed care Be treated with respect and concern for your dignity and privacy Get information on treatment options and alternatives presented in a manner and language you understand Take part in decisions about your health care, including the right to refuse treatment Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation Get a copy of your medical records and ask that the records be amended or corrected Your Responsibilities As a member of HealthPlus Amerigroup Medicaid Advantage Plus, you have the responsibility to: Receive all of your covered benefits through Medicaid Advantage Plus and get approval for services as required Provide clear and complete medical and personal information about yourself to your HealthPlus Amerigroup Medicaid Advantage Plus providers and representatives Contact us when you need help or have a question Follow your plan of care that was agreed upon and request changes as needed Maintain Medicaid Advantage Plus and Medicare eligibility Notify HealthPlus Amerigroup Medicaid Advantage Plus when you go away or out of town ADVANCE DIRECTIVES There may come a time when you can’t decide about your own health care. By planning in advance, you can arrange now for your wishes to be carried out. First, let family, friends and your doctor know what kinds of treatment you do or don’t want. Second, you can appoint an adult you trust to make decisions for you. Be sure to talk with your Primary Care Provider (PCP), your family or others close to you so they will know what you want. Third, it is best if you put your thoughts in writing. The documents listed below can help. You do not have to use a lawyer, but you may wish to speak with one about this. You can change your mind and these documents at any time. We can help you get these documents. They do not change your right to quality health care benefits. The only purpose is to let others know what you want if you can’t speak for yourself. Health Care Proxy - With this document, you name another adult that you trust (usually a friend or family member) to decide about medical care for you if you are not able to do so. If you do this, you should talk with the person so he or she knows what you want.

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Cardiopulmonary Resuscitation and Do Not Resuscitate - You have the right to decide if you want any special or emergency treatment to restart your heart or lungs if your breathing or circulation stops. If you do not want special treatment, including cardiopulmonary resuscitation (CPR), you should make your wishes known in writing. Your PCP will provide a Do Not Resuscitate (DNR) order for your medical records. You can also get a DNR form to carry with you and/or a bracelet to wear that will let any emergency medical provider know about your wishes. Organ Donor Card - This wallet-sized card says that you are willing to donate parts of your body to help others when you die. Also, check the back of your driver’s license to let others know if and how you want to donate your organs. HOW TO REPORT SOMEONE WHO IS MISUSING THE MEDICAID ADVANTAGE PLUS PROGRAM Fraud and abuse of the health care system creates waste of both time and money that could be spent on others who truly need these services. If you know someone who is misusing the Medicaid Advantage Plus program, we encourage you to report him or her. To report doctors, clinics, hospitals, nursing homes or Medicaid Advantage Plus enrollees, write or call HealthPlus Amerigroup at: Corporate Investigation Department HealthPlus, an Amerigroup Company P. O. Box 62509 Virginia Beach, VA 23462 1-866-805-4589 Suspicions of fraud and abuse can be e-mailed directly to the HealthPlus Amerigroup Corporate Investigations Department at [email protected]. Or go online at healthplus.amerigroup.com. Click the link for Report Waste, Fraud & Abuse to report details about a possible issue. This information is sent directly to the e-mail address above, which is checked every business day. You can also call the State of New York, Office of the Medicaid Inspector General’s Fraud and Abuse Unit at 1-877-873-7283.

HealthPlus Amerigroup is a culturally diverse company. We welcome all eligible individuals into our health care programs, regardless of health status. If you have questions or concerns, please call 1-866-805-4589 (TTY 1-800-855-2880) and ask for extension 34925. Or visit healthplus.amerigroup.com.

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NOTICE OF PRIVACY PRACTICES 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.

THIS NOTICE IS IN EFFECT APRIL 14, 2003. WHAT IS THIS NOTICE? This Notice tells you: How HealthPlus Amerigroup handles your protected health information How HealthPlus Amerigroup uses and gives out your protected health information Your rights about your protected health information The HealthPlus Amerigroup responsibilities in protecting your protected health information This Notice follows what is known as the HIPAA Privacy Regulations. These regulations were given out by the federal government. The federal government requires companies such as HealthPlus Amerigroup to follow the terms of the regulations and of this Notice. This Notice is also available on the HealthPlus Amerigroup web site at healthplus.amerigroup.com. NOTE: You may also get a Notice of Privacy Practices from the State and other organizations.

WHAT IS PROTECTED HEALTH INFORMATION? Protected Health Information (PHI) - The HIPAA Privacy Regulations define protected health information as: Information that identifies you or can be used to identify you Information that either comes from you or has been created or received by a health care provider, a health plan, your employer or a health care clearinghouse Information that has to do with your physical or mental health or condition, providing health care to you, or paying for providing health care to you. In this Notice, protected health information will be written as PHI.

WHAT ARE THE HEALTHPLUS AMERIGROUP RESPONSIBILITIES TO YOU ABOUT YOUR PROTECTED HEALTH INFORMATION?

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Your/your family’s PHI is personal. We have rules about keeping this information private. These rules are designed to follow state and federal requirements.

HealthPlus Amerigroup must: Protect the privacy of the PHI that we have or keep about you Provide you with this Notice about how we get and keep PHI about you Follow the terms of this Notice Follow state privacy laws that do not conflict with or are stricter than the HIPAA Privacy Regulations We will not use or give out your PHI without your authorization, except as described in this Notice.

HOW DO WE USE YOUR PROTECTED HEALTH INFORMATION? The sections that follow tell some of the ways we can use and share PHI without your written authorization. FOR PAYMENT - We may use PHI about you so that the treatment services you get may be looked at for payment. For example, a bill that your provider sends us may be paid using information that identifies you, your diagnosis, the procedures or tests and supplies that were used. FOR HEALTH CARE OPERATIONS - We may use PHI about you for health care operations. For example, we may use the information in your record to review the care and results in your case and other cases like it. This information will then be used to improve the quality and success of the health care you get. Another example of this is using information to help enroll you for health care coverage. We may use PHI about you to help provide coverage for medical treatment or services. For example, information we get from a provider (nurse, doctor or other member of a health care team) will be logged and used to help decide the coverage for the treatment you need. We may also use or share your PHI to: Send you information about one of our disease or case management programs Send reminder cards that let you know that it is time to make an appointment or get services like EPSDT or Child Health Checkup services Answer a customer service request from you Make decisions about claims requests and appeals for services you received Look into any fraud or abuse cases and make sure required rules are followed

OTHER USES OF PROTECTED HEALTH INFORMATION BUSINESS ASSOCIATES - We may contract with business associates that will provide services to HealthPlus Amerigroup using your PHI. Services our business associates may provide include Call HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -25-

dental services for members, a copy service that makes copies of your record and computer software vendors. They will use your PHI to do the job we have asked them to do. The business associate must sign a contract to agree to protect the privacy of your PHI. PEOPLE INVOLVED WITH YOUR CARE OR WITH PAYMENT FOR YOUR CARE - We may make your PHI known to a family member, other relative, close friend or other personal representative that you choose. This will be based on how involved the person is in your care or payment that relates to your care. We may share information with parents or guardians, if allowed by law. LAW ENFORCEMENT - We may share PHI if law enforcement officials ask us to. We will share PHI about you as required by law or in response to subpoenas, discovery requests and other court or legal orders. OTHER COVERED ENTITIES - We may use or share your PHI to help health care providers that relate to health-care treatment, payment or operations. For example, we may share your PHI with a health care provider so that the provider can treat you. PUBLIC HEALTH ACTIVITIES - We may use or share your PHI for public health activities allowed or required by law. For example, we may use or share information to help prevent or control disease, injury or disability. We also may share information with a public health authority allowed to get reports of child abuse, neglect or domestic violence. HEALTH OVERSIGHT ACTIVITIES - We may share your PHI with a health oversight agency for activities approved by law, such as audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative or criminal proceedings or actions. Oversight agencies include government agencies that look after the health care system; benefit programs including Medicaid and SCHIP; and other government regulation programs. RESEARCH - We may share your PHI with researchers when an institutional review board or privacy board has followed the HIPAA information requirements. CORONERS, MEDICAL EXAMINERS, FUNERAL DIRECTORS, AND ORGAN DONATION - We may share your PHI to identify a deceased person, determine a cause of death or do other coroner or medical examiner duties allowed by law. We also may share information with funeral directors, as allowed by law. We may also share PHI with organizations that handle organ, eye or tissue donation and transplants. TO PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY - We may share your PHI if we feel it is needed to prevent or reduce a serious and likely threat to the health or safety of a person or the public.

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TO PREVENT DELAYS IN TREATMENT - We may share your PHI to prevent delays in treatment. For example, if you switch health plans, we may share your PHI with your new health plan if we feel it is needed to avoid delays in your treatment. MILITARY ACTIVITY AND NATIONAL SECURITY - Under certain conditions, we may share your PHI if you are or were in the Armed Forces. This may happen for activities believed necessary by appropriate military command authorities. DISCLOSURES TO THE SECRETARY OF THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES - We are required to share your PHI with the Secretary of the United States Department of Health and Human Services. This happens when the Secretary looks into or decides if we are in compliance with the HIPAA Privacy Regulations.

WHAT ARE YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION? We want you to know your rights about your PHI and your HealthPlus Amerigroup family members’ PHI. RIGHT TO GET THE HEALTHPLUS AMERIGROUP NOTICE OF PRIVACY PRACTICES Each head of case or head of household will receive a printed copy of this Notice in the New Member Welcome package. We have the right to change this Notice. Once the change happens, it will apply to PHI that we have at the time we make the change and to the PHI we had before we made the change. A new Notice that includes the changes and the dates they are in effect will be mailed to you at the address we have for you. The changes to our Notice will also be included on our web site. You may ask for a paper copy of the Notice of Privacy Practices at any time. Call Member Services toll free at 1-800-600-4441. If you are deaf or hard of hearing and want to talk to Member Services, call the toll-free AT&T Relay Service at 1-800-855-2880. RIGHT TO REQUEST A PERSONAL REPRESENTATIVE You have the right to request a personal representative to act on your behalf, and HealthPlus Amerigroup will treat that person as if that person were you. Unless you apply restrictions, your personal representative will have full access to all of your HealthPlus Amerigroup records. If you would like someone to act as your personal representative, HealthPlus Amerigroup requires your request in writing. A personal representative form must be filled out and mailed back to the HealthPlus Amerigroup Member Privacy Unit. To ask for a personal representative form, please contact Member Services. We will send you a form to complete. The address and phone number are at the end of this Notice.

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RIGHT TO ACCESS You have the right to look at and get a copy of your enrollment, claims, payment and case management information on file with HealthPlus Amerigroup. This file of information is called a designated record set. We will provide the first copy to you in any 12-month period without charge. If you would like a copy of your PHI, you must send a written request to the HealthPlus Amerigroup Member Privacy Unit. The address is at the end of this Notice. We will answer your written request in 30 calendar days. We may ask for an extra 30 calendar days to process your request if needed. We will let you know if we need the extra time. We do not keep complete copies of your medical records; if you would like a copy of your medical record, contact your doctor or other provider; follow the doctor’s or provider’s instructions to get a copy; your doctor or other provider may charge a fee for the cost of copying and/or mailing the record We have the right to keep you from having or seeing all or part of your PHI for certain reasons; for example, if: − The release of the information could cause harm to you or other persons − The information was gathered or created for research or as part of a civil or criminal proceeding We will tell you the reason in writing. We will also give you information about how you can file an appeal if you do not agree with us. RIGHT TO AMEND You have the right to ask that information in your health record be changed if you think it is not correct. To ask for a change, send your request in writing to the HealthPlus Amerigroup Member Privacy Unit. We can send you a form to complete. You can also call Member Services to request a form. The address and phone number are at the end of this Notice. State the reason why you are asking for a change If the change you ask for is in your medical record, get in touch with the doctor who wrote the record; the doctor will tell you what you need to do to have the medical record changed We will answer your request within 30 days of when we receive it. We may ask for an extra 30 days to process your request if needed. We will let you know if we need the extra time. We may deny the request for change. We will send you a written reason for the denial if: The information was not created or entered by HealthPlus Amerigroup The information is not kept by HealthPlus Amerigroup You are not allowed by law to see and copy that information The information is already correct and complete Call HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -28-

RIGHT TO AN ACCOUNTING OF CERTAIN DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION You have the right to get an accounting of certain disclosures of your PHI. This is a list of times we shared your information when it was not part of payment and health care operations. Most disclosures of your PHI by our business associates or us will be for payment or health care operations. To ask for a list of disclosures, please send a request in writing to the HealthPlus Amerigroup Member Privacy Unit. We can send you a form to complete. For a copy of the form, contact Member Services. The address and phone number are at the end of this Notice. Your request must give a time period that you want to know about. The time period may not be longer than 6 years and may not include dates before April 14, 2003. RIGHT TO REQUEST RESTRICTIONS You have the right to ask that your PHI not be used or shared. You do not have the right to ask for limits when we share your PHI if we are asked to do so by law enforcement officials, court officials or State and Federal agencies in keeping with the law. We have the right to deny a request for restriction of your PHI. To ask for a limit on the use of your PHI, send a written request to the HealthPlus Amerigroup Member Privacy Unit. We can send you a form to fill out. You can contact Member Services for a copy of the form. The address and phone number are at the end of this Notice. The request should include: The information you want to limit and why you want to restrict access Whether you want to limit when the information is used, when the information is given out or both The person or persons that you want the limits to apply to We will look at your request and decide if we will allow or deny the request within 30 days. If we deny the request, we will send you a letter and tell you why. RIGHT TO CANCEL A PRIVACY AUTHORIZATION FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION We must have your written permission (authorization) to use or give out your PHI for any reason other than payment and health care operations or other uses and disclosures listed under Other Uses of Protected Health Information. If we need your authorization, we will send you an authorization form explaining the use for that information. You can cancel your authorization at any time by following the instructions below. Call HealthPlus Amerigroup Member Services at 1-866-805-4589 (TTY 1-800-855-2880) -29-

Send your request in writing to the HealthPlus Amerigroup Member Privacy Unit. We can send you a form to complete. You can contact Member Services for a copy of the form. The address and phone number are at the end of this Notice. This cancellation will only apply to requests to use and share information asked for after we get your Notice. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS You have the right to ask that we communicate with you about your PHI in a certain way or in a certain location. For example, you may ask that we send mail to an address that is different from your home address. Requests to change how we communicate with you should be submitted in writing to the HealthPlus Amerigroup Member Privacy Unit. We can send you a form to complete. For a copy of the form, contact Member Services. The address and phone number are at the end of this Notice. Your request should state how and where you want us to contact you.

WHAT SHOULD YOU DO IF YOU HAVE A COMPLAINT ABOUT THE WAY THAT YOUR PROTECTED HEALTH INFORMATION IS HANDLED BY HEALTHPLUS AMERIGROUP OR OUR BUSINESS ASSOCIATES? If you believe that your privacy rights have been violated, you may file a complaint with HealthPlus Amerigroup or with the Secretary of Health and Human Services. To file a complaint with HealthPlus Amerigroup or to appeal a decision about your PHI, send a written request to the HealthPlus Amerigroup Member Privacy Unit or call Member Services. The address and phone number are at the end of this Notice. To file a complaint with the Secretary of Health and Human Services, send your written request to: Office for Civil Rights U.S. Department of Health and Human Services 26 Federal Plaza, Suite 3312 New York, NY 10278 You will not lose your HealthPlus Amerigroup membership or health care benefits if you file a complaint. Even if you file a complaint, you will still get health care coverage from HealthPlus Amerigroup as long as you are a member.

WHERE SHOULD YOU CALL OR SEND REQUESTS OR QUESTIONS ABOUT YOUR PROTECTED HEALTH INFORMATION? You may call us toll free at 1-800-600-4441.

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Or you may send questions or requests, such as the examples listed in this Notice, to the address below: Member Privacy Unit HealthPlus, an Amerigroup Company 4425 Corporation Lane Virginia Beach, VA 23462 Send your request to this address so that we can process it in a timely manner. Requests sent to persons, offices or addresses other than the address listed above might be delayed. If you are deaf or hard of hearing, you may call the toll-free AT&T Relay Service at 1-800-855-2880.

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