Read 929-1029 NJ mbr hbk 1 10 text version

Your Healthy Life

Member Handbook New Jersey

Member Services:

1-800-941-4647

929-1029 1/10

Welcome to AmeriChoice!

We are glad that you chose AmeriChoice. AmeriChoice is part of UnitedHealth Group, which is the largest health care company in the country. We want to be sure you get off to a good start as a new member. This handbook tells you about the benefits and services available to you as our member. If you would like someone to explain any of these benefits or if you have any questions about your coverage, please call our Member Service Center at 1-800-941-4647 (English or languages other than Spanish), 1-800-943-4647 (Spanish) or 1-800-852-7897 (TTY/TDD). Please note: Welcome to AmeriChoice! is translated into the following languages: Arabic French/Creole Spanish Persian Vietnamese Turkish

¡Bienvenido(a) a AmeriChoice!

Nos alegra que haya elegido a AmeriChoice. AmeriChoice es parte de UnitedHealth Group, la empresa dedicada a la salud y al bienestar de las personas más grande del país. Queremos asegurarnos de que tenga un buen inicio como miembro nuevo. Este manual le informa sobre los beneficios y servicios a su disposición como nuestro miembro. Si necesita una explicación para cualquiera de estos beneficios o si tiene preguntas sobre su cobertura, llame a nuestro Centro de servicios para los Miembros al |1-800941- 4647 (inglés u otros idiomas que no sean español) o 1-800-852-7897 (TTY/TDD).

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AmeriChoice kontan sèvi w!

Nou kontan se AmeriChoice ou chwazi. AmeriChoice se yon pati nan UnitedHealth Group, ki se pi gwo konpayi pou sante ak byennèt nan peyi a. Nou vle sèten ou byen derape, kòm manm tou nèf. Tiliv sa a ap ba w enfòmasyon sou avantaj ak sèvis ou kapab jwenn kòm manm nou. Si w ta vle yon moun esplike w nenpòt avantaj sa yo oswa si w gen nenpòt kesyon sou kouvèti w la, rele Sant Sèvis Kliyan nou an, nan 1-800-941-4647 (pou lang angle ak pou lòt lang ki pa panyòl) oswa 1-800-852-7897 (aparèy TTY/TDD).

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What is AmeriChoice?

AmeriChoice will work with you and your AmeriChoice doctor to make sure that you get all the services you need to stay healthy. There are no limits on the number of times you may see your AmeriChoice doctor for health care. AmeriChoice has doctors in all of New Jersey's 21 counties. Our staff is available to you 24 hours a day, 7 days a week, to answer your questions and to help you get quality health care. You can be a member of AmeriChoice while you are eligible for NJ FamilyCare/Medicaid. Your benefits are decided by the State of New Jersey. The different NJ FamilyCare benefit packages will be explained later in this handbook. The Division of Medical Assistance and Health Services must approve your enrollment in AmeriChoice. It may take between 30 and 45 days after you apply to join AmeriChoice for your membership to become effective. Coverage with AmeriChoice will become effective on the first day of the month after you are approved. If you are covered by Medicaid or NJ FamilyCare A before your coverage with AmeriChoice becomes effective, you will be able to get the health care you need from the regular Medicaid fee-for-service program or from the health plan you belonged to before you joined AmeriChoice. If you are getting medical services before your enrollment with AmeriChoice, you should call and give us: · A listing of the services that you are receiving · The names of the doctors that you are seeing · The locations where you are seeing them

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Contents

WELCOME TO AMERICHOICE! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i WHAT IS AMERICHOICE?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii THE AMERICHOICE MEMBER SERVICE CENTER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 GETTING TO KNOW AMERICHOICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 YOUR AMERICHOICE MEMBER ID CARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 YOUR PERSONAL DOCTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 GETTING TO KNOW YOUR PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 IF YOU WISH TO CHANGE YOUR PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 IF YOUR PROVIDER LEAVES AMERICHOICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 BENEFITS SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 SUMMARY OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 WHEN YOU HAVE AN EMERGENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 URGENT CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 ROUTINE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 SPECIALIST CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 HOSPITAL CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 SPECIAL NEEDS MEMBERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 APPOINTMENTS WITH DOCTORS AND OTHER HEALTH CARE PROVIDERS . . . . . . . . . . . . . . . . . . . . . . . . . . 21 SECOND OPINIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 SELF-REFERRAL SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 DENTAL CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 VISION EXAMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 AMERICHOICE ROUTINE VISION CARE BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 MEDICAL TRANSPORTATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 PRESCRIPTION DRUGS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 PRENATAL (PREGNANCY) CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 CARE FOR CHILDREN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 EPSDT PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 IF YOU WANT TO APPEAL A DECISION BY AMERICHOICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 IF YOU HAVE A PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

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IF YOU GET A BILL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 OTHER INSURANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 LEAVING AMERICHOICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 LIVING WILLS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 MEDICAID BENEFITS RECEIVED AFTER AGE 55 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 TREATMENT OF MINORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 HOW AMERICHOICE PAYS ITS PROVIDERS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 YOUR RIGHTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 NEW JERSEY HMO CONSUMER BILL OF RIGHTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 NJ FAMILYCARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 NJ FAMILYCARE C (PERSONAL CONTRIBUTIONS TO CARE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 NJ FAMILYCARE D CO-PAYMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 MEDICAID, NJ FAMILYCARE A, B AND C EXCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 NJ FAMILYCARE D EXCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 REPORTING FRAUD, WASTE OR ABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 FOR MORE INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 TERMS TO REMEMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 HELPFUL HINTS FOR A SUCCESSFUL DOCTOR'S VISIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 HEALTH PLAN NOTICES OF PRIVACY PRACTICES, NOTICE FOR MEDICAL INFORMATION . . . . . . . . . . . . . 47 HEALTH PLAN NOTICES OF PRIVACY PRACTICES, NOTICE FOR FINANCIAL INFORMATION . . . . . . . . . . . . 50

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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The AmeriChoice Member Service Center

It is important to us that you always have someone to turn to when you have questions or suggestions about your health care. That is why we have the AmeriChoice Member Service Center. The AmeriChoice Member Service Center will: · Explain what services your benefit package covers · Help you get medical care · Help you schedule an appointment with your personal doctor · Tell you about AmeriChoice health education programs and special events in your area · Change your doctor or tell you about doctors in your neighborhood · Help to solve a problem you may have about getting health care · Send you a new identification card if yours is lost · Listen to any suggestions you may have for improving the services AmeriChoice offers If you have any questions about the information in this book or about your AmeriChoice coverage, you may call our toll-free Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. Member Service Center Representatives are available 24 hours a day, 7 days a week. They will answer your questions and help you understand your health care benefits. If you would like to write to AmeriChoice: AmeriChoice of New Jersey, Attn: Member Services, 1 Riverfront Plaza Station, P.O. Box 200089, Newark, NJ 07102 Si usted prefiere hablar con un representante en Español, por favor llame al 1-800-943-4647 y uno de nuestros representantes les ayundara. If you speak a language other than Spanish or English, call 1-800-941-4647. A translator will help with your questions. If you are deaf or hearing impaired, you can call us through the AT&T relay service at 1-800-852-7897.

Getting to Know AmeriChoice

AmeriChoice is a Health Maintenance Organization (HMO) servicing NJ FamilyCare/Medicaid recipients. We offer Care Management services for members who are hospitalized, pregnant or have a serious health condition. From time to time, AmeriChoice will send you educational information in the mail about special health programs such as dental screenings, lead awareness, and adolescent immunizations. To make sure that you get this information, let us know if you move so that we can correct your address and phone number. Please read the information carefully as it may be important for you or a family member. Upon joining AmeriChoice, you will receive a Welcome Call. The Welcome Call briefly tells you about the AmeriChoice services available to you. It will also explains how to get care from your Primary Care Provider (PCP) and specialists. It gives you information on how to contact the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 if you have questions, problems or have not received a Welcome Call. As a new member of AmeriChoice, you will receive a Welcome Kit which is package prepared especially for you to introduce you to AmeriChoice. The Welcome Kit contains the Member Handbook (an explanation of the benefits and services as a member), Provider Directory (a listing of doctors addresses and telephone numbers), and a Welcome letter from AmeriChoice. On an annual basis, you will receive a new Member Handbook. Each household is entitled to receive a Provider Directory when it is printed. If you have not received a Welcome Kit, please call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 and a representative will help you.

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Your AmeriChoice Member ID Card

Every member of AmeriChoice has a member ID card that shows he or she is part of our plan. If you have not received this card, please call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. You should carry both your AmeriChoice ID card and your Health Benefits ID card (HBID) with you at all times. You will need to show them whenever you need services from a doctor, pharmacy, or hospital. You must use your AmeriChoice ID card to get all covered non-emergency health services through AmeriChoice providers. Your AmeriChoice ID card does not replace the HBID card sent to you by the State when Medicaid eligibility is approved. You may only need to show the HBID card to receive services that are available to you from those programs. See pages 6-17 for a complete list of services and whether the service is available from the regular, Fee-For-Service Medicaid program, or from AmeriChoice. Your AmeriChoice ID card covers you for services obtained within the State of New Jersey. To receive services in another state, your doctor must contact AmeriChoice for prior authorization. If this is not done, you may receive a bill unless the care provided was emergent. See page 31 for instructions on what to do if you receive a bill. Your AmeriChoice ID card looks like the example shown below. Your AmeriChoice ID card should contain your name, AmeriChoice ID number, your PCP's name and telephone number. If you are a member of the AmeriChoice NJ FamilyCare program, your AmeriChoice card will say that. Your card will also show if you need to make a co-payment and what the amount of the co-payment should be. On the back of your AmeriChoice ID card, there is a statement that usage of the card grants your consent to release to AmeriChoice or its delegates any medical information to enable AmeriChoice to administer your coverage. Your signature or where applicable, an authorized person's signature on the enrollment application/PSF also allows release of your medical records. Never lend your card to anyone. If your card is lost or stolen, call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 to report the loss and we will send you a new card.

Both ID cards are valid. Your doctor will honor either card when presented.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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Your Personal Doctor

With AmeriChoice, you have a personal doctor who provides many services directly to you. This doctor is called your Primary Care Provider, or PCP. Your PCP is the doctor you see or talk to first for most medical care. Your PCP is the one who: · Provides medical care for most common health problems · Gives checkups · Refers you to specialists · Admits you to the hospital when necessary · Arranges for any medical tests you may need · Keeps your medical records There are several kinds of doctors who may be PCPs: · Family practice doctors who treat adults and children · General practice doctors who treat adults and children · Internal medicine doctors, or internists, who treat adults over the age of 18 · Pediatricians who treat children up to age 21 Each enrolled family member may select his or her own PCP. We have many fine doctors right in your community. If you have lost or misplaced your listing just call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 and ask the Representative to send you one. If you have a PCP when you join AmeriChoice, you should tell the Health Benefits Coordinator and AmeriChoice. You should also tell the Health Benefits Coordinator and AmeriChoice if you are seeing any other providers. If you or a member of your family does not have a PCP when you join AmeriChoice, we will help you pick one that is right for you or them. Just call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 and a Representative will help you. Please let the Representative know if you have any cultural or language (foreign or sign language) requirements that will aid you in having a successful experience at your PCP's office. With your permission, a relative or a close friend or someone else you trust can talk to us about selecting the right PCP for you. If you have been receiving very complex, highly specialized health care services over a long period of time or have a degenerative or life-threatening condition, you may be eligible to have your specialist or specialty care center serve as your PCP. Please contact the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 if you would like to discuss this option. Your PCP or a back-up doctor who works with your PCP and who is approved by AmeriChoice will be available to you 24 hours a day, 7 days a week. That means that you can call your PCP after office hours when you have a health problem. Call your PCP if you or an enrolled family member is homebound or have other special needs. Your PCP will be able to help you get the health care services you need. If you or an enrolled family member is homebound, you will work with your Care Manager to arrange services as needed such as home health care services, etc. If you cannot reach your PCP or need more help, call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. A Member Service Center Representative will help you.

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Getting to Know Your PCP

Having a PCP you know and who knows you is an important part of being an AmeriChoice member. The best way to get to know your PCP--and to have your PCP get to know you--is to have a complete physical examination as soon as you can after you join AmeriChoice. This examination is also called a baseline exam. It is a medical and personal introduction for you and your PCP. When your PCP gives you a physical exam, he or she will ask you questions about your health history. This checkup can help find problems before they become serious. Once your PCP has met you and learned your health history, he or she can work better with you to keep you healthy. The more your PCP knows about your health history, the better he or she can work with you to manage your medical care. Some PCPs have trained health care assistants, like physician assistants, certified nurse practitioners and clinical nurse specialists that work with them. They may help your doctor take care of you, but only if you approve and only if they identify themselves to you first. To make an appointment for a baseline exam, call your PCP's office. Be sure to tell the office staff that it is your first visit and you want a baseline exam. If you have any problems, call the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. A Member Service Center Representative will help you. After you have had your baseline exam, AmeriChoice will send you a gift for having taken this important step. You should visit your PCP at least once a year. Your PCP will see that you get a complete health exam and preventive health care services to help keep you from getting sick. If you require an interpreter for either sign or a foreign language to assist you when you go to your appointment, call the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. A Member Service Center Representative will help you.

If You Wish to Change Your PCP

We want you to be satisfied with your choice of PCP. We will always be available to help you if you have any questions or problems with your doctor. As a member of AmeriChoice, you have the right to change your PCP. If you are thinking about changing your PCP, call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. We can talk with you about your reasons for changing and maybe help you solve any problems with your PCP. We will also send you a current directory of our providers. If you decide to change doctors, a Member Service Center Representative will help you choose a new PCP. He or she will make sure that you get a new AmeriChoice member ID card with your new PCP's name and phone number on it. A request for a new PCP change may be denied if the requested PCP does not treat members of that age group or the PCP can not accept new patients. He or she will also explain when you can begin to see your new PCP. If your PCP ever believes that another doctor would be able to give you better care, he or she can ask us to help you select another PCP. If your PCP only treats members up to a certain age, he or she can ask us to help you select another PCP. If that happens, we will work with you to find a new PCP. If you do not listen to your doctor or do not follow his or her advice about your health care, he or she also can ask us to help you choose a new PCP. If that happens, we will work with you to find a new PCP.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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You can request a copy of your medical records or request that they be sent to your new PCP. Your signed enrollment application allows the release of medical records and sharing of information between your providers as well as the appropriate AmeriChoice staff.

If Your Provider Leaves AmeriChoice

If your provider leaves AmeriChoice, you may continue to see that provider for a limited amount of time under certain conditions: Condition Length of time you may continue to see a provider who has left the AmeriChoice network Up to four months Up to six months if medically necessary Up to one year Up to six weeks after your baby is born

It is medically necessary for you to continue receiving care from that provider You have had an operation right before your doctor leaves the AmeriChoice network You are receiving oncology services or psychiatric care You are pregnant

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Benefits Summary

The New Jersey Department of Human Services, Division of Medical Assistance and Health Services administers the benefits for recipients of Medicaid and NJ FamilyCare. The table below shows the service and if AmeriChoice covers that service. It also shows services that are covered under the Medicaid Fee-for-Service program for enrolled members. For services listed as "Medicaid FFS," AmeriChoice members will need to show both the AmeriChoice ID card and the Health Benefits ID card. If you have questions about what is covered or how to get services, call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897.

Summary of Benefits

BENEFITS (Subject to AmeriChoice policies and procedures) Abortion and related services Acupuncture

MEDICAID & NJ FAMILYCARE A Medicaid FFS COVERED

DDD CLIENTS Medicaid FFS COVERED

NJ FAMILYCARE B&C Medicaid FFS COVERED

NJ FAMILYCARE D Medicaid FFS NOT COVERED (Except when performed as a form of Anesthesia in conjunction with approved surgery)

Allergy Testing Audiology

COVERED with PCP COVERED with PCP COVERED with PCP COVERED with PCP Referral Referral Referral Referral COVERED COVERED COVERED Limited to children under the age of 16 years NOT COVERED Except for administration and processing of blood including fees for autologous blood donation

Blood & Plasma Products

COVERED

COVERED

COVERED

Bone Mass Measurement (Bone Density) Case Management Chiropractor Services (Manual Manipulation of Spine)

COVERED with PCP COVERED with PCP COVERED with PCP COVERED with PCP Referral Referral Referral Referral COVERED COVERED COVERED COVERED

COVERED with PCP COVERED with PCP COVERED with PCP NOT COVERED Referral Referral Referral

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

6

BENEFITS (Subject to AmeriChoice policies and procedures)

MEDICAID & NJ FAMILYCARE A

DDD CLIENTS COVERED COVERED ­ Contact AmeriChoice for Additional Information COVERED For preventive & routine services ­ member may self refer to network providers

NJ FAMILYCARE B&C COVERED

NJ FAMILYCARE D COVERED

Colorectal/ Prostate COVERED Screening Exams Court Ordered Services COVERED ­ Contact AmeriChoice for Additional Information COVERED |For preventive & routine services ­ *Member May Self Refer to network providers

COVERED ­ Contact NOT COVERED AmeriChoice for Additional Information COVERED For preventive & routine services ­ member may self refer to network providers Limited to Preventive services (including oral examinations, xrays, oral prophylaxis, topical application of fluorides and sealants) only COVERED to age 12 Exception comprehensive orthodontia treatment services will be provided through completion of required services for any member under the age of 19 whose orthodontia services were initiated while enrolled with AmeriChoice under Medicaid, NJ FamilyCare A, B or C. AmeriChoice is not responsible for orthodontia services to a NJ FamilyCare D member under age 19 that were initiated while that member was enrolled with another HMO. The member must continue enrollment

Dental Services

Active treatment begins with the placement of the orthodontic appliances (banding) or the extraction of teeth as part of an authorized comprehensive orthodontic treatment plan.

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

7

BENEFITS (Subject to AmeriChoice policies and procedures) Dental Services (continued)

MEDICAID & NJ FAMILYCARE A

DDD CLIENTS

NJ FAMILYCARE B&C

NJ FAMILYCARE D in the HMO where services were initiated until those services were completed or until the member loses Medicaid/NJ FamilyCare eligibility. Cases that were authorized before reassignment to NJ FamilyCare D but active treatment was not initiated until after reassignment to NJ FamilyCare D do not qualify for continuation of care.

Diabetic Education Diabetic Supplies and Equipment Durable Medical Equipment (DME)/Assistive Technology Devices DYFS Residential Treatment Educational or Special Remedial Services

COVERED

COVERED

COVERED

COVERED

COVERED with PCP COVERED with PCP COVERED with PCP COVERED with PCP Referral Referral Referral Referral COVERED Prior Authorization Required If Greater than $500 Medicaid FFS Medicaid FFS COVERED Prior Authorization Required If Greater than $500 Medicaid FFS Medicaid FFS COVERED Prior Authorization Required If Greater than $500 Medicaid FFSC Medicaid FFS NOT COVERED

NOT COVERED NOT COVERED

Early and Periodic COVERED Screening Diagnostic and Treatment (EPSDT) Services Immunizations (0-21 yrs of age)

COVERED

COVERED with limitations (see page 28)

EPSDT is NOT COVERED. WellChild Visits are covered, including, Immunizations and lead screening & treatments

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

8

BENEFITS (Subject to AmeriChoice policies and procedures) Emergency Room Care

MEDICAID & NJ FAMILYCARE A COVERED

DDD CLIENTS COVERED COVERED

NJ FAMILYCARE B&C COVERED COVERED

NJ FAMILYCARE D COVERED COVERED

Emergency Medical COVERED Transportation (Ambulance) Routine Eye Exams and Optometrist Services Eyeglasses (Lenses and Frames)/ Contacts Members May Self Refer Family Planning Basic Services (Self Referral Reproduction Health Procedures/ Devices) COVERED *Member May Self Refer COVERED $100 allowance (see page 24 for limitations)

COVERED *Member May Self Refer COVERED $100 allowance (see page 24 for limitations)

COVERED *Member May Self Refer COVERED $100 allowance (see page 24 for limitations)

COVERED *Member May Self Refer one routine eye exam per year COVERED $100 allowance (see page 24 for limitations)

COVERED *Member May Self Refer to participating Ob/Gyn MEDICAID FFS When furnished by a non-participating HMO doctor

COVERED *Member May Self Refer to participating Ob/Gyn MEDICAID FFS When furnished by a non-participating HMO doctor

COVERED *Member May Self Refer to participating Ob/Gyn MEDICAID FFS When furnished by a non-participating HMO doctor

COVERED *Member May Self Refer to participating Ob/Gyn Obtaining Family Planning Services outside of AmeriChoice's network is not available to NJ FamilyCare D members. For the exceptions that might apply, contact the Member Service Center at 1-800-941-4647.

Hearing Exams

COVERED with PCP COVERED with PCP COVERED with PCP Limited to children Referral Referral Referral under the age of 16 years COVERED with PCP Referral ­ Prior Authorization required if greater than $500 COVERED with PCP Referral ­ Prior Authorization required if greater than $500 COVERED with PCP NOT COVERED Referral ­ Prior Authorization required if greater than $500

Hearing Aids and Batteries

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

9

BENEFITS (Subject to AmeriChoice policies and procedures) Hemodialysis HIV/AIDS Testing

MEDICAID & NJ FAMILYCARE A

DDD CLIENTS

NJ FAMILYCARE B&C

NJ FAMILYCARE D

COVERED with PCP COVERED with PCP COVERED with PCP COVERED with PCP Referral Referral Referral Referral COVERED *Member May Self Refer COVERED with Prior Authorization (except for eligible ABD*s - services are COVERED by Medicaid FFS) COVERED with Prior Authorization COVERED COVERED If participating providers with AmeriChoice NOT COVERED COVERED COVERED *Member May Self Refer COVERED with Prior Authorization (except for eligible ABDs - services are COVERED by Medicaid FFS) COVERED with Prior Authorization COVERED COVERED If participating providers with AmeriChoice NOT COVERED COVERED COVERED *Member May Self Refer COVERED with Prior Authorization COVERED *Member May Self Refer COVERED limited to skilled nursing and medical social services with Prior Authorization COVERED with Prior Authorization COVERED COVERED If participating providers with AmeriChoice NOT COVERED COVERED

Home Health Care

Hospice Immunizations Independent Clinics and Federally Qualified Health Centers Infertility Testing & Services Inpatient Hospitalization (acute care, rehabilitiation & special hospitals) Lab Tests and X-Rays Mammograms (Screening)

COVERED with Prior Authorization COVERED COVERED If participating providers with AmeriChoice NOT COVERED COVERED

COVERED with PCP COVERED with PCP COVERED with PCP COVERED with PCP Referral Referral Referral Referral COVERED *Member May Self Refer baseline for women 35-39 and annual for women 40+ COVERED by Medicaid FFS COVERED COVERED *Member May Self Refer baseline for women 35-39 and annual for women 40+ COVERED by Medicaid FFS COVERED COVERED *Member May Self Refer baseline for women 35-39 and annual for women 40+ NOT COVERED COVERED COVERED *Member May Self Refer baseline for women 35-39 and annual for women 40+ NOT COVERED NOT COVERED Limited to Diabetic Supplies

Medical Day Care Medical Supplies

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network. * ABD ­ Aged, Blind, and Disabled

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

10

BENEFITS (Subject to AmeriChoice policies and procedures) Methadone & Methadone Maintenance

MEDICAID & NJ FAMILYCARE A Methadone for pain management is COVERED by AmeriChoice; Methadone maintenance for substance abuse treatment is covered by Medicaid FFS COVERED

DDD CLIENTS Methadone for pain management is COVERED by AmeriChoice; Methadone maintenance for substance abuse treatment is covered by Medicaid FFS COVERED

NJ FAMILYCARE B&C Methadone for pain management is COVERED by AmeriChoice; Methadone maintenance for substance abuse treatment is covered by Medicaid FFS COVERED

NJ FAMILYCARE D Methadone for pain management is COVERED by AmeriChoice; Methadone maintenance for substance abuse treatment is NOT COVERED COVERED

Nurse Practitioners/ Certified Nurse Midwives Obstetrical/ Maternity Care Organ Transplant Evaluation

COVERED *Member May Self Refer COVERED with Prior Authorization

COVERED *Member May Self Refer COVERED with Prior Authorization COVERED with Prior Authorization

COVERED *Member May Self Refer COVERED with Prior Authorization COVERED with Prior Authorization

COVERED *Member May Self Refer COVERED with Prior Authorization COVERED with Prior Authorization

Organ Transplants COVERED with includes donor and Prior Authorization recipient costs unless individuals were already placed on transplant list while in Medicaid FFS prior to initial enrollment in AmeriChoice. In those cases, members are covered by FFS or the original HMO. AmeriChoice is responsible for transplant-related donor and recipient inpatient costs for an individual placed on a transplant list or who becomes eligible for a

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

11

BENEFITS (Subject to AmeriChoice policies and procedures) Organ Transplants (continued) transplant while enrolled in managed care prior to disenrollment to the Medicaid FFS program within 2 months of the transplant. Orthodontia

MEDICAID & NJ FAMILYCARE A

DDD CLIENTS

NJ FAMILYCARE B&C

NJ FAMILYCARE D

COVERED with Prior Authorization

COVERED with Prior Authorization

COVERED with Prior Authorization

NOT COVERED Exception ­ comprehensive orthodontia treatment services shall be provided, through completion of required services, for any member under 19 years whose orthodontia services were initiated while enrolled with AmeriChoice as a Medicaid, NJ FamilyCare A, B, or C member. AmeriChoice shall not be responsible for orthodontia services to a NJ FamilyCare D member under the age of 19 years old that were initiated while that member was enrolled with another health plan. The member must continue enrollment

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

12

BENEFITS (Subject to AmeriChoice policies and procedures) Orthodontia (continued)

MEDICAID & NJ FAMILYCARE A

DDD CLIENTS

NJ FAMILYCARE B&C

NJ FAMILYCARE D in the health plan where services were initiated until those services were completed or until the member loses Medicaid/NJ FamilyCare eligibility. Active treatment begins with the placement of the orthodontic appliances (banding) or the extraction of teeth as part of an authorized comprehensive orthodontic treatment plan. Cases that were authorized before reassignment to NJ FamilyCare D but active treatment was not initiated until after reassignment to NJ FamilyCare D do not qualify for continuation of care.

Orthopedic Shoes

COVERED with PCP COVERED with PCP COVERED with PCP NOT COVERED Referral Referral Referral COVERED with Referral COVERED with Referral COVERED with Referral COVERED with Referral COVERED with Referral COVERED with Referral

Outpatient Hospital COVERED Services with Referral Outpatient Surgery, COVERED Same Day Surgery, with Referral Ambulatory Surgical Center

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

13

BENEFITS (Subject to AmeriChoice policies and procedures) Pain Management Services Pap Smears and Pelvic Exams Parenting/Child Birth Education

MEDICAID & NJ FAMILYCARE A COVERED with Prior Authorization COVERED *Member May Self Refer COVERED *Member May Self Refer Medicaid FFS

DDD CLIENTS COVERED with Prior Authorization COVERED *Member May Self Refer COVERED *Member May Self Refer Medicaid FFS

NJ FAMILYCARE B&C COVERED with Prior Authorization COVERED *Member May Self Refer COVERED *Member May Self Refer NOT COVERED

NJ FAMILYCARE D COVERED with Prior Authorization COVERED *Member May Self Refer COVERED *Member May Self Refer NOT COVERED

Personal Care (in home) /Aide Services Podiatry Care ­ Medically Necessary (OfficeBased, NonSurgical) Podiatry CareSurgical Prescription Drugs

NOT COVERED

NOT COVERED

NOT COVERED

NOT COVERED

COVERED with Referral COVERED Drug Formulary OTC & Legend drugs (MEDICAID FFS for ABD population) COVERED COVERED

COVERED with Referral COVERED Drug Formulary OTC & Legend drugs (MEDICAID FFS for ABD population) COVERED COVERED

COVERED with Referral COVERED Drug Formulary OTC & Legend drugs

COVERED with Referral COVERED Drug Formulary NOT COVERED OTC

Post-acute Care Preventive Health Care and Counseling and Health Promotion

COVERED COVERED

COVERED COVERED

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

14

BENEFITS (Subject to AmeriChoice policies and procedures) Primary Care Provider Private Duty or Skilled Nursing Care Prostate Cancer Screening Exams

MEDICAID & NJ FAMILYCARE A COVERED COVERED if related to EPSDT screening COVERED *Member May Self Refer

DDD CLIENTS COVERED COVERED if related to EPSDT screening COVERED *Member May Self Refer

NJ FAMILYCARE B&C COVERED COVERED if related to EPSDT screening COVERED *Member May Self Refer

NJ FAMILYCARE D COVERED COVERED (only when authorized by AmeriChoice) COVERED *Member May Self Refer

Prosthetics & Orthotics

COVERED with PCP COVERED with PCP COVERED with PCP Prosthetics Referral Referral Referral Limited to the initial provision of a Prior Authorization Prior Authorization Prior Authorization prosthetic device required if greater required if greater required if greater that temporarily or than $500 than $500 than $500 permanently replaces all or part of an external body part lost or impaired as a result of disease, injury, or congenital defect. Repair and replacement services are covered when due to congenital growth. Orthotics ­ NOT COVERED

Radiation/ Chemotherapy/ Hemodialysis Radiology Scans (MRI, MRA, PET)

COVERED with PCP Referral COVERED with Prior Authorization

COVERED with PCP Referral COVERED with Prior Authorization

COVERED with PCP Referral COVERED with Prior Authorization

COVERED with PCP Referral COVERED with Prior Authorization

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

15

BENEFITS (Subject to AmeriChoice policies and procedures) Rehabilitation (Outpatient Occupational Therapy/Physical Therapy/Speech Therapy)

MEDICAID & NJ FAMILYCARE A Medicaid FFS

DDD CLIENTS Medicaid FFS

NJ FAMILYCARE B&C Medicaid FFS Limited to 60 days per therapy/ per year

NJ FAMILYCARE D Medicaid FFS Limited to delays in speech development resulting from disease, injury or congenital defects Limited to treatment for 60 consecutive business days per incident/injury beginning with the 1st treatment per contract year

Second Medical/Surgical Opinions Sex Abuse Examinations Skilled Nursing Facility Care (LTC) Sleep Apnea Studies/Sleep Therapy

COVERED with PCP Referral Medicaid FFS COVERED for 30 Days COVERED with Prior Authorization

COVERED with PCP Referral Medicaid FFS COVERED for 30 Days COVERED with Prior Authorization COVERED with Prior Authorization

COVERED with PCP Referral Medicaid FFS NOT COVERED COVERED with Prior Authorization COVERED with Prior Authorization

COVERED with PCP Referral Medicaid FFS NOT COVERED NOT COVERED

Smoking Cessation COVERED with Products Prior Authorization Specialty Physician Services (For OB, Member May SelfRefer) Speech Tests Thermograms & Thermography Transportation ­ Emergency Transportation Ambulance, Invalid Coach (nonemergency) Transportation ­ Lower Mode

COVERED with Prior Authorization

COVERED with PCP COVERED with PCP COVERED with PCP COVERED with PCP Referral Referral Referral Referral

COVERED with PCP COVERED with PCP COVERED with PCP COVERED with PCP Referral Referral Referral Referral COVERED with PCP COVERED with PCP COVERED with PCP NOT COVERED Referral Referral Referral COVERED COVERED with Prior Referral COVERED COVERED with Prior Referral COVERED COVERED with Prior Referral COVERED NOT COVERED

Medicaid FFS

Medicaid FFS

NOT COVERED

NOT COVERED

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

16

BENEFITS (Subject to AmeriChoice policies and procedures) Urgent Care

MEDICAID & NJ FAMILYCARE A COVERED Care required within 48 hours COVERED FFS

DDD CLIENTS COVERED Care required within 48 hours COVERED FFS

NJ FAMILYCARE B&C COVERED Care required within 48 hours NOT COVERED

NJ FAMILYCARE D COVERED Care required within 48 hours NOT COVERED

Waiver and demonstration program services

BEHAVIORAL HEALTH Atypical Medicaid FFS Antipsychotic Drugs within the Specific Therapeutic Drug Classes H7T and H7X Inpatient Medicaid FFS Psychiatric Hospital Services for individuals under 21 or 65 and over Inpatient Substance Medicaid FFS Abuse (diagnosis, treatment and detoxification) Intermediate Care Medicaid FFS Facilities/ Mental Retardation (ICF/MR) Outpatient Substance Abuse (diagnosis, treatment and detoxification) Outpatient Mental Health including any testing Medicaid FFS Medicaid FFS Medicaid FFS Medicaid FFS

COVERED with Prior Authorization

Medicaid FFS

Medicaid FFS 35 days per year

COVERED with Prior Authorization

Medicaid FFS

Medicaid FFS Limited to Detox only NOT COVERED

Medicaid FFS

NOT COVERED

COVERED 1st visit Medicaid FFS *Member May Self Refer, After 1st visit, Prior Authorization needed COVERED with Prior Authorization Medicaid FFS

Medicaid FFS Limited to Detox only

Medicaid FFS

Medicaid FFS Outpatient benefits for short-term, outpatient evaluation and crisis intervention or home health mental health services - limited to 20 visits per year. Medicaid FFS see Outpatient Mental Health Medicaid FFS

Partial Care for Mental Health Partial Hospitalization

Medicaid FFS

Medicaid FFS

Medicaid FFS

Medicaid FFS

Medicaid FFS

Medicaid FFS

Medicaid FFS ­ The member is COVERED using his/her Health Benefits ID card. Services are approved by the appropriate Medicaid Provider. *Member May Self Refer ­ The member may choose a doctor from the AmeriChoice Provider Network.

17

When You Have an Emergency

What is an emergency?

The law defines an emergency this way: An emergency is a health problem that a "prudent layperson" possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: 1. placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of the person or others in serious jeopardy; or 2. serious impairment to such person's bodily functions; or 3. serious dysfunction of any bodily organ or part of such person; or 4. serious disfigurement of such person. For a pregnant woman, the beginning of contractions can be considered an emergency. An emergency can result from an accident or a sudden illness and can happen at any time of the day or night. If you have an emergency illness or injury, you must act quickly. At any time of the day or night, you should call 911 and ask for help or go to the nearest hospital emergency room. Emergency care is available to you 24 hours a day, 7 days a week. You do not have to call AmeriChoice or your doctor first to get permission if it is an emergency. You don't have to worry about the cost of going to an Emergency Room if you think you have a medical emergency. AmeriChoice will pay for the cost of the examination the hospital does to determine if an emergency medical condition exists. Even if you are outside the AmeriChoice service area when you have an emergency, you are still covered by the AmeriChoice plan. However, if you are outside of the United States or its territories, services are not covered either by AmeriChoice or by the Medicaid program. Be sure to take your AmeriChoice member ID card to the emergency room. Give the name and telephone number of your PCP to the emergency room staff. That way your doctor can approve all care following the emergency treatment. Also, be sure that you or someone calls your PCP or AmeriChoice at 1-800-941-4647 or TDD at 1-800-852-7897 within 24 hours after you seek emergency treatment in or out of the service area. Here are some examples of emergencies: · Bad burns · Chest pains · Choking or problems breathing · Convulsions · Fainting or dizzy spells · Feeling that you might kill somebody or kill yourself · Loss of consciousness · Poisoning or an overdose of medication · Possible broken bones · Serious accidents · Severe pain in any part of your body · Severe wounds or heavy bleeding · Sudden change in vision · Suddenly not being able to move (paralysis) · Sudden, severe pain or pressure in the chest or upper abdomen Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

18

· Throwing up constantly · Vomiting blood If you have any of these symptoms, call 911 or have someone take you to the nearest hospital emergency room. Remember, hospital emergency rooms are there to treat an illness or an injury that is sudden and severe. Emergency room doctors are trained to prevent a sudden severe health problem from causing permanent damage or death. Emergency room doctors will handle a true emergency immediately. They will continue treatment until the patient is out of danger. But, when people who are not in serious danger go to the emergency room, they often have to wait a long time for treatment. If you aren't sure if the illness or injury is an emergency, you can call your PCP and he or she will be able to help you decide.

Urgent Care

An urgent condition is a health problem that is serious but is not life threatening. It requires attention from a doctor within 24 hours. If you have an urgent condition, call your PCP first. Your PCP will know what is best for you. Even if you are out of town, call your PCP first and he or she will tell you how to get care. Here are some examples of urgent conditions: · Colds · Coughs · Ear aches · Minor cuts and bruises · Runny noses · Rashes or itching · Sore throats · Sprained muscles · Upset stomachs

Routine Care

Routine care includes physical exams and other kinds of treatment and services that you need to stay healthy. You can make appointments for routine care when it is convenient for you and your doctor, but you should make sure that you get care on a regular basis.

Specialist Care

Sometimes you may have a health problem that your PCP will not treat because you need special medical care. When that happens, your PCP will send you to a "specialist," a doctor who is trained in the type of health care you need. Specialists include, for example, cardiologists (heart doctors), dermatologists (skin doctors), gynecologists (doctors who specialize in women's health care), hematologists (a doctor who treats blood problems), podiatrists (a doctor who treats foot and ankle problems), and ophthalmologists (doctors who treat eye problems). If your PCP wants you to see a specialist, you and your PCP can choose the specialist from the AmeriChoice network. We will send you a directory of our specialists if you need one. If you have a chronic disability, you can see a specialist who is experienced in treating that disability. When your PCP sends or refers you to a specialist, this is called a "referral." Here's how it works: Your PCP will give you the name of a specialist from the AmeriChoice network and the information you will need to help you make an appointment with that specialist. Or, together, you can choose the specialist you want from the AmeriChoice network. Your PCP may give you a card or piece of paper that lists the name of the specialist and the appointment date and time or just give you information to take to the specialist to explain why you are making the appointment.

19

When your PCP refers you to another doctor, make sure you understand what your condition is and what treatment you can expect. If you think you need a specialist, talk to your PCP about it. If you have any questions about referrals, call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. Sometimes people with certain illnesses or medical conditions will do better if a specialist coordinates their care or if they are cared for by a hospital specialty center instead of a PCP. If you have been receiving your primary care services through a specialist or hospital specialty center or think you would do better with a specialist coordinating your care, call the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 to discuss your case with one of our medical experts. If you have a condition that needs ongoing care from a specialist, you can ask your PCP or AmeriChoice for a "standing referral" that will let you see that doctor whenever you have to, without talking to your PCP first. If you have a condition requiring ongoing specialist care, call the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. If AmeriChoice does not have a doctor with the training and experience that you need, we will arrange for you to see a doctor outside of AmeriChoice. Of course, you will not pay for this care. We will work with your PCP to get you this referral.

Hospital Care

If your PCP decides you need hospital care, he or she will arrange for you to be admitted to the hospital and will notify AmeriChoice. If you have any questions about your hospital admission, talk to your PCP.

Special Needs Members

Care Management services at AmeriChoice are known as The Personal Care Model (PCM). PCM cares for members with complex needs and especially those with chronic conditions. PCM services are available to members with special needs. Pertinent medical information is sent to AmeriChoice by the State. Special Needs members are called to complete a Complex Needs Assessment (CNA) when they joined AmeriChoice. PCM services include: · Education including mailings of materials and outreach to members who may have been detected with illnesses such as congestive heart failure, asthma or diabetes · Helping members improve their self-management skills · Helping members improve their quality of life by working with them to reduce the need for emergency treatment and multiple admissions to the hospital Once the CNA is completed, AmeriChoice will work out an Individual Health Care Plan (IHCP). IHCPs help doctors and other providers and AmeriChoice case managers make sure you get all the services you need. The IHCP will be completed within 90 days of enrollment for all children under 21 years old and within 180 days for all other adults. The IHCP will be completed no later than 90 days after the effective date of enrollment for adult clients of the Division of Developmental Disabilities (DDD). A specialist may be used as a PCP for a member with special needs per the Specialist Care process on page 22. If you have questions about care management services, contact the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

20

Appointments with Doctors and other Health Care Providers

AmeriChoice understands that when you are not feeling well or want to see a doctor or other health care provider, you do not want to wait too long for an appointment. That is why we require all our providers to follow certain standards about the amount of time you wait when you ask for an appointment. Here are some tips on making appointments: · Be ready to answer some questions about your health problem so that the doctor's office can be sure they are giving you the correct type of appointment (emergent, urgent or routine). This will also allow the office to make sure that you have the right amount of time scheduled with the doctor. · Please remember that it is important for you to call for an appointment first, except if it is an emergency. Be sure that you keep your appointments and be on time. · When you cannot keep your appointment or be on time, it is important to call the provider to cancel or say you will be late. Here are the standards our providers are required to follow:

SERVICE

Emergency Services Urgent care There is a medical problem that requires action but is not life threatening. Symptomatic acute care You do not feel well but you are not in any immediate danger. Routine care Well or preventive care, such as an annual exam or a checkup on medications. Specialist referrals Urgent Specialty care Baseline physicals for new adult enrollees Baseline physicals for new children members and adult clients of DDD Prenatal care Care for pregnant women

SCHEDULING STANDARD

Immediately Within 24 hours

Within 72 hours

Within 28 days

Within 30 days Within 24 hours of referral Within 180 calendar days of initial enrollment Within 90 days of initial enrollment, or for children as required by EPSDT (well child) guidelines Within: · 21 days of a positive pregnancy test (home or lab) · 3 days of identification of high risk · 7 days of request in 1st and 2nd trimester · 3 days of 1st request in 3rd trimester Within 30 days for routine physicals needed for school, camp, work or similar purpose 3 weeks for routine appointments; 48 hours for urgent care Less than 45 minutes

Routine physicals Lab and Radiology services Waiting time in office

21

SERVICE

Initial Pediatric appointments

SCHEDULING STANDARD

Within 90 days of enrollment; AmeriChoice will try to contact and coordinate the first appointment for all child members · Baseline exam within 2 weeks · Emergency dental treatment within 48 hours of injury to teeth or gums (less for a more serious condition), with follow-up treatment by a dental provider · Urgent care appointments within 3 days · Routine, non-symptomatic appointments within 30 days Most dental packages cover care for children and some cover up to age 21 or if the member is pregnant. Please review the benefit chart beginning on page 6 for your specific coverage.

Dental appointments

Mental Health/Substance Abuse appointments · Emergency services: immediately (available through AmeriChoice for DDD clients only) · Urgent care appointments: within 24 hours of request · Routine care appointments: within 10 days of request SSI and New Jersey Care-ABD elderly and disabled enrollees Each new member, or appropriate authorized person, will be contacted by AmeriChoice to offer an initial visit to the member's selected PCP within 45 days of the member's effective date. If the member is identified through the enrollment process as having special needs, the member will be contacted within 10 business days of enrollment and offered an expedited appointment.

Second Opinions

If you are ever referred to a specialist because of a serious medical condition, such as cancer or surgery that is medically necessary, you have the right to get another opinion from a different specialist. This is called a "second opinion." When you want a second opinion, tell your provider and call the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 and ask to be referred for a second opinion. The Member Service Center Representative will help you get an appointment with a provider in the right specialty. The specialist who gives the second opinion will not be authorized to perform tests or X-rays and may not perform the procedure. You may be asked to bring test information with you to the second opinion visit. After obtaining the second opinion, it is your responsibility to tell either the original specialist or AmeriChoice whether you want to have or cancel the procedure.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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Self-Referral Services

Most of the time when you need medical care, you should call your PCP first. Sometimes, you can arrange for care yourself without seeing your PCP. These are called Self-Referral Services. They include: · Dental care (if dental benefits are included in your benefit coverage) · Routine vision exams · Family planning and birth control services · Routine well-woman care and prenatal care from an OB/GYN To get Self-Referral Services, call a provider listed in the Self-Referral Section of the AmeriChoice Provider Directory. If you have any questions about Self-Referral Services, please call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897.

Dental Care

Dental care is very important to your overall health. As an AmeriChoice member, you may see a network dentist for routine examinations, diagnostic treatment, teeth cleaning, fillings or emergency treatments without a referral. Some special dental care requires prior authorization from AmeriChoice. Your AmeriChoice network dentist will handle this for you. Members are strongly encouraged to have a dental examination upon joining the AmeriChoice plan and to see a dentist every six months. AmeriChoice covers dental services for members who are covered by Medicaid, NJ FamilyCare A, B and C. Dental services for members who are covered by NJ FamilyCare D are limited to preventive (i.e. examinations, x-rays, cleanings, sealants and topical application of fluorides) dental services for children under the age of 12. Note: Comprehensive orthodontic treatment service will be provided through completion for any member under age 19 whose orthodontia services were initiated while enrolled with AmeriChoice as a Medicaid, NJ FamilyCare A, B or C enrollee. The AmeriChoice Provider Directory lists all dentists who are part of the AmeriChoice plan. You must choose a dentist from this list. If you have any questions about dental services or about choosing a dentist, call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897.

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Vision Exams

AmeriChoice provides eye and vision exams and eyeglasses or contact lenses if they are prescribed for you by an ophthalmologist--a physician who specializes in the care of the eyes--or an optometrist--a doctor who specializes in identifying and correcting vision problems. You do not need a referral from your PCP to see an AmeriChoice optometrist or an ophthalmologist for a routine eye exam. Choose one from the AmeriChoice Provider Directory or call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 for help. With AmeriChoice, you do not need a referral for routine eye care. (If you have an eye injury or eye disease, you must work with your Primary Care Provider, who will help you get the care you need, as well as any necessary referrals.)

AmeriChoice Routine Vision Care Benefit

Your Health Plan Medicaid and NJ FamilyCare A & B-- Children (Under age 21) and Adults (60 and over) Eye Exam Benefit One routine exam every year Additional exams are covered if medically needed. Eye Wear Benefit One new pair of glasses* every year or contact lenses every two years or as medically necessary. Replacements for broken or lost glasses are covered, if medically needed. One routine exam every year No co-pay Additional exams are covered if medically needed. One new pair of glasses* every two years (adults 19-59) or every year (adults 60 and over); or contact lenses every two years or as medically necessary. Replacements for broken or lost glasses are covered, if medically needed. One new pair of glasses* every year or contact lenses every two years or as medically necessary. Replacements for broken or lost glasses are covered, if medically needed. One new pair of glasses* or contact lenses every two years or as medically necessary.

Medicaid and NJ FamilyCare A ­ Adults (Age 21 to 59)

NJ FamilyCare C Children (Under age 21)

One routine exam every year $5 co-pay may apply Additional exams are covered if medically needed.

NJ FamilyCare D (All age groups)

One routine exam every year $5 co-pay may apply Additional exams are covered if medically needed.

*Members who are entitled to the benefit may choose glasses, up to a $100 retail value, from a select group of frames available at participating providers. If you pick frames that are not in that select group or decide to get contact lenses, you will be informed of the cost. Participating providers will apply a $100 allowance against the cost of the glasses or contact lenses/contact lens fitting. If you wear disposable contact lenses, you are covered for many of the most popular brands on the market. You may receive up to 4 boxes (depending upon the prescription) when they are obtained from a network provider. You will be responsible for paying any remaining costs. The only exception to this will be if special lenses are medically necessary and then those lenses will be covered in full. Under specific conditions, contact lenses may be provided instead of glasses.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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Replacing lost, stolen or damaged eyewear

Up to once every 12 months, for Medicaid and NJ FamilyCare A, B, and C members, AmeriChoice will cover the replacement of lost, stolen or damaged optical appliances with prior-authorization if there is medical necessity. Your eye doctor should call Spectera at 1-800-828-1525, the company that AmeriChoice works with for routine vision care, for authorization. NJ FamilyCare D members are limited to one pair of glasses (or contact lenses) per 24-month period, or as medically necessary.

When your prescription changes

AmeriChoice may cover the replacement of optical appliances such as eyeglasses or contact lenses more often than the benefit specifies (see grid above) when there is a prescription change. Your eye doctor should call Spectera at 1-800-828-1525 for authorization. Costs of medically necessary lenses will be covered in full and vision exams may occur more frequently than listed above when medically necessary. If you have any questions about your AmeriChoice vision benefits, call the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. If you have an eye injury or a disease, you may have to see an ophthalmologist. An ophthalmologist is a specialist doctor. You must get a referral from your PCP to see an ophthalmologist. Of course, AmeriChoice covers all medically necessary care you get from an ophthalmologist.

Medical Transportation

AmeriChoice will always pay for an ambulance when you need it in a medical emergency. Sometimes you may need transportation to medical services because you have a severe injury or illness. If this is necessary, your PCP will work with AmeriChoice to have you driven to and from the needed medical services. If you need what the State of New Jersey defines as lower mode transportation, such as a bus or taxi, that can be arranged. Just contact your county Board of Social Services or AmeriChoice. If you live in Hudson or Essex counties, call LogistiCare at 1-866-527-9933 for lower mode transportation. NJ FamilyCare D members are covered only for emergency ambulance transportation. Call your PCP or the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 if you have any questions about medical transportation services.

Prescription Drugs

AmeriChoice pays for most prescription drugs. In addition, AmeriChoice pays for certain over-the-counter (OTC) drugs. For NJ FamilyCare D members, OTC drugs are not covered. To get your prescription filled, you must take your prescription and your AmeriChoice member ID card to a pharmacy that is part of the AmeriChoice network. If you use a pharmacy that is not part of the AmeriChoice network, you will have to pay for the prescription yourself. The AmeriChoice Provider Directory lists AmeriChoice pharmacies. You may also call the AmeriChoice Member Service Center at 1800-941-4647 or TDD at 1-800-852-7897 to locate an AmeriChoice pharmacy that is convenient for you. Generic drugs are provided when available. Generic drugs are approved by the U.S. Government's Food and Drug Administration (FDA) and provide the same medical benefit(s) as their brand name counterparts. If a generic drug is available, the brand name drug will not be provided, unless your doctor provides information that explains why the brand drug is medically necessary. If your doctor wants you to have the brand name drug, he/she will need to provide information to the AmeriChoice Pharmacy Department that documents why the brand name drug is medically necessary.

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Certain drugs are not covered by AmeriChoice. Drugs that are not covered include: · Drugs that are used for cosmetic purposes · Weight loss drugs except Xenical · Drugs that are used to treat infertility · Drugs that are used to stimulate hair growth · Investigational or experimental drugs Some drugs require your doctor to obtain prior authorization before the prescription is filled. Your doctor must contact AmeriChoice for approval before you receive any drug that requires prior authorization. Prior authorization determinations will be made within 24 hours once AmeriChoice has all of the necessary information. AmeriChoice will authorize a 72-hour supply of the prescribed medication to cover you during the period that the prior authorization is being processed. Members who have a pattern of misusing prescription or OTC drugs may be required to use only one pharmacy to fill their prescriptions. This is called a "lock-in." If this happens, AmeriChoice will contact you and you will be able to choose the AmeriChoice pharmacy designated for the lock-in. You may respond to AmeriChoice within 30 days of receiving the notification letter. We will make sure you can get the medicines you need, in case of an emergency. Please note: a 72 hour emergency supply at other pharmacies may be allowed.

Mental Health and Substance Abuse Services

Most Medicaid and NJ FamilyCare recipients can get these services from any Medicaid-approved provider by using the NJ FamilyCare/Medicaid card. Some testing and services related to the diagnosis and treatment of a mental health or substance abuse disorder are covered by AmeriChoice and will need to be coordinated between the Medicaid approved mental health or substance abuse provider and AmeriChoice. Members who are clients of the Division of Developmental Disabilities (DDD) and Community Care Waiver (CCW), receive the following services through AmeriChoice: · Psychotherapy · Psychological counseling and testing · Substance abuse (narcotics, drugs and alcohol) treatment Call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 and follow the prompts to find out how.

Family Planning

AmeriChoice provides family planning services and supplies, including counseling and birth control. You can choose to get this care from an AmeriChoice provider (your PCP or a family planning provider) or from a Medicaid-approved provider who is not part of AmeriChoice. We encourage you to use AmeriChoice providers whenever possible. NJ FamilyCare D members must use an AmeriChoice Provider. If you decide to go to a non-AmeriChoice provider, you will need to show your Medicaid card or NJ FamilyCare card. Certain NJ FamilyCare D members (contact the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 to find out if you are entitled to this benefit) may also go to a non-AmeriChoice provider. If you have any questions about getting family planning services, call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 and a Member Service Center Representative will help you.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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Prenatal (Pregnancy) Care

The health care a woman receives before the birth of her baby is known as "prenatal care." Prenatal care is important. It helps the doctor see how the pregnancy is going and whether there are any problems. Even if a woman has been pregnant before, going to the doctor regularly while she is expecting is important.

Doctors a woman sees are:

Doctor Gynecologist Obstetrician Obstetrician/Gynecologist Type of Care Women's health care Takes care of women during pregnancy and delivers babies Both of the above Short Name GYN OB OB/GYN

If you think you are pregnant, here is how you can check. Call or visit your PCP who will help you find an obstetrician. You do not need a referral from your PCP to see an AmeriChoice OB/GYN or to go to a family planning center. If you are pregnant, contact your county Board of Social Services for help with other program eligibility. The AmeriChoice Provider Directory lists prenatal care providers that are part of our plan. If you have any questions about how to get prenatal care, please call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. You should talk with your PCP as soon as you know you are pregnant. Your PCP may have information about your health that is important for your prenatal care provider to know. It is best to begin prenatal care as soon as you think you are pregnant. Without early and regular prenatal care, there is a much greater risk that your baby will be born sickly, not weigh enough, be born too early or have to stay in the hospital for a long time after it is born. AmeriChoice recommends that a woman see her doctor at least 15 times during her pregnancy and at least once after her baby is born and she leaves the hospital--and more often if the doctor says so. Call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 to tell us that you are pregnant and when your baby is due. When your baby is born, you can stay in the hospital for at least 48 hours after the delivery if it is a normal vaginal delivery. If you have a Caesarian section, you can stay in the hospital at least 96 hours after your baby is born. When your baby is born, you must enroll him or her in Medicaid by contacting the County Board of Social Services or Medical Assistance Customer Center (MACC) as soon as possible. They will automatically enroll your baby. You should call AmeriChoice, too, and let us know. NJ FamilyCare members should contact the NJ FamilyCare Program at 1-800-356-1561. As a part of your benefits, you are entitled to have a nurse visit you at home to make sure that you are ready for the baby. The nurse will answer any questions that you may have about how to care for your baby. If you are interested in a nurse visit, call our Healthy First Steps Team at 1-800-905-4315.

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Care for Children

During the first few years of your baby's life, you should take your child to the doctor every few months for checkups. These checkups include immunizations (shots) that protect your child from diseases. · Ask your child's doctor about the immunizations that your child may need to have. You may also locate the most recent Immunization Schedule Chart by going online at: http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2009/09_0-6yrs_schedule_pr.pdf http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2009/09_7-18yrs_schedule_pr.pdf

EPSDT Program

It is important for your child to see the doctor for regular checkups even when he or she feels healthy. This way, if your child starts to have a health problem, you can call a doctor who already knows your child. With AmeriChoice, your child will receive services recommended by the EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Program. These services are usually provided by your child's PCP. The EPSDT Program helps AmeriChoice members make sure their children stay healthy and checks to make sure they are growing normally. EPSDT services include: · Shots (immunizations) · Physical exams · Eyesight and hearing tests · Checks on eating habits · Lab tests · Dental checkups · Referrals for specialty care · Lead screening · Other services, referrals, or therapies that are medically necessary. Some of these services need to be approved by AmeriChoice in advance of your child receiving the service. Your child's PCP will contact AmeriChoice to ask for the authorization and, if approved, to make the arrangements. Many of these services are already a part of what your child's doctor offers during a "well child" visit. Well child visits should be obtained according to the following schedule: immediately after birth and at 6 weeks, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, 18 months and 2 years of age and then every year until age 20. Note: Treatment services for NJ FamilyCare B and C are limited to those that are provided by AmeriChoice or those specified services covered under the Medicaid Fee-For-Service program. The services include early and periodic screening, preventive and diagnostic medical services, dental, vision, hearing and lead screenings. Only includes those treatment services identified through the examination that are available through AmeriChoice or specified services under the Medicaid program. NJ FamilyCare D coverage is limited to well-child care, lead screenings and treatments, preventive dental for children under age 12 and immunizations (see Summary of Benefits on page 6)

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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If You Want to Appeal a Decision by AmeriChoice

AmeriChoice reviews all the care you receive to make sure that it is covered by AmeriChoice or by Medicaid or the NJ FamilyCare program. Any decision by AmeriChoice to deny or limit medical care will be made by a doctor at AmeriChoice. The doctor making the decision will talk to your doctor. If you ever think that AmeriChoice has denied you a service you are entitled to, you, or your provider with your written consent, have the right to appeal that decision. You can do this informally at first by calling the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 and asking to have the decision reviewed. We will do your appeal as soon as possible, and always within five (5) business days of your request. If it is a decision about urgent or emergency care, AmeriChoice will do this within 72 hours. You or your doctor can talk to the AmeriChoice Medical Director or the AmeriChoice doctor who made the decision if you want. If we still decide to deny the service, we'll tell you the reason in writing. If you or your doctor disagree with our decision, you, or your doctor with your written consent, can ask for a formal Internal Utilization Management Appeal. You can do this verbally by calling the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 or by writing to AmeriChoice at: Grievances and Appeals Department P.O. Box 31364 Salt Lake City, UT 84131 AmeriChoice will write back to you within ten (10) business days to say we have gotten your appeal. Doctors who have not been involved in the decision to deny the services will review your appeal. If necessary, doctors trained in the particular medical specialty that concerns your care will be part of the review. The panel will review your appeal as soon as possible, and always within 20 business days of getting your letter. (If your appeal is about urgent or emergency care, they will get back to you within 72 hours.) You will get a letter telling you what AmeriChoice has decided. The letter will also tell you how to ask for an external appeal. AmeriChoice members, or a provider acting for them with their consent, have 60 calendar days after they get the decision of the Internal Utilization Management Appeal panel to ask an Independent Utilization Review Organization (IURO) selected by the New Jersey Department of Banking and Insurance to do another review of the case. AmeriChoice will send you the forms you need to appeal to an IURO when we write to you about the decision of the Internal Utilization Management Appeal panel. (If you are enrolled in NJ FamilyCare/Medicaid A, you can ask for a Medicaid Fair Hearing. Certain members of NJ FamilyCare D may ask for a Medicaid Fair Hearing. Contact the AmeriChoice Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 to find out if you are entitled to this benefit. See page 30 of this handbook for how to do that.) To appeal to an IURO, you or your provider must mail the form, and a filing fee of $25 (fee may be reduced to $2 if filed by Medicaid recipient or if State determines that member cannot afford the $25 fee), to: New Jersey Department of Banking and Insurance Office of Managed Care P.O. Box 329 Trenton, NJ 08625-0329 The decision of the IURO is binding. That means that neither AmeriChoice, nor the member, may appeal a decision by the IURO. If the IURO decides you should get the care, AmeriChoice will provide it. AmeriChoice will never penalize you or your provider if you file an appeal.

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If You Have a Problem

A complaint is a problem that you have with AmeriChoice or an AmeriChoice provider that can be solved to your satisfaction within five (5) business days. The easiest way to get answers to your questions or to file a complaint is to call the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. You can also write to us at: Grievances and Appeals Department P.O. Box 31364 Salt Lake City, UT 84131 If we cannot resolve your complaint within five (5) business days, your complaint becomes a grievance. A grievance is any complaint that you send to us in writing or that you call us about that we cannot resolve within five (5) business days. After five (5) business days, you will receive a letter acknowledging your grievance. AmeriChoice will look into your grievance and work hard to find a satisfactory answer within thirty (30) calendar days. We will send you a letter with our answer written in your primary language informing you of your right to file grievances and appeal grievance decisions. If our answer to your complaint or grievance does not satisfy you within sixty (60) calendar days of our response to you, you have the right to appeal our decision by contacting the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 and a Member Service Center Representative will write up and file your appeal. If our answer to your appeal does not satisfy you, within sixty (60) calendar days of our response to you, you have the right to file a formal appeal by contacting the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 and a Member Service Center Representative will write up and file your formal appeal. If you have additional information that you feel may be helpful in deciding your case, you must present it. You will receive an acknowledgement letter within ten (10) business days. We will get back to you with a decision within twenty (20) calendar days. If you are still not satisfied with AmeriChoice's response to you and you are a NJ FamilyCare/Medicaid A enrollee as well as certain NJ FamilyCare D members, you may ask for a Medicaid Fair Hearing with the New Jersey Department of Human Services, Division of Medical Assistance and Health Services, within twenty (20) calendar days of the date of the denial of services. For certain members of other NJ FamilyCare D (contact the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 to find out if you are entitled to this benefit), you may ask for a Fair Hearing by writing to: Fair Hearing Section Division of Medical Assistance and Health Services P.O. Box 712 Trenton, New Jersey 08625-0712 If your complaint or grievance is about a medical issue, qualified medical staff will make our decision on the matter. Whenever we make a decision on a complaint or a grievance, we will tell you why we decided the way we did and we will tell you about any rights you may have to appeal our decision. If you want, you can ask your doctor or someone else to represent you when you make a complaint or file a grievance. All AmeriChoice members also have the right to contact the New Jersey Department of Banking and Insurance by calling 1-888-393-1062 and the Division of Medical Assistance and Health Services by calling 1-800-701-0710.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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Neither AmeriChoice, nor any of its providers, will ever penalize you or your provider for filing a complaint or a grievance or a request for a Fair Hearing. You may call the AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 whenever you have a question about your rights as a member of AmeriChoice.

If You Get a Bill

For most members, AmeriChoice provides services at no cost. You should not be charged for any approved medical services when you get them from an AmeriChoice provider unless your benefit package has a copayment as outlined on pages 37-38. The federal Medicaid and Medicare Act prohibits participating providers from billing program participants for any eligible services. Refer to the following laws: 42 C.F.R. § 447.20 ­ the provider furnishing the service to the individual may not seek to collect from the individual any payment for eligible services. 42 C. F.R. § 447.15 ­ healthcare providers participating in state Medicaid and Medicare programs agree to accept Medicaid and Medicare payments as payment in full. 42. U.S.C. § 1396a (a) (25) (c) ­ state plans may not allow health care providers to seek payment for eligible services from a beneficiary or the beneficiary's relatives. With the exceptions noted in this Handbook (such as emergency care, out-of-network family planning care, etc.), you should get all your health care from AmeriChoice. If you go to a provider outside the AmeriChoice plan for a service that AmeriChoice could provide (except in an emergency), without first getting our permission, neither AmeriChoice nor Medicaid nor NJ FamilyCare will pay for that care. You may be asked to pay for services that are not covered by Medicaid or AmeriChoice. You cannot be charged for any such service unless you understood and agreed before the care was given that you would pay for it. If you are asked to pay for such a service and you are not sure whether it is covered, call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. If you get a medical bill, call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. You will be asked some questions, so please have information, like your member number, the date of the service, the provider of the service and why you think you have received a bill, available when you call. You may also call your PCP or the provider that sent you the bill if you choose to do so, but it is not necessary. Let AmeriChoice fix this problem for you.

Other Insurance

It is important to let us know if you have other insurance. If you have other insurance coverage, coordinating benefit payments is helpful so you can get the maximum benefits allowable under each plan. Your main insurance will pay first. AmeriChoice will pay last. Your main insurance will provide you with an explanation of benefits (EOB). The explanation of benefits is a document sent to you by your main insurance plan. You should receive one for each medical claim. It tells you exactly how each claim was covered by your main insurance. If you are enrolled in traditional Medicare and AmeriChoice Medicaid is secondary, the secondary claim must be submitted with a claim form with the Medicare explanation of benefits. Your provider is responsible for submitting the claim to AmeriChoice. If you are enrolled in AmeriChoice Personal Care Plus and AmeriChoice Medicaid, your doctor should bill AmeriChoice Personal Care Plus first.

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Some individuals in the Aged, Blind and Disabled (ABD) category, including DDD clients, may be enrolled in AmeriChoice. These individuals are not responsible for payment if the other payer denies payment of services provided for you and another payer has denied the approved services. AmeriChoice will pay for these services according to the terms of its contractual agreement with the provider. For members who have auto insurance coverage, you do not have the option to select your health insurance as an option for Personal Injury Protection (PIP) insurance coverage. The State of New Jersey will pursue and recover any AmeriChoice paid benefits for services if: · The member was covered by another health insurance including but not limited to, coverage by any health care insurer, HMO, Medicare or an employer-administered ERISA plan; · The member had casualty insurance including but not limited to, no fault auto insurance benefits, worker's compensation benefits and medical payments coverage through a homeowner's insurance policy; · The member had legal causes of action for damages instituted on behalf of a Medicaid member against a third party or when the State receives notice that legal counsel has been retained by or on behalf of any member; and/or · The member is deceased, was age 55 or older and had an estate.

Leaving AmeriChoice

AmeriChoice wants you to be pleased with our health plan. If you are thinking about leaving AmeriChoice, you should call the Member Service Center or the State of New Jersey's Health Benefits Coordinator to talk about your concerns. You can tell us or them your reasons for leaving AmeriChoice in writing if you wish, too. You can call the Member Service Center 24 hours a day at 1-800-941-4647 or TDD at 1-800-852-7897 to talk with an AmeriChoice Member Service Center Representative. You can contact a Health Benefits Coordinator (HBC) by calling 1-800-701-0710 or TTY 1-800-701-0720. If you decide to disenroll from AmeriChoice, please contact the Health Benefits Coordinator. The New Jersey Division of Medical Assistance and Health Services must approve your disenrollment. It can take from 30-45 days to process your disenrollment request. The Health Benefits Coordinator will let you know when you will be effective with the new health plan. While you remain an AmeriChoice member, you must use AmeriChoice doctors and specialists. If you regularly refuse to follow your doctor's instructions about treatment or cooperate with your doctors or follow our rules or commit fraud, you may be disenrolled from AmeriChoice. If this happens, AmeriChoice will send you a letter to explain the disenrollment process. This does not mean that you do not have the right to refuse any treatment you do not want to have. If you move out of New Jersey, you may need to disenroll from AmeriChoice. As soon as AmeriChoice is aware of your new location, we will ask the New Jersey Division of Medical Assistance and Health Services to disenroll you due to your change of residence. This applies to all members except Persons with Disabilities and NJ FamilyCare B, C, and D members (contact the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 to find out how this affects you). You may lose coverage if you fail to recertify with NJ FamilyCare or Medicaid. You must renew each year to keep your insurance. Here's how:

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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NJ FamilyCare Members: · The Health Benefits Coordinator (HBC), on behalf of the Department of Human Services, will send your preprinted renewal application directly to your house. · Fill it out and send it back to NJ FamilyCare. · Call the HBC at 1-800-701-0710 or TTY at 1-800-701-0720 if you have any questions or need help with the renewal application form. Remember, if you are an adult and enrolled in a NJ FamilyCare program and you do not re-certify annually, you will be dropped from the program and you will not be able to re-enroll. Medicaid Members: · To avoid a gap in your coverage, you must recertify with New Jersey Medicaid before your termination date to continue to receive your medical benefits. If you do not, you could lose both your New Jersey Medicaid and your AmeriChoice benefits. · To ensure that you receive continuous enrollment, you should contact your caseworker to make sure there is no break in your health coverage one month before your termination date. Continuous enrollment means that if there is no break in your Medicaid coverage, your HMO enrollment will continue automatically. · If you are a new mother, don't forget to sign up your newborn baby with your local county Medical Assistance Customer Center (MACC). What happens when you delay in recertifying your Medicaid until after your termination date? You will lose your AmeriChoice and Medicaid benefits until you contact the MACC office. You will be automatically reenrolled in AmeriChoice if you have lost your Medicaid eligibility for 2 months or less. The MACC office will let you know when you will re-join AmeriChoice. So, to make sure that you continue to receive services from AmeriChoice and Medicaid, recertify as soon as you receive notice from the MACC office or from AmeriChoice.

Timing of Disenrollments:

· If you are a NJ FamilyCareA/Medicaid member, you may disenroll: 1. Any time during the first three months of enrollment; 2. For good cause at any time; 3. After 12 months of enrollment and every 12 months thereafter for any reason; 4. Members enrolled through SSI, New Jersey Care ABD or DYFS may disenroll at any time; 5. You are required to join another HMO. · If you are a NJ FamilyCare B, C or D member, you may disenroll: 1. For good cause at any time; 2. After 12 month lock-in period beginning with enrollment and every 12 months thereafter for any reason; 3. You are required to join another HMO. If you are a NJ FamilyCare/Medicaid A member and you leave AmeriChoice, but you are still eligible for benefits, you will be required to join another health plan. To join another HMO, you must call the Health Benefits Coordinator (HBC) at 1-800-701-0710 or TTY 1-800-701-0720. If you leave AmeriChoice for any reason, you are required to return your AmeriChoice ID card to us.

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Living Wills

All adult AmeriChoice members have the right to provide advance written instructions about medical care in case they become incapacitated per § 42 CFR 489.100. Advance directives are written instructions that you make ahead of time in case you become too ill to make those decisions for yourself. They are sometimes called "living wills" or a "medical power of attorney." You can state what kind of treatment you want or do not want--such as being fed with tubes if you are unable to eat or being on a respirator (breathing machine)--and you can name a person who can make those decisions for you per § 42 CFR 422.128. If there is a change in NJ State Law, the information must reflect changes as soon as possible, but no later than 90 days after the effective date of the State law. It is a good idea to make sure that your PCP and any specialists you see know your wishes before you are hospitalized. If you do not have a "living will" or "advance directive" and would like more information, please call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. You may change your decisions about your "living will" or "advance directive" at any time.

Medicaid Benefits Received After Age 55

Medicaid benefits received after age 55 may be reimbursable to the State of New Jersey from the member's estate. The recovery may include premium payments made on behalf of the member to the managed care organization in which the member enrolls.

Treatment of Minors

If you are a minor (under the age of 19 years old), you have the right to approve your own health care in certain situations, for example, if you are pregnant. You may also review the information that helps the doctor to make decisions. In the case of an emergency where a minor's condition requires prompt attention for the preservation of life and limb, such attention should be given immediately regardless of whether the consent has been received. Minors are informed of their rights as a part of the complaint and grievance process. If you have any questions about your rights, call the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897.

How AmeriChoice Pays Its Providers

Different providers in the AmeriChoice network have agreed to be paid in different ways by AmeriChoice. Your provider may be paid each time he or she treats you (that is known as "fee-for-service"), or your provider may be paid a set fee every month, whether or not you actually receive services (that is called "capitation"). AmeriChoice does not give any of its providers extra payments, or "incentives" (rewards), related to limiting referrals or the care you receive. In fact, we encourage our providers to make sure that you receive all the appropriate services you may need. In certain cases, AmeriChoice has its own insurance to cover very high hospital bills. This insurance is called "stop loss" coverage. It does not affect our members' health care in any way. If you want more information about how your Primary Care Providers in the AmeriChoice network, or any other AmeriChoice providers, are paid, you can call our Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 or write to the AmeriChoice Member Services Department at P.O. Box 200089, Riverfront Plaza Station, Newark, NJ 07102.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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Your Rights

As a member of AmeriChoice, you have certain rights concerning health care. Regardless of your illness or medical treatment, you cannot be refused treatment. But a PCP may refer you to a specialist for treatment that he or she cannot provide. Although you do not have to tell your doctor about any illnesses that you may have, the doctor may not be able to help you unless he or she knows about the illnesses. 1. You have the right to be treated with respect, dignity and privacy by AmeriChoice and its providers. 2. You have the right to be told about any illness you have. 3. You have the right to be told of any care or treatment that your PCP feels should be done before anything is done, even if AmeriChoice does not cover it. This includes the right to get accurate, easy to understand information to help you make good choices about your treatment. 4. You have the right to refuse treatment as far as the law allows and to know what the outcome may be. 5. You have the right to expect your doctors to keep your records and anything you say private. No information will be released to anyone without your consent, unless required by law. 6. You have the right to request a current directory of providers in the AmeriChoice network to choose your own PCP. 7. You have the right to get needed medical services within a fair length of time. 8. If you have a baby, you have the right to stay in the hospital for at least 48 hours after the delivery if it is a normal vaginal delivery. If you have a Caesarian section, you can stay in the hospital at least 96 hours after your baby is born. 9. You have the right to complain to AmeriChoice and to get a reply in a timely manner. 10. You have the right to be informed of AmeriChoice rules and any changes that are made. 11. You have the right to make suggestions regarding AmeriChoice policies and procedures. 12. You have the right to talk about your medical records with your PCP and to get a complete copy of those records. 13. You have the right to know of all Medicaid benefits due to you and of all medical services you can use with AmeriChoice. 14. You have the right to ask for a second opinion about any medical care that your PCP advises you to have. 15. You have the right to know how AmeriChoice decides whether a service is covered and/or is medically necessary. 16. You have the right to a translator if you need one when you talk to us or one of our providers. 17. You have the right to participate in all decisions about your health care and the development of any plan of care designed for you. 18. You have the right to speak to providers in private and to have your medical records kept private. 19. You have the right to be free from harm, including unnecessary physical restraints or isolation, excessive medication, physical or mental abuse or neglect. 20. You have the right to be free of hazardous procedures.

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21. You have the right to have services provided that promote a meaningful quality of life and independence for yourself, including living in your own home or another community setting as long as it is medically and socially feasible, and the right to the preservation and support of your natural support system.

New Jersey HMO Consumer Bill of Rights

In addition to the rights you have as a member of AmeriChoice that were explained on the previous pages, you have some other rights as a member of a health plan in New Jersey. These include: 1. You have the right to obtain a current directory of doctors in the AmeriChoice network. 2. You have the right to have a choice of specialists following a referral. 3. If you have a chronic disability, you have the right to be referred to specialists who are experienced in treating disabilities. 4. You have the right to have access to a primary care provider or a back-up 24 hours a day, 365 days a year. 5. You have the right to call 911 in a potentially life-threatening situation without prior authorization from AmeriChoice. 6. You have the right to have AmeriChoice pay for your medical screening exam in the emergency room to determine if an emergency medical condition exists. 7. You have the right to receive up to 120 days (or one year depending on your condition) of continued coverage--if it is medically necessary--from a doctor who terminated from AmeriChoice. 8. You have the right to have a doctor make the decision to deny or limit your coverage. 9. You have the right to no "gag rules." Your doctors are free to discuss all medical treatment options, even if they are not covered services. 10. You have the right to know how AmeriChoice pays providers so you know if there are any financial incentives (rewards) or disincentives (no rewards) when he or she makes medical decisions. 11. You have the right to appeal a decision to deny or limit coverage, first with AmeriChoice and then through an independent organization for a filing fee. 12. You have the right to know that you or your doctor cannot be penalized for filing a complaint or appeal. 13. You have the right to be notified of any changes in benefits, services, or our provider network. 14. You have the right to be free from balance billing. 15. You have the right to receive from any of your providers an explanation, in terms you can understand, of your complete medical condition. 16. You have the right to choose a PCP within the limits of the covered benefits. 17. You have the right to be provided with information about AmeriChoice's policies and procedures, products, services, providers and appeal procedures. 18. You have the right to file a complaint or an appeal to us or the State Department of Banking and Insurance or the Division of Medical Assistance and Health Services. You have the right to receive an answer to those complaints within a reasonable period of time. Those who are on Medicaid, NJ FamilyCare A and certain members on NJ FamilyCare D have a right to a Medicaid Fair Hearing. Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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NJ FamilyCare

If you are enrolled in NJ FamilyCare A, the benefits and the AmeriChoice policies that affect you are exactly the same as those described in this Member Handbook. If you are enrolled in NJ FamilyCare B or C, all the AmeriChoice benefits described in this Member Handbook are covered, but you are not entitled to a Medicaid Fair hearing if you have a complaint or grievance against the health plan. You are entitled to file a grievance and you are entitled to access the appeal process. Contact the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897. Certain NJ FamilyCare D members are entitled to a Medicaid Fair Hearing. Contact the Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897 to find out if you are entitled to this benefit. Also, members of NJ FamilyCare C and D must pay the following fees: NJ FamilyCare C 1. Co-payments between $5 and $10 as indicated on pages 37-38. 2. Total annual co-payments will not be more than 5% of your family's yearly income. It is, however, the responsibility of the member or his or her family to keep track of total payments throughout the year and to notify the Health Benefits Coordinator at 1-800-701-0710 or TTY 1-800-701-0720 once you reach that amount. NJ FamilyCare D 1. A monthly premium that can vary from $34 to $113.50 depending on your family's income and your household size. 2. Co-payments as indicated on page 38 but not to exceed $35 per service. 3. Total annual premiums and co-payments will not be more than 5% of your family's yearly income. It is, however, the responsibility of the member or his or her family to keep track of total payments throughout the year and to notify the Health Benefits Coordinator at 1-800-701-0710 or TTY 1-800-7010720 if you reach that amount. If you have questions about these NJ FamilyCare rules, please call the toll-free AmeriChoice Member Service Center at 1-800-941-4647 or TDD at 1-800-852-7897.

(Subject to Change)

NJ FamilyCare C (Personal Contributions to Care)

Outpatient hospital visits (except for preventive services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Emergency services in a hospital Emergency Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10 Physician visits (except for well-child visits, lead screening and treatment, age-appropriate immunizations, prenatal care, and pap smears, when appropriate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Independent clinic visits (including to Federally Qualified Health Centers; except for preventive services). $5 Podiatrist visits (no routine care). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Optometrist visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Nurse midwife visits (except for prenatal care visits). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Dentist visits (except for preventive services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5

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Chiropractor visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Nurse practitioner visits (except for preventive care services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Generic prescription drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1 Brand name prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5

(Subject to Change)

NJ FamilyCare D Co-Payments

Note: Co-payments are required only if indicated on your ID Card. Primary care/specialist physician office visits during normal office hours (except for well-child care, lead screening and treatment, age-appropriate immunizations, prenatal care). . . . . . . . . . . . . . . . . . . . . . . . $5 Primary care/specialist physician office visits during non-office hours or home visit . . . . . . . . . . . . . . . . . . $10 Initial maternity visit (to doctor or nurse midwife) during normal office hours . . . . . . . . . . . . . . . . . . . . . . . . $5 Initial maternity visit (to doctor or nurse midwife) during non-office hours . . . . . . . . . . . . . . . . . . . . . . . . . $10 Nurse practitioners visit (except preventive services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Nurse practitioners visit during non-office hours (except for preventive services) . . . . . . . . . . . . . . . . . . . . $10 Optometrist visits (except for newborns covered under fee-for-service) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Podiatrist visits (no routine care). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Psychologist services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Laboratory and X-ray services that are not part of an office visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Emergency room services (except if admitted to the hospital or if referred to the Emergency Room by your PCP for services that should have been given in the doctor 's office) . . . . . . . . . . . . . . . . . . . . . . . . $35 Outpatient hospital clinic visits (except for preventive services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Prescription drugs ­ more than a 34-day supply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10 Hospital Outpatient mental health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25 Outpatient substance abuse services for detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 Outpatient rehabilitation visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 There are no co-payments for the following services: · Emergency ambulance services · All maternity visits after the first visit · Outpatient surgery · Home health services · Hospice services

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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· Inpatient hospital services · Inpatient substance abuse detoxification services · Inpatient mental health services · Skilled-nursing facility services · Preventive dental visits for enrollees under age 12

Medicaid and NJ FamilyCare A, B and C Exclusions

The following services are not covered for NJ FamilyCare plan participants or Medicaid for NJ FamilyCare A, B and C programs: · Services not medically necessary · Cosmetic surgery, except when medically necessary and with prior approval · Experimental organ transplants and investigational services · Infertility diagnosis and treatment services · Rest cures, personal comfort, convenience items and custodial care · Respite Care · Services involving the use of equipment in facilities, the purchase, rental or construction of which has not been approved by applicable laws of the State of New Jersey and regulations issued pursuant thereto · All claims arising directly from services provided by or in institutions owned or operated by the federal government such as Veterans Administration hospitals · Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals under 65 years of age and over 21 years of age. · Services provided to all persons without charge. Services and items provided without charge through programs of other public or voluntary agencies (for example, New Jersey Department of Health and Senior Services, New Jersey Heart Association, First Aid Rescue Squad and so forth) shall be utilized to the fullest extent possible. · Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military. · Services provided outside the United States and territories. · Services or items furnished for any condition or accidental injury arising out of and in the course of employment for which any benefits are available under the provisions of any workers' compensation law, temporary disability benefits law, occupational disease law, or similar legislation, whether or not the Medicaid beneficiary claims or receives benefits thereunder and whether or not any recovery is obtained from a third-party for resulting damages. · That part of any benefit which is covered or payable under any health, accident, or other insurance policy (including any benefits payable under the New Jersey no-fault automobile insurance laws), any other private or governmental health benefit system, or through any similarly third-party liability, which also includes the provision of the Unsatisfied Claim and Judgment Fund. · Any service or items furnished for which the provider does not normally charge. · Services furnished by an immediate relative or member of the Medicaid beneficiary's household.

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· Services billed for which corresponding health care records do not adequately and legibly reflect the requirements of the procedure code utilized by the bill provider. · Services or items reimbursed based upon submission of a cost study when there are no acceptable records or other evidence to substantiate either the costs allegedly incurred or beneficiary income available to offset those costs. In the absence of financial records, a provider may substantiate costs or available income by means of other evidence acceptable to the Division.

NJ FamilyCare D Exclusions

The following services are not covered for NJ FamilyCare D participants either by AmeriChoice or DMAHS: · Non-medically necessary services · Intermediate Care Facilities/Mental Retardation · Private duty nursing unless authorized by the contractor · Personal Care Assistant Services · Medical Day Care Services · Chiropractic Services · Dental service except preventive dentistry for children under age 12 · Orthotic devices · Targeted Case Management for the chronically ill · Residential treatment center psychiatric programs · Religious non-medical institutions care and services · Durable Medical Equipment · EPSDT except for well-child care including immunizations and lead screening and treatments · Transportation Services including non-emergency ambulance, invalid coach and lower mode transportation · Hearing Aid Services and Audiology Exception: Limited to children under 16 years · Blood and Blood Plasma, except administration of blood, processing of blood, processing fees and fees related to autologous blood donations are covered · Cosmetic Surgery · Custodial Care · Special Remedial and Educational Services · Experimental and Investigational Services · Medical Supplies, except diabetic supplies

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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· Infertility Services · Rehabilitative Services for Substance Abuse · Weight reduction programs or dietary supplements, except surgical operations, procedures or treatment of obesity when approved by the contractor · Acupuncture and acupuncture therapy, except when performed as a form of anesthesia in connection with covered surgery · Temporomandibular joint disorder treatment, including treatment performed by prosthesis placed directly in the teeth · Recreational Therapy · Sleep Therapy · Court-ordered services · Thermograms and thermography · Biofeedback · Radial keratotomy · Respite Care · Skilled nursing facility services Exception: Covered for rehabilitation and hospice

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Reporting Fraud, Waste or Abuse

AmeriChoice wants you to report any provider (for example a doctor, dentist, therapist, hospital or medical equipment supplier), if you suspect fraud, waste or abuse for services provided to you or anyone with AmeriChoice of New Jersey insurance coverage. Some common forms of fraud, waste and abuse are: · Billing or charging you for services that your health plan covers, except any copayments listed on your AmeriChoice ID card · Billing or charging AmeriChoice of New Jersey for services that they did not provide to you · Offering you gifts or money to let them provide treatment or services to you · Offering you free services, equipment, or supplies in exchange for your AmeriChoice ID number · Giving you treatment or services that you do not need If you suspect Fraud, Waste or Abuse, please contact the Member Service Center at 1-800-941-4647 or TDD 1-800-852-7897. You do not have to give your name but if you do, the provider will not be told that you called. If you don't speak English, an interpreter will be made available. You can also report suspected fraud, waste or abuse to the State of New Jersey by calling 877-55-FRAUD.

For More Information

If you have any questions about the information in this Handbook or about any AmeriChoice service, call our Member Service Center at 1-800-941-4647, 1-800-852-7897 (TDD). AmeriChoice Member Service Center Representatives are available 24 hours a day, 7 days a week to help you. Para hablar con un representante en Español, llame al 1-800-943-4647. If you speak a language besides English or Spanish, or need a tape recording of the information in this handbook, call 1-800-941-4647 or TDD at 1-800-852-7897 and we will help you! You also should call us if you want an explanation of service access arrangements if you are homebound, if you want to know how to get Women, Infants and Children (WIC) services or you want to know about the availability of care management services. WIC is a program that provides supplemental nutritious foods to pregnant, breastfeeding and postpartum women, infants and children up to the age of five. WIC services include nutrition education and counseling, breastfeeding promotion and support, immunization screening and health care referrals. As long as you or your children are eligible to apply for WIC benefits you will be eligible to continue to receive WIC benefits. WIC service agencies are conveniently located throughout New Jersey. Call toll Free 1-866-44 NJ WIC (446-5942) to see if you are eligible for the WIC program or to get more information. You may also get information about WIC from our Healthy First Steps Team at 1-800-905-4315. Do you have any ideas about how to make AmeriChoice better? Would you like to help make AmeriChoice plans and policies? Call us at 1-800-941-4647 (English) or 1-800-943-4647 (Spanish) or TDD at 1-800-8527897. If you do not speak English or Spanish, AmeriChoice will get someone who speaks your language. If you prefer, you can write to AmeriChoice at: P.O. Box 200089, Riverfront Plaza Station, Newark, NJ 07102.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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Terms to Remember

Here are some definitions of the terms we used in this Member Handbook that may give you a better understanding of the information given in this Handbook. ABD (Aged, Blind and Disabled) ­ members of the Medicaid eligibility category of Aged, Blind and Disabled and are eligible for enrollment in the managed care program. Abuse ­ provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid/NJ FamilyCare program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes member practices that result in unnecessary cost to the Medicaid/NJ FamilyCare program. AmeriChoice Personal Care Plus ­ the managed Medicare Special Needs program that enrolls individuals who have both Medicaid and Medicare Parts A & B. Appeal ­ a request by a member or provider for review of an action. Appointment ­ a scheduled meeting with a doctor. Baseline Exam ­ a complete physical examination as soon as you join a health plan. When your Primary Care Provider gives you a physical examination, he or she will ask questions about your health history. Complaint ­ a problem that you have with AmeriChoice or a Plan provider that can be solved to your satisfaction within 5 business days. DDD ­ Division of Developmental Disabilities. Its clients are eligible for enrollment in the managed care program. DDD/CCW ­ Division of Developmental Disabilities Community Care Waiver. Its clients are eligible for enrollment in the managed care program. Directory of Providers ­ list of primary care providers, specialists and self-referral providers who are part of the AmeriChoice provider network. It includes PCPs, specialists, dentists, vision centers and OB/GYNs. Disenrollment ­ when you are leaving AmeriChoice. To disenroll, you must contact your County Board of Social Services, Medical Assistance Customer Center, or the Health Benefits Coordinator. Emergency ­ a health problem that an average person with a basic understanding of medicine and health, could reasonably expect that not taking immediate medical attention could result in (1) placing the health of the person (with respect to a pregnant woman, the health of the woman or her unborn child) that has such condition in serious danger, or in the case of a behavioral condition, placing the health of such person or others in serious danger; or (2) serious injury of such person's bodily functions; or (3) serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person. See p. 20 for some examples of emergencies. Enrollment ­ joining AmeriChoice. Family Practice Provider ­ a doctor who is trained to take care of children and adults. Fraud ­ an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. It includes any act that constitutes fraud under applicable federal or State law. Grievance ­ a problem that you have with AmeriChoice or a Plan provider that cannot be solved to your satisfaction within five (5) business days. Immunizations ­ shots that prevent a person from getting certain diseases. Babies have to completely take several types of shots over the first two years of their life to prevent them from getting certain diseases. Internist ­ a doctor who is trained to provide basic preventive services, complete exams, give

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immunizations, and other general practice medicine for adults. Medically Necessary Care ­ services or supplies that are needed to prevent or diagnose and cure conditions that would cause suffering, endanger a person's life, result in illness or limit a person's normal activities. Member ­ a person who is enrolled with AmeriChoice. Member Identification Card ­ a card issued by AmeriChoice that identifies your health plan. The ID card has the member identification number and how to contact AmeriChoice at any time. Providers and pharmacies (if necessary) will ask for this card. Carry it with you at all times along with your Health Benefits Identification (HBID) card. Member Service Center ­ the toll-free AmeriChoice telephone number you can call 24 hours a day, 7 days a week to ask questions about AmeriChoice or get help with problems you are having with your health care. The number is 1-800-941-4647 for English and translations, 1-800-943-4647 for Spanish and 1-800-852-7897 for TTY/TDD. Member Service Center Representative ­ a person who works for AmeriChoice who gives information, answers questions about AmeriChoice, and handles problems you may have with your health care. AmeriChoice Customer Service Representatives can be reached by calling the AmeriChoice Customer Service Center at 1-800-941-4647 for English and translations, 1-800-943-4647 for Spanish and 1-800-8527897 for TTY/TDD. Non-Participating Provider (non-par) ­ a health care provider who has not contracted with AmeriChoice to be a participating provider of health care. If a member sees a non-par provider without a referral or medical authorization, the member is responsible for the bill. This is also known as out-of-network provider. Nurse Practitioner ­ a primary care provider that works under the direction of a physician to provide basic preventive services, immunizations and other general practice medicine for children and adults. Participating Provider ­ a physician, primary care physician (PCP), specialist, lab, hospital, pharmacy, skilled nursing facility or other health care facility that is part of the AmeriChoice provider network. Pediatrician ­ a doctor who is trained to take care of babies and children under 21 years of age. Post Stabilization Care Services ­ covered services, related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition, or to improve or resolve the enrollee's condition. Prenatal Care ­ the health care a woman receives before the birth of her baby. Preventive Care ­ health care that prevents serious disease. This can include regular checkups, immunizations, well-baby, well-child, and well-woman care, dental screenings and lead screenings. Primary Care Provider or PCP ­ the doctor/health care professional who is part of the AmeriChoice provider network and who provides direct care, arranges specialty care for a member, and keeps your medical records. Prior Authorization ­ a request made by a doctor to AmeriChoice for the member to receive services from a non-participating doctor or hospital. Provider ­ a physician, hospital, group practice, nursing home, pharmacy or any individual or group of individuals that provides a health care service.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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Referral ­ approval from a PCP to see a participating specialist. The PCP can write a referral on his/her prescription pad or on paper with his/her letterhead, and can help make the first appointment with the specialist. Specialist ­ a doctor or other provider who is trained in a special type of medicine or health care. The PCP will give a referral to a specialist when special care is needed. Urgent Care ­ treatment for a problem that is serious but not life-threatening. It requires attention from a doctor within 24 hours. See page 16 for some examples of conditions that have need of urgent care. Waste - overutilization of services, or other practices that result in unnecessary costs. Generally not considered caused by criminally negligent actions but rather the misuse of resources.

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Helpful Hints for a Successful Doctor's Visit

The following hints may help you have a more successful well-visit with your child's doctor. You should also make sure that you bring your child's health records with you each time you visit your child's doctor. · Before your child's next visit, make a list of the questions that you want to ask your child's doctor. · Always have your child's immunization card with you so the doctor can keep it up-to-date.

Questions You May Want To Ask Your Child's Doctor...

· If my child is sick, can he/she still get his/her immunizations that are right for his/her age? · Is it time for my child to have a lead test? · Is it time for my child to have a hearing and vision test? · Is my child's height and weight something I should be worried about at this time? · Any other concerns that you may have.

Things That Your Child's Doctor Should Know...

· If your child has been to a hospital or emergency room since his/her last visit. · Information about your family history i.e. does diabetes or heart conditions run in your family. · Any changes in your child's eating, sleeping or social behavior (making friends, getting in trouble at school, not able to sit still or concentrate, etc). · If you do not understand something about your child's diagnosis or medications.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

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HEALTH PLAN NOTICES OF PRIVACY PRACTICES

NOTICE FOR MEDICAL INFORMATION: Pages 47-50. NOTICE FOR FINANCIAL INFORMATION: Pages 50-51.

MEDICAL INFORMATION PRIVACY NOTICE

THIS SAYS HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND SHARED. IT SAYS HOW YOU CAN GET ACCESS TO THIS INFORMATION. READ IT CAREFULLY. Effective January 1, 2010 We1 must by law protect the privacy of your health information ("HI"). We must send you this notice. It tells you: · How we may use your HI. · When we can share your HI with others. · What rights you have to your HI. We must by law follow the terms of this notice. "Health information" (or HI) in this notice means information that can be used to identify you. And it must relate to your health or health care. We have the right to change our privacy practices. If we change them, we will mail a notice within 60 days. We will post the new notice on our website www.myuhc.com. We have the right to make changes that apply to HI that we have and to future information.

1

This Medical Information Notice of Privacy Practices applies to the following health plans that are affiliated with UnitedHealth Group: ACN Group of California, Inc.; All Savers Insurance Company; All Savers Insurance Company of California; American Medical Security Life Insurance Company; AmeriChoice of Connecticut, Inc.; AmeriChoice of Georgia, Inc.; AmeriChoice of New Jersey, Inc.; AmeriChoice of Pennsylvania, Inc.; Arizona Physicians IPA, Inc.; Arnett HMO, Inc.; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.; Evercare of Arizona, Inc.; Evercare of New Mexico, Inc.; Evercare of Texas, LLC; Golden Rule Insurance Company; Great Lakes Health Plan, Inc.; Health Plan of Nevada, Inc.; IBA Health and Life Assurance Company; MAMSI Life and Health Insurance Company; MD Individual Practice Assocation, Inc.; Midwest Security Life Insurance Company; National Pacific Dental, Inc.; Neighborhood Health Partnership, Inc.; Nevada Pacific Dental; Optimum Choice, Inc.; Oxford Health Insurance, Inc.; Oxford Health Plans (CT), Inc.; Oxford Health Plans (NJ), Inc.; Oxford Health Plans (NY), Inc.; Pacific Union Dental, Inc.; PacifiCare Behavioral Health of California, Inc.; PacifiCare Behavioral Health, Inc.; PacifiCare Dental; PacifiCare Dental of Colorado, Inc.; PacifiCare Insurance Company; PacifiCare Life and Health Insurance Company; PacifiCare Life Assurance Company; PacifiCare of Arizona, Inc.; PacifiCare of California; PacifiCare of Colorado, Inc.; PacifiCare of Nevada, Inc.; PacifiCare of Oklahoma, Inc.; PacifiCare of Oregon, Inc.; PacifiCare of Texas, Inc.; PacifiCare of Washington, Inc.; Sierra Health & Life Insurance Co., Inc.; Spectera, Inc.; U.S. Behavioral Health Plan, California; Unimerica Insurance Company; Unimerica Life Insurance Company of New York; Unison Family Health Plan of Pennsylvania, Inc.; Unison Health Plan of Delaware, Inc.; Unison Health Plan of Ohio, Inc.; Unison Health Plan of Pennsylvania, Inc.; Unison Health Plan of South Carolina, Inc.; Unison Health Plan of Tennessee, Inc.; Unison Health Plan of the Capital Area, Inc.; United Behavioral Health; UnitedHealthcare Insurance Company; UnitedHealthcare Insurance Company of Illinois; UnitedHealthcare Insurance Company of New York; UnitedHealthcare Insurance Company of the River Valley; UnitedHealthcare Insurance Company of Ohio; UnitedHealthcare of Alabama, Inc.; UnitedHealthcare of Arizona, Inc.; UnitedHealthcare of Arkansas, Inc.; UnitedHealthcare of Colorado, Inc.; UnitedHealthcare of Florida, Inc.; United HealthCare of Georgia, Inc.; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare of Kentucky, Ltd.; United HealthCare of Louisiana, Inc.; UnitedHealthcare of Mid-Atlantic, Inc.; UnitedHealthcare of the Midlands, Inc.; UnitedHealthcare of the Midwest, Inc.; United HealthCare of Mississippi, Inc.; UnitedHealthcare of New England, Inc.; UnitedHealthcare of New York, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Tennessee, Inc.; UnitedHealthcare of Texas, Inc.; United HealthCare of Utah; UnitedHealthcare of Wisconsin, Inc.; UnitedHealthcare Plan of the River Valley, Inc.

47

How We Use or Share Information

We must use and share your HI if asked for by: · You or your legal representative. · The Secretary of the United States Department of Health and Human Services to make sure your privacy is protected. We have the right to use and share HI. This must be for your treatment, to pay for care and to run our business. For example, we may use and share it: · To Pay premiums, determine coverage, and process claims. This also may include coordinating benefits. For example, we may tell a doctor you have coverage. We may tell a doctor how much of the bill may be covered. · For Treatment or managing care. For example, we may share your HI with providers to help them give you care. · For Health Care Operations related to your care. For example, we may suggest a disease management or wellness program. We may study data to see how we can improve our services. · To tell you about Health Programs or Products. This may be other treatments or products and services. These activities may be limited by law as of February 17, 2010. · For Plan Sponsors. We may give enrollment and summary HI to an employer plan sponsor. We may give them other HI if they agree to limit its use per federal law. · For Reminders on benefits or care. Such as appointment reminders. We may use or share your HI as follows: · As Stated by Law. · To Persons Involved With Your Care. This may be to a family member. This may happen if you are unable to agree or object. Such as in an emergency or when you agree or fail to object when asked. If you are not able to object, we will use our best judgment. · For Public Health Activities. This may be to prevent disease outbreaks. · For Reporting Abuse, Neglect or Domestic Violence. We may only share with entities allowed by law to get this HI. This may be a social or protective service agency. · For Health Oversight Activities to an agency allowed by the law to get the HI. This may be for licensure, audits and fraud, waste, and abuse investigations. · For Judicial or Administrative Proceedings. Such as to answer a court order or subpoena. · For Law Enforcement. Such as to find a missing person or report a crime. · For Threats to Health or Safety. This may be to public health agencies or law enforcement. Such as in an emergency or disaster. · For Government Functions. This may be for military and veteran use, national security, or the protective services. · For Workers' Compensation. To comply with labor laws. · For Research. Such as to study disease or disability, as allowed by law. · To Give Information on Decedents. This may be to a coroner or medical examiner. Such as to identify the deceased, find a cause of death or as stated by law. We may give HI to funeral directors. Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

48

· For Organ Transplant. To help get, bank or transplant organs, eyes or tissue. · To Correctional Institutions or Law Enforcement. For persons in custody: (1) To give health care. (2) To protect your health and the health of others. (3) For the security of the institution. · To Our Business Associates if needed to give you services. Our associates agree to protect your HI. They are not allowed to use HI other than as per our contract with them. As of February 17, 2010, our associates will be subject to federal privacy laws. · To Notify of a Data Breach. To give notice of unauthorized access to your HI. We may send notice to you or to your plan sponsor. · Other Restrictions. Federal and state laws may limit the use and sharing of highly confidential HI. This may include state laws on: 1. HIV/AIDS 2. Mental health 3. Genetic tests 4. Alcohol and drug abuse 5. Sexually transmitted diseases and reproductive health 6. Child or adult abuse or neglect or sexual assault Except as stated in this notice, we use your HI only with your written consent. If you allow us to share your HI, we do not promise that the person who gets it will not share it. You may take back your consent, unless we have acted on it. To find out how, call the phone number on the back of your ID card.

Your Rights

You have a right: · To ask us to limit use or sharing for treatment, payment, or health care operations. You can ask to limit sharing with family members or others involved in your care or payment for it. We may allow your dependents to ask for limits. We will try to honor your request, but we do not have to do so. · To ask a provider not to send HI to us if you paid for the care in full. · To ask to get confidential communications in a different way or place. (For example, at a P.O. Box instead of your home.) We will agree to your request when a disclosure could endanger you. We take verbal requests. You can change your request. This must be in writing. Mail it to the address below. · To see or get a copy of HI that we use to make decisions about you. You must ask in writing. Mail it to the address below. We may send you a summary. We may deny your request. If we deny your request, you may have the denial reviewed. As of February 17, 2010, if we keep an electronic record, you may ask for an electronic copy to be sent to you or a third party. · To ask to amend. If you think your HI is wrong or incomplete you can ask to change it. You must ask in writing. You must give the reasons for the change. Mail this to the address below. If we deny your request, you may add your disagreement to your HI. · To get an accounting of HI shared in the six years prior to your request. This will not include any HI shared: (i) Prior to April 14, 2003. (ii) For treatment, payment, and health care operations. (iii) With you or with your consent. (iv) With correctional institutions or law enforcement. This will not list disclosures if federal law does not make us keep track of them.

49

· To get a paper copy of this notice. You may ask for a copy at any time. Even if you agreed to get this notice electronically, you have a right to a paper copy. You may also get a copy at our website, www.myuhc.com.

Using Your Rights

· To Contact your Health Plan. Call the phone number on the back of your ID card. Or you may contact the UnitedHealth Group Call Center at 1-866-799-1328. · To Submit a Written Request. Mail to: UnitedHealth Group PSMG Privacy Office MN006-W800 P.O. Box 1459 Minneapolis, MN 55440 · To File a Complaint. If you think your privacy rights have been violated, you may send a complaint at the address above. You may also notify the Secretary of the U.S. Department of Health and Human Services. We will not take any action against you for filing a complaint.

FINANCIAL INFORMATION PRIVACY NOTICE

THIS NOTICE SAYS HOW YOUR FINANCIAL INFORMATION MAY BE USED AND SHARED. IT SAYS HOW YOU CAN GET ACCESS TO THIS INFORMATION. REVIEW IT CAREFULLY. Effective January 1, 2010 We2 protect your "personal financial information" ("FI"). This means non-health information about an enrollee or an applicant obtained to provide coverage. It is information that identifies the person and is not public.

Information We Collect

We get FI about you from: · Applications or forms. This may be name, address, age and social security number. · Your transactions with us or others. This may be premium payment data.

2 For purposes of this Financial Information Privacy Notice, "we" or "us" refers to the entities listed in footnote 1, beginning on the first page of the Health Plan Notices of Privacy Practices, plus the following UnitedHealthcare affiliates: ACN Group IPA of New York, Inc.; ACN Group, Inc.; Administration Resources Corporation; AmeriChoice Health Services, Inc.; Behavioral Health Administrators; Behavioral Healthcare Options, Inc.; DBP Services of New York IPA, Inc.; DCG Resource Options, LLC; Dental Benefit Providers, Inc.; Disability Consulting Group, LLC; HealthAllies, Inc.; Innoviant, Inc.; MAMSI Insurance Resources, LLC; Managed Physical Network, Inc.; Mid Atlantic Medical Services, LLC; Midwest Security Care, Inc.; National Benefit Resources, Inc.; OneNet PPO, LLC; OptumHealth Bank, Inc.; Oxford Benefit Management, Inc.; Oxford Health Plans LLC; PacifiCare Health Plan Administrators, Inc.; PacificDental Benefits, Inc.; ProcessWorks, Inc.; RxSolutions, Inc.; Sierra Health-Care Options, Inc.; Sierra Nevada Administrators, Inc.; Spectera of New York, IPA, Inc.; UMR, Inc.; Unison Administrative Services, LLC; United Behavioral Health of New York I.P.A., Inc.; United HealthCare Services, Inc.; UnitedHealth Advisors, LLC; United Healthcare Service LLC; UnitedHealthcare Services Company of the River Valley, Inc.; UnitedHealthOne Agency, Inc.

Member Services is available 24 hours a day, 7 days a week at 1-800-941-4647. If you have trouble hearing, call AT&T TDD Relay Service at 1-800-852-7897.

50

Sharing of FI

We do not share FI about our enrollees or former enrollees, except as required or permitted by law. To run our business, we may share FI without your consent to our affiliates. This is to tell them about your transactions, such as premium payment.

Confidentiality and Security

We limit access to your FI to our employees and providers who manage your coverage and provide services. We have physical, electronic and procedural safeguards per federal standards to guard your FI. We do regular audits to ensure secure handling.

Your Right to Access and Correct FI

In some States3, you may have a right to ask for access to your FI. You can ask: · For the source of the FI. · For a list of disclosures made in the two years before your request. · To view and copy your FI in person. · For a copy to be sent. (We may charge a fee.) · For corrections, amendments or deletions. Follow these directions: To access your FI: Send a request in writing with your name, address, social security number, phone, and the FI you want to access. State if you want access in person or a copy sent. When we get your request, we will contact you within 30 business days. To correct, amend, or delete any of your FI: Send a request in writing with your name, address, social security number, phone, the FI in dispute, and the identity of the document or record. Upon receipt of your request, we will contact you within 30 business days. We will tell you if we have made the correction, amendment or deletion. Or we will tell you we refuse to do so and the reasons why. You may challenge this. Send requests: United Healthcare Customer Service ­ Privacy Unit PO Box 740815 Atlanta, GA 30374-0815

3

California and Massachusetts.

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