* Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Amerigroup
Community Care. CVS Pharmacy, Giant Eagle, Kroger, Target and Walmart are independent companies providing pharmacy
services on behalf of Amerigroup Community Care. Availity, LLC is an independent company providing administrative support
services on behalf of Amerigroup Community Care.
https://providers.amerigroup.com
Coverage provided by Amerigroup Inc.
SABUCR-0042-20 514501MUPENMUB November 2020
Medicare Advantage
New Jersey Medicare Advantage plan changes
2021 highlights
Not all benefits listed below are available to all Medicare Advantage members. Complete details are in
the member’s Evidence of Coverage.
End-stage renal disease
Medicare beneficiaries with end-stage renal disease (ESRD) may enroll in all Medicare
Advantage plans beginning January 1, 2021:
Previously, ESRD beneficiaries could only obtain Medicare Advantage coverage
under limited circumstances. With this new enrollment option, ESRD beneficiaries
may select a Medicare Advantage plan during open enrollment regardless of
previous coverage.
Amerigroup however does have a preferred plan for those with ESRD in Bergen,
Essex, Hudson, Middlesex, Monmouth, Morris, Ocean, Passaic, Somerset, Union
counties called Amerivantage ESRD Care (HMO-POS C-SNP), which offers benefits
and a care model specifically designed to meet the needs of these members.
Acupuncture
Medicare coverage of acupuncture: Beneficiaries are covered for up to 12 visits in 90 days
under the following circumstances (copays or coinsurance may apply):
Chronic low back pain defined as:
Annual benefit changes for Medicare Advantage plan members under
Amerigroup will be effective January 1, 2021.
The following is a summary of these changes. Complete details are in the member’s Evidence of
Coverage. To view the Evidence of Coverage, go to https://providers.amerigroup.com and
select your state. Find Provider Resources & Documents. Under Quick Tools, select Medicare
Advantage 2021 Products. The document that opens will contain links to each plan’s Evidence of
Coverage changes may include medical and Part D benefits, copays, coinsurance, deductibles,
formulary coverage, pharmacy network, premiums and out-of-pocket maximums.
Some group-sponsored Medicare Advantage plan benefits vary from the Medicare Advantage
plans offered to individuals. Please refer to the member’s Evidence of Coverage or call Provider
Services at the number on the member ID card for more benefit details.
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o Lasting 12 weeks or longer
o Nonspecific, in that it has no identifiable systemic cause (i.e., not associated
with metastatic, inflammatory, infectious, etc. disease);
o Not associated with surgery
o Not associated with pregnancy
An additional eight sessions will be covered for members demonstrating
improvement. No more than 20 acupuncture treatments may be administered
annually.
Treatment must be discontinued if the member does not improve or regresses.
Some plans may also offer additional acupuncture benefits that go beyond Original
Medicare coverage.
Emergency World Wide Coverage
Emergency World Wide Coverage limit increases from $25,000 to $100,000.
Electronic Health Monitoring
For the Amerivantage ESRD Care (HMO-POS C-SNP), telemonitoring benefit will be renamed
to Electronic Health Monitoring and will include the following options:
Blood Glucose Monitoring: Members with uncontrolled diabetes, particularly those
on insulin, can be eligible for electronic health monitoring of blood glucose.
Blood Pressure Monitoring: Members with uncontrolled blood pressure levels can
be eligible for electronic health monitoring of blood pressure. Blood pressure cuffs
are for use at home for ongoing monitoring of members’ blood pressure and
symptoms of hypertension.
Weight Monitoring Device for cardiac patients: Members can be eligible for a
home-based electronic weight-monitoring device. A sudden increase in weight may
indicate potential heart failure symptoms.
Everyday Extras
The Everyday Extras package allows members to select one of the following benefits to help them
achieve their health goals. These benefits may help your patients with meals, mobility and more. Prior
authorization and/or recommendation from a licensed clinician may be required for some of these
benefits. Members may choose one of the following benefits at enrollment or throughout the plan year.
Members can request their selection through customer service. Because some benefits have an
eligibility requirement, members are encouraged to consult their physician prior to their selection. On
many plans, these benefits maybe embedded as individual benefits. Please refer to the member’s
Evidence of Coverage.
Personal home helper
This benefit provides in-home support for caregiver respite, home-based chores and
activities of daily living (ADL) to address needs while recovering from injury or illness. It
covers up to four hours per day for 31 days or 124 hours of care in a calendar year. Prior
authorization is required. Benefit levels may vary by plan.
Transportation
Transportation to and from medical visits, SilverSneakers® locations and pharmacy visits are
covered by this benefit. This benefit covers up to 60 one-way trips each calendar year. The
service requires approval at least 48 hours in advance. Benefit levels may vary by plan.
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Assistive devices
This provides up to a $500 allowance toward the purchase of assistive or safety devices,
such as toilet seats compliant with the Americans with Disabilities Act (ADA) standards,
shower stools, hand-held shower heads, reaching devices, temporary wheelchair ramps and
more. Benefit levels may vary by plan.
Healthy meals — post-discharge
Members can receive meals to prevent, treat or avoid a health-related issue. Member must
have a recent discharge and a BMI greater than 25, a BMI less than 18.5 or an HbA1C
greater than 9.0. Nutritional assessment and prior authorization are required.
Adult Day Center
This benefit includes one visit per week for up to eight hours. It also includes transportation
to and from the adult day care location. To be eligible, the member must need help with at
least two ADL, and a clinician must recommend the benefit. The member must submit a
request for reimbursement for a plan-approved, licensed facility. The maximum
reimbursement is $80 per day. Prior authorization is required.
Health and fitness tracker
Members can receive a wearable health and fitness tracker to help them achieve their
health goals. Members are eligible for one device every two years. This benefit also comes
with access to online programs to improve their physical health and brain skills. These
programs include fitness and health coaching, as well as exercises that can improve their
attention, memory and navigation abilities.
Healthy Pantry
Members are eligible for monthly nutritional counseling sessions, plus monthly pantry
staples (non-perishable) to help them make changes to their diet that would help a
diagnosed chronic medical condition. This benefit is filed under CMS’ guidelines for Special
Supplemental Benefits for the Chronically Ill (SSBCI). Prior authorization is required.
Pest control
Based on qualifying clinical criteria, members could have their home treated every three
months to control pests if an infestation is having a direct impact on a diagnosed chronic
medical condition. This benefit filed under CMS’ guidelines for Special Supplemental
Benefits for the Chronically Ill (SSBCI). Prior authorization is required.
Service dog support
Members can get up to $500 per year to help pay for items used to care for their ADA
service dog, like leashes or vests. This benefit is filed under CMS’ guidelines for Special
Supplemental Benefits for the Chronically Ill (SSBCI). Prior authorization is required.
Medicare Advantage HMO
One existing HMO will consolidate in the following areas in 2021:
Consolidating plan for 2021
Counties
Atlantic, Cape May, Cumberland, Gloucester, Mercer, Morris, Salem,
Sussex
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Two existing HMOs will expand into the following areas in 2021:
Expanding plans for 2021
Counties
Cape May, Salem, Sussex
Cape May, Salem, Sussex
The following HMO plan names will change in 2021:  
2020 plan name
2021 plan name
Counties
Amerivantage ESRD
(HMO-POS C- SNP)
Amerivantage ESRD Care
(HMO-POS C-SNP)
Bergen, Essex, Hudson,
Middlesex, Monmouth, Morris,
Ocean, Passaic, Somerset,
Union
Formulary and pharmacy
Formulary and pharmacy benefits for 2021 are as listed below:
100-day prescription refills
Members are eligible to receive a 100-day supply for the same price as a 90-day supply fill
for tier six select care drugs.
Erectile dysfunction drugs
Many of our plans offer erectile dysfunction drugs. Please check your patient’s formulary
to see if they have coverage.
Please encourage your patients to review the 2021 formulary information within their Annual Notice of
Change (ANOC) mailing or their new member kit, or online. Ask them if the coverage for any of their
prescriptions has been changed, and consider alternative medications in a lower cost-sharing tier that
may meet their needs.
Most individual MAPD plans have a pharmacy network that includes preferred and standard network
retail pharmacies. Members may save more by paying a lower cost-sharing amount at preferred
cost-sharing pharmacies. Our preferred cost-sharing pharmacies include CVS Pharmacy,* Giant Eagle,*
Kroger,* Target,* Sam’s Club* and Walmart.* Additional independent pharmacies have been added to
the cost-sharing network for 2021.
Balance billing reminder
CMS and Anthem do not allow you to balance bill most Medicare Advantage HMO, PPO, D-SNP, C-SNP,
or I-SNP members for Medicare-covered services. CMS provides an important protection for Medicare
beneficiaries and our members such that, after our members have met any plan deductibles, they only
have to pay the plan’s cost-sharing amount for services covered by our plan. As a Medicare provider
and/or a plan provider, you are not allowed to balance bill members for an amount greater than their
cost share amount. This includes situations where we pay you less than the charges you bill for a service.
This also includes charges that are in dispute.
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Members who are dually eligible may be protected from liability of Medicare premiums, deductible,
coinsurance and copayment amounts. These dual eligibles include: Qualified Medicare Beneficiaries
(QMB/QMB+) and other Full Benefit Dual Eligibles (FDBE) who have no Share of Cost (SOC). This
protection includes cost share being applied to this/these claims. Providers may not bill a dual eligible
that has this coverage for any balance left unpaid (after submission to Medicare, a Medicare carrier and
subsequently Medicaid) as specified in The Balanced Budget Act of 1997. Providers who serve dual
eligible beneficiaries must accept as payment in full the amounts paid by Medicare as well as any
payment under the state Medicaid processing guidelines. Providers who balance bill the dual eligible
beneficiary are in violation of these regulations and are subject to sanctions. Providers also may not
accept dual eligible beneficiaries as ‘private pay’ in order to bill the patient directly and providers
identified as continuing to bill dual eligible beneficiaries inappropriately will be reported to CMS for
further action/investigation.
There are some dual-eligible Medicare Advantage members, including Specified Low-Income Medicare
Beneficiary (SLMB/SLMB+), Qualified Individual (QI) and Qualified Disabled Working Individual (QDWI)
Medicare Advantage members, where billing is appropriate. Providers should always validate Medicaid
benefits for any additional coverage beyond Medicare to confirm the appropriateness of balance billing.
Once confirmed, providers may balance bill Medicaid as a secondary payer then balance bill the member
for the remaining balance. As reminder, you are not allowed to balance bill members for an amount
greater than their cost share amount.
Prior authorization for Medicare Advantage plans
Prior authorization requirements are available at
https://www.availity.com. Contracted and noncontracted
providers who are unable to access Availity* may call our
Provider Services at the phone number on the back of the
member’s ID card for prior authorization requirements.
Please check the member ID card for any identification and/or
group number changes that may affect claim submissions.
Sample 2021 member ID cards will be available by going to
https://providers.amerigroup.com and selecting New Jersey.
Find Provider Resources & Documents. Under Quick Tools,
select Medicare Advantage 2021 Products
Member enrollment receipts
The Member Enrollment Receipt is a document found at the end
of member enrollment kits that allows the agent or broker to fill
in plan, provider and agent information for the new member’s reference.
The receipt includes:
Rx BIN, Rx PCN, and Rx GRP numbers
Names, phone numbers, and websites for ancillary benefit information like dental, vision and
hearing.
The enrollment receipt does not contain a member ID, and we expect our plan members to continue to
bring their plan ID cards to their provider visits. If a member arrives to an appointment without their
plan ID card, please follow your standard procedure for validating enrollment in our plan.