Member Information

You want to feel your best. And we want to help. Get started by reviewing your member handbook to make sure you understand your health plan. Then, to get the most out of your plan, click on the links below to learn more about all of your benefits.

 

New dental benefits and outpatient occupational therapy benefits for adult members starting October 1, 2017. (English | Español)

Understanding your benefits
Your health is important to us. That’s why we want to be sure you and your family get the medical care you need. Covered services are listed below. To learn more, please read your Member Handbook.

Covered services
Your PCP and case manager will help you get the health care and long-term care services you need. Below is a list of covered services. You can also view a list of non-covered services and benefit changes. There may be some limitations based on AHCCCS rules and policies. If you have Medicare, read the Medicare handbook called “Other Things You Should Know About Medicare” to find out which services are covered.

Long Term Care services

  • Nursing homes
  • Home- and community-based services
    • Adult day health care
    • Attendant care
    • Spouse attendant care
    • Self-directed attendant care
    • Day treatment and training
    • Emergency alert systems
    • Habilitation
    • Home delivered meals
    • Home health services
    • Homemaker services
    • Home modifications
    • Hospice
    • Personal care
    • Respite and group respite care
  • Alternative residential settings
    • Adult foster care
    • Assisted living home
    • Assisted living center
    • Alzheimer’s treatment assistive living
    • Behavioral health level II and III
    • Rural substance abuse transitional agency
    • Therapeutic Home Care – adult and child
    • Traumatic brain injury homes

Medical services

  • Hospital care
  • Doctor office visits, including specialists
  • Routine physical exams
  • Health risk assessments and screening
  • Nutritional assessments
  • Laboratory and X-ray
  • Durable medical equipment and supplies
  • Medications on Mercy Care Plan’s list of covered medicines. Members with Medicare will receive their medications from Medicare Part D.
  • Emergency care
  • Care to stabilize you after an emergency
  • Rehabilitation services, including occupational, speech, physical and respiratory therapy
  • Routine immunizations
  • Medically necessary organ and tissue transplants and related prescriptions
  • Kidney dialysis
  • Emergency and pre-transplant dental services; medically necessary dentures
  • Medically necessary foot care
  • Maternity care (prenatal, labor and delivery, postpartum)
  • Family planning services
  • Behavioral health services and settings
  • Medically necessary transportation to and from required medical services; emergency transportation
  • Outpatient surgery and anesthesia
  • Audiology services
  • Cataract removal; medically necessary vision services
  • Medical foods, with limitations
  • Urgent care

Additional services for children (under 21)

  • Routine preventive dental services, including oral health screenings, cleanings, fluoride treatments, dental sealants, oral hygiene education, X-rays, fillings, extractions and other medically necessary procedures and therapeutic and emergency dental services
  • Vision services, including exams and prescriptive lenses
  • Regular checkups and immunizations
  • Chiropractic services
  • Children’s rehabilitative services
  • Conscious sedation
  • Incontinence briefs, with limitations

Additional services for Qualified Medicare Beneficiaries (QMBs)
Any service covered by Medicare but not by AHCCCS.

  • Chiropractic services

Your guide to getting the care you need
Trying to learn how to get the care and services you need? Your Member Handbook can help.

Handbook archives:

Here you’ll find:

  • Important phone numbers
  • Your rights and responsibilities as a member
  • Which services are covered and which are not
  • Information on how to get the care you need
  • How to get help with appointments
  • Tips to keep you healthy

You can also call Member Services to get a printed Member Handbook. You can reach Member Services at:

  • 602-263-3000 or 1-800-624-3879, Hearing Impaired (TTY/TDD) 711
  • Click on the "Contact Us" link on the Home Page

Looking for an advance directive or other form? You can download any of the forms below at no cost.

When you become a member of Mercy Care Plan Long Term Care, you are assigned a case manager. You will receive case management services for as long as you stay on the ALTCS program. Your case manager will work with you, your guardian and your doctor to help decide which services will best meet your needs.

Learn more about:

The role of the case manager
Case managers visit members in their homes and assess the member’s needs. Families are encouraged to help with the assessment.

These visits are held based on where the member lives:

  1. If the member lives in a nursing home, the case manager visits every six months.
  2. If the member lives in an assisted-living facility, the case manager visits every three months.
  3. If the member lives in his or her own home, or family home in the community, the case manager visits every three months.
  4. Members who are not using ALTCS services need to have one face-to-face visit each year and a phone call every three months. However, a member can call their case manager any time service is needed. Please call the case manager right away to schedule a face-to-face assessment if needed.

If the case manager is not visiting as often as shown above, please call us immediately and we will help.

Once the assessment is done, the case manager, member and family talk about how to meet the member’s needs. Remember that ALTCS services are to help add to the care that is already being provided. It is never meant to completely take away family involvement.

Case managers will never force a member to move to any setting against their or their families’ wishes*. We will always work with the member and family to have the member live in the setting that will meet their needs. If the family and member are ready to move to an assisted-living or nursing home, the case manager will help. If the member wants to stay at home with support services, we will gladly work to find services to meet their needs.

Based on the service plan created with the member/family, the case manager makes sure the services on the service plan are ordered. Any other service needs, such as medications, provider services and treatments, should always go through the member’s providers.

*Members with mental health diagnoses who are under court ordered treatment are subject to follow the courts’ requirements.

Prevention services
The case manager must help support and educate the member about specific health related topics. These include:

Flu shots
Every year we coordinate more than 8,000 flu shots for Mercy Care Long Term Care members. Getting the flu is serious. It can lead to pneumonia, hospitalization and even death. The flu shot helps to prevent the flu and its complications. The case manager can help schedule the flu shot. Members should talk to their case manager every year about the flu shot. October is the best time to get the shot.

Diabetes improvement
Every year we work to help our members with diabetes get the tests they need to check if their diabetes is under control. You should work with your PCP to come up with a plan if your diabetes is not under control. Tests you need include:

  • A retinal eye exam to see if your eyes are in good health
  • Blood tests to check your blood sugar levels
  • Blood tests to check the levels of the fats in your blood

These tests must be completed every year to help you be healthier. Talk to your PCP to make sure you get the tests you need.

Advance directives
All Mercy Care Long Term Care members should have paperwork completed to help your providers know your health care wishes, if you should ever be unable to make those decisions for yourself. This paperwork is called advance directives. Take the time to complete advance directive forms, which can include a Health Care Power of Attorney and a Living Will. Return a copy of your completed forms to your case manager. If you have not yet completed this paperwork, your case manager will continue to talk about the importance of this form with you during your enrollment with Mercy Care Long Term Care.

Learn more about advance directives.

Seeing your Primary Care Physician (PCP)
It is very important for you to have a “medical home.” This means having a primary provider that you visit routinely. They will review your medicines and make sure you get the preventive services you need to feel as well as possible. We ask that Mercy Care Long Term Care members see their PCP every three months to go over any changes to their health and review all medications.

These visits help the PCP get to know you and your needs. This can also help to keep you out of the long lines at the emergency room. It can also help to keep you from being admitted to the hospital because you were closely monitored while living in your home.

When to contact your case manager
Call your case manager for any of these reasons:

  • Your caregiver did not show-up as scheduled
  • Your caregiver leaves before shift is over
  • Your caregiver is not providing all the care they were assigned to do
  • Your caregiver quit
  • You are having trouble getting an appointment with your PCP every time you call
  • You are having trouble picking up your prescriptions or getting them filled
  • You are having trouble getting your supplies or equipment
  • You were discharged from the hospital and need help re-starting services
  • You want to change your living situation. For example, you want to move home from a nursing home or you want to move from your home to an assisted-living facility.
  • You want to cancel or put services on hold
  • You want to look at having different/more services in your home
  • You want to report an issue at a nursing home or assisted-living home
  • When you have a new address or phone number

If you have one of the following medical conditions:  depression, high blood pressure, diabetes, asthma or congestive heart disease, please contact us so we can help you take care of your disease.

How to contact your case manager
At your first visit, your case manager gave you a welcome letter, a business card, and a refrigerator magnet with the case manager’s name and phone number. If you cannot find these items, please call 602-263-3000 or toll-free 1-800-624-3879. Hearing Impaired call (TTY/TDD) 1-866-602-1982 and ask to speak to your case manager or ask for your case manager’s work phone number to call them directly.

Trouble reaching your case manager?
If you have tried more than once to call your case manager and are still not getting a response, please call 602-263-3000 or toll-free 1-800-624-3879. Hearing Impaired (TTY/TDD) 1-866-602-1982. Ask to speak to your case manager’s supervisor or the case management manager.

As a member of Mercy Care Plan Long Term Care, you have a right to receive quality health care. If you feel you have been treated unfairly, have difficulty seeing your doctor, or have any other health care issues, please call Member Services at 602-263-3000 or  1-800-624-3879 (TTY/TDD 1-866-602-1982).

Help prevent fraud and abuse
Caregivers must complete time sheets that accurately reflect the hours they have worked. Caregivers who fraudulently fill in time and their hiring agencies could be held liable for falsifying information.

You can take the following steps to help stop fraud and abuse.

  1. Never sign a blank time sheet or a time sheet that is not completely filled in.
  2. Never sign a time sheet if you know the caregiver did not work the time listed. This is fraud. If this happens, call the agency or your case manager to report this situation.
  3. Never sign a time sheet if it is for dates you were in the hospital. Caregivers cannot provide you care or care for your house while you are in the hospital. This is fraud. In addition, caregivers cannot “make up” the time once you return from the hospital. This can be considered fraud. For example, if you needed bathing assistance five days a week and were in the hospital for four days, the caregiver cannot visit you on the fifth day and try to make up the time for the first four days.

We understand that during these difficult economic times it may be tempting to help caregivers get a full paycheck even if they haven’t provided all the care that they were assigned to provide. However, this is considered fraud and an abuse of the Medicaid health system.

Report fraud and abuse on our website.

A hospital stay is a transition from your usual every day care. Although going to the hospital can be stressful, you can take steps to prepare. If you require a hospital stay, we hope this flyer will help you and your caregivers prepare. English (English | Español)

Mercy Care Plan reports our health plan's quality scores and related information, as required by our contract with AHCCCS.

AHCCCS Acute Member Survey Results and Health Plan Report Card

2012 AHCCCS Health Plan Report Card

All Survey Information

If you disagree with our decision described in the Notice of Adverse Benefit Determination letter, you have the right to request an appeal. An appeal is a formal procedure asking us to review the request again and confirm if our original decision was correct. During this process, you may submit additional supporting documents or information that you believe would support a different outcome and decision.

You, your representative, or a provider acting with your written permission, may request an appeal with us. The appeal must be submitted within 60 calendar days from the date on your Notice of Adverse Benefit Determination letter. The appeal may be submitted in writing or by telephone. If you need an interpreter, one will be provided. We will not retaliate against you or your provider for filing an appeal.

To file an appeal, you must mail, call or fax the request using the following:

Mercy Care Plan
Appeals Department
4350 E Cotton Center Blvd.
Building D
Phoenix, AZ 85040

Phone: 602-453-6098 or 1-800-624-3879
Fax: 602-230-4503


Request for Standard Appeal
When we get your appeal, we will send you a letter within five (5) calendar days. This letter will let you know that we got your appeal and how you can give us more information. If you are appealing services that you want to continue while your case is reviewed, you must file your appeal no later than 10 calendar days from the date on the Notice of Adverse Benefit Determination letter.

In most cases, we will resolve your appeal within 30 calendar days. Sometimes, we might need more information to make a decision. When this occurs and we believe it is in your best interest, we will request an extension on your appeal. An extension allows an additional 14 calendar days to complete our review and make a decision. If we ask for an extension, we will mail you a written notice explaining this and tell you what information we need still need. If we don’t receive the additional information within this timeframe, we may deny the appeal. You may also request a 14 calendar day extension if you need more time to gather information for the appeal.

Once we have completed the review of your appeal, we will send you a letter with our decision. The letter tells you about our decision and explains how it was made. If we deny your appeal, you may request that AHCCCS look at our decision through a State Fair Hearing. You can request this next step by following the directions we provide in the decision letter.

If you request a State Fair Hearing, you will receive information from AHCCCS about what to do. We will forward your appeal file and related documentation to AHCCCS at the Office of Administrative Legal Services.

If after the State Fair Hearing, AHCCCS will make a decision. If they find that our decision to deny your appeal was correct, you may be responsible for payment of the services you received while your appeal was being reviewed. If AHCCCS decides that our decision on your appeal was incorrect, we will authorize and provide the services promptly.


Request for expedited resolution
You or your representative can request an expedited resolution to your appeal if you believe that the timeframe of a standard resolution might jeopardize your life, health or ability to attain, maintain or regain maximum function. We may ask you to send us supporting documentation from your provider. If your provider agrees, we will expedite the resolution of your appeal. We will also automatically expedite the resolution of your appeal if we believe following the standard resolution process could jeopardize your life or health.

If we request that you send us supporting documentation from your provider but do not receive it, your appeal will be resolved within 30 calendar days. When we decide not to expedite the resolution of your appeal, we will notify you promptly. We will attempt to call you and will mail you a written notice within two (2) calendar days that explains this outcome. For more information, please see Request for Standard Appeal in this handbook.

When we expedite the resolution of your appeal, we will resolve your appeal within three (3) business days. Sometimes, we may need more information to make a decision. When this occurs and we believe it is in your best interest, we will request extension on your appeal. An extension allows an additional 14 calendar days to complete our review and make a decision. If we ask for an extension, we will mail you a written notice explaining this and tell you what information we need still need. If we don’t receive the additional information within this timeframe, we may deny the appeal. You may also request a 14 calendar day extension if you need more time to gather information for the appeal.

Once we have completed the review your appeal, we will send you a letter with our decision. The letter tells you our decision and explains how it was made. If we deny your appeal, you may request for AHCCCS to review our decision through a State Fair Hearing. You can request this next step by following the directions we provide in the decision letter.

If you request a State Fair Hearing, you will receive information from AHCCCS about what to do. We will forward your appeal file and related documentation to AHCCCS at the Office of Administrative Legal Services.

After the State Fair Hearing, AHCCCS will make a decision. If they find that our decision to deny your appeal was correct, you may be responsible for payment of the services you received while your appeal was being reviewed. If AHCCCS decides that our decision on your appeal was incorrect, we will authorize and provide the services promptly.


Quick tips about denial, reduction, suspension or termination of services and appeals

  • You will get a letter (Notice of Adverse Benefit Determination) when a service has been denied or changed.
  • If you want to ask for a review (appeal) of Mercy Care Plan’s action, follow the directions in your notification letter.
  • To request that services be continued, you must file your appeal no later than 10 days from the date of your notification letter, or within the time frame listed in the notification letter.


Appeals for members determined to have a serious mental illness (SMI)
A serious mental illness (SMI) is a mental disorder in persons 18 years of age or older that’s severe and persistent. Crisis Response Network, a provider that has a contract with Mercy Care Plan, will make a determination of serious mental illness upon referral or request. Members asking for a determination of serious mental illness and members who have been determined to have a serious mental illness can appeal the result of a serious mental illness determination.

Crisis Response Network will send you a letter by mail to let you know the final decision on your SMI determiniation. This letter is called a Notice of Decision. The letter will include information about your rights and how to appeal the decision. If you do not agree with the results of the SMI eligibility determination you may file an appeal. To file an appeal, you can call Crisis Response Network at 1-855-832-2866.

Members determined to have a serious mental illness may also appeal the following adverse decisions:

  • Initial eligibility for SMI services
  • A decision regarding fees or waivers
  • The assessment report, and recommended services in the service plan or individual treatment or discharge plan
  • The denial, reduction, suspension or termination of any service that is a covered service funded through Non‑Title 19/21 funds
  • Capacity to make decisions, need for guardianship or other protective services, or need for special assistance
  • A decision is made that the member is no longer eligible for SMI services
  • A PASRR determination in the context of either a preadmission screening or an annual resident review, which adversely affects the member


To file an appeal, you must call or send a letter to:

Mercy Care Plan
Appeals Department
4350 E Cotton Center Blvd.
Building D
Phoenix, AZ 85040

602-453-6098 or 1-800-624-3879
Fax: 602-230-4503


If you file an appeal you will continue to get any services you were already getting unless:

  • A qualified clinician decides that reducing or terminating services is best for you,
  • Or, you agree in writing to reducing or terminating services.


If the appeal is not decided in your favor, Mercy Care Plan may require you to pay for the services you received during the appeal process.

A grievance is any expression of dissatisfaction related to the delivery of your health care that is not defined as an appeal. This is also called a complaint. You may have a problem with a doctor or felt that office staff treated you poorly. You may have received a bill from your specialist or had difficulty reaching the transportation company for your ride home. A grievance might include concerns with the quality of the medical care you received. Please let us know if you have a concern like this or need help with another problem. The fastest way to report a grievance is to call Member Services at 602-263-3000 or  1-800-624-3879 (TTY/TDD 1-866-602-1982). 

A Member Services representative will document your grievance. It is important to provide as much detail as possible. The representative will explain the grievance resolution process and answer any other questions you may have. We may also need to call you back to provide updates or ask you for more information. We want to ensure that you are receiving the care and services you need.


If you prefer to file your grievance in writing, please send your complaint to:

Mercy Care Plan
Grievance Department
4350 E Cotton Center Blvd.
Building D
Phoenix, AZ 85040


Filing a grievance will not affect your future health care or the availability of services. We want to know about your concerns so we can improve the services that we offer.

  • When you call to report a grievance, we will try to help resolve any concerns you have right away. If you submit your grievance in writing, we will send you a letter within five (5) calendar days. The letter acknowledges our receipt of your grievance and explains how you will be notified of the resolution.
  • If you submit a grievance over the telephone, we may be able to resolve your concerns and tell you the resolution during the call.
  • If your grievance involves concerns about the quality of care or medical treatment you received, we will send the case to our Quality Management department.
  • When we cannot resolve your grievance right away, we will let you know and explain the next steps. During our investigation of your concerns, we will work with other departments at Mercy Care Plan as well as your health care provider(s).
  • During our investigation, we may need to speak with you again. We may have more questions or we may want to confirm that your immediate needs are met.
  • Once the review of your grievance is complete, we will notify you of the resolution.
  • If your grievance was reviewed by our Quality Management department, you will get the resolution in writing.
  • For other cases, we will call you and explain the resolution to your grievance. If we are unable to reach you, we will send the resolution in writing.
  • We are committed to resolving your concerns as quickly as possible and in no more than 90 days from the date you submitted your grievance.

 

Grievance/Request for Investigation for members determined to have a serious mental illness (SMI)

There is a special process for members determined to have a serious mental illness.

You can file a Grievance/Request for Investigation if you feel:

  • Your rights have been violated
  • You have been abused or mistreated by staff of a provider
  • You have been subjected to a dangerous, illegal, or inhumane treatment environment


You have 12 months from the time that the rights violation happened to file a Grievance. You may file a Grievance by calling Mercy Care Plan Member Services at 602-263-3000 or 1-800-624-3879 (TTY/TDD 711). Representatives are available Monday through Friday from 7 a.m. to 6 p.m. You may ask staff to help you file your grievance. You can also file a grievance in writing.


To file a written Grievance/Request, mail the form to:

Mercy Care Plan
Attn: Grievance and Appeals
4350 E. Cotton Center Blvd.,
Building D
Phoenix, AZ 85040


Grievances concerning physical abuse, sexual abuse or a person’s death are investigated by AHCCCS. To file a grievance concerning physical abuse, sexual abuse or a person’s death, contact:

AHCCCS Office of Grievance and Appeals
801 E. Jefferson
MD 6200
Phoenix, AZ 85034

Phone: 602‑364‑4575
Fax: 602-364-4591
Deaf or hard of hearing individuals may call the Arizona Relay Service at 711 or 1‑800‑367‑8939 for help contacting AHCCCS.

If you file a Grievance/Request for Investigation, the quality of your care will not suffer.

Fraud
Committing fraud or abuse is against the law. Your health benefits are given to you based on your health and financial status. You should not share your benefits with anyone. If you misuse your benefits, you could lose your AHCCCS benefits. AHCCCS may also take legal action against you. If you think a person, member or provider is misusing the program, please call Member Services or AHCCCS. For a complete listing of provider actions that can lead to fraud/abuse, please go to definitions section ‑ Provider Fraud/Abuse. Fraud is a dishonest act done on purpose.

Examples of member fraud are:

  • Letting someone else use your Mercy Care Plan ID card
  • Getting prescriptions with the idea of abusing or selling drugs
  • Changing information on your Mercy Care Plan ID card
  • Changing information on a prescription

 
Examples of provider fraud are:

  • Billing for services that were not given
  • Ordering services that are not medically necessary
  • Referring members to an emergency room or other service when it is not medically necessary

 

Abuse
Abuse can mean providers that take actions resulting in needless costs to AHCCCS. This includes providing medical services that are not required. It may also mean the provider does not meet required health care standards. Abuse can also include member actions that result in extra cost to AHCCCS.

Abuse means provider practices that are inconsistent with sound financial, business, or medical practices. This can result in an unnecessary cost to the Medicaid program. Abuse can also be a refund 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 program.


Reporting
If you think a person, member or provider is misusing the program, please let us know.
Mercy Care Plan Fraud Hotline: 18008106544
AHCCCS Fraud Reporting: 6024174193 or 18884876686

If you would like a printed copy of the Member Handbook or Provider Directory, call Member Services at:

  • 602-263-3000 or 1-800-624-3879
    Hearing Impaired (TTY/TDD) 711
  • Click on the "Contact Us" link on the Home Page