www.MercyCarePlan.com
MEMBER HANDBOOK
OCTOBER 2006
L O N G T E R M C A R E P R O G R A M
1
INTRODUCTION
Welcome to Mercy Care Plan…………………………2
Your Member Handbook ………………………………2
Your Provider Directory ………………………………2
Personal Information……………………………………2
Mercy Care Plan Address, Office Hours and Phone …
Numbers ……………………………………………3
Language and Interpretation Services ………………3
Tips for Using Mercy Care Plan ………………………4
Member Confidentiality and Our Privacy Practices …5
Member Services ………………………………………5
Member and Provider Advisory Council ……………5
Member Information ……………………………………5
Your Rights as a Member …………………………5
Your Responsibilities as a Member ………………7
Member Identification Card ……………………………8
New Medical Procedures………………………………8
About Your Providers …………………………………9
COVERED SERVICES
Services That Are Covered …………………………10
Services That Are Not Covered ……………………11
Case Management Services…………………………12
Home and Community Based Services ……………12
Alternative Living Settings ……………………………13
ALTCS Transitional Program…………………………13
Nursing Home Care …………………………………13
Pharmacy Services……………………………………13
Prescriptions………………………………………13
What You Need to Know About ……………………
Your Prescription ……………………………14
Refills………………………………………………14
Mail Order …………………………………………14
Behavioral Health Services …………………………14
Covered Behavioral Health Services……………14
How to Get Behavioral Health Services ………15
Behavioral Health Emergencies…………………15
Dental Services ………………………………………15
Vision Services ………………………………………15
Children’s Services……………………………………15
Women’s Services ……………………………………16
Family Planning Services ……………………………16
Pregnancy Services …………………………………16
Special Health Programs ……………………………17
Transportation …………………………………………17
HOW TO GET SERVICES
About Your PCP ………………………………………18
How to See Your PCP …………………………18
What You Need to Know About ……………………
Your PCP’s Office……………………………18
Changing Your PCP………………………………18
Referrals ………………………………………………19
Authorizations …………………………………………19
Appointments …………………………………………19
Appointment Availability …………………………19
Making an Appointment …………………………20
Arriving for Your Appointment……………………20
After-Hours Care………………………………………20
Urgent Care……………………………………………20
Emergency Care………………………………………20
What is an Emergency? …………………………20
What is Not an Emergency? ……………………21
Out-of-Area Coverage ………………………………21
Your Share of Cost……………………………………21
Share of Cost ……………………………………21
Room and Board …………………………………22
Coordination with Medicare ………………………
and Other Insurance ………………………22
Children’s Rehabilitative Services (CRS) Copayments
and Deductibles …………………………………22
If You Have Other Insurance…………………………22
Qualified Medicare Beneficiary (QMB) ……………
Copayments and Deductibles ……………23
Getting Bills for Services ………………………………
When Can You be Billed for Services?…………23
What If You Get a Bill for Services? ……………23
IMPORTANT INFORMATION
Member Grievances …………………………………24
Actions …………………………………………………24
Denials, Reduction, Suspension or Termination of
Services and Request for Appeal……………………24
Notice of Action ………………………………………25
Appeals Process………………………………………25
Request for Expedited Resolution …………………25
Fraud …………………………………………………26
Abuse …………………………………………………26
Change of Address……………………………………26
Annual Enrollment Choice (AEC)……………………26
Program Contractor Changes ………………………27
Decisions About Your Health Care …………………27
Living Wills and Other Health Care Directives…27
Making Your Advance Directives Legal…………28
After You Complete Your Advance Directives …28
Sources of Additional Information and Forms………29
Definitions ……………………………………………30
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TABLE OF CONTENTS
www.MercyCarePlan.com
Copyright © 2006 Southwest Catholic Health Network Corporation & Schaller Anderson of Arizona, L.L.C.

A History of Commitment and Caring
“Care” is more than just a part of our name. It’s a part of all we do. Our members know us for all we do and how we do it. For instance, like the doctors, hospitals and dentists who treat and respect our members. At Mercy Care Plan, we take extra steps to reach our members, their families and communities. And, we know we reach them because our members give us high marks for customer service.

And because we care, we’re always there.

YOUR MEMBER HANDBOOK

Please read this handbook. It tells you:
• Your rights and responsibilities as a member
• How to get health care services
• How to get help with appointments
• Which services are covered and which are not
The handbook is available on audiocassette or CD from Member Services for members with a visual impairment. It is also available in text format on the Mercy Care Plan Web site at www.MercyCarePlan.com. Both the Member Handbook and Provider Directory are provided at no cost to you.

YOUR PROVIDER DIRECTORY
You will receive a list of Mercy Care Plan doctors to choose from, along with your Member Handbook. You may find PCP and specialist information, such as languages spoken and whether a provider is accepting new members, in this Directory. You can find the same information on the Mercy Care Plan Web site at www.MercyCarePlan.com. The Directory will also tell you what languages the provider speaks and whether the provider is accepting new members. If you need a list of specialists, call us and we will send you one. You can also find specialists on the Mercy Care Plan Web site at www.MercyCarePlan.com

PERSONAL INFORMATION
My Member ID Number: ___________________________________________
My PCP (Primary Care Physician):___________________________________
My PCP’s Phone Number: _________________________________________
My Case Manager: _______________________________________________
My Case Manager’s Phone Number: _________________________________
Benefits are funded primarily under contract with AHCCCS and the State of Arizona.
Mercy Care Plan follows federal and state laws that apply under the contract with AHCCCS.
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ALAN!
MERCY CARE PLAN ADDRESS, OFFICE HOURS AND PHONE NUMBERS
MERCY CARE PLAN
2800 N. Central Ave. Suite 400
Phoenix, Arizona 85004
www.MercyCarePlan.com

Hours:
General: 7:00 a.m. - 6:00 p.m. (Monday - Friday)
Long Term Care Case Management: 8:00 a.m. - 5:00 p.m. (Monday - Friday)
Phone Numbers:
Member Services: (602) 263-3000 / (800) 624-3879
Hearing Impaired (TDD/TTY): (602) 248-9273 / (866) 624-3879
M - F 8 a.m. - 5 p.m.
Emergency 24 hours: (800) 624-3879
Behavioral Health Crisis: (800) 888-1477

If you have questions or need help, please call us 7 a.m. – 6 p.m. (Monday - Friday).
If it is after-hours and your question cannot wait until the next business day, call the 24-hour emergency number.

LANGUAGE AND INTERPRETATION SERVICES
Mercy Care Plan has many health care providers who speak languages other than English. Check your Provider Directory in your welcome packet to find a doctor who speaks your language.
Mercy Care Plan can also help you get an interpreter if you need one for your health care visits. Your Primary Care Provider (PCP), specialist or case manager may use our interpretation line during your visit. If you need help in your language or if you have a hearing impairment, you or your case manager can call Member Services for an interpreter.

(602) 263-3000 or (800) 624-3879
TDD/TTY Line (602) 248-9273 or (866) 624-3879
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TIPS FOR USING MERCY CARE PLAN
1. When you join Mercy Care Plan, you use Mercy Care Plan doctors, nurses and hospitals. You
may choose your own Primary Care Provider (PCP) or we will find you one near your home. If
you live in a nursing home, one of Mercy Care Plan’s doctors will visit and care for you there.
2. Your PCP is the doctor who manages your health care. He/she will order your health care
services and will send you to a specialist if you need to see one. Your PCP will work with your
case manager to make sure you receive the medical and long-term care services that are right
for you.
3. You will have your own Mercy Care Plan case manager. Your case manager will help you and your PCP in planning, approving and arranging your long-term care services to keep you as
independent as possible. If you have questions or need help, call your case manager. Your case
manager is there to help you.
4. The names and phone numbers of your PCP and case manager are in your welcome letter.
Write their names and telephone numbers in the “Personal Information” section (Page 2) of this
handbook. Keep it handy so you can find it when you need it.
5. Your case manager will give you a copy of this Member Handbook and a Provider Directory when you join Mercy Care Plan. The Provider Directory is a list of Mercy Care Plan (MCP) providers you may choose from. You may also go the MCP Web site at 
www.MercyCarePlan.com to find a provider. If you still need help, call your case manager. We
hope that you stay with one doctor so that he/she can get to know you and your health care
needs. If you do need to change your doctor, call Member Services for help.
6. You will be sent a member identification (ID) card. Show this card when you get health care
services. If you do not have it, you will still be able to get care. Just be sure to tell your doctor
that you are a MCP Long Term Care (ALTCS) member.
7. If you need a ride to get covered services, please see “Transportation” (Page 17).
8. If you are not happy with the services you receive, please call your case manager. If you are not happy with your case manager, you can call Member Services at (602) 263-3000 or
(800) 624-3879 for help.
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IMEMBER CONFIDENTIALITY AND OUR PRIVACY PRACTICES
You will find a copy of the Privacy Rights notice in your welcome packet. The notice tells how we use your records, including information that identifies you, for health plan activities
and to pay for your services. It also tells you how you can look at your records, get a copy of them or change them. You can get one set of your medical records at no cost to you. Your health care information will be kept private and confidential, and will be given out only if the law allows it or with your permission.

MEMBER SERVICES
Mercy Care Plan’s Member Services Department can answer questions about benefits, help in finding a doctor, arrange rides to medical appointments, solve problems in getting health care services and go out of our way to help you!
(602) 263-3000 or (800) 624-3879
TDD/TTY Line (602) 248-9273 or (866) 624-3879

MEMBER AND PROVIDER ADVISORY COUNCIL
Mercy Care Plan has a Long Term Care Member and Provider Advisory Council. The Council advises Mercy Care Plan on policies, programs, network issues, quality indicators and studies for the Arizona Long Term Care System (ALTCS) program.

The Council meets every three months and members include physicians, members, home and community based providers, a community representative, an institutional provider, an advocate and the Mercy Care Plan CEO and medical director or designees. If you are interested in becoming a member, please call Member Services.

MEMBER INFORMATION
As a Mercy Care Plan member, you have rights and responsibilities. These are listed below. It is important that you read and understand each one. If you have questions, please ask your case manager.

Your Rights as a Member
You, your family or your guardian(s) have the right to:
Information you can get:
• The name of your PCP and case manager.
• One copy of your medical records at no cost to you. You may not be able to get a copy of medical records that are psychotherapy notes put together for a civil, criminal or administrative action.
• A description of covered services.
• Information about Mercy Care Plan, its services, providers and your rights and responsibilities as a member.
• How Mercy Care Plan provides for after hours and emergency care.
• How Mercy Care Plan pays providers, controls cost and uses services.
• General grievance results and a summary of member survey results.
• The cost to you if you choose to pay for a service that Mercy Care Plan does not cover.
• What treatment choices or other types of care are available to you and the benefits and/or drawbacks of each choice.
• How to get services, including authorization requirements.
• How MCP evaluates new technology to include as a covered service.
• Advance directives and information on how to have medical decisions made for you if you are not able to make them for yourself.
• Changes to your services or if your PCP leaves Mercy Care Plan.

Respect and Dignity
• You can get covered services without concern about payer source, race, ethnicity, national origin (to include those with limited English proficiency), religion, gender, age, mental or physical disability, sexual orientation, genetic information, ability to pay or ability to speak English.
• You can get quality medical services that support your personal beliefs, medical condition and
background in a language you understand.
• You can get interpretation services if you do not speak English or have a hearing impairment to help you get the medical services you need. You may ask for materials in an alternative format.

Treatment Decisions
• You can choose a Mercy Care Plan PCP to plan your health care.
• You can change your PCP if you need to.
• You can talk with your PCP to get complete and current information about your health care and
condition so that you and/or your family understand and can be a part of making decisions about
your health care.
• You can be informed about which procedures you will have and who will do them.
• You can decide who you want to be with you for treatments and exams.
• You can have a female in the room for breast and pelvic exams.
• You can say no to treatment, services or PCPs and be told what may happen if you do not have the treatment. Your eligibility or medical care does not depend on your agreement to follow a treatment plan.
• You will be told in writing by Mercy Care Plan when any of your health care services requested by your PCP are reduced, suspended, terminated or denied. You must follow the instructions in your notification letter.


Emergency Care and Specialty Services
• You can get emergency health care services without the approval of your PCP or Mercy Care Plan when you have a medical emergency, and you may go to any emergency room or other setting for emergency care.
• You may get behavioral health services without the approval of your PCP or Mercy Care Plan.
• You can see a specialist with a referral from your PCP.
• You can refuse care from a doctor you were referred to and ask for a second opinion.

Confidentiality and Privacy
• You have a right to privacy and confidentiality of your health care information.
• You have a right to talk to health care professionals privately.

Reporting Your Concerns to Mercy Care Plan
• Tell us about any complaints or issues you have with your health care services.
• You may file an appeal and get a decision in a reasonable amount of time.
• You can give Mercy Care Plan suggestions on changes to policies and services.
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Personal Rights
• You may share a room with your husband or wife if you want to and it is appropriate.
• You may remain in your home if you want to.
• You may have a choice of a single occupancy unit if you live in an assisted-living facility.
• You can manage your own money or choose someone you trust to do it for you.
• You can use your rights as a citizen.
• You can choose to speak or not to speak with people.
• You can keep and use your personal clothing and belongings if there is space and if there are no
medical reasons not to.
• You can say no to drugs or restraints, except for times when your doctor thinks it is needed to protect you or others from harm.
• You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
• You have freedom to say no to tasks a provider may ask you to do that are not part of your care plan.
• You can transfer or leave a long-term care home only because of medical reasons, for your own
good or the good of others, or for not paying.

Your Responsibilities as a Member
As a member, you, your family or your guardian(s) have these responsibilities:
Respect
• Respect the doctors, pharmacists, staff and people providing services to you.
• Protect your ID card. Do not lose it or share it with anyone.
• Take care of equipment loaned to you, like wheelchairs and the things that belong to the place where you live.
• Be considerate of the rights of the staff and other people living in the same place. Be respectful of their property.

Share Information
• Show your member ID card or identify yourself as a Mercy Care Plan member to health care
providers before getting services. If you have other insurance in addition to Mercy Care Plan, show your doctor or pharmacist your other insurance ID card as well.
• If you do not understand your health condition or treatment plan, ask your PCP to explain.
• Tell your doctor and/or case manager about any other insurance you may have, and apply for other benefits you may be eligible for.
• Give your doctor all the facts about your health problems, past illnesses, hospital stays, all
medications, shots and other health concerns. Let your doctor and/or your case manager know about any changes in your condition.
• Notify Mercy Care Plan any time you feel a provider or another member is not using health plan
benefits correctly.
• Report changes like your address, phone number and/or assets, and other matters that could
affect your eligibility to your case manager and/or to the eligibility interviewer at the office where you applied for AHCCCS.

Follow Instructions
• Know the name of your assigned PCP and your case manager.
• Follow the instructions that you and your PCP have agreed on, including the instructions of nurses and other health care professionals. Ask what can happen if you do not follow these instructions.
• Pay your share of cost and/or room and board at the start of every month.

Appointments
• Schedule appointments during office hours when possible instead of using urgent or emergency care.
• Keep appointments and come on time. Call your doctor’s office ahead of time when you cannot keep your appointment.

MEMBER IDENTIFICATION CARD
When you become a member of ALTCS, AHCCCS will send you a member ID card. Your card will have your name, ID number and the name of your health plan. If you do not get your ID card, call AHCCCS at (602) 417-7000 or (800) 962-6690. If you lose your card, call AHCCCS for a new one. Protect your ID card! Do not give it to anyone except those giving you health care services. If you loan, sell or give your ID card to anyone else, you may lose your ALTCS eligibility and/or legal action may be taken.

If you lose eligibility, do not throw away your member ID card. You will not be given another card if you become eligible again.

QUICK TIPS ABOUT YOUR MEMBER ID CARD
• AHCCCS will send you a member ID card. If you lose it, call AHCCCS at (602) 417-7000 or (800) 962-6690 for a new one.
• Be sure to carry your ID card with you and show it every time you get health care services.
• Keep your ID card even if you lose eligibility.

NEW MEDICAL PROCEDURES
Mercy Care Plan, other health plans and AHCCCS work together to look at new medical procedures and services to make sure you get safe, up-to-date, high-quality medical care. We also look at medical procedures used now to find better ways to treat you. Doctors review new health care methods and decide if they should become covered services. Investigational services and treatments that are being researched and studied are not covered services.

To decide if new technology will be a covered service, doctors for both Mercy Care Plan and AHCCCS:
• Study the purpose of each technology
• Review medical literature
• Determine the impact of a new technology
• Develop guidelines on how and when to use the technology
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ABOUT YOUR PROVIDERS
Your health and well being are very important to us. Because of that, Mercy Care Plan doctors are chosen very carefully. They must meet strict requirements to care for our members, and we regularly check the care they give you.
If you need more information about your doctor, you may contact:
• Doctor's office
• Arizona Medical Board www.azmd.gov at (480) 551-2700 or (877) 255-2212 (toll-free)
• Arizona Medical Association www.azmedassn.org
• American Board of Medical Specialties www.abms.org
• Arizona Board of Osteopathic Examiners www.azosteoboard.org at (480) 657-7703
• Member Services at (602) 263-3000 or (800) 624-3879
To get more information about a dentist, you may contact the:
• Arizona State Board of Dental Examiners www.azdentalboard.org at (602) 242-1492
To get more information about an optometrist, contact:
• Arizona State Board of Optometry www.asbo.state.az.us at (602) 542-3095
M e r c y C a r e P l a n — L o n g Te r m C a r e
SERVICES THAT ARE COVERED 
Below is a list of covered services. There may be some limitations based on AHCCCS rules and
policies. Some services require a referral from your PCP. Be sure to ask your PCP if a referral is needed.
1SERVICES THAT ARE COVERED
Long Term Care Services
1. Nursing homes
2. Home and community based services
• Adult day health care
• Attendant care
• Emergency alert systems
• Habilitation
• Home delivered meals
• Home health services
• Homemaker services
• Home modifications
• Hospice
• Personal care
• Respite and group respite care
3. Alternative residential settings
• Adult foster care
• Therapeutic foster homes – adult and child
• Assisted living home
• Assisted living center
• Alzheimer’s treatment assistive living
• Behavioral health level II and III
• Traumatic brain injury homes
Medical Services
1. Hospital care
2. Doctor office visits, including specialists
3. Routine physical exams
4. Health risk assessments and screening
5. Nutritional assessments
6. Laboratory and X-ray
7. Durable medical equipment and supplies
8. Medications on Mercy Care Plan’s list of covered medicines. Members with Medicare will receive their medications from Medicare Part D.
9. Emergency care
10. Care to stabilize you after an emergency
11. Rehabilitation services, including occupational, speech, physical and respiratory therapy
12. Routine immunizations
13. AHCCCS-approved organ and tissue transplants and related prescriptions
14. Cochlear implants
15. Kidney dialysis
16. Emergency and pre-transplant dental services; medically necessary dentures
17. Medically necessary foot care
18. Maternity care (prenatal, labor and delivery, postpartum)
19. Family planning services
20. Behavioral health services and settings
21. Medically necessary transportation to and from required medical services; emergency
transportation
22. Outpatient surgery and anesthesia
23. Audiology services
24. Cataract removal; medically necessary vision services
25. Medical foods, with limitations
26. Urgent Care

Additional Services for Children (under 21)
1. 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
2. Vision services, including exams and prescriptive lenses
3. Regular checkups and immunizations
4. Chiropractic services
5. Children’s Rehabilitative Services
6. Conscious sedation
7. Incontinence briefs, with limitations

Additional Services for Qualified MedicareBeneficiaries
1. Chiropractic services
2. Any service covered by Medicare but not by AHCCCS

Your PCP and case manager will help you get the health care and long-term care services you need. 
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SERVICES THAT ARE NOT COVEREDV
Below is a list of services that are not covered. Please call your case manager if you need help finding community resources in your area for services that are not covered.
ICES THAT ARE NOT COVERED
All Members
1. Services from a provider who is not a Mercy Care Plan provider (unless prior approved by Mercy Care)
2. Cosmetic services or items
3. Personal comfort items
4. Any service that needs prior authorization that was not prior authorized
5. Services or items given free of charge, or for which charges are not usually made
6. Services of special duty nurses, unless medically necessary and prior authorized
7. Physical therapy that is not medically necessary
8. Routine circumcisions
9. Experimental services as determined by the health plan medical director
10. Abortions and abortion counseling unless medically necessary, pregnancy is the result of
rape or incest or if physical illness related to the pregnancy endangers the life of the mother
11. Health services when you are in prison or in a facility for the treatment of tuberculosis
12. Experimental organ transplants, unless approved by AHCCCS Administration
13. Sex change operations and reversal of voluntary sterilization
14. Drugs and supplies without a prescription
15. Treatment to straighten teeth, unless medically necessary
16. Prescriptions not on our list of covered medications, unless approved by Mercy Care
Plan
17. Diapers solely for personal hygiene

Other Services Not Covered for Members Over 21,Including But Not Limited to:
*1. Hearing aids
*2. Routine eye examinations for prescriptive lenses or glasses
*3. Routine dental services
*4. Chiropractic services (except for QMB members)
*These services are available to Mercy Care Advantage members.

CASE MANAGEMENT SERVICES
When you become a member of Mercy Care Plan, you will have a case manager. Your case manager will work with you, your guardian and your PCP to assess your needs and to make sure you receive the medical and long-term care services that are right for you.

Your independence and your right to make decisions for yourself are very important to Mercy Care Plan. You, or your family or guardian if necessary, will work as partners with your case manager and your doctor to come up with a plan for your services which will keep you as independent as possible. Your case manager will arrange for the care you need, so if you have questions or need your services changed, call your case manager. In addition, if you experience any problems with your services, such as a provider not showing up when scheduled, please let your case manager know right away.

To make sure the care you get is paid for, your case manager must approve all your ALTCS services before you get them. If you arrange for services without your case manager’s help, you may have to pay for them yourself. 

HOME AND COMMUNITY BASED SERVICES
Home and community based services support you in keeping your independence and living in your own home or a community setting. Your case manager will work with you, your family or guardian, and your PCP to find the right type, amount and length of services that are just right for you, based on AHCCCS rules and policies. Once these services are decided, your case manager will approve and arrange them for you. These services may include:
• Adult Day Health Care – health care and personal services that you get in an adult day center.
Meals, health checks and therapies may also be offered.
• Attendant Care Services – a trained person comes into your home to help you with a combination of services such as personal care, housekeeping and meal preparation.
• Emergency Alert System – equipment that allows you 24-hour access to emergency help when you need it.
• Home Modification – this service makes adaptive changes to your home to increase your
independence.
• Habilitation – this service provides training in independent living skills. Speech, occupational or physical therapy may be provided as part of this service. This includes habilitation services such as Day Treatment and Training and Supportive Employment.
• Home Delivered Meals – healthy meals are prepared and brought to your home.
• Home Health Service – this service provides part-time care in your home to prevent you from being hospitalized again. It may include nursing care, a health aide, equipment or therapy.
• Homemaker – this service is help with household jobs like cleaning, shopping or running errands.
• Hospice Care - services that help members who need health care and emotional support during the final stages of life.
• Personal Care – this service offers help with eating, bathing and dressing.
• Respite – this service provides personal care to give your family or usual caregiver a rest. This
service can be provided in your home, assisted living facility or skilled nursing home. If you receive attendant care, personal care, homemaker or respite services, your case manager will complete a back-up plan with you. This plan will list the names and numbers of people to call in case your caregiver does not come as scheduled. You may also choose how soon you need to have someone help you in your home.
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ALTERNATIVE LIVING SETTINGS
Besides your own home, ALTCS has other types of living arrangements available for members who need them. These types of settings provide supervisory services, personal care or direct care, and are licensed or certified. Members are required to pay a room and board fee for these settings. Your case manager will let you know what you need to pay.
• Adult Foster Care – this setting (for up to four residents) provides special care for you in someone else’s home.
• Therapeutic Foster Homes – Adult - provides behavioral health and ancillary services for at least one and up to three people. Child – licensed by DES as a professional foster care home.
• Assisted Living Home – this setting provides care and supervision for up to ten people.
• Assisted Living Center– this setting provides apartments within the center that include a private sleeping area and kitchen and bathroom areas. Other services are provided as needed.
• Alzheimer’s Treatment Assistive Living Facility – these settings provide special care and services to members with Alzheimer’s disease.
• Behavioral Health Level II and III – these settings provide behavioral health treatment with 24-hour supervision. They may include on site medical services and intensive behavioral health treatment programs.
• Traumatic Brain Injury Treatment Facility – this setting provides treatment and services for people with traumatic brain injuries.

ALTCS TRANSITIONAL PROGRAM
This program is available for members who have improved to the point where they do not need institutional care but who still need many long-term care services. Home and community based placements are arranged for these members. Members in the transitional program may not remain in a skilled nursing home longer than 90 consecutive days.

NURSING HOME CARE
Nursing homes provide room, board and nursing services for members who need these services all the time, but who do not need to be in a hospital or need daily care from a doctor. Many homes also offer special services or several levels of care for special needs.

PHARMACY SERVICES
Prescriptions
As of January 1, 2006, pharmacy benefits are covered by Mercy Care Plan only for members that do NOT have Medicare.

Mercy Care Plan has a list of covered medications for your doctor to use. The list is reviewed and updated regularly by doctors to make sure you receive safe, effective medicines. If you want a copy of the list, call Member Services or go to our Web site at www.MercyCarePlan.com.
If you need medicine, your PCP will choose one from our list and write you a prescription. If the medication you need is not on our list, your doctor may ask Mercy Care Plan to make an  exception. Some over the counter medications are also covered when your PCP orders them. Prescriptions must be filled at a pharmacy listed in your Provider Directory. There are no copayments for medicines. If you have other insurance, Mercy Care Plan will only pay the copays if the drug is also on the Mercy Care Plan drug list. Do not pay any copayments yourself. Mercy Care Plan may not pay you back.
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If you live in a nursing home, the staff will take care of managing your medications for you.

If you have both Medicare and Medicaid and are enrolled in Mercy Care Advantage, Mercy Care Advantage will pay for your pharmacy benefits. If you are in nursing home for at least 30 days, you will not have a copayment for your medications.

If you have both Medicare and Medicaid and are NOT enrolled in Mercy Care Advantage, your other Medicare drug plan will pay for your pharmacy benefits.

What You Need to Know About Your Prescription
Your PCP may give you a prescription for medicine. Your doctor or dentist may give you a prescription for medication. Be sure and let him/her know about any medications received from another doctor or medications that are non-prescription or herbal you buy on your own. Before you leave the office, ask these questions:
• Is this medication covered by Mercy Care Plan? If not, is there one like it that is right for my care?
(This will keep you from having to find out at the pharmacy that your medication is not covered).
• How should the medicine be taken? When? For how many days?
• What are the side effects of the medication and what should you do if a side effect happens?


Refills
• If you live in a nursing home, the staff will get refills for you.
• The label on your medication bottle tells you how many refills your PCP has ordered for you. If your doctor has ordered refills, you may only get refills one at a time for each prescription.
• If your doctor has not ordered refills for you, be sure to call them at least five days before your
medicine runs out and talk to them about getting a refill. Your PCP may want to see you before giving you a refill.

Mail Order
• If you take medications regularly for conditions like high blood pressure or arthritis, you may be able to join Mercy Care Plan’s mail order maintenance medication program. Call Member Services if you have questions or need more information.

BEHAVIORAL HEALTH SERVICES
Behavioral health services can help you with personal problems that may affect you and your family. These problems may be from depression, anxiety or using drugs or alcohol. Some services may be provided in your home, nursing home or assisted living home. Please check with your case manager.

Covered behavioral health services include:
• Behavior management (behavioral health personal care, family support/home care training, selfhelp/peer support)
• Behavioral health case management (limited)
• Behavioral health nursing services
• Emergency/crisis services
• Emergency and non-emergency transportation
• Evaluation and assessment
• Individual/family/group therapy and counseling
• Inpatient hospital
• Non-hospital inpatient psychiatric facilities (Level 1 residential treatment centers; sub-acute facilities)
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• Opioid agonist treatment
• Lab and radiology services for psychotropic medication regulation and diagnosis
• Partial care (supervised day program, therapeutic day program and medical day program)
• Psychosocial rehabilitation (living skills training, health promotion, supportive employment, etc.)
• Psychotropic medication, adjustment and monitoring
• Respite care (with limitations)
• Rural substance abuse transitional agency services
• Screening
• Therapeutic foster care

How to Get Behavioral Health Services
You do not need a referral from your doctor for behavioral health services. Call your case manager for a list of current providers or for help in setting up an appointment. If you need a ride to an appointment, call Member Services.

Behavioral Health Emergencies
If you are in a crisis situation and think you might hurt yourself or someone else, please call 911. You can also call our crisis line if you have a crisis.
Mercy Care Plan Behavioral Health Crisis Line (800) 888-1477

DENTAL SERVICES
• For members under 21, both routine and emergency dental services are covered.
• For members 21 and over, only emergency dental services, medically necessary dentures and dental care for transplant services are covered.

If you are under 21 and need dental care, you may go to any general dentist on our list. You do not need a referral from your doctor to see a dentist. To change your dentist, just choose another one from the same list. You may call Member Services for the list.

VISION SERVICES
• Coverage for members under 21 includes routine and emergency vision services.
• Coverage for members 21 and over includes emergency and some medically necessary vision
services only.

For vision care, if you are under 21, your PCP can give you a list of eye care doctors to choose from. You may also call Member Services for the list. If you are 21 or older, your doctor will help you set up an appointment if it is medically needed.

CHILDREN’S SERVICES
Mercy Care Plan has a children’s program for members under 21. Children may get checkups and covered health and dental services at no cost. Checkups are the best way to make sure children are healthy and stay healthy. Follow-up treatment for any problems found during the checkup is also covered. Postcards are sent when a child is due for a checkup.
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Checkups may include:
1. Complete unclothed physical exam
2. Developmental history and behavioral health screening
3. Oral health and dental screenings
4. Immunizations (shots)
5. Tuberculosis test
6. Speech, hearing and eye exams
7. Lab work
8. Health education and guidance about your child’s health care and development
9. Talking about your child’s behaviors

WOMEN’S SERVICES
It is very important for women who are sexually active or who are 18 and older to see their PCP or a Mercy Care Plan obstetrician/gynecologist (OB/GYN) for a well-woman exam every year. Make your appointment around the same time every year to help you remember it.
Either your PCP or an OB/GYN doctor can do your well-woman exam. If you want to see an OB/GYN doctor, you do not need to see or ask your PCP first. You can find OB/GYN doctors in your Provider Directory.

FAMILY PLANNING SERVICES
Ask your doctor for help with family planning. Covered services include:
• Birth control counseling
• Birth control methods, including sterilization for male and female members 21 and older
• Natural family planning
• Emergency oral birth control pills – no prior authorization is required
• Medical and lab exams, including ultrasounds, related to family planning
• Treatment of complications resulting from contraceptive use

The following are not covered family planning services:
• Infertility services, including diagnostic testing, treatment or reversal of surgical infertility
• Pregnancy termination counseling
• Pregnancy terminations and hysterectomies
• Hysteroscopic tubal sterilization

PREGNANCY SERVICES
Pregnant women need special care. You may go directly to a Mercy Care Plan OB/GYN doctor for care. (You do not need to see or ask your PCP first). If you are not sure you are pregnant, make an appointment with your PCP for a pregnancy test. Covered services include:
• Prenatal care
• Labor and delivery
• Postpartum care
• Voluntary, confidential HIV/AIDS testing services are available, as well as counseling for members who test positive.
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SPECIAL HEALTH PROGRAMS
Mercy Care Plan has many health programs to help members with special health needs. For example, we have programs for members with HIV/AIDS, asthma, diabetes, congestive heart failure, chronic obstructive pulmonary disease and transplants. Mercy Care Plan staff help members manage their health care by working with community agencies and their doctors. Please call your case manager for more information about special health programs available to you.

TRANSPORTATION (RIDES)
Mercy Care Plan can help you get to your necessary health care visits. If you live in a nursing home or assisted living home, staff will arrange a ride for you if needed, including an ambulance if necessary.

If you live at home or in another community setting, it is important for you to find out first if a relative, friend or neighbor can give you a ride. If you can ride the bus, we will send you bus tickets or passes at no cost to you.

How to Get a Ride
If you are not able to find a ride or cannot use the bus:
• Call Member Services at (602) 263-3000 or (800) 624-3879 as soon as you schedule your
appointment so we can arrange your ride. For non -urgent appointments call at least three (3)
days in advance. If you have an urgent need to see your doctor, call Member Services at least three (3) hours before your appointment to arrange your ride.
• Let Member Services know if you need to travel by wheelchair or stretcher. This will help us arrange the right ride for you.
• If you have many appointments scheduled, or if you have regular appointments for visits like physical therapy or dialysis, Mercy Care Plan can set up rides all at once.
• After your appointment, call your transportation provider to arrange a pick-up time.
If you call the same day, we will not be able to arrange a ride for you in time, unless it is urgent. You may have to reschedule your appointment.
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TO GET SERVICES
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ABOUT YOUR PCP
Mercy Care Plan will send you a welcome letter when you become a member. Your welcome letter will have the name and phone number of your assigned PCP. If you live at home or in another residential setting, you may choose a PCP from the list of doctors your case manager will give you. If you do not choose a doctor, Mercy Care Plan will choose one for you. Your PCP is the doctor who will coordinate your health care. Your PCP orders your health care services,
equipment and supplies, and decides when you need to see a specialist. Your services must be ordered and approved by your PCP.

If you live in a nursing home, a Mercy Care Plan doctor will come to where you live to see you and care for you. This doctor is your PCP.

How to See Your PCP
In some cases, if it is medically necessary, your PCP may visit you in your own home or in an alternative residential setting. If you live in a nursing home, the staff will tell you when your PCP will visit and they will call your doctor if there are any changes in your health.

If you live at home or in an alternative residential setting, you, your family, guardian or caregiver can call your PCP to make an appointment.

What You Need to Know About Your PCP’s Office
You, your family or guardian should ask your PCP these questions. By knowing the answers to these questions, you will be better prepared if you have a medical problem.
• What are your office hours?
• Do you see patients on weekends and/or at night?
• Will you talk about problems with me over the phone?
• Is there anyone else who works with you who can help me?
• Who should I contact after the office has closed if I have an urgent problem?
• How long do I have to wait for an appointment?

Changing Your PCP
We hope that you stay with one PCP because this will help him/her get to know you and your health care needs. However, sometimes you may need to change to another doctor. Some reasons why you may need to change are:
• You do not understand what your PCP says
• You do not feel comfortable talking to your PCP
• Your PCP’s office is too far away

Member Services will help you change PCPs and will send you a letter confirming the change. The change will take place the first of the following month. Before changing though, try talking to your PCP first. You, your PCP and your case manager might be able to solve the problem without you having to change doctors. If the problem cannot be fixed, your case manager will
help you choose a new PCP. If you decide to change three or more times, Member Services will work with you and your doctor before making any more changes.
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QUICK TIPS ABOUT YOUR PCP
• Your PCP will coordinate all of your health care services.
• Call your doctor if you have questions about referrals.
• Know their office hours and what to expect for after-hours service.
• If you have a problem with your PCP, talk to him/her about it or call your case manager for help first.
• If you need to change, your case manager will help you.

REFERRALS
Your PCP may refer you to other providers to get special services. A referral is when your PCP sends you to a specialist for a specific problem. A referral can also be to a lab or hospital, etc. Mercy Care Plan may need to review and approve certain referrals and special services first before you can go get the services. Your PCP will know when to get Mercy Care Plan’s approval. If your referral needs to be approved by Mercy Care Plan your PCP will let you know what’s happening. 

You may also request a second opinion from another Mercy Care Plan doctor.

AUTHORIZATIONS
An authorization is an approval from Mercy Care Plan for you to get the special services your PCP has referred you to. Mercy Care Plan may take up to 14 business days to approve a routine authorization request and three (3) business days for an urgent request. If Mercy Care Plan does not receive all the necessary information to authorize the request, a 14 day extension may be requested. If you have questions about whether your service has been authorized, call your PCP. You do not need approval from Mercy Care Plan to get emergency services.

APPOINTMENTS
Appointment Availability
There are three different kinds of appointments you may need:
• Emergency or Same Day - you need to be seen today. Same day appointments are for when you have a condition that is not a true emergency but is one that needs to be seen right away. Examples are shortness of breath, an abscessed tooth, high fever, earache, etc.

• Urgent or Acute - you need to be seen within one (1) to three (3) days of your call. Some examples are sore throat, rash, constipation, mild nausea and vomiting, the flu, cough, etc. For urgent appointments, you can expect to be seen:
• By your PCP within two (2) days
• By a specialist or dentist within three (3) days 

• Routine - you can wait to be seen for three (3) - five (5) weeks from your call. An example is a yearly checkup. For routine appointments, you can expect to be seen:
• By your PCP within 21 days
• By a specialist within 45 days
• By a dentist within 45 days
These are the timeframes our doctors and dentists use to help you get care you need when you need it. If you cannot get an appointment in these timeframes, please call Member Services for help. You can also go to an urgent care center if you have an urgent problem and your doctor cannot see you right away.
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Making an Appointment
Call your PCP’s office to make an appointment. When you contact the office:
• Let them know you are a Mercy Care Plan ALTCS member.
• Tell them your symptoms. This will help them decide how soon you need to be seen.
If you cannot make it to your appointment, please call your PCP’s office before the appointment time to cancel. Be sure to reschedule!

Arriving For Your Appointment
If you are going to your PCP for the first time, please get there at least 15 minutes early. They will need to get information about you to start your health record. When you go to an appointment, show your member ID card to the office staff before you are seen. If you do
not have your ID card with you, you will still be seen. Let them know you are a Mercy Care Plan ALTCS member. You may need to show a current picture ID. Ask the office to call Mercy Care Plan for more information.

Your PCP may have to spend extra time with another patient or may have an emergency that puts him/her behind schedule. When this happens, you may have to wait a little longer to be seen. But, if you usually have to wait more than 45 minutes for scheduled appointments, please tell your case manager.

AFTER-HOURS CARE
Except in an emergency, if you get sick after the office is closed or on a weekend, call the office anyway. An answering service will make sure your doctor gets your message. Your PCP will call you back to tell you what to do. Be sure your phone accepts blocked calls. Otherwise, the doctor may not be able to reach you.

You can even call your PCP in the middle of the night. You most likely will have to leave a message with the answering service. It may take a while for them to get back to you, but a doctor will call you back to tell you what to do.

URGENT CARE
You may go to an urgent care center if you are not able to get in to see your PCP right away and need urgent care. Look in your Provider Directory to find the center closest to you or look on our Web site at www.MercyCarePlan.com.

EMERGENCY CARE
What is an Emergency?
An emergency is a medical condition that could cause serious health problems or even death if not treated immediately. You do not need approval from Mercy Care Plan or your PCP to get emergency services and you may go to any emergency department. Emergencies may include:
• Poisoning/overdose
• Severe chest pain
• You cannot move your arms or legs (paralysis)
• Bleeding that you cannot stop
• Loss of consciousness
• Broken bones
• Deep cuts or serious burns
• Pregnant with bleeding and/or pain

If you have an emergency, call 911. If 911 is not available in your area, dial zero (0) for help. You may also go to the closest emergency room (ER) for help.



What is Not an Emergency?
Some medical conditions not considered emergencies are:
• Flu, colds, sore throats, earaches
• Urinary tract infections
• Prescription refills or requests
• Health conditions that you have had for a long time
• Back strain
• Migraine headaches

If you need care for a condition that is not an emergency, call your PCP first. If you live in a nursing home or other residential setting, the staff will call your PCP for you.

QUICK TIPS ABOUT EMERGENCIES
• If you have an emergency, go to the closest ER or call 911.
• If you have an urgent situation but not an emergency, call your PCP.
• Only use the ER in a real emergency.

OUT - OF - AREA COVERAGE
No services are covered outside of the United States.

If you become sick in another county or state, Mercy Care Plan will only pay for emergency services. If you have an emergency while away, go to the closest emergency room. Show your member ID card to the hospital and tell them you are a Mercy Care Plan Long Term Care member. Ask the hospital to send the bill to Mercy Care Plan for payment. Do not pay the bill yourself. Follow-up care is not covered while you are away. You should get any follow-up care you need from your PCP.

Mercy Care Plan may approve health care services that are only available away from where you live. If this happens, we may pay for your transportation, lodging and food costs. Mercy Care Plan will only pay for these services if they are approved by us first. Please call Member Services before your trip so we can help make arrangements.

YOUR SHARE OF COST
As an ALTCS member, you are required to contribute toward the cost of your care. What costs do you have to pay?

Share of Cost
If you live in a nursing home, ALTCS will decide what your share of cost will be based on your income and certain expenses. They will send you a notice telling you the amount. The nursing home will collect your share of cost from you every month.
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Room and Board
If you live in an alternative residential setting, such as an Adult Foster Care Home, Assisted Living Home or an Assisted Living Center, you are required to pay for your room and board. Your case manager will let you know what you need to pay.

If you live at home, you probably will not have a share of cost since you already pay for living expenses. If you live at home and do have a share of cost, Mercy Care Plan will collect the money from you or your representative.


Coordination with Medicare and Other Insurance
If you have Medicare, QMB or Medicare HMO, they will pay for your services first. If you are entitled to AHCCCS covered services and Medicare Parts A and B, Mercy Care Plan is responsible for sharing in the cost for AHCCCS covered services and for certain Medicare services not covered by AHCCCS, like chiropractic. Mercy Care Plan will pay your coinsurance, deductible or copayment amounts to your doctor. Do not pay your copayments yourself. Ask your PCP to bill Mercy Care Plan for the copayment.

Unless you have an emergency, if you choose to go to another provider who is not one of the Mercy Care Plan approved doctors found in your Provider Directory or not with your Medicare HMO, you will be responsible for paying your Medicare coinsurance, deductibles or copayments.
Please call Member Services first if you have questions.

If you have Medicare, read the Medicare handbook called “Other Things You Should Know About Medicare” to find out which services are covered and which are not.

CHILDREN’S REHABILITATIVE SERVICES (CRS) COPAYMENTS AND DEDUCTIBLES
If you are a CRS eligible member and have private insurance or Medicare, you are not required to use CRS services for a CRS covered condition. If you choose to use your private insurance or Medicare for a CRS covered condition, Mercy Care Plan will pay all applicable deductibles and copayments.

However, when your private insurance or Medicare is exhausted, or certain annual or lifetime limits are reached, Mercy Care Plan will refer you to CRS to determine whether you are eligible for CRS services. If you choose to enroll in CRS for services, CRS will pay all applicable deductibles and copayments.

IF YOU HAVE OTHER HEALTH INSURANCE
If you have other insurance, here are some important things to know.
1. Always give pharmacies, doctors and hospitals your other health insurance information and your Mercy Care Plan information.
2. Your other health insurance pays for your health care expenses FIRST. After they pay, Mercy Care Plan will pay its part.
3. If your doctor writes a prescription for a medication that is not on Mercy Care Plan’s list of covered drugs, do the following:
• Ask your doctor for a prescription that is on Mercy Care Plan’s list of covered medications; or
• If you can’t take any other medication except the one prescribed, ask your doctor to ask for
an exception from Mercy Care Plan 

If you are in an accident and get treatment for your injuries, you must report this to your case manager.
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Qualified Medicare Beneficiary (QMB) Copayments And Deductibles
If you meet certain income and resource limits, you may be able to get into a program called QMB (Qualified Medicare Beneficiary) in addition to ALTCS. QMB members may get all ALTCS services as well as Medicare Parts A and B services. QMB members may receive Medicare services that are not covered by ALTCS, like chiropractor services. AHCCCS pays the Medicare Part B premium each month for QMB members.
GETTING BILLS FOR SERVICES
When Can You be Billed for Services?
If you get services that are not covered or that have not been approved by Mercy Care Plan, you may be billed. Talk to your doctor about payment options before getting any health care services that are not covered. Remember, if you ask for a service that is not a covered benefit and sign a statement agreeing to pay the bill, you are responsible to pay for it.

Also, if a provider asks you to pay for a covered service instead of sending the bill to Mercy Care Plan and you do, we may not be able to pay you back.

What If You Get a Bill for Services?
If you get a bill for a covered service:
• Call the provider right away.
• Give them your insurance information and Mercy Care Plan’s address.
• Do not pay the bill yourself.
If you still get bills after giving the provider your health care information, please call Member Services for help.
• Sometimes you may be eligible for covered benefits back to the date you applied for AHCCCS. If you already paid for services during this time, you should first ask the provider to bill Mercy Care Plan and then to pay you back. If they won’t, Mercy Care Plan may be able to help you. You can send your paid receipts to Member Services with a detailed note explaining why you paid for
services. Receipts must be received by Mercy Care Plan within six (6) months from the date you
received the service.
• You should not pay for covered services or medicines after you have joined Mercy Care Plan. We cannot pay you back.
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MEMBER GRIEVANCES
If you have a grievance or problem with a provider or a concern about the quality of care or services you have received, please call Member Services or your case manager. We will do our best to answer your questions or help you solve your problem. Filing a grievance will not affect your health care services. We want to know your concerns so we can improve our services to you. You can call Member Services for help with problems with authorizations, covered 
services, payment for services or the quality of the services you are receiving. If you call to report a grievance that is not about quality of care, we will try to solve it right away and tell you the result right then if we can. If we cannot solve your problem right away, we will solve it within two (2) days. If we need to get more information, we may take up to seven (7) days to solve the problem.

If you have a quality of care grievance we will send your complaint to our Quality Management Department for review.

QUICK TIPS ABOUT MEMBER GRIEVANCES
• If you have a problem with your doctor or his/her staff, talk to your doctor first.
• If you are not happy with the services you received, call Member Services.
• You may file a grievance with Member Services about the quality of care you received.

ACTIONS
An action by Mercy Care Plan means:
• The denial or limited authorization of a service you or your doctor have asked for
• The reduction, suspension or ending of an existing service
• The denial of payment for a service, either all or part
• Failure to provide services in a timely manner
• Failure to act within certain timeframes for grievances and appeals
• Denial of a rural member’s request to get services out of the network when MCP is the only health plan in the area

DENIALS, REDUCTION, SUSPENSION OR TERMINATION OF SERVICES AND REQUEST FOR APPEAL
Denial of Services Reduction, Suspension or Termination of Services
Member requests for many medical and long term care services must be reviewed and approved first by Mercy Care Plan doctors. If Mercy Care Plan decides that the services cannot be approved, we will write to you within 14 working days and tell you why or within three (3) days for an expedited request. We will also let your doctor know. You can discuss it with your doctor.
IMPORTANT INFORMATION
If a reduction, suspension or termination of your medical or long-term care services happens, we will write to you at least 10 days before the change to let you know.
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NOTICE OF ACTION
If Mercy Care Plan decides that the requested service cannot be approved, or if a service is reduced, suspended or ended, you will get a “Notice of Action” which will tell you:
• What action was taken and the reason for it
• Your right to file an appeal and how to do it
• Your right to ask for a fair hearing with AHCCCS and how to do it
• Your right to ask for an expedited resolution and how to do it
• Your right to ask that your benefits be continued during your appeal, how to do it and when you may have to pay the costs for the services

APPEALS PROCESS
If you disagree with Mercy Care Plan’s decision about your health care services, you may file an appeal either in writing or over the phone. If you need an interpreter, one will be provided. You, your representative or a provider acting with your written permission may file an appeal within 60 days from the date of your denial, suspension, reduction or termination letter (notification letter). To file an appeal, you must call or send a letter to:

Mercy Care Plan
Appeals Department
2800 N. Central Ave., Suite 400
Phoenix, AZ 85004
(602) 263-3000 or (800) 624-3879

When Mercy Care Plan gets your appeal, we will send you a letter within five (5) days telling you that we have your appeal and how you may give us more information either in person or in writing. If you wish services to continue while your appeal is reviewed, you must file your appeal no later than 10 days from the date of Mercy Care Plan’s notification letter to you.

The Appeals Department will review your appeal and send a decision in writing to you within 30 days. The letter will tell you what Mercy Care Plan’s decision was and the reason for the decision. If Mercy Care Plan denies your appeal, you may then request a fair hearing with AHCCCS by following the steps in our decision letter to you.

If you request a hearing, you will receive information from AHCCCS about what to do. Mercy Care Plan will forward its file and documentation to the AHCCCS Office of Administrative Legal Assistance. If after the hearing AHCCCS decides that Mercy Care Plan’s decision was correct, you may be responsible for payment of the services you received while your appeal was being reviewed. If AHCCCS decides that Mercy Care Plan’s decision was incorrect, Mercy Care Plan will authorize and provide the services promptly.

REQUEST FOR EXPEDITED RESOLUTION
You may file an appeal within 60 days from the date of your notification letter and request that Mercy Care Plan review its decision within three (3) days (expedited resolution). You may request an expedited resolution by writing or calling Mercy Care Plan at the address and number listed under “Appeals Process.” You may request that services be continued during your appeal if you file your request within 10 days from the date of the letter from Mercy Care Plan.

If Mercy Care Plan decides that it is not medically necessary to issue a decision in three (3) days, your appeal will be resolved within the standard 30 days. We will try and call you to let you know we will follow the standard 30 day process, and we will send you a written notice within two (2) calendar days. If Mercy Care Plan denies your request for services, you may request a fair hearing with AHCCCS by following the steps in your decision letter. If after the hearing AHCCCS decides that Mercy Care Plan's decision was correct, you may be responsible for payment of the services you received while you’re appeal was being reviewed.

QUICK TIPS ABOUT DENIALS, REDUCTION, SUSPENSION OR
TERMINATION OF SERVICES
• You will be sent a letter (Notice of Action) 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 letter.
• To request that services be continued, you must file your appeal no later than 10 days from the date of your notice, or within the time frame in your letter.

FRAUD
Your health care benefits are given to you based on your eligibility for the program. You should not share your benefits with anyone. Providers must report any misuse of benefits to Mercy Care Plan, and we report this information to AHCCCS. If you misuse your benefits, you could lose them altogether. And, AHCCCS may take legal action against you. If you think a person, member or provider is misusing the program, please call Member Services or AHCCCS.

Fraud also means things like loaning, selling or giving your member ID card to someone else, misusing benefits, wrongful billing by a provider or any action to defraud the program.

ABUSE
Abuse means physical, sexual or emotional harm or injury. It also means neglect or exploitation by others. Your safety and well being are very important to Mercy Care Plan. If you or your family has any concerns, please call your case manager right away.

CHANGE OF ADDRESS
Mercy Care Plan and ALTCS need your correct address. If you are moving, call your case manager with your new address before you move. Call the ALTCS office where you applied and let them know, too.
If you plan to move to a new county other than Maricopa County or to the Indian Reservation, call your case manager as soon as you know about the move so they can arrange and coordinate your care and services with the program contractor in your new county. If you do not let your case manager know, you may not get the services you need.

ANNUAL ENROLLMENT CHOICE (AEC)
Mercy Care Plan is your Program Contractor. Annual Enrollment Choice (AEC) is the time during the year when you may choose a new program contractor if you want. ALTCS will send you information about program contractors in your area two months before your AEC so that you can look through it and decide whether you want to change or not. Before you decide to change, please call your case manager or Member Services. We may be able to help you with any problems you might be having.
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Information
PROGRAM CONTRACTOR CHANGES
You may change program contractors once a year on the date you first became an ALTCS member. You may also change at any time if any of the following is true:
1. You were not given a choice when you first joined.
2. You did not get your AEC letter so you could choose.
3. You got your AEC letter but were not able to take part in your AEC due to things out of your control.
4. Other members of your family are enrolled with another program contractor.
5. You were given wrong information about available choices, or there was an error on the part of
AHCCCS or Mercy Care Plan.
6. You move to your own home in another county.
7. You re-enrolled in ALTCS within 90 days and were not re-enrolled with the same program contractor.

*Some changes need approval from the new program contractor before you can change. An example of a change needing approval is if you move to a nursing home or assisted living home in another county.

*Be sure to call your case manager before you make any changes.

DECISIONS ABOUT YOUR HEALTH CARE
Living Wills and Other Health Care Directives for Adult Members
There may be a time when you are so ill that you cannot make decisions about your health care. If this happens, advance directives are documents that protect your right to refuse health care you do not want, or to request care you do want.

There are four kinds of Advance Directives. Mercy Care Plan strongly encourages you to have one or more of these papers filled out.
• Living Will - a paper that tells doctors what kinds of services you do or do not want if you become ill and may die. In your Living Will, you might tell doctors if you want to be kept alive with machines or fed through tubes if you cannot eat or drink on your own.
• Durable Medical Power of Attorney - a paper that lets you choose a person you trust to make
decisions about your health care when you cannot.
• Mental Health Care Power of Attorney - names a person to make mental health care decisions if you are found incapable to do so.
• Pre-Hospital Medical Care Directive - states your wishes about refusing certain life-saving
emergency care given outside a hospital or in a hospital emergency room. You must complete a
special orange form.

Mercy Care Plan has written policies to ensure advance directive wishes are followed.
You should get help writing your Living Will and Medical Power of Attorney. Ask your case manager or doctor for help if you are not sure whom to call.
M e r c y C a r e P l a n — L o n g Te r m C a r e
Making Your Advance Directives Legal
For both a Living Will and a Medical Power of Attorney, you must choose someone you trust to be your agent. Your agent is the person who will make decisions about your health care if you cannot yourself. He/she can be a family member or a close friend. To make an Advance Directive legal, you must:
• Sign and date it in front of another person, who also signs it. This person cannot:
• Be related to you by blood, marriage or adoption;
• Have a right to receive any of your personal and private property;
• Be appointed as your agent, or
• Be involved with the paying of your health care.
OR
Sign and date it in front of a notary public. The notary public cannot be your agent or any person involved with the paying of your health care.
If you are too ill to sign your Medical Power of Attorney, you may have another person sign for you.

After You Complete Your Advance Directives
• Keep your original signed papers in a safe place.
• Give copies of the signed papers to your doctor(s), hospital, and anyone else who might become
involved in your health care. Talk to these people about your wishes concerning health care.
• If you want to change your papers after they have been signed, you must fill out new ones. You should make sure you give a copy of the new paper to all the people who already have a copy of the old one.
• Be aware that your directives may not be effective in the event of a medical emergency.
• You can also have advance directives registered with the Arizona Registry at www.azsos.gov/adv_dir.
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Information
SOURCES OF INFORMATION AND FORMS
The following organizations provide health care directive forms and information:

Arizona Attorney General’s Office
1275 W. Washington
Phoenix, AZ 85007
(602) 542-5025
www.azag.gov

Department of Economic Security
Aging and Adult Administration
1789 W. Jefferson, Site Code 950A
Phoenix, AZ 85007
(602) 542-4446
Dorothy Garske Center
Your Health Care Choices Program
4250 E. Camelback Rd., Suite 185K
Phoenix, AZ 85018
(480) 966-2674

Your local Area Agency on Aging and Senior Center may also have forms and information.

The following national organization also provides health care directive forms and information:
AARP
601 “E” Street, N.W.
Washington, D.C. 20049
(202) 434-2277 (AARP)
(888) 687-2277
The following organization will provide information and answer questions about health care directives and related legal matters.

Arizona Senior Citizens Law Project
1818 S.16th Street
Phoenix, AZ 85034
(602) 252-6710
M e r c y C a r e P l a n — L o n g Te r m C a r e
30 Important Information  Tab
DEFINITIONS
Action - an action by Mercy Care Plan means:
• The denial or limited authorization of a service you or your doctor have asked for
• The reduction, suspension or ending of an existing service
• The denial of payment for a service, either all or part
• Failure to provide services in a timely manner
• Failure to act within certain timeframes for grievances and appeals
• Denial of a rural member’s request to get services out of the network when Mercy Care Plan
is the only health plan in the area
AHCCCS – (Arizona Health Care Cost Containment System) is the state agency that manages the Medicaid program in Arizona using federal and state funds. AHCCCS contracts with managed care health plans to deliver medical services to eligible members.
ALTCS – (Arizona Long Term Care Containment System) is the state agency that manages the Medicaid program in Arizona using federal and state funds. AHCCCS contracts with managed care health plans and program contractors to deliver medical and long-term care services to eligible members.
Appeal Resolution – the written determination by Mercy Care Plan about an appeal.
Authorization – an approval from your doctor and/or health plan before getting other health care services including, but not limited to, laboratory and radiology tests and visits to specialists and other health care providers (see referral).
Copayment – a small amount of money you pay when you get certain covered services.
Emergency – an emergency is a medical condition that could cause serious health problems or even death if not treated immediately.
Durable Medical Equipment (DME) – equipment which:
A) may be used over and over;
B) is primarily used to serve a medical purpose;
C) usually is not useful to a person when they are not sick or hurt,
D) is easily used in the home.
Some examples are crutches, wheelchairs, walkers, etc.
Grievance – Any written or verbal expression of dissatisfaction over a matter other than an action, as defined in this Handbook, by a member or provider authorized in writing to act on the member's behalf. A grievance may be submitted orally or in writing to any Mercy Care Plan staff person. Grievances include, but are not limited to, issues regarding:
• Quality of care or services
• Accessibility or availability of services
• Interpersonal relationships (e.g. rudeness of a provider or employee, cultural barriers or
insensitivity)
• Claims or billing
• Failure to respect a Member's rights
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Grievance System – a system that includes a process for enrollee grievances, enrollee appeals, provider claim disputes and access to the State Fair Hearing system.
Medically Necessary – a covered service that will prevent disease, disability and other poor health conditions or their progress, or prolong life.
Notice of Action – if Mercy Care Plan decides that the requested service cannot be approved, or if an existing service is reduced, suspended or ended, a member will receive a “Notice of Action”
telling them what action was taken and the reason for it; their right to file an appeal and how to
do it; their right to ask for a fair hearing with AHCCCS and how to do it; their right to ask for an
expedited resolution and how to do it; and, their right to ask that their benefits be continued
during the appeal, how to do it and when they may have to pay the costs for the services
Prescription – an order from your doctor for medicine. The prescription may be called in over the telephone or can be written down.
Primary Care Physician (PCP) – the doctor who provides or authorizes all your health care needs. Your PCP refers you to a specialist if you need special health care services.
Qualified Medicare Beneficiaries (QMB) – members who qualify for both AHCCCS and Medicare who have their Medicare Part A and Part B premiums, coinsurance and deductibles paid for by AHCCCS.
Referral – when your PCP sends you to a specialist for a specific, usually complex, problem.
Share of Cost – a contribution you pay for nursing home care, based on your income and expenses.
Specialist – a doctor who treats specific health care needs. For example, a cardiologist is a specialist. You must get a referral from your doctor before seeing a specialist.
Special Health Care Needs – members who have serious and chronic physical, developmental or behavioral conditions and who require medically necessary health and related services of a type or amount greater than those generally required by members. All ALTCS members are considered to have special needs.