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Health care tohelp you live betterMercy Care PlanLong Term Care2012-2013 Member HandbookVisit: www.MercyCarePlan.com

Phoenix4350 E. Cotton Center Blvd.,Building DPhoenix, AZ 85040Tucson5431 E. Williams Cir.,Suite 101BTucson, AZ 85711Call Mercy Care Plan Member ServicesMonday through Friday 7 a.m. to 6 p.m.602-263-3000 or 1-800-624-3879,Hearing Impaired (TTY/TDD) 1-866-602-1982For e-mail, go to: www.MercyCarePlan.com, andSelect: MercyOneSource.PERSONAL INFORMATIONMy Member ID number:_______________________________________________________________My PCP:__________________________________________________________________________My PCP’s phone number:______________________________________________________________My Pharmacy’s phone number:_________________________________________________________My Pharmacy’s address:_______________________________________________________________My Case Manager’s name is: ___________________________________________________________My Case Manager’s number is: _______________________________________________________Contract services are funded in part under contract with the State of Arizona. Mercy Care Plan followsfederal and state laws that apply under the contract with AHCCCS. This is general health information andshould not replace the advice orcare you get from your provider. Always ask your provider about your ownhealth care needs.Updated October, 2012

TABLE OF CONTENTSLong Term Care Member Handbook 2012-2013INTRODUCTIONWelcome to Mercy Care Plan!.................................................... 5Your member handbook............................................................. 5Your provider directory................................................................ 5Mercy Care Plan website: www.Mercycareplan.Com........ 5Member advisory council............................................................ 6Change of address/out of area moves.................................... 6Member services........................................................................... 6Member confidentiality and our privacy practices.............. 6Language and interpretation services.................................... 7About Mercy Care Plan................................................................ 8About providers............................................................................. 8Member rights and responsibilities.......................................... 9Member identification (ID) card.............................................. 11COVERED SERVICESCase management services..................................................... 12Home and community based services.................................. 16Alternative living settings......................................................... 18Transitional program ................................................................. 18Nursing home care..................................................................... 18Pharmacy services...................................................................... 18Payment for drugs.......................................................................20Durable medical equipment (DME)........................................20Behavioral health services........................................................ 21Disease management................................................................22EPSDT/Children’s Services........................................................22Women’s services........................................................................23Family planning services........................................................... 24Tobacco cessation....................................................................... 24Transportation (rides) services................................................ 24HOW TO GET SERVICESPrimary care physician (PCP)................................................... 26Types of care.................................................................................28After-hours care..........................................................................29Out-of-area coverage................................................................30How your pcp helps you get services....................................30Request for expedited resolution...........................................33Cost sharing..................................................................................33IMPORTANT INFORMATIONMedicare copayments, coinsurance and deductibles......34Children’s rehabilitative services (CRS)copayments and deductibles..................................................34If you have other health insurance.........................................34Getting bills for services............................................................35Important information...............................................................36Member grievances ...................................................................36Fraud and abuse..........................................................................36Annual enrollment choice (AEC).............................................36Health plan changes...................................................................37Decisions about your health care...........................................37RESOURCESHealth care directives and legal resources..........................39If you lose eligibility resources................................................. 41Community resources................................................................45Low-fee dental services............................................................49Definitions..................................................................................... 51INTRODUCTION1

INTRODUCTION2

Long Term Care Member Handbook 2012-2013Contract Services are funded primarily under contract with AHCCCS and the State of Arizona. Mercy Care Planfollows federal and state laws that apply under the contract with AHCCCS.MERCY CARE PLAN4350 E. Cotton CenterBldg. DPhoenix, AZ 85040AndINTRODUCTION5431 East Williams CircleSuite 101BTucson, AZ 85711-7501Mercy Care Plan Member Services7 a.m. to 6 p.m. Monday-Friday602-263-3000 or Toll-free 1-800-624-3879Hearing Impaired (TTY/TDD): 1-866-602-1982Nurses Line: Our nurse line is available after hours and on the weekends to answer generalmedical question. Call Mercy Care Plan, and select the “speak to a nurse” option.Long Term Care Case Management: If you need to contact your case manager prior to thenext scheduled visit, call him or her directly. Your case manager’s telephone number is listed onthe business card that she or he left you. Call your assigned case manager directly between thehours of 8 a.m. and 5 p.m. If you cannot get in touch with your case manager or do not know thename of your case manager, call Mercy Care Plan Member Services.Behavioral Health Crisis: 1-800-876-5835MEDICAL EMERGENCY or LIFE-THREATENING situation:Use the emergency medical services (EMS) available and/or activate EMS by dialing 9-1-1.www.MercyCarePlan.com3

INTRODUCTION4

WELCOME TO MERCY CARE PLAN!Long Term Care Member Handbook 2012-201325 Years of Commitment and CaringFor more than 25 years, our Members have trusted Mercy Care to be there for them ortheir families. To us, you are more than a Mercy Care member; you are a member ofour family. With the Mercy Care doctors, hospitals and home and community basedagencies, we all work together for you. We take the extra steps to reach you, your lovedones and your community. “Care” is more than just a part of our name—it is a valueshared by all of us at Mercy Care Plan.INTRODUCTIONYOUR MEMBER HANDBOOKPlease 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••Definition of TermsThe handbook is available on audiocassette or CD from Member Services for members who are visually impaired. Itis also available in text format on the Mercy Care Plan Web site at www.MercyCarePlan.com.All Mercy Care Plan printed materials are available in an alternative format. For access to these alternative formats,please contact Member Services. These materials (including the Member Handbook and Provider Directory) areprovided to you at no cost.YOUR PROVIDER DIRECTORYAlong with your Member Handbook, you will receive a directory of Mercy Care Plan doctors. You can get aprovider directory at no cost to you. You can select your doctor from this list. In this directory, you will find PCPand specialist information, such as languages spoken and whether a provider is accepting new members. Youcan find the most up-to-date listing on the Mercy Care Plan Web site at www.MercyCarePlan.com.MERCY CARE PLAN WEBSITE: WWW.MERCYCAREPLAN.COMVisit our website. You can get updated information on Mercy Care Plan. You can search for a doctor, pharmacy,urgent care or hospital near you.You can also get your own health information by going to our secure web portal MercyOne Source. With yoursecure log-in, you can:••Look up the status of a claim••Check the status of a prior authorization request••See your assigned PCP••Email Mercy Care Plan Member Services5

Our website is also linked to Medline Plus. Here you can find health information:INTRODUCTION••Learn about a medical problem••Read the latest health news••Research drugs and supplements••Look up symptomsMEMBER ADVISORY COUNCILMercy Care Plan has a Member Advisory Council (MAC). The council is made up of members just like you whoare concerned about health care. Members volunteer to serve at least two years. New council members may bechosen each year. The MAC advises Mercy Care Plan on issues that are important to members. If you are not onthe council, you may still suggest changes to policies and services by calling Member Services. You may also callMember Services for more information on how to join the council.CHANGE OF ADDRESS/OUT OF AREA MOVESMercy Care Plan and ALTCS need your correct address. If you are moving, call your case manager with yournew address before you move. Let the ALTCS office where you applied for ALTCS know of your move.If you plan to move to a new county, other than Pima or Maricopa counties, or to the Indian Reservation, callyour case manager. They can arrange and coordinate your care and services with the program contractor inyour new county. If you do not let your case manager know, you may not get the services you need.If we do not have your correct address, you may not get important information from us. If you move out ofstate, country or the MCP service area, you will need to choose a new health plan.MEMBER SERVICESMercy Care Plan’s Member Services Department can answer questions about benefits, help you find a doctor,arrange rides to medical appointments, and solve problems in getting health care services.Mercy Care Plan Member Representatives are available to help you!Monday through Friday, 7 a.m. to 6 p.m.Please call 602-263-3000 or toll-free 1-800-624-3879.Hearing Impaired (TTY/TDD)1-866-602-1982MEMBER CONFIDENTIALITY AND OUR PRIVACY PRACTICESYou will find a copy of the Privacy Rights notice in your welcome packet. The notice has information on ways inwhich Mercy Care Plan uses your records; including information on your health plan activities and payments forservices. Your health care information is kept private and confidential. It is given out only with your permissionor if the law allows it.6

Long Term Care Member Handbook 2012-2013LANGUAGE AND INTERPRETATION SERVICESMercy Care Plan has many health care providers who speak languages in addition to English. Check theProvider Directory or the Mercy Care Plan Website (www.MercyCarePlan.com) to find a doctor who speaks yourlanguage.You can get a telephone or sign language interpreter for your health care visits at no cost to you. Your PrimaryCare Physician (PCP), Case Manager or specialist can call an interpreter through our interpretation line duringyour visit. If you need help in your language or if you have a hearing impairment, call Member Services for aninterpreter.If you need information in this language, please call Mercy Care Plan Member Representatives.INTRODUCTIONMonday through Friday, 7 a.m. to 6 p.m. Please call 602-263-3000 or toll free 1-800-624-3879. HearingImpaired (TTY/TDD) 1-866-602-1982.7

ABOUT MERCY CARE PLANINTRODUCTIONMercy Care Plan (MCP) is a contracted health plan with the Arizona Health Care Cost Containment System(AHCCCS), Arizona’s Medicaid agency. Mercy Care Plan is a managed care plan. As a managed health plan, weprovide health care to our members through a selected group of doctors, hospitals and pharmacies. You willneed to use doctors (called Primary Care Physicians ‐ or PCPs) who are part of our network.Mercy Care Plan and AHCCCS work together to look at new medical procedures and services to make sure youget safe, up-to-date, high-quality medical care. A team of doctors review new health care methods and decideto include (or not) them as covered services. Experimental services and treatments under research and studiedare not covered services.To decide if new technology will be a covered service, 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 technologyABOUT PROVIDERSYour health care is important to us, so our doctors and dentists are carefully chosen. They must meet strictrequirements to care for our members, and we regularly check the care they give you. If you need moreinformation about your doctor, you may contact the organizations in the following table.NAME OF ORGANIZATION TELEPHONE NUMBER WEBSITEArizona Medical Association 1-800-482-3480 www.azmedassn.orgArizona Medical Board 480-551-2700www.azmd.govor Toll free 1-877-255-2212American Board of Medical1-866-275-2267 www.abms.orgSpecialtiesArizona State Board of Dental602-242-1492 www.azdentalboard.orgExaminersArizona Board of Osteopathic480-657-7703 www.azdo.govExaminersArizona State Board of Optometry 602-542-3095 www.optometry.az.gov8

Long Term Care Member Handbook 2012-2013MEMBER RIGHTS AND RESPONSIBILITIESAs a Mercy Care Plan member, you have rights and responsibilities. It is important you read and understandeach one of the rights and responsibilities statements. If you have questions, please ask your case manager.InformationYou, your family or your guardian(s) have the right to:••The name of your PCP and/or case manager••One copy of your medical records at no cost to you. You have the right to inspect your medical records. Youmay not be able to get a copy of medical records that contain psychotherapy notes put together for a civil,criminal or administrative action.••A copy of the Mercy Care Plan Long Term Care Member Handbook••A description of Mercy Care Plan’s services, providers and your rights and responsibilities as a member••Information on how Mercy Care Plan provides for after hours and emergency care••Information on how Mercy Care Plan pays providers, controls costs and uses services including whether ornot Mercy Care Plan has a Physician incentive plan (PIP) and associated information••The right to know whether stop loss-insurance is required••General grievance results and a summary of member survey results••Information on how Mercy Care Plan evaluates new technology to include as a covered service••Information on Advance Directives••Information on how medical decisions can be made for you when you are not able to make them••Actions to take if your PCP leaves Mercy Care Plan••Your costs to get a service that Mercy Care Plan does not coverINTRODUCTIONRespect and Dignity••You can get covered services without regard to payer source, race, ethnicity, national origin (to include thosewith limited English proficiency), ancestry, marital status, religion, gender, age, mental or physical disability,sexual orientation, genetic information, and ability to pay or ability to speak English.••You can get quality medical services that support your personal beliefs, medical condition and backgroundin a language you understand.••You can get interpretation services if you do not speak English or have a hearing impairment.••You can get materials in an alternative formats (such as large type or audio recording) or in anotherlanguage.••You will be informed, in writing, by Mercy Care Plan when any of your health care services are reduced,suspended, terminated or denied. You must follow the instructions in your notification letter.Treatment Decisions••You can get information on how to get services and authorizations for services.••You can choose a Mercy Care Plan PCP to plan your health care. You can change your PCP.••You can talk with your PCP to get complete and current information about your health care and condition.This information helps you and/or your family understand your condition and be a part of making decisionsabout your health care.••You can get information on medical procedures to get and who will perform them.••You can request a second opinion from a doctor outside of Mercy Care Plan’s network at no cost to you.••You can refuse care from a doctor to whom you were referred.••You can choose someone to be with you for treatments and exams.••You can have a female in the room for breast and pelvic exams.9

INTRODUCTION••You have the right to know treatment choices or types of care available to you and the benefits and/ordrawbacks of each choice. You can get this information in a way that you understand and is appropriate toyour medical condition.••You can say, “no” to treatments, services and PCPs. You have the right to be told what may happen bynot having the treatment. Your eligibility or medical care does not depend on your agreement to follow atreatment plan.••You can say,” no” to tasks that a provider may ask you to perform that are not part of your care plan.••You can say, “no” to drugs or restraints, except for times when your doctor thinks these actions are neededto protect you or others from harm.••You can ask Mercy Care Plan to amend or correct your medical records.••You can transfer or leave a long-term care home because of medical reasons, for your own good or thegood of others, or for not paying.••If you have an emergency, you can get emergency health care services without the approval of your PCP orMercy Care Plan. 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 aspecialist with a referral from your PCP.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 the Health 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.Personal Rights••If you live in a nursing facility or an alternative residential facility, you may choose to share a room with yourspouse when appropriate.••If you choose, you may remain in your home.••If you live in an Assisted Living Center, you have a choice of a single occupancy unit.••You can manage your own money or choose someone you trust manage your money on your behalf.••You can use your rights as a citizen.••You can choose to speak or not to speak with people.••If you live in a nursing facility or an alternative residential facility, you can keep and use your personalclothing and belongings when there is space and no medical reasons not to.••You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline,convenience or retaliation.Member ResponsibilitiesAs 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.10

Long Term Care Member Handbook 2012-2013••Take care of equipment loaned to you such as wheelchairs and the possessions belonging to the placewhere you live.••Be considerate of the rights of staff and others who are living in the same place as you.••Be respectful of their property.Share Information••Show your member ID card or identify yourself as a Mercy Care Plan member to health care providersbefore getting services. If you have additional insurance, in addition to Mercy Care Plan) show your doctoror pharmacist your other insurance ID card.••If you do not understand your health condition or treatment plan, ask your PCP to explain.••Tell your doctor and/or case manager about insurance that you have. Apply for benefits for which you maybe eligible through your additional insurance.••Give your doctor all the facts about your health problems. This includes past illnesses, hospital stays, allmedications, shots and other health concerns. Let your doctor and/or your case manager know about anychanges in your health condition.••Notify Mercy Care Plan any time you feel a provider or another member is not using health plan benefitscorrectly.••Report changes that could affect your eligibility such as address, phone number and/or assets to yourcase manager and/or to the office where you applied for AHCCCS eligibility.INTRODUCTIONFollow Instructions••Know the name of your assigned PCP and your case manager.••Follow the treatment instructions that you and your PCP have agreed on, including the instructions fromnurses 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 (instead of using urgent or emergency care.)••Keep appointments. Go to your appointments on time. Call your doctor’s office ahead of time when youcannot keep your appointment.MEMBER IDENTIFICATION (ID) CARDWhen you become a member of Mercy Care Plan, Mercy Care Plan will send you a new ID card. Your card willhave your name and ID number. If you do not get or lose your ID card, call Mercy Care Plan Member Services.Be sure to carry your ID card with you and show it every time you get health care services. Protect your ID card.Do not give it to anyone except those giving health care services to you. If you loan, sell or give your ID card toanyone else, you may lose your ALTCS eligibility and/or legal action may be taken.If you have an Arizona driver’s license or state issued ID, AHCCCS will get your picture from the ArizonaDepartment of Transportation Motor Vehicle Division. When providers pull up the AHCCCS eligibility verificationscreen, they will see your picture (if available) with your coverage details.11

CASE MANAGEMENT SERVICESWhen you become a member of Mercy Care Plan Long Term Care, you are assigned a case manager. You willcontinue to receive case management services for as long as you remain on the ALTCS program. Your casemanager will work with you, your guardian or designee, and your PCP to assess your needs.If you live in your own home or in an Alternative Residential Setting, your Case Manager will visit you faceto face every 3 months. If you live in a Nursing Home, your Case Manager will visit you face to face every 6months.At each visit, your Case Manager will complete “Assessment Tools.” These tools help learn more about you. YourCase Manager will ask about your strengths; what you can do to take care of yourself; and areas in which youneed help. The Case Manager will work with you and your family to help decide which services will best meetyour needs.COVERED SERVICESIf you do not know:••your case manager’s name••how to contact your case manager between scheduled visitsCall Mercy Care Plan Member Services. They will be able to help you.Long Term Care and Medical Covered Services and BenefitsYour PCP and case manager will help you get the health care and long-term care services you need. Below is a listof covered services. 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 servicesare covered.Long Term Care Services1. Nursing homes2. 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• Personal care• Respite and group respite care• Self-Directed Attendant Care• Hospice Care12

Long Term Care Member Handbook 2012-20133. 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 homesMedical Services1. Hospital care2. Diabetes Care ‐ including A/C and LDL, and eye exam for diabetes related care3. Flu shot ‐ no cost service4. Doctor office visits, including specialists5. Health risk assessments and screening6. Nutritional assessments7. Laboratory and X-ray8. Durable medical equipment and supplies9. Medications on Mercy Care Plan’s list of covered medicines. Members with Medicare will receive their medications fromMedicare Part D.10. Emergency care11. Care to stabilize you after an emergency12. Rehabilitation services, including occupational, speech, physical and respiratory therapy. (Limitations apply)13. Routine immunizations14. Kidney dialysis15. Maternity care (prenatal, labor and delivery, postpartum)16. Family planning services17. Behavioral health services and settings18. Medically necessary transportation to and from required medical services; emergency transportation19. Outpatient surgery and anesthesia20. Audiology services21. Medical foods, with limitations22. Urgent Care23. Limited Visions Services, for members over 21 years of age, includes emergency eye care and somemedically necessary vision services such as cataract removal. Members with diabetes should see anophthalmologist yearly for a retinal exam.24. Treatment of sexually transmitted diseasesCOVERED SERVICES13

Additional Services for Children (under 21)1. Routine preventive dental services, including oral health screenings, cleanings, fluoride treatments, dentalsealants, oral hygiene education, X-rays, fillings, extractions and other medically necessary procedure andtherapeutic and emergency dental services.2. Vision services, including exams and prescriptive lenses3. EPSDT visits (same as wellness visits) ‐ include Regular checkups and immunizations4. Chiropractic services5. Children’s Rehabilitative Services6. Conscious sedation7. Incontinence briefs, with limitations8. Additional Services for Qualified Medicare Beneficiaries (QMBs)9. Chiropractic services10. Any service covered by Medicare but not by AHCCCSCOVERED SERVICESLong Term Care and Medical Covered Services and Benefits Not coveredBelow is a list of services that are not covered.* Please call your case manager if you need help finding communityresources in your area for services that are not covered.These services are not covered for All Members*This list is not all inclusive1. Services from a provider who is NOT a Mercy Care Plan provider (unless approved before the visit by MercyCare)2. Cosmetic services or items3. Personal comfort items4. Any service that requires authorization prior to getting the service and did get authorized5. Services or items given free of charge, or for which charges are not usually made6. Services of special duty nurses, unless medically necessary and authorized prior to receiving7. Physical therapy that is not medically necessary8. Routine circumcisions9. Experimental services as determined by the health plan medical director10. 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 mother11. Health services when you are in prison or in a facility for the treatment of tuberculosis12. Experimental organ transplants13. Sex change operations and reversal of voluntary sterilization14. Drugs and supplies without a prescription15. Treatment to straighten teeth, unless medically necessary16. Prescriptions not on our list of covered medications, unless approved by Mercy Care Plan17. Incontinence briefs solely for personal hygiene14

Long Term Care Member Handbook 2012-2013Limited and Excluded Benefits/Services: for Members 21 years or olderThe following services are not covered for adults 21 years and older. (If you are a Qualified Medicare Beneficiary,we will continue to pay your Medicare deductible and coinsurance for these services.)BENEFIT/ SERVICE SERVICE DESCRIPTION SERVICE EXCLUSIONS OR LIMITATIONSChiropracticservicesHands on therapy forspinal manipulation oradjustmentExcluded except for QMB membersInsulin PumpsPercussive VestsBone-AnchoredHearing AidCochlear ImplantLower limbMicroprocessorcontrolled joint/ProstheticOrthoticsDental andEmergency DentalServiceA machine that is worn togive insulin through the dayto a person as neededThis vest is placed on aperson's chest and shakesto loosen mucous.A hearing aid that is put ona person's bone near theear by surgery. This is tocarry sound.A small device that is put ina person's ear by surgery tohelp he/she hear better.A device that replaces amissing part of the bodyand uses a computer tohelp with the moving of thejoint.A support or brace forweak joints or muscles. Anorthotic can also support adeformed part of the body.Emergency services arethose times that you needfor care immediately like abad infection in your mouthor pain in your teeth or jaw.AHCCCS will not pay for insulin pumps. Supplies, equipmentmaintenance (care of the pump) and repair of pump parts willbe paid for.AHCCCS will not pay for percussive vests. Supplies, equipmentmaintenance (care of the vest) and repair of the vest will bepaid for.AHCCCS will not pay for Bone-Anchored Hearing AID (BAHA).Supplies, equipment maintenance (care if the hearing aid) andrepair of any parts will be paid for.AHCCCS will not pay for cochlear implants. Supplies,equipment maintenance (care of the implant) and repair of anyparts will be paid for.AHCCCS will not pay for a lower limb (leg, knee or foot)prosthetic that includes a microprocessor (computer chip) thatcontrols the joint.AHCCCS will no longer pay for orthotics. Supplies, equipmentmaintenance and repair of component parts will be paid for.Orthotics means items like leg braces, wrist splints and neckbraces. Maintenance (care of existing orthotics) and repair ofparts will still be paid for.AHCCCS will not cover dental services (including emergencydental services) unless the care needed is a medical or surgicalservice related to dental (oral) care. Covered dental servicesfor members 21 years of age and older must be related tothe treatment of a medical condition such as acute pain,infection, or fracture of the jaw. Covered dental servicesinclude examining the mouth, x-rays, care of fractures of thejaw or mouth, giving anesthesia, and pain medication and / orantibiotics.Certain pre-transplant services and prophylactic extraction ofteeth in preparation for radiation treatment of cancer of thejaw, neck or head are also covered.COVERED SERVICES15

COVERED SERVICESBENEFIT/ SERVICE SERVICE DESCRIPTION SERVICE EXCLUSIONS OR LIMITATIONSServices byPodiatristWell ExamsTransplantsPhysical TherapyInpatient hospitalday limitVision ServicesRespite CareAny service that is done bya doctor who treats feetand ankle problems.Well exams are defined asa doctor visit for a checkupand not during a time ofillness.A transplant is defined asthe transfer of an organ orblood cells from one personto another.Exercises taught orprovided by a PhysicalTherapist to make youstronger or help improvemovement.There is a 25-day inpatienthospital limit for adultsaged 21 years or olderwithin a 12-month period.Routine, emergency andmedically necessary visionservicesRespite care is offeredas a temporary break forcaregivers to take time forthemselves.AHCCCS will not pay for services provided by a podiatrist orpodiatric surgeon for adults. Contact your health plan for othercontracted providers who can perform medically necessaryfoot and ankle procedures, including reconstructive surgeries.Well visits are not covered for individuals 21 years of ageor older. Well visits are when a person goes to the doctor’soffice for a routine checkup. These exams are consideredpreventative in nature.Approval is based on the medical need and if the transplantis on the “covered” list. Only transplants listed by AHCCCS ascovered will be paid for.Outpatient physical therapy visits are limited to 15 visits percontract year (10/1--9/30). The member who has Medicareshould talk to the health plan for help in determining how thevisits will be counted.The 12 months will run from October 1 through September 30of the next year. AHCCCS will no longer pay for hospital stayspast the 25th day. Some exceptions apply.Coverage for members 21 years of age and over includesemergency and some medically necessary services such ascataract removal. Members with diabetes should see anophthalmologist yearly for a retinal exam.Respite Care hour limit for both adults and children receivingALTCS benefits or behavioral health services. The number ofrespite hours available to adults and children receiving ALTCSbenefits or behavioral health services is 600 hours within a12-month period. The 12 months will run from October 1through September 30 of the next year.HOME AND COMMUNITY BASED SERVICESHome and community based services support you in keeping your independence and living in your own homeor a community setting. Your case manager will work with you, your family or guardian, and PCP to find theright kinds of services and amount and length of those services that are just right for you. These are based onAHCCCS rules and policies. Not all services will be right for you. Once these services are decided, your casemanager will approve and arrange them for you.If you receive attendant care, personal care, homemaker or respite services, your case manager will completea back-up plan with you. This plan will list the names and numbers of people and agencies to call when yourcaregiver does not come as scheduled. You must choose how soon someone is needed in your home to helpyou.16

Long Term Care Member Handbook 2012-2013Services may include:••Adult Day Health Care ‐ health care and personal services that you get in an adult day center. Meals, healthchecks and therapies may also be offered.••Attendant Care Services ‐ a trained person from a certified caregiver agency comes into your home to helpyou with a combination of services such as personal care, housekeeping and meal preparation.••Community Transition Program ‐ this service provides financial assistance to members moving from anursing home to a home in the community. Ask your case manager to explain the AHCCCS rules for thisservice.••Emergency Alert System ‐ equipment that allows you 24-hour access to emergency help when you need it.••Habilitation ‐ this service provides training in independent living skills. Speech, occupational or physicaltherapy may be provided as part of this service. This includes habilitation services such as Day Treatmentand 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 beinghospitalized 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.••Home Modification ‐ this service makes adaptive changes to your home to increase your independence.••Hospice Care ‐ services that help members who need health care and emotional support during the finalstages of life.••Personal Care ‐ this service offers help with eating, bathing and dressing.••Private Duty Nursing ‐ nursing services for members who need more individual and continuous care.••Respite ‐ this service provides personal care to give your unpaid family caregiver a rest. This service can beprovided in your home, assisted living facility or skilled nursing home. Spouse Attendant Care ‐ your spousecan become your paid attendant caregiver while you are living at home. State guidelines must be followed.Speak to your case manager if you are interested in this service.COVERED SERVICESMember-Directed Care OptionsMember directed allow members to have more control over how certain services are provided, includingservices like attendant care, personal care and housekeeping. The models are not a service, but rather definethe way in which services are delivered. Member-directed options are available to most Arizona Long Term CareSystem (ALTCS) members who live in their own home. The options are not available to members who live in analternative residential setting or nursing facility. ALTCS members or their representatives are encouraged tocontact their case manager to learn more about and consider member-directed options:••Self-Directed Attendant Care (SDAC) ‐ this is a service delivery option for members who want to be incharge of their attendant caregiver service. Member’s using this service will hire/fire, train, and be in chargeof his or her own caregivers. Members have more control and responsibilities in this service delivery option.They can hire anyone that has the basic skills needed, give work, and make schedules within the weeklyhours, which are determined by meeting with the Case Manager.••Skilled Self-Directed Attendant Care ‐ this option is for members that have a self-directed attendant andwant this attendant to be trained on specific skilled services such as bowel care or giving insulin shots. Yourcase manager can tell you the skilled services, which are included in this program.17

ALTERNATIVE LIVING SETTINGSBesides your own home, ALTCS offers other types of living arrangements for members. These types of settingsprovide supervisory services, personal care or directed care, and are licensed or certified. Members are requiredto pay a Room and Board fee for these settings. Your case manager will let you know what you need to pay.COVERED SERVICES••Adult Foster Care ‐ this setting (for up to four (4) residents) provides special care for you when you are livingin a licensed foster care home.••Assisted Living Home ‐ this setting provides care and supervision for up to ten people.••Assisted Living Center- this setting provides apartments and includes a private sleeping area, kitchen andbathroom areas. Other services are provided as needed.••Alzheimer’s Treatment Assistive Living Facility ‐ these settings provide special care and services to memberswith Alzheimer’s disease.••Behavioral Health Level II and III ‐ these settings provide behavioral health treatment with 24-hoursupervision. They may include on site medical services and intensive behavioral health treatment programs.••Therapeutic Home Care ‐ Adult ‐ provides behavioral health and additional services for at least one and upto three people. Child ‐ licensed by DES as a professional foster care home.••Traumatic Brain Injury Treatment Facility ‐ this setting provides treatment and services for people withtraumatic brain injuries.••Rural Substance Abuse Transitional Agency ‐ an agency providing behavioral health services.TRANSITIONAL PROGRAMThis program is for members who have improved to the point where they do not need institutional care butwho still need many long-term care services. Home-and-community-based placements are arranged for thesemembers.Members in the transitional program may not remain in a skilled nursing home longer than 90 consecutive days.AHCCCS ALTCS eligibility workers place members on and take them off the transitional program after evaluatingthe member’s current functional and medical status.NURSING HOME CARENursing 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 servicesor several levels of care for special needs.PHARMACY SERVICESIf you need medicine, your doctor will choose one from Mercy Care Plan’s list/ of covered drugs directory(called Formulary) and write you a prescription. Mercy Care Plan directory of covered medicines is reviewedand updated regularly by doctors to make sure you receive safe, effective medicines. Some over-the-countermedicines are covered when your PCP orders themIf you want a copy of the list, call Member Services or go to our Web site at www.MercyCarePlan.com for themost up-to-date list.If the medicine is not on the list of covered drugs and you cannot take any other medicines except the oneprescribed, your doctor may ask Mercy Care Plan to make an exception. If you have Medicare, you will need topay the designated co-pay for each of your prescriptions.18

Long Term Care Member Handbook 2012-2013If you have other insurance (not Medicare), Mercy Care Plan will pay the copays only if the drug is also on theMercy Care Plan drug list. The pharmacy should process the prescriptions through Mercy Care Plan. Do not payany copayments yourself. Mercy Care Plan may not be able to pay you back.PharmaciesAll prescriptions must be filled at a pharmacy in Mercy Care Plan’s network. You can find a list of pharmacies inthe MCP Provider Directory or our website at www.MercyCarePlan.com and select “Find a Pharmacy.”If you need pharmacy services after hours, on weekends or holiday, many pharmacies are open 24 hours, 7 daysa week. Look in your Provider Directory or online to find 24 hour, 7 days a week pharmacies.What You Need to Know About Your PrescriptionYour doctor or dentist may give you a prescription for medication. If you live in a nursing home or assisted livingfacility staff will take care of managing your medications for you and getting refills.Be sure to let the staff know about any medications you get from another doctor or non-prescription or herbalmedications that you buy. Before you leave the office, ask these questions:••Why am I taking this medication? What is it supposed to do for me?••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?••What will happen if I do not take this medication?Carefully read the drug information from the pharmacy. It has information on things you should and should notdo and possible side effects of the medication. If you have questions, please ask your pharmacist.RefillsIf you live in a nursing home or assisted living facility, the staff will take care of managing your medications foryou and getting refills. The label on your medication bottle tells you the number of refills your PCP has orderedfor you. If your doctor has ordered refills, you may only get refills one at a time for each prescription.COVERED SERVICESIf your doctor has not ordered refills for you, be sure to call them at least five (5) days before your medicine runsout and talk to them about getting a refill. Your PCP may want to see you before giving you a refill.Mail Order PrescriptionsIf you take medicine for an ongoing health condition, you can have your medicines mailed to your home. MercyCare Plan works with a company to give you this service. You can get mail order prescription service at no costto you.If you choose this option, your medicine comes right to your door and you can schedule your refill. Here aresome other features of home delivery.••Pharmacists check each order for safety.••You can order refills by mail, by phone, online, or you can sign up for automatic refills.••You can talk with pharmacists by phone at any time ‐ 24 hours a day, 7 days a week.If you are interested in ordering by using the mail order process, ask your case manager for help.19

Diabetes Testing SuppliesIf you have diabetes, Mercy Care covers certain blood glucose meters and test strips. Please see Mercy CarePlan’s drug list (Formulary) for a list of covered meters and test strips. If you need a meter and test strips, askyour doctor to write a prescription for you. You can pick up your meter and test strips at a pharmacy listed inyour Mercy Care Plan Provider Directory.PAYMENT FOR DRUGSAHCCCS covers drugs, which are medically necessary, cost effective, and allowed by federal and state law.COVERED SERVICES••For AHCCCS recipients with Medicare, AHCCCS does NOT pay for any drugs paid by Medicare or for thecost-sharing (coinsurance, deductibles, and copayments) for these drugs. AHCCCS and its Contractorsare prohibited from paying for these medications or the cost-sharing (coinsurance, deductibles, andcopayments) for drugs available through Medicare Part D even if the member chooses not to enroll in thePart D plan.••Beginning January 1, 2013 AHCCCS will no longer pay for barbiturates to treat epilepsy, cancer, or mentalhealth problems or any benzodiazepines for members with Medicare.••This is because federal law requires Medicare to begin paying for these drugs starting January 1, 2013. Someof the common names for benzodiazepines and barbiturates are:Generic NameBrand NameAlprazolamXanaxDiazepamValiumLorazepamAtivanClorazepate DipotassiumTranxeneChlordiazepoxide Hydrochloride LibriumClonazepamKlonopinOxazepamSeraxTemazepamRestorilFlurazepamDalmanePhenobarbitalPhenobarbitalMebaralMephobarbital••AHCCCS will still pay for barbiturates that are NOT used to treat epilepsy, cancer, or mental health problemsfor Medicare members even if it is after January 1, 2013.••For information about copayments for drugs that are covered by AHCCCS, please read the section aboutcopayments.DURABLE MEDICAL EQUIPMENT (DME)Members can get medically necessary Durable Medical Equipment (DME). Medically necessary DME may beprovided to Mercy Care Plan members living in or being discharged to home and community based settings.DME is ordered by the Primary Care Provider. Case managers may assist in coordinating this process.Skilled Nursing Facilities (SNF) are required to provide non-customized DME to members while residing in SNF’s.20

Long Term Care Member Handbook 2012-2013Medically necessary customized equipment and specialty beds may be provided to members by Mercy CarePlan. A Customized DME is medical equipment that is made special for one member and cannot be used byother members.BEHAVIORAL HEALTH SERVICESBehavioral health services may help you with personal problems that may affect you and your family. Someproblems may be from depression, anxiety or using drugs or alcohol. Some services may be provided in yourhome, nursing home or assisted living facility. Mercy Care has a Behavioral Health Coordinator who helps casemanagers in providing needed behavioral health services for our members.Covered behavioral health services include:••Behavior management (personal care, family support/home care training, peer support)••Behavioral health case management services (with limitations)••Behavioral health nursing services••Emergency behavioral health care••Emergency and non-emergency transportation••Evaluation and assessment••Individual, group and family therapy and counseling••Inpatient hospital services••Non-hospital inpatient psychiatric facilities (Level 1 residential treatment centers and sub-acute facilities)••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)••Psychotropic medication••Psychotropic medication adjustment and monitoring••Respite care (with limitations)••Rural substance abuse transitional agency services••Screening••Home care training to home care clientCOVERED SERVICESHow to Get Behavioral Health ServicesYou do not need a referral from your doctor for behavioral health services. Call your case manager to discussyour behavioral health service need and s/he will assist you in obtaining services. If you need a ride to anappointment, call Member Services.Behavioral Health EmergenciesIf you think you might hurt yourself or someone else, please call 911. You can also call our crisis line if you have abehavioral health crisis.Mercy Care Plan Behavioral Health Crisis Line 1-800-876-583521

DISEASE MANAGEMENTMercy Care Plan has special programs available to members with the following conditions:••Asthma;••Congestive Heart Failure (CHF);••Chronic Obstructive Pulmonary Disease (COPD); and/or••DiabetesThe disease management program is an optional part of your regular benefits and provided at no cost to you. Ifyou enroll in one of these programs, our nurses will work with you and your doctor to give you more informationon what your condition means to your everyday life, the names and contact numbers for resources in yourcommunity that can help manage your illness, and to put together a care plan to help you meet your goal offeeling better.COVERED SERVICESIf you would like more information about these programs, call us at 1-866-642-1579/TTY 602-659-1144between 6:00 a.m. and 8:00 p.m. Arizona TimeEPSDT/CHILDREN’S SERVICES(Same as Wellness Visit)Early Periodic Screening, Diagnostic and Treatment (EPSDT) is a comprehensive child health program ofprevention and treatment, correction, and improvement (amelioration) of physical and mental health problemsfor AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and accessibilityof health care resources, as well as to assist Medicaid recipients in effectively utilizing these resources. EPSDTservices provide comprehensive health care through primary prevention, early intervention, diagnosis,medically necessary treatment, and follow-up care of physical and behavioral health problems for AHCCCSmembers less than 21 years of age. EPSDT services include screening services, vision services, dental services,hearing services and all other medically necessary mandatory and optional services listed in federal law 42USC 1396d (a) to correct or ameliorate defects and physical and mental illnesses and conditions identified inan EPSDT screening whether or not the services are covered under the AHCCCS state plan. Limitations andexclusions, other than the requirement for medical necessity and cost effectiveness do not apply to EPSDTservices.A well child visit is synonymous with an EPSDT visit and includes all screenings and services described in theAHCCCS EPSDT and dental periodicity schedules.Amount, Duration and Scope: The Medicaid Act defines EPSDT services to include screening services, visionservices, dental services, hearing services and “such other necessary health care, diagnostic services, treatmentand other measures described in federal law subsection 42 USC 1396d (a) to correct or ameliorate defects andphysical and mental illnesses and conditions discovered by the screening services, whether or not such servicesare covered under the (AHCCCS) state plan.” This means that EPSDT covered services include services thatcorrect or ameliorate physical and mental defects, conditions, and illnesses discovered by the screening processwhen those services fall within one of the 28 optional and mandatory categories of “medical assistance” asdefined in the Medicaid Act. Services covered under EPSDT include all 28 categories of services in the federallaw even when they are not listed as covered services in the AHCCCS state plan, AHCCCS statutes, rules, orpolicies as long as the services are medically necessary and cost effective.22

Long Term Care Member Handbook 2012-2013EPSDT includes, but is not limited to, coverage of: inpatient and outpatient hospital services, laboratory andx-ray services, physician services, nurse practitioner services, medications, dental services, therapy services,behavioral health services, medical supplies, prosthetic devices, eyeglasses, transportation, and family planningservices. EPSDT also includes diagnostic, screening, preventive and rehabilitative services. However, EPSDTservices do not include services that are solely for cosmetic purposes, or that are not cost effective whencompared to other interventions.WOMEN’S SERVICESWell-Woman ExamFemale members, 21 years of age and over, have direct access to a gynecologist within the Mercy Care Plan’snetwork without a referral from a primary care provider. A well woman exam is not a covered benefit formembers 21 years of age and over. However, preventative screening services are a covered benefit.Female members under the age of 21 years, have direct access to preventive and well care services from agynecologist in Mercy Care Plan’s network without a referral from a primary care provider.Preventative Screening ServicesPreventative screening services include, but are not limited to, cervical cancer screening, pap smear,mammograms, colorectal cancer, and screening for sexually transmitted infections.Pap ScreeningA Pap test is recommended every one to three (1-3) years for women who are sexually active or who are 21years old and older. Mercy Care Plan members can see their PCP or a Mercy Care Plan obstetrician/gynecologist(OB/GYN) for a Pap test. If you want to see an OB/GYN doctor, you do not need to see or ask your PCP first. Youcan find OB/GYN doctors in your Provider Directory or by visiting www.MercyCarePlan.com.COVERED SERVICESMammogramMercy Care Plan recommends a mammogram every one to two (1-2) years for women age 40 and over. You cancall your doctor for a mammogram order. You can then schedule your mammogram with the radiology facility.You can find a list of radiology facilities in your area in the Provider Directory or by visiting www.MercyCarePlan.comPregnancyPregnant women may go directly to an OB/GYN who is in Mercy Care Plan’s network. A pregnant woman doesnot have to go to the PCP before visiting the OB/GYN.Prenatal HIV/AIDS Testing: If you are pregnant, you will have a complete checkup at your first doctor’s visit.The doctor or nurse will check for infections and sexually transmitted diseases. Voluntary, confidential HIV/AIDStesting services are available, as well as counseling for members who test positive.Postpartum Visits: After a woman delivers her baby, it is important to see their OB/GYN for a postpartum visit.These should be scheduled within 60 days after the delivery of the baby.23

FAMILY PLANNING SERVICESFamily Planning Services are administered by Schaller Anderson, an Aetna Company. These services arecovered at no cost and are available to men and women.Talk to your PCP if you need help with family planning. Covered services include:COVERED SERVICES••Contraceptive counseling••Pills••Depo Provera••IUD (Intra-uterine devices)••Diaphragms••Condoms••Foams and suppositories••Male and female sterilization (members must be 21 or older to have tubal ligations and vasectomies).••Natural family planning••Post coital emergency oral contraception ‐ no prior authorization is required••Medical and lab exams, including ultrasounds related to family planning••Treatment of complications resulting from contraceptive use••Hysteroscopic tubal sterilizationThe following are NOT covered family planning services:••Infertility services, including diagnostic testing, treatment or reversal of surgical infertility••Pregnancy termination counseling••Pregnancy terminations and hysterectomiesWIC (Women, Infants and Children: A resource for youWIC (Women, Infants and Children) is a community resource available to pregnant women, infants and childrenunder five years of age. This group provides food, breast feeding education, and information on healthy dietinformation. For more information on WIC, refer to the “Community Resources” section at the back of this bookor call Mercy Care Plan Member Services.TOBACCO CESSATIONThe Tobacco Education and Prevention Program (TEPP) can help people stop using tobacco. Many people havequit smoking through programs offered by the Arizona Smokers Helpline (ASHLine). The ASHLine has severalvaluable and free resources. If you want more information to help quit tobacco, please call the Arizona SmokersHelpline (ASH) at (800) 556-6222 or visit www.ashline.org or talk to your PCP. Ashline also offers information tohelp protect you and your loved ones from secondhand smoke.TRANSPORTATION (RIDES) SERVICESIf necessary, Mercy Care Plan can help you get to your covered health care visits. If you live in a nursing home orassisted living facility, staff will arrange a ride for you and, if needed, an ambulance.If you live at home or in another community setting, it is important for you to find out first if a relative, friend orneighbor can give you a ride. If you can ride the bus, we will send you bus tickets or passes at no cost to you.24

Long Term Care Member Handbook 2012-2013How to Get a RideYou must call at least three (3) days in advance to get a ride. If you call the same day, we will not be able toarrange a ride for you in time, unless it is urgent. You may have to reschedule your appointment.If you have, many appointments scheduled, or if you have regular appointments for visits like dialysis, MercyCare Plan can set up all rides at one time.After your appointment, call your transportation provider to arrange a pick-up time.Dos and Don’ts for Getting a RideThings to do (Do’s)••DO call Mercy Care Plan as soon as you make yourappointment.••DO call Mercy Care Plan at least three (3) hoursbefore an appointment that you made on thesame day for urgent care.••DO let us know if you have special needs, like awheelchair or oxygen.••DO make sure your prescription is ready for pickup before calling for a ride.Things not to do (Don’ts)••DO NOT schedule a ride with Mercy Care Plan ifyou are not going to be at your pick-up place.••DO NOT be late for your pick-up time.••DO NOT forget to call Mercy Care Plan to cancelyour ride if you find another one or if you changeyour appointment.••DO NOT wait until the day of your appointment tocall for a ride. We will not be able to set up a ride.If you have a medical emergency, dial 911. Use of emergency transportation must be for emergencies only.COVERED SERVICES25

PRIMARY CARE PHYSICIAN (PCP)HOW TO GET SERVICESWhen you sign up for Mercy Care Plan, you are asked to select a Primary Care Physician from Mercy Care Plan’sProvider Directory. Select a doctor in the area close to your home. If you do not select a PCP, Mercy Care will selectone for you. The name of your PCP can be found in your welcome packet and on your Member ID card.If you live in a nursing home, a doctor from Mercy Care Plan’s network will come to where you live to see and carefor you. . If you live in a nursing home, the staff will tell you of your PCP visit. They will call your doctor if there are anychanges in your health.In some cases, when medically necessary, your PCP may visit you in your own home or alternative residential setting.If you live at home or in an alternative residential setting, you, your family, guardian or caregiver can call your PCP tomake an appointment.We hope that you will stay with your assigned PCP so that you can work with someone who you know and knowsyou well. If you want to change doctors, we encourage you to talk with your PCP and Case Manager first and letthem know why you would like to change. You may be able to work together to solve your problem or they may beable to suggest another provider to you. We do understand that you may wish to change doctors for reasons suchas:••You and your doctor don’t seem to understand each other••You aren’t comfortable talking with your doctor openly••Your doctor’s office is too far from homeHOW TO GET SERVICESIf you need or want to change your PCP, you should contact your case manager. S/he will help you make the change.The change will be effective on the first day of the month AFTER you call.You will get a letter in the mail to let you know the name and address of your new doctor. If you request three (3) ormore PCP changes while you are with Mercy Care Plan, our Member Services representatives will try and work withyou and your doctor before making another change.You will need to schedule a visit with your assigned PCP soon after enrollment. You will want to start a relationshipwith him/her. Your PCP can screen you to find out your health care needs. When you contact your doctor’s office tomake your appointment, ask the following questions. These questions will help prepare you for future visits.Questions to ask when making your PCP office visitYou can write the answers here, if you choose, so that they are handy when you need them:••What are your office hours?••Do you see patients on the weekends or at night?••Will you talk to me about my problems over the phone?••Is there anyone else that works with you that can help me if you are not available?••Who should I contact if you are closed and I have an urgent situation?••How long do I have to wait for an appointment?If you cannot make it to your appointment, please call your PCP’s office before the appointment timeto cancel.26

Long Term Care Member Handbook 2012-2013If you are going to your PCP or dentist for the first time, please get there at least 15 minutes early. They will need toget your information to start your health record. Show your member ID card to the office staff as soon as you arrive‐ before the doctor sees you. If you do not have your ID card, your will still see you. You may need to show a currentpicture 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 behindschedule. When this happens, you may have to wait a little longer to be seen. If you usually have to wait more than45 minutes for scheduled appointments, please notify Mercy Care Plan Member Services.QUICK TIPS ABOUT APPOINTMENTS••If you are seeing your PCP for the first time, call your PCP’s office first to makesure they are accepting new patients and to verify their address.••Call your PCP early in the day to make an appointment.••Tell the staff person your symptoms.••Take your member ID card with you.••If you are a new patient, go to your appointment 15 minutes early.••Let the office know when you arrive and show them your ID card.Make the most of your doctor’s visit with “Ask Me 3”Ask Me 3 is a quick, effective, tool that was created to help you talk to your health care provider and betterunderstand your health care needs. Every time you talk to your doctor or pharmacist, use the questions shownbelow. Everyone needs help understanding medical information. Asking these questions will help you get better orstay well. Take a pen and paper when you go to the doctor to write down the answers to these questions:1. What is my main problem?2. What do I need to do?3. Why is it important that I do these things?Patient-centered medical home (PCMH)Would you like to have some help in planning and coordinating your health care needs?For most people getting their health care needs or their family member’s needs taken care of can be hard tomanage. This can be especially difficult when you are helping a close family member. Mercy Care Plan understandsthis and offers a type of care that might be right for you.Mercy Care Plan is providing a new way to deliver and coordinate your health care through providers who are usingthe Patient-Centered Medical Home (PCMH) care model. This model focuses on you working with a health careteam. And, YOU are the most important person on the health care team!Together with your health care team, your primary care is planned and coordinated for you! Go towww.MercyCarePlan.com to:••Get more information on why the PCMH model might be right for you••See a list of provider groups participating in PCMHHOW TO GET SERVICESTo find out more about how to participate in a PCMH, please call Mercy Care Plan Member Services.27

TYPES OF CAREThere are three different kinds of care you can get: Routine, Urgent and Emergency.The chart below gives you examples of each type of care and tells you what to do. Always check with your doctor ifyou have questions about your care.Type of CareRoutine ‐ This is regular care to keep you healthy. Forexample:••Checkups (Wellness exams ‐ EPSDT ‐ are coveredfor individuals under the age of 21)••Yearly exams••ImmunizationsWhat to DoCall your doctor to make an appointment for preventivecare. You can expect to be seen by:••Your PCP within 21 days••A specialist within 45 day••A dentist within 45 daysHOW TO GET SERVICESUrgent/Sick Visit ‐ This is when you need care rightaway but you are not in danger of lasting harm or oflosing your life. For example:••Sore throat••Flu••A cut that may need stitches••MigrainesCall your doctor before going to an urgent care center.You can expect to be seen by:••Your PCP within two (2) days••A specialist or dentist within three (3) daysIf it is late at night or on the weekends, your doctor hasan answering service that will get your message to yourdoctor. Your doctor will call you back and tell you whatto do.You should NOT go to the emergency room for urgent/sick care.28

Long Term Care Member Handbook 2012-2013Type of CareEmergency ‐ This is when you have a serious medicalcondition and are in danger of lasting harm or theloss of your life if you do not get help right away. Forexample:••Poisoning••Sudden chest pains ‐ heart attack••Car accident••Convulsions••Very bad bleeding, especially if you are pregnant••Broken bones••Serious burns••Trouble breathing••OverdoseWhat to DoWhat is Not an Emergency?Some medical conditions that are NOT usuallyemergencies:••Flu, colds, sore throats, earaches••Urinary tract infections••Prescription refills or requests••Health conditions that you have had for a longtime••Back strain••Migraine headachesAFTER-HOURS CAREExcept in an emergency, if you or your child get sick when the doctor’s office is closed or on a weekend, youshould still call the office. An answering service will make sure your doctor gets your message. Your PCP will callyou back and tell you what to do. Be sure your phone accepts blocked calls. Otherwise, the doctor may not beable 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 theanswering service. It may take a while for them to get back to you, but a doctor will call you back to tell you whatto do.HOW TO GET SERVICESIf you live in Maricopa, Pima, or Yuma County, you can also go to an Urgent Care Center if you have an urgentproblem and your doctor cannot see you right away. Look in the Mercy Care Plan Provider Directory or theMercy Care Plan website at www.MercyCarePlan.com. Look for a center close to your home.You should NOT go to the Emergency Room for Urgent/Sick Care.29

Long Term Care Member Handbook 2012-2013Routine ‐ your physician would like a more thorough examination from a specialist or a special testwithin the next few weeks. You will receive a written notification (Notice of Action) within fourteen (14)days telling you whether we can approve the request and what to do next.Sometimes, we will need more information in order to make our decision. If this is the case, we may need toask your doctor for an extension of up to fourteen (14) days. If we ask for an extension, we will let you and yourdoctor know what it is that we need to help us decide. If we do not receive the additional information within thefourteen (14) day period, we may deny the request for Prior Authorization.If we ask for an extension or change the urgency level of your request, you may file what is called a Grievance(see Grievances in this handbook). Please send your grievances to:Mercy Care Plan4350 E. Cotton Center BlvdBuilding DPhoenix, AZ 85040How do we make our decision about your request?We provide a listing of services that require Prior Authorization on our website (http://MercyCarePlan.com) andin the Provider Manual. You have the right to review this listing and to see how we make our decisions. Our PriorAuthorization decisions are based on Practice Guidelines and Clinical Criteria that are found on the internet.(http://www.guideline.gov)Actions that might be taken on your requestAn action by Mercy Care Plan means:••The denial or limited authorization of a service you or your doctor has asked for••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 onlyhealth plan in the area••The reduction, suspension or ending of an existing serviceRequired NOTICE OF ACTIONs (NOA)When a service that you are already receiving or have requested cannot be approved, we will send you andyour physician a written notification called a Notice of Action. There are specific time-frames for when you willreceive a Notice of Action.••If you or your doctor makes a request for a new service, you will receive your notification within 30 days (ifurgent, you will receive the notification in 3 days).••If a service that you are already receiving is reduced, suspended, or ended, you will receive a Notice of Actionten (10) days before the change occurs.HOW TO GET SERVICESThe NOA letter lets you know:••What action was taken and the reason••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 topay the costs for the services31

••You have the right to request an extension to give us information to help us make a decision••If you receive a Notice of Action letter, that does not tell you what you asked for, what we decided and why,you can call us.––We will look at the letter and, if needed, write a new letter that better explains the services and the action––If you still do not understand the NOA letter, you have the right to contact AHCCCSYou have the right to receive a reply from Mercy Care Plan within 30 days to your request for a copy of therecords. The response may be the copy of the record or a written denial that includes the basis for the denialand information about how to seek review of the denial. You can also ask Mercy Care plan to tell you or send toyou in the mail how decisions are made. This will also tell you what the decision is based on.If you disagree with our decision (Appeal)If you disagree with Mercy Care Plan’s action about your health care services, you may file an appeal either inwriting or over the phone. If you need an interpreter, one will be provided. Mercy Care Plan cannot retaliateagainst you or your provider for filing an appeal.You, your representative or a provider acting with your written permission may file an appeal within 60 daysfrom 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 PlanAppeals Department4350 E. Cotton CenterBldg. DPhoenix, AZ 85040602-453-6098 or 1-800-624-3879Fax: (602) 230-4503HOW TO GET SERVICESWhen Mercy Care Plan gets your appeal, we will send you a letter within five (5) days. The letter will explain thatwe have received your appeal and tell you how to give us more information either in person or in writing. If youwish services to continue while your appeal is reviewed, you must file your appeal no later than 10 days fromthe date of Mercy Care Plan’s Notice of Action letter to you.The Appeals Department will review your appeal and send a decision in writing to you within 30 days. Theletter will tell you what Mercy Care Plan’s decision and the reason for the decision. If Mercy Care Plan deniesyour appeal, you may then request that AHCCCS look at our decision. You can request a State Fair Hearing withAHCCCS 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 willforward its file and documentation to AHCCCS at the Office of Administrative Legal Services.If after the hearing AHCCCS decides that Mercy Care Plan’s decision was correct, you may be responsible forpayment of the services you received while your appeal was being reviewed. If AHCCCS decides that MercyCare Plan’s decision was incorrect, Mercy Care Plan will authorize and provide the services promptly.32

Long Term Care Member Handbook 2012-2013REQUEST FOR EXPEDITED RESOLUTIONYou may file an appeal within 60 days from the date of your notification letter and request that Mercy Care Planreview its action within three (3) days (expedited resolution). You may request an expedited resolution by writingor calling Mercy Care Plan at the address and number listed under “Appeals Process.” You may request that yourservices be continued during your appeal if you file your request within 10 days from the date of the letter fromMercy Care Plan.If Mercy Care Plan decides that it is not medically necessary to issue a decision in three (3) days from the daywe receive your appeal, your appeal will be resolved within the standard 30 days. We will try to call you to letyou know that we will follow the standard 30 day process and send you a written notice within two (2) calendardays. If Mercy Care Plan denies your request for services, you may request a fair hearing with AHCCCS byfollowing the steps in your decision letter.If after the hearing AHCCCS decides that Mercy Care Plan’s decision was correct, you may be responsible forpayment of the services you received while your appeal was being reviewed.QUICK TIPS ABOUT DENIAL, REDUCTION, SUSPENSION ORTERMINATION OF SERVICES AND APPEALSCOST SHARING••You will be sent a letter (Notice of Action) when a service has beendenied 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 laterthan 10 days from the date of your notice, or within the time frame inyour letterAs an ALTCS member, you may have to contribute toward the cost of your care. What costs might you have topay?Share of CostALTCS will decide what your share of cost will be based on your income and certain expenses. They will sendyou a notice telling you the amount. If you live in a nursing home, the nursing home will collect your share ofcost from you every month. If you live in an alternative residential setting or assisted living facility you will haveto pay “room and board” to the facility, but you may also have a share of cost that ALTCS has set. If you live athome, you probably will not have a share of cost since you already pay for living expenses. If you live at home oran assisted living facility, and do have a share of cost, Mercy Care Plan will collect the money from you or yourrepresentative.HOW TO GET SERVICES33

MEDICARE COPAYMENTS, COINSURANCE AND DEDUCTIBLESQualified Medicare Beneficiary (QMB) Copayments and DeductiblesIf you meet certain income and resource limits, you may be able to get into a program called QMB (QualifiedMedicare Beneficiary) in addition to ALTCS. QMB members may get all ALTCS services as well as Medicare PartsA and B services. QMB members may receive Medicare services that are not covered by ALTCS, like chiropractorservices. AHCCCS pays the Medicare Part B premium each month for QMB membersIf 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 & B, then:••Mercy Care Plan is responsible for sharing in the cost for AHCCCS covered services and for certain Medicareservices not covered by AHCCCS, like chiropractic.••Mercy Care Plan will pay your coinsurance, deductible or copayment amounts to your doctor. Do not payyour copayments yourself. Ask your PCP to bill Mercy Care Plan for the copayment.If you have Medicare:••you are responsible for your pharmacy co-payments for Medicare Part D.If you are a Qualified Medicare Beneficiary (QMB) member:••MCP may pay for services not covered by AHCCCS or from a provider who is not part of our network.Unless you have an emergency, if you choose to go to another provider who is not one of the Mercy Care Planapproved doctors found in your Provider Directory or not with your Medicare HMO:••you would be responsible for paying your Medicare coinsurance, deductibles or copayments.HOW TO GET SERVICESPlease call Member Services if you have questions.CHILDREN’S REHABILITATIVE SERVICES (CRS) COPAYMENTS AND DEDUCTIBLESIf you are a CRS eligible member and have private insurance or Medicare, you are not required to use CRSservices for a CRS covered condition. If you choose to use your private insurance or Medicare for a CRS coveredcondition, 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 toenroll in CRS for services, CRS will pay all applicable deductibles and copayments.IF YOU HAVE OTHER HEALTH INSURANCEIf 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 MercyCare Plan information.2. Your other health insurance pays for your health care expenses FIRST. After they pay, Mercy Care Plan willpay its part. Call Member Services to provide Mercy Care Plan with the name, address, and phone number ofyour primary insurance provider.If you are in an accident and get treatment for your injuries, you must report it to your case manager.34

Long Term Care Member Handbook 2012-2013GETTING BILLS FOR SERVICESWhen can you be billed for services?If you get services that are not covered or not approved by Mercy Care Plan, you may be billed.••Talk to your doctor about payment options before getting any non-covered health care service.••If you ask for a service that is not a covered benefit and sign a statement agreeing to pay the bill, you areresponsible to pay for it.••If you pay for a service as requested by your provider, we may not be able to pay you back.What actions should you take if you are billed for services?If you get a bill for a covered service:••Call the provider right away.••Give them all of your insurance information and Mercy Care Plan’s address.Mercy Care Plan4350 E. Cotton Center Blvd., Bldg. DPhoenix, AZ 85040••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 alreadypaid for services during this time, you should first ask the provider to bill Mercy Care Plan and then to payyou back. If they refuse to pay you back and bill Mercy Care Plan, then:––Send your paid receipts to Member Services––Include a detailed note explaining why you paid for services.––Receipts must be received by Mercy Care Plan within six 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 payyou back.HOW TO GET SERVICES35

MEMBER GRIEVANCESIMPORTANT INFORMATIONIf you have a grievance or problem with a provider or a concern about the quality of care or services you havereceived, please call Member Services. We will do our best to answer your questions or help you solve yourproblem. Filing a grievance will not affect your health care services. We want to know your concerns so we canimprove our services to you. You can call Member Services for help with problems with authorizations, coveredservices, payment for services or the quality of the services you are receiving.••If you call to report a complaint that is not about quality of care, we will try to solve it right away and tell youthe result right then if we can.••If we cannot solve your problem right away, we will solve it as soon as we can. We will let you know theresolution within 90 days.If you have a quality of care grievance, we will send it to our Quality Management Department for review. Wewill investigate your grievance and send you a letter within 90 days to tell you the result.FRAUD AND ABUSEYour health benefits are given to you based on your health and financial status. You should not share yourbenefits with anyone. Providers must report any misuse of benefits to Mercy Care Plan. We then report thisinformation to AHCCCS. If you misuse your benefits, you could lose your AHCCCS benefits. AHCCCS may alsotake legal action against you. If you think a person, member or provider is misusing the program, please callMember Services or AHCCCS.Fraud and abuse also means:••loaning, selling or giving your member ID card to someone••inappropriate billing by a provider or any action intended to defraud the AHCCCS program.AbuseAbuse means physical, sexual or emotional harm or injury. It also means neglect or exploitation by others. Yoursafety and well-being are very important to Mercy Care Plan. If you or your family has any concerns, please callyour Mercy Care Plan Member Services or your case manager right away.ANNUAL ENROLLMENT CHOICE (AEC)Mercy Care Fraud Hotline: 1-800)-810-6544AHCCCS Fraud Reporting: 602-417-4193 or 1-888-487-6686IMPORTANT INFORMATIONMercy Care Plan is your health plan. Annual Enrollment Choice (AEC) is the time during the year when you maychoose a new health plan if you want. ALTCS will send you information about health plans in your area beforeyour AEC time. You can look through it and decide whether you want to change or not. You will have one monthto choose. Before you decide to change, please call your case manager or Member Services. We may be able tohelp you with any problems you might be having.36

Long Term Care Member Handbook 2012-2013HEALTH PLAN CHANGESYou may change health plans once a year on the date you first became an AHCCCS member or ALTCS eligible.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 health plan.5. You were given wrong information about available choices, or there was an error on the part of AHCCCS orMercy Care Plan.6. You move to your own home to another county other than Pima or Maricopa County.7. You re-enrolled in ALTCS within 90 days and were not re-enrolled with the same health plan.8. You are pregnant and need to stay with your doctor who is not a Mercy Care Plan doctor. If you need tochange your doctor, please call Mercy Care Plan Member Services.Some changes need approval from the new health plan before you can change. An example of a changeneeding 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 CARELiving Wills and Other Health Care Directives for Adult MembersThere 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 requestcare you do want.There are four (4) kinds of Advance Directives. Mercy Care Plan strongly encourages you to have one or more ofthese papers filled out. Mercy Care Plan has written policies to make sure your wishes are followed. You shouldget help writing your living will and/or health care directives. If you are not sure who to call for help, ask yourcase manager or doctor for help.Four (4) Kinds of Health Care Directives1. Living Will ‐ a paper that tells doctors what kinds of services you do or do not want if you become ill andmay die. In your Living Will, you might tell doctors if you want to be kept alive with machines or fed throughtubes if you cannot eat or drink on your own.2. Durable Medical Power of Attorney ‐ a paper that lets you choose a person you trust to make decisionsabout your health care when you cannot.3. Mental Health Care Power of Attorney ‐ names a person to make mental health care decisions if you arefound incapable to do so.4. Pre-Hospital Medical Care Directive ‐ states your wishes about refusing certain life-saving emergencycare given outside a hospital or in a hospital emergency room. You must complete a special orange form.37IMPORTANT INFORMATION

Making Your Advance Directives LegalFor a Medical Power of Attorney, you must choose someone you trust to be your agent. Your agent is the personwho will make decisions about your health care if you cannot yourself. He/she can be a family member or aclose friend. To make an Advance Directive legal, you must either:1. 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.OR2. Sign and date it in front of a notary public. The notary public cannot be your agent or any person involvedwith 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.What to do after you complete writing 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 inyour 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 makesure 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.IMPORTANT INFORMATION38

HEALTH CARE DIRECTIVES AND LEGAL RESOURCESRESOURCESLong Term Care Member Handbook 2012-2013Health Care DirectivesThe following organizations provide health care directive forms and information.LOCAL RESOURCESHealth Care Decisions1510 E. Flower St.Phoenix, AZ 85014(602) 222-2229www.Hcdecisions.orgRESOURCESArizona Attorney General’s Office1275 W. WashingtonPhoenix, AZ 85007(602) 542-5025 or (800) 352-8431www.azag.govArizona Attorney General’s Office ‐ Tucson400 West CongressSouth Building, Suite 315Tucson, AZ 85701-1367(520) 628.6504Department of Economic Security (DES)Division of Aging and Adult Services1789 W. Jefferson, Site Code 950APhoenix, AZ 85007(602) 542-4446Your local Area Agency on Aging and Senior Center may also have forms and information.NATIONAL ORGANIZATIONSAARP601 “E” Streets, N.W.Suite A1-200Washington, D.C. 20049(202) 434-2277 (AARP)(888) 687-2277For an AARP office in Arizona, go to: http://www.aarp.org/states/az/39

Health Care Directives and Legal ResourcesRESOURCESThe following organizations provide information and answer questions about health care directives andother related legal matters.Arizona Senior Citizens Law Project1818 S.16th St.Phoenix, AZ 85034(602) 252-6710Community Legal ServicesP.O. Box 21538 Phoenix, AZ 85036-1538Phone: (602) 258-3434 / 1-800-852-9075305 South 2nd AvenuePhoenix, AZ20 W. First St. Suite 101, Mesa, AZ 85201Phone: (480) 833-1442 / 1-800-896-3631OmbudsmanArea Agency on Aging Region 1, Maricopa CountyLong Term care Ombudsman Program1366 E. Thomas RoadSuite 108602-264-2255Phoenix, AZ 85014Arizona Center for Disability law ‐ Maricopa5025 E. Washington Suite 202Phoenix, Arizona 85034602-274-6287Arizona Center for Disability Law ‐ Pima100 North Stone Ave Suite 305Tucson, AZ520-327-9547Center For Independent LivingArizona Bridge to Independent Living ‐ Maricopa5025 E. Washington Suite 200Phoenix, AZ602-386-4278Arizona Bridge to Independent Living ‐ Pima1023 N. Tyndall AveTucson, AZ520-561-886240

Long Term Care Member Handbook 2012-2013Pima Council on Aging8467 E. BroadwayTucson AZ 857100520-790-7262Southern Arizona Legal Aid (SALA) Community Legal ServicesPhone: (602) 258-3434 / 1-800-852-9075http://www.sazlegalaid.org/Administration Building2343 E. Broadway Blvd., Ste. 200Tucson, AZ 85719-6007Phone: (520) 623-9465 / 1-800-640-9465RESOURCESTohono O’odham Legal Services;a division of Southern Arizona Legal AidPhone: (520) 520-623-9465 / 1-800-248-6789IF YOU LOSE ELIGIBILITY RESOURCESWe also want you to be able to get medical care if you do lose your AHCCCS eligibility. Below is a list of clinicsthat offer low cost or free medical care. Call the clinics to find out about services and costs. If you havequestions or need help call Member Services.LOW COST/SLIDING SCALE HEALTH CAREClinica Adelante, Inc.Adelante Women’s Health Care14300 W Granite Valley Dr Ste A2Sun City West, AZ 85375-5865Phone: 623-544-3214Clinica Adelante, Inc.Tidwell Family Care Center16560 N Dysart RdSurprise, AZ 85374-3717Phone: 623-546-2294Clinica Adelante, Inc.Wickenburg Family Care Center466 W Wickenburg WayWickenburg, AZ 85390-2226Phone: 623-546-2294Clinica Adelante, Inc.East Valley Family Care2204 S Dobson Rd Ste 101Mesa, AZ 85202-6457Phone: 602-241-0909Clinica Adelante, Inc.Gila Bend Primary Care Center100 N Gila BlvdGila Bend, AZ 85337Phone: 928-683-2269John C. Lincoln Community Health CenterJohn C. Lincoln Women’s/Children’s Health Center9221 N Central AvePhoenix, AZ 85020-2415Phone: 602-331-5717Clinica Adelante, Inc.Buckeye Family Care Center306 E Monroe AveBuckeye, AZ 85326-2706Phone: 623-386-4814Maricopa Integrated Health SystemMcDowell Healthcare Center1144 E McDowell Rd Ste 300Phoenix, AZ 85006-2620Phone: 602-344-41

RESOURCESMaricopa Integrated Health SystemSunnyslope Family Health Center934 W Hatcher RdPhoenix, AZ 85021-3139Phone: 602-344-6300Maricopa Integrated Health SystemsComprehensive Health Center2525 E Roosevelt StPhoenix, AZ 85008-4948Phone: 602-344-5011Maricopa Integrated Health SystemGlendale Family Health Center5141 W Lamar RdGlendale, AZ 85301-3423Phone: 623-344-6700Maricopa Integrated Health SystemMesa Family Health Center59 S HibbertMesa, AZ 85210-1414Phone: 480-344-6200Maricopa Integrated Health SystemGuadalupe Family Health Center5825 E Calle GuadalupeGuadalupe, AZ 85283-2664Phone: 480-344-6000Maricopa Integrated Health SystemSouth Central Family Health Center33 W Tamarisk StPhoenix, AZ 85041-2422Phone: 602-344-6400Maricopa CountyMaricopa County Health Care For The Homeless220 S 12th StPhoenix, AZ 85034Phone: 602-372-2100Maricopa Integrated Health SystemChandler Family Health Center811 S Hamilton StChandler, AZ 85225-6308Phone: 480-344-6100Maricopa Integrated Health SystemEl Mirage Family Health Center12428 W Thunderbird RdEl Mirage, AZ 85335-3113Phone: 623-344-6500Maricopa Integrated Health SystemAvondale Family Health Center950 E Van Buren StAvondale, AZ 85323-1506Phone: 623-344-6800Maricopa Integrated Health SystemSeventh Avenue Family Health Center1407 S 9th AvePhoenix, AZ 85007-3904Phone: 602-344-6600Mountain Park Health Center ‐ Baseline635 E Baseline RdPhoenix, AZ 85042-6583Phone: 602-243-7277Mountain Park Health Center ‐ Maryvale4616 N 51st Ave Ste 203Phoenix, AZ 85031-1721Phone: 623-247-6266Mountain Park Health Center ‐ TempeTempe Community Health Center1492 S Mill Avenue #312Tempe, AZ 85281Phone: 480-927-1000Mountain Park Health Center ‐ Goodyear140 N. Litchfield Rd. STE 200Goodyear, AZ 85338Phone: 602-243-7277Mountain Park Health CenterEast Phoenix690 N Cofco Center Ct Ste 230Phoenix, AZ 85008-6464Phone: 602-286-609042

Long Term Care Member Handbook 2012-2013Native HealthNative American Community HealthCenter, Inc.4520 N. Central Ave. , STE 620Phoenix, AZ 85012-3020Phone: 602-279-5262PS Medical Group515 W Buckeye Rd Ste 402Phoenix, AZ 85003-2651Phone: 602-257-9229Estrella Family Medical ‐ Maryvale4700 N. 51 Avenue, Suite 1Phoenix, AZ 85031Phone: 623-298-4642OSO Medical378 N Litchfield RdGoodyear, AZ 85338-1239Phone: 623-925-2622Sun Health Del E. Webb Health Center1395 W Wickenburg WayWickenburg, AZ 85390-4231Phone: 928-684-5428St. Vincent De Paul Medical/Virginia G. Piper Dental Clinic420 W Watkins St.Phoenix, AZ 85003-2830Phone: 602-261-6868PIMA COUNTYDesert Senita Community Health Center410 N Malacate StAjo, AZ 85321-2254Phone: 520-387-5651El Rio Health CenterEl Rio Flowing Wells Dental4009 N Flowing Wells RdTucson, AZ 85705-2404Phone: 520-408-0836El Rio Health Center839 W Congress StTucson, AZ 85745-2891Phone: 520-792-9890El Rio Health Northwest Clinic330 W Prince RdTucson, AZ 85705-3526Phone: 520-670-3909El Rio Health Southwest II, Internal Medicine1510 W Commerce CtTucson, AZ 85746-6015Phone: 520-670-3909St. Elizabeth of Hungary Clinic140 W Speedway Blvd Ste 100Tucson, AZ 85705-7698Phone: 520-628-7871MHC HealthcareErickson Health Center6750 E Stella RdTucson, AZ 85730-2202Phone: 520-584-5010MHC HealthcareEast Side Health Center8181 E Irvington RdTucson, AZ 85730Phone: 520-574-0783MHC HealthcareEl Pueblo Health Center101 W Irvington RdTucson, AZ 85714-3050Phone: 520-573-0096MHC HealthcareFreedom Park Health Center5000 E 29th StTucson, AZ 85711-6401Phone: 520-790-8500MHC HealthcareKeeling Health Center435 E Glenn StTucson, AZ 85705-4664Phone: 520-696-6969RESOURCES43

RESOURCESMHC HealthcareOrtiz Community Health12635 W Rudasill RdTucson, AZ 85743-9724Phone: 520-682-3777United Community Health Center, Inc.Presidio Point Clinic275 W Continental Road, Suite 142Green Valley, AZ 85614520-407-5400United Community Health CenterThree Points15921 W Ajo WayTucson, AZ 85746-6099520-407-5700United Community Health Center, Inc.Continental Family Medical Center1260 S Campbell AveGreen Valley, AZ 85614-0503Phone: 520-407-5900COCHISE COUNTYChiricahua Community Health Center ‐ Bisbee108 Arizona StBisbee, AZ 85603-1804Phone: 520-432-3309Chiricahua Community Health Center ‐ Douglas1100 F AveDouglas, AZ 85607-1919Phone: 520-364-3285United Community Health Center ‐ Arivaca17388 W 3rd StArivaca, AZ 85601Phone: 520-407-5500United Community Health Center, Inc.81 W Esperanza Blvd STE 201Green Valley, AZ 85614-2666Phone: 520-407-5600United Community Health Center, Inc.Sahuarita Wellness Center2875 E. Sahuarita RdSahuarita, AZ 85629-9000520-576-5770United Community Health Center, Inc.Continental Pediatrics/Dental1150 E Whitehouse Canyon RdGreen Valley, AZ 85614Phone: 520-407-5800United Community Health Center, Inc.Continental Pediatrics/Dental1150 E Whitehouse Canyon RdGreen Valley, AZ 85614Phone: 520-407-5800Chiricahua Community Health Center ‐ Elfrida10566 N US Hwy 191PO Box 263Elfrida, AZ 85610-0263Phone: 520-642-2222Copper Queen Medical Associates RHC ‐ Douglas100 E 5th StDouglas, AZ 85607-2859Phone: 520-364-7659Copper Queen Medical Associates RHC101 Cole AveBisbee, AZ 85603-1327Phone: 520-432-2042Southeast Arizona Medical Center2174 W Oak AvenueDouglas, AZ 85607Phone: 520-364-793144

Long Term Care Member Handbook 2012-2013GRAHAM COUNTYGREENLEE COUNTYCanyonlands Community Health CareSafford Clinic2016 W.16th StSafford AZ 85546Phone: 928-428-1500COMMUNITY RESOURCESCanyonlands Community Health CareDuncan227 Main StreetDuncan, AZ 85534Phone: 928-359-1380RESOURCESAHCCCS801 E. Jefferson StreetPhoenix, AZ 85034(602) 417-4000www.MyAHCCCS.comMy AHCCCS online (www.MyAHCCCS.com) allows AHCCCS members to view their own active healthcare andhealth plan enrollment for the following services:••View a two-year history of eligibility••Enrollment information••Link to their active health plan websites••Your correct addressAZ Department of Health Services150 N. 18th Avenue, Suite 310Phoenix, AZ. 85007(602) 542-00221631 A. 10th AveTucson, AZ 85701(520) 243-7777Area Agency on Aging. Region 11366 E Thomas Rd. Suite 108Phoenix, AZ 85014(602) 264-2255 or 888-783-7500www.aaaphx.orgInformation for caregivers24 hour Senior Help LineElder rights/ elder resource center45

RESOURCESAlzheimer’s Association Central Arizona Regional Office1028 E. McDowell Rd.Phoenix, AZ 85006(602) 528-0545 or (800) 272-3900ALZ.org/dswThe Alzheimer’s Association is the leading voluntary health organization in Alzheimer care, support andresearch. Resources include: care finder, help line, library, workshops and support groups, and tips forcaregivers.Arizona Head StartHead Start is a great program that gets preschoolers ready for kindergarten. Preschoolers enrolled in HeadStart will get healthy snacks and meals too. Head Start offers these services and more at no cost to you.www.azheadstart.org3910 S. Rural RoadTempe, AZ. 85282(480) 829-8868Arizona Early Intervention Program (AzEIP)The Arizona Early Intervention Program (AzEIP, pronounced Ay-zip), helps families of children with disabilities ordevelopmental delays age birth to three years old. They provide support and can work with their natural abilityto learn.www.azdes.gov/AzEIP3839 N. 3rd Street, Suite 304Phoenix, AZ 85012(602) 532-9960 or (888) 439-5609Child and Family Resourceswww.ChildFamilyResources.orgPrograms include:Child Care Resources & Referral, where parents can call and get a list of childcare centersCenter for Adolescent Parents where teen mothers can earn their high school diploma or GED while gettingfree, onsite child care.2830 W Glendale AvePhoenix, AZ 85051602-234-39412800 E. Broadway Blvd -Angel Charity BuildingTucson, AZ 85716520-881-8941999 E. Frye Blvd, Suite 110Sierra Vista, AZ 85635520-458-7535 ‐ Fax928-428-7248 ‐ Fax46

Long Term Care Member Handbook 2012-2013Bullhead City1071 Hancock Road,Suite 1Bullhead City, AZ 86442(928) 758-9300(928) 758-9095 faxCasa Grande Office1729 N. Trekell RoadSte. 120Casa Grande, AZ 85122(520) 518-5292(520) 518-5491 faxRESOURCESDouglas1065 F Avenue #4Douglas, AZ 86426(520) 364-3244(520) 364-4042 faxKingman715 N. Main Street,Suite AKingman, AZ 86401(928) 753-4410(928) 753-4452 faxNogales1827 N. Mastick WayNogales, AZ 85621(520) 281-9303(520) 281-9560 faxYuma201 S 3rd AveYuma, AZ 85364928-783-4003928-783-4941 fax47

Community Information and ReferralCall 2-1-2 for information on this program or go to www.cir.orgRESOURCESCommunity I&R is a call center that can help you find many community services.••food banks, clothes, shelters, help to pay rent and utilities.••health care, help when you or someone else is in trouble, support groups, counseling, help with drug oralcohol problems.••financial help, job training, transportation, education programs.••adult day care, Meals on Wheels, respite care, home health care, transportation, homemaker services.••counseling, help with learning, protective services.Centers for Independent LivingCenter For Independent LivingArizona Bridge to Independent Living ‐ Maricopa5025 E. Washington Suite 200Phoenix, AZ602-386-4278Arizona Bridge to Independent Living ‐ Pima1023 N. Tyndall AveTucson, AZ520-561-8862Pima Council on Aging8467 E. BroadwayTucson, AZ 85710Pima Council On Aging Helpline: 520-790-7262Medicare Information: 520-546-2011Administration/Business: 520-790-0504Fax: 520-790-7577WIC (Women, Infants and Children)www.fns.usda.gov/wicWIC serves pregnant women, infants, and children under five years old. WIC provides food, breast feedingeducation, and information on healthy diet.48

Long Term Care Member Handbook 2012-2013LOW-FEE DENTAL SERVICESMountain Park Dental Clinic (5 locations)(602) 243-7277(scheduling all locations)www.MPHC-AZ.org1492 S. Mill Ave. Suite 312Tempe, AZ 85281690 N. Cofco Center Court STE 230Phoenix, AZ 85008RESOURCES635 E. Baseline Rd.Phoenix, AZ 850426601 W Thomas Rd.Phoenix, AZ 85033140 N Litchfield Rd STE 200Goodyear, AZ 85338Native American Community Health Center4520 N. Central Ave. STE 620Phoenix, AZ 85012(602) 279-5262www.NativeHealthPhoenix.comPhoenix College Clinic1202 W. Thomas Rd.Phoenix, AZ 85013(602) 285-7323www.pc.maricopa.eduSt. Vincent de Paul420 W. Watkins St.Phoenix, AZ 85002(602) 261-6868www.StVincentdePaul.netPIMA COUNTYEl Rio Dental Congress839 W. Congress St.Tucson, AZ 85745(520) 792-9890www.elrio.org/dental_services49

RESOURCESEl Rio Northwest DentalFlowing Wells4009 N. Flowing Wells Rd.Tucson, AZ 85705(520) 792-9890www.elrio.org/dental_servicesEl Rio Southwest(Commerce)1530 W. Commerce Ct.Tucson, AZ 85746(520) 770-2700www.elrio.org/dental_servicesPima Community CollegeHygiene School2202 W. Anklam Rd., Room K-212Tucson, AZ 85709(520) 206-6090http://pima.eduSun Life Family Health Center865 N. Arizola Rd.Casa Grande, AZ 85222(520) 381-0381www.sunlifefamilyhealth.orgDesert Senita Medical Center410 Malacate St.Ajo, AZ 85321(520) 387-5651www.ajochc.org50

Action ‐ an action by Mercy Care Plan means:DEFINITIONSLong Term Care Member Handbook 2012-2013••The denial or limited authorization of a service you or your doctor have requested••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 inthe areaRESOURCESAHCCCS ‐ (Arizona Health Care Cost Containment System) is the state agency that manages the Medicaidprogram in Arizona using federal and state funds. AHCCCS contracts with managed care health plans andprogram contractors to deliver medical and long-term care services to eligible members.ALTCS ‐ (Arizona Long Term Care System) is the AHCCCS program that provides Medicaid services to elderlyand physically disabled members. Mercy Care Plan is contracted with ALTCS to provide long-term care servicesto eligible members.Appeal Resolution ‐ the written determination by MCP about an appeal.Authorization ‐ an approval that you need from your doctor and/or Mercy Care Plan before getting otherhealth care services including, but not limited to, laboratory and radiology tests and visits to specialists andother health care providers (see referral).Copayment ‐ a small amount of money that you pay covered services.Durable Medical Equipment (DME) ‐ Equipment which:••Can be used over and over;••Is primarily used to serve a medical purpose;••Usually, is not useful to a person when they are not sick or hurt;••Is easily used in the home.••Some examples are crutches, wheelchairs, walkers, etc.Emergency ‐ a medical condition that might cause serious health problems or even death if it is not treatedimmediately.Grievance ‐ Any written or verbal expression of dissatisfaction over a matter other than an action, as defined inthis Handbook, by a Member or provider authorized in writing to act on the Member’s behalf. A grievance maybe 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 rightsGrievance System ‐ a system that includes the following processes: member grievances and appeals, providerclaim disputes and access to the State Fair Hearing system.51

Medically Necessary ‐ a covered service that will prevent disease, disability, and other poor health conditionsor their progress; or prolong life.RESOURCESNotice of Action ‐ if Mercy Care Plan decides that the requested service cannot be approved, or if an existingservice is reduced, suspended or ended, a member will receive a “Notice of Action” telling them what actionwas taken and the reason for it; their right to file an appeal and how to do it; their right to ask for a fair hearingwith AHCCCS and how to do it; their right to ask for an expedited resolution and how to do it; and, their right toask that their benefits be continued during the appeal, how to do it and when they may have to pay the costsfor the services.Prescription ‐ an order from your doctor for medicine, DME, therapy or other nursing services.Primary Care Physician (PCP) ‐ the doctor who provides or authorizes all your health care needs. Your PCPrefers you to a specialist if you need special health care services.Qualified Medicare Beneficiaries (QMB) ‐ members who qualify for both AHCCCS and Medicare who havetheir 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.Room and Board ‐ a cost you pay for food and housing when you live in an alternative residential setting.Share of Cost ‐ the amount that AHCCCS determines a member must pay toward the cost of their care. Roomand board is the amount that Mercy Care determines a member must pay toward the cost of assisted living.Specialist ‐ a doctor who treats specific health care needs. For example, a cardiologist is a specialist. You mustget a referral from your doctor before seeing a specialist.Special Health Care Needs ‐ members who have serious and chronic physical, developmental or behavioralconditions and who require medically necessary health and related services of a type or amount greater thanthose generally required by members. All ALTCS members are considered to have special needs.52