Member Information

Information about your health plan

You have access to a lot of information about your plan. And we want to make it easy for you to find what you’re looking for. Click the menus below for key information about Mercy Care Advantage. If you have any questions, call Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711), 8:00 a.m. - 8:00 p.m., 7 days a week for more information.

Advance Directives

It is important for everyone to plan for end of life care. Even if you are not sick or injured now, you should consider what kind of care you would want if you were. What if you were unable to express your wishes?

Advance directives are documents that protect your right to request health care you do want, or to refuse health care you do not want. Click on the links below to get more information that can help you arrange for your wishes to be honored. The Arizona Attorney General's office also has information that can help.

Living Will

A living will is a legal document that tells others your wishes for life-sustaining measures. These might include:

Breathing machines
Tube feeding
Resuscitation if your breathing or heartbeat stops
Dialysis

You can choose to accept or refuse this type of care in advance, by writing it into your living will.

A living will may also tell others whether you want to be an organ donor.

This document is not a legal opinion. Members should review their advance directives with a lawyer to verify that they are properly prepared. Mercy Care Advantage is not responsible for the information available on the Attorney General’s website, or for updating information about changes to the law affecting advance directives.

Download a Living Will form.

Medical Power of Attorney (POA)

A Medical POA is a legal document that names your health care proxy. A health care proxy is a person you trust to make health care decisions for you if you are unable to do it for yourself.

This is different from a POA that gives someone else the ability to make financial decisions for you. Sometimes it is also called a durable POA for health care.

Download a Medical POA form.

Mental Health Care Power of Attorney (POA)

A Mental Health Care POA Form is a document that names a person to make mental health care decisions if you are found to be incapable of doing so.

Download a Mental Health Care POA form.

Pre-Hospital Medical Directive

Pre-Hospital Medical Care states your wishes about refusing certain life-saving emergency care given outside a hospital or in a hospital emergency room. You must complete a special orange form.

Download a Pre-Hospital Medical Care Directive form.

For both a Living Will and a Medical Power of Attorney, you must choose someone to be your agent. Your agent is the person who will make decisions about your health care if you cannot. For example, he/she can be a family member or a close friend. Download a Letter to My Agent (Representative) form.

In Arizona, an Advance Directive must be:

1. Signed and dated in front of another person who also signs it. This person cannot:

Be related to you by blood, marriage or adoption
Be under 18
Have a right to receive any of your estate (personal and private property) by will or under law at the time this is signed
Be appointed as your agent
Be involved with the paying of or providing any of your health care
Be designated (chosen) to make medical decisions on your behalf

2. Signed and dated in front of a notary public. The notary public cannot be your agent or any person involved with the paying of your health care.

After you complete your Advance Directives:

Keep your original signed papers in a safe place.
Give copies of the signed papers to your doctor(s), hospital and anyone else who might become involved in your health care. Talk to these people about your wishes about health care.
If you want to change your papers after you have signed them, you must complete new papers. You should make sure you give a copy of the new paper to all the people who already have a copy of the old one.
For information about registering your advance directives with the Arizona Registry, please go to www.azsos.gov/adv_dir .

Coordination of Benefits

Coordination of benefits (COB) means using all of your insurance coverages to pay for health care services.

If you have Mercy Care Advantage for your Medicare benefits but enroll in another Medicaid plan, your Medicaid benefits will be provided and paid for by that plan. Your health care providers will need to know you have Mercy Care Advantage for Medicare coverage and the other plan for Medicaid (AHCCCS Complete Care/ALTCS/DDD).

If you have additional health insurance with an employer or a federal program (Tricare), or if you recently lost this coverage, please notify us so we can pay your health care expenses correctly.

Case Management/Disease Management

Do you need help managing your health?
Sometimes you need some extra help to cope with a health issue. That’s why we offer Case Management.

But not everyone needs a high risk case manager. If they do, most people need a high risk case manager only for a short time. We want you to be able to take care of yourself.

Ask yourself these questions:

Do you go to the ER a lot?
Are you having trouble getting things your doctor has ordered?
Did your doctor just tell you that you have a disease like CHF (congestive heart failure), diabetes, asthma or COPD (chronic obstructive pulmonary disease)?
Do you need help getting on the Arizona Long Term Care System?
Do you have HIV or hemophilia?
Has your doctor said you need a transplant?
Has your doctor sent you to a specialist, but you don't know what to do?

If you answered "yes" to any of these questions, ask your primary doctor to tell us you might need a high risk case manager. Then, a nurse will look at the reason and decide if you need a high risk case manager or if someone else can help you.

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

Disasters

Mercy Care Advantage will comply with our Medicare contract obligations and responsibilities when a Federal Disaster or other Public Health Emergency Declaration is issued and impacts our Mercy Care Advantage members.

In this type of situation, Mercy Care Advantage will comply with instructions issued by the government and the state to help ensure members affected by a disaster or public health emergency have access to timely care. This may include waivers to prior authorization requirements and obtaining care from non-contracted providers, if accessing care from contracted providers is not possible. Mercy Care Advantage will take appropriate action steps to keep our members informed when this type of situation occurs.

Frequently Asked Questions (FAQs)

FAQs

Answers to frequently asked questions

You can call Member Services with any questions that are not answered here.
Mercy Care Advantage Member Services
602-586-1730 or 1-877-436-5288 (TTY 711)
8:00 a.m. - 8:00 p.m., 7 days a week

Information available on our website:

Go to the Find a Provider webpage to search online for network doctors, specialists, hospitals and dentists.
Go to our Member Materials webpage to access Mercy Care Advantage member materials.
Go to our Part D Prescription Drug Benefits webpage for more information about Mercy Care Advantage prescription drug coverage.

What should I do if I lose my member ID card or don’t get one?
Call Member Services to get a new ID card.

What is a PCP?
A PCP is a “primary care provider” (doctor) you choose from the Mercy Care Advantage network to provide your routine and preventive care.

Can I choose my doctors?
You can only use doctors who are part of our network, except in an emergency. The health providers in our network can change at any time. You can look for doctors in our network on the Find a Provider page. You may also call Member Services for assistance in locating a doctor or to change your PCP.

How will I know the name of my PCP?
We send you a welcome letter when you join. Your welcome letter will have the name and telephone number of your assigned PCP.

How do I see a specialist?
Your PCP will make a referral to a specialist when necessary.

What happens if I go to a doctor who is not in the Mercy Care Advantage network?
If you choose to go to a doctor outside of our network, you must pay for these services yourself, except in limited situations (for example, emergency care). Neither Mercy Care Advantage, nor Original Medicare will pay for these services.

How do I know which services are covered and which are not?
Information about services that are covered and not covered with Mercy Care Advantage can be found in the Summary of Benefits and the Evidence of Coverage. You can view these materials on our Member Materials webpage or call Member Services with any questions.

What should I do if I get a bill?
If you get a bill, call the health care provider and give them your Mercy Care Advantage information. If they continue to bill you, call Member Services for help.

Which hospitals can I use?
Go to the Find a Provider webpage to look up hospitals in the Mercy Care Advantage network or call Member Services for help.

What is an emergency?
An emergency is a medical condition that could cause serious health problems or even death if not treated immediately. You can get emergency health care services without the approval of your PCP or Mercy Care Advantage when you have a medical emergency. You may go to the nearest emergency room or other setting for emergency care. If you have to be hospitalized for any reason, you may go to the hospital your doctor sends you to.

What if I have an emergency while in another state?
Go to the nearest emergency room and present your Mercy Care Advantage ID card. Do not pay for the services. The emergency department should bill the health plan using the information on the back of your ID card.

Can I go to urgent care if I need to?
Yes. You can search for an urgent care facility on the Find a Provider webpage.

Which dentist can I see?
You can search for a network dentist on the Find a Provider webpage.

Does Mercy Care Advantage cover Medicare Part B and Part D prescription drugs?
Yes, the Mercy Care Advantage plan covers both Medicare Part B and Part D prescription drugs. Please refer to the Evidence of Coverage on our Member Materials webpage for more detailed coverage information.

Where can I get my prescriptions filled?
You must use a network pharmacy to fill your prescriptions. We may not pay for prescriptions filled at an out-of-network pharmacy, except in limited situations such as an emergency. The pharmacies in our network can change at any time. You can access the Mercy Care Advantage online pharmacy directory on the Find a Provider webpage.

What is a Prescription Drug Formulary?
A formulary is a list of drugs covered by Mercy Care Advantage to meet patient needs and is approved by CMS. We may periodically add, remove, make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members' ability to fill their prescriptions, we must notify members in writing before the change is made.

If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can review the formulary and the Mercy Care Advantage Transition of Coverage policy on our Part D Prescription Drug Benefits page.

What do I do if I need help paying for prescription drugs? People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to one hundred (100) percent of drug costs, including monthly premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, or to see if you qualify, call:

1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week;
The Social Security Administration at 1-800-772-1213, between 7 a.m. and 7 p.m., Monday - Friday. TTY/TDD users should call 1-800-325-0778; or
Your state Medicaid office.

If you are eligible for Extra Help, Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you are not getting this extra help, please call the numbers above for more information and to find out if you qualify.

What is a Medication Therapy Management (MTM) program?
The MTM program is a free service we may offer to eligible members. The MTM program works to identify members at risk for potential drug-related problems and helps these members better understand the drugs they take. View MTM program details on the Mercy Care Advantage Part D Prescription Drug Benefits page or contact Member Services.

What if I need a drug that is not covered by Mercy Care Advantage?
As a member of Mercy Care Advantage, you have the right to request a coverage determination, which includes the right to request an exception for a drug not covered on our formulary. A coverage decision is a decision we make about your benefits and coverage or the amount we will pay for your drugs. You can ask us for an “exception” to cover a Part D drug that is not on our formulary. You can ask for an “exception” for us to waive a restriction on a drug on our formulary, such as a limit on the quantity of a drug. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem, with us or one of our network pharmacies, that does not involve coverage for a prescription drug. Go to our Part D Prescription Drug Benefits page for more information.

How to Prepare for a Hospital Admission

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

Medicare National Coverage Determinations

The Centers for Medicare and Medicaid Services (CMS) released new National Coverage Determinations that affect your coverage. Learn more by selecting a link below.

2017 ACTIVITY

2016 ACTIVITY

2015 ACTIVITY

2014 ACTIVITY

Mercy Care Advantage Rewards

Your health is important to us, and the steps you take to stay healthy deserve a reward!

Mercy Care Advantage Rewards is a program that rewards you for taking care of your health. In this program, you’ll find recommended health care activities —such as preventive screenings and tests — and you can receive rewards for completing them. The more activities you complete, the more you’ll earn!

To enroll, visit the Mercy Care Advantage Rewards website.

Model of Care

Mercy Care Advantage (MCA) is a Medicare Dual-Eligible Special Needs Plan (D-SNP plan) that is available to people with Medicare and Medicaid. As a D-SNP plan, we are required to implement a Model of Care and set goals to help us deliver coordinated care and covered services to our members with special needs. These goals help us identify and track the unique medical needs of our members so we can improve upon the care and services we provide. Each year we evaluate our Model of Care to determine if we have met the quality measures and health outcome goals set. We use the results to make improvements to our Model of Care. If you would like to learn more about our MCA Model of Care or the evaluation process, please contact our Member Services department.

Mercy Care Advantage has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 2021 based on a review of the Mercy Care Advantage Model of Care.

Privacy Notice

View the Mercy Care Advantage Privacy Notice English | Español

Referrals and Prior Authorization

Referrals & Prior Authorization

Getting specialty services
There are times when a health problem can’t be treated by your doctor alone and specialty care may be needed. If you need care from a specialty provider, your primary care provider (PCP) will need to request a referral for you. Some covered medical services will need prior authorization before you can receive the service.

Referrals
A referral is when your PCP sends you to a specialist provider for a specific problem. This might include heart problems, skin disorders or serious allergies. A referral can also be to a lab or hospital, etc. You may also request a second opinion from another Mercy Care Advantage doctor.

Prior Authorizations
A prior authorization is an approval from Mercy Care Advantage for you to get the special services your PCP or specialist provider wants you to receive. We may take up to 14 days to approve a routine authorization request and 3 business days to approve an urgent request.

If we need additional information to authorize the request, a 14-day extension may be requested. If we do not receive the information requested from your doctor, we may deny the request. You will receive a notice of action letter that explains your rights.

If your doctor sends in an urgent authorization request and it does not meet the criteria for an urgent request, we will send you a letter and let you know that it will be processed as a regular request. You can file a grievance if you disagree. For more information about grievances, please go to our Grievances, Coverage Determinations and Appeals webpage.

You can view the Mercy Care Advantage Prior Authorization List to see if a service requires pre-approval. You do not need approval from Mercy Care Advantage to get emergency services.

If you have questions about whether your service has been authorized, call your PCP or Member Services.

Mercy Care Advantage providers are expected to follow certain guidelines when giving our members care. If you need help understanding any of these guidelines, please call Member Services and ask for help.

Important information for members requiring specialty services
Certain acute outpatient services and planned hospital admissions require prior authorization before the service can be covered. Please refer to the Evidence of Coverage for more explanation about which services and circumstances require prior authorization.

Rights and Responsibilities

To find out more about Mercy Care Advantage member rights and responsibilities, go to our Rights and Responsibilities webpage.

Seamless Enrollment

In May 2016, the Centers for Medicare & Medicaid Services (CMS) approved Mercy Care Advantage to process Seamless Conversion Enrollments. Seamless Conversion Enrollment is an enrollment method that allows Mercy Care Advantage to automatically enroll Mercy Care members who are becoming Medicare eligible due to turning 65 or reaching the end of their 24‐month Medicare disability-waiting period. In October 2016, we began notifying eligible Mercy Care members in writing to explain they will be automatically enrolled in Mercy Care Advantage as of their Medicare entitlement effective date. The notice explains the benefits of being a Mercy Care Advantage member and how this plan will help coordinate with their Mercy Care coverage. Members do have the option to “Opt-Out” of the Mercy Care Advantage plan prior to their enrollment effective date.

Mercy Care Advantage is making outreach calls to eligible members to explain the plan benefits and assist with questions. If you have questions about the Mercy Care Advantage Seamless Enrollment process, please call our Seamless Enrollment team at 1-866-277-1025, (TTY 711), Monday through Friday from 8:00 a.m. – 5:00 p.m.

View an example of the Seamless Enrollment Initial Notice letter.

Spotlight Member Newsletters

Spring/Summer 2019 English | Español

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Last Updated: 12/10/2019