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Coverage and care

Need help understanding how your Medicare and Medicaid work together? Find out about seamless enrollment and coordination of benefits. Then learn about our model of care and how the Medicare national coverage determinations affect your coverage. These are some key topics that affect your Mercy Care Advantage (HMO SNP) plan.

Seamless enrollment

Mercy Care Advantage is a Medicare dual-eligible special needs plan (D-SNP). It’s for people with Medicare and Medicaid. Seamless conversion enrollment allows us to enroll Mercy Care members into Medicare.

Are you turning 65 soon? Reaching the end of your 24‐month Medicare disability waiting period? If so, we’ll let you know by mail when we’re about to enroll you. Here are some facts to know:

The notice will tell you about all your Medicare member benefits.
It’ll explain how your Medicare plan will work with your current Mercy Care coverage. 
You’ll have the option to opt out (decline) before we enroll you. 
See a sample of the letter.

Have questions? Call our seamless enrollment team at 1-866-277-1025 (TTY 711). You can call 8 a.m. to 5 p.m., Monday to Friday.

Coordination of benefits

Coordination of benefits means using all your insurance coverage to pay for care.

Do you have Mercy Care Advantage for Medicare and another health plan for Medicaid? If so, your Medicaid plan will provide and pay for your Medicaid benefits. Your providers will need to know you have:

Mercy Care Advantage for Medicare benefits and coverage
Another plan for Medicaid benefits and coverage:
- Arizona Health Care Cost Containment System (AHCCCS) Complete Care Regional Behavioral Health Agreement (ACC-RBHA)
- Arizona Long Term Care System (ALTCS)
- Division of Developmental Disabilities (DDD)

Do you have other insurance with an employer or a federal program (Tricare)? Or have you recently lost coverage? Let us know so we can pay for your health care correctly.

Not yet a member?

Call Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711). We’re here for you 8 a.m. to 8 p.m., 7 days a week.

Model of care 

As a Medicare dual-eligible special needs plan (D-SNP), we rely on a model of care. We set goals to help us provide coordinated care and services to our members with special needs. These goals help us track the needs of our members. Each year we review our model of care to make sure we’ve met our quality and health outcome goals. We use the results to improve our services and model of care.

Want more info on our model of care or the review process? Call us at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). We're here for you ${MCA_MS_hours}. The Centers for Medicare & Medicaid Services (CMS) has approved our model of care through December 31, 2024.

Clinical practice guidelines

We’ve chosen certain clinical guidelines to:

Help our providers give you consistent, high-quality care
Ensure good use of services and resources
Provide treatment protocols for specific conditions, as well as preventive health

These guidelines clarify our standards and expectations. They should not:

Come before your provider’s responsibility to provide treatment based on your needs
Substitute as orders for your treatment
Guarantee coverage or payment for the type or level of care your provider advises

We have adopted these guidelines for adults. Need to learn more about the guidelines? Check the topics and links that follow.

Your provider can review the Arizona opioid prescribing guidelines (PDF).

As people age, we need to catch disease as early as possible. This helps ensure the best care, leading to the best results. Providers can learn more about preventive and treatment guidelines for specific conditions in adults.

Adult immunization schedule

Remember — kids aren’t the only ones who need immunizations. Be sure you’re up to date on your flu, hepatitis A and B, measles, mumps and rubella (MMR) and other vaccines.

Community-acquired pneumonia (CAP) clinical guideline

The CAP clinical guideline is to develop an integrated approach to the outpatient management of CAP with an emphasis on:

Prevention
Early detection
Patient education

See guidelines (PDF) from the Infectious Diseases Society of America and American Thoracic Society Consensus.

HIV guidelines

Your provider can check guidelines and resources from the National Insitutues of Health.

Preventive health care guidelines for adults

Health maintenance exam by age and frequency
- 18 to 25 years of age, every 5 years
- 26 to 39 years of age, every 5 years
- 40 to 49 years of age, every 3 years
- 50 to 65 years of age, every 1 to 2 years
- 65 years and older, every 1 to 2 years
Cervical cancer screening
- Every 1 to 3 years starting at age 18 or when sexually active. Frequency may decrease with no history of abnormal Pap tests and three or more tests are normal.
Diabetes screening
- Test at age 45 for adults with no symptoms and then every 3 years.