Mercy Care rights and responsibilities

Mercy Care DCS CHP

Mercy Care DCS CHP members and caregivers have the right to be treated with respect and consideration when they’re getting the health care services they need and deserve. 

Federal and State laws

Mercy Care DCS CHP complies with all Federal and State laws, including: 

• Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 80, 
• The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91, 
• The Rehabilitation Act of 1973, 
• Title IX of the Education Amendments of 1972 (regarding education programs and activities), 
• Titles II and III of the Americans with Disabilities Act; and 
• Section 1557 of the Patient Protection and Affordable Care Act. 

Member and caregiver rights 

You (members and caregivers) have the right to: 

• Receive information about Mercy Care DCS CHP, the services Mercy Care DCS CHP provides, the Mercy Care DCS CHP provider network and the Mercy Care DCS CHP provider directory at no charge. 
• File a complaint to Mercy Care DCS CHP about inadequate Notice of Adverse Benefit Determination letters or any aspect of Mercy Care DCS CHP’s service. 
• File a complaint with AHCCCS, Division of Health Care Management, Medical Management Unit at medicalmanagement@azahcccs.gov, if Mercy Care DCS CHP does not resolve the complaints about the Notice of Adverse Benefit Determination Letter to the member’s satisfaction. 
• Request information on the structure and operation of Mercy Care DCS CHP or Mercy Care DCS CHP’s contractors or subcontractors (42 CFR 438.10(g)(3)(i)). 
• Request information regarding if Mercy Care DCS CHP has physician incentive plans that affect referral from doctors. 
• Know about the type of compensation arrangements with providers, whether stop-loss insurance is required of providers and the right to review member survey results. 
• Not be discriminated against in the delivery of health care services based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment. 

Confidentiality and confidentiality limitations

You have the right to:

• Privacy and confidentiality of your health care information. 
• Talk to health care professionals privately. 
• Get a copy of the “Privacy Rights” notice in your welcome packet. The notice has information on ways Mercy Care uses your records, which includes information on your health plan activities and payments for services. Your health care information will be kept private and confidential. It will be given out only with your permission or if the law allows it. 
• Know about health care privacy.
   
  • There are laws about who can see your medical and behavioral health information with or without your permission. Substance use treatment and communicable disease information (for example, HIV/AIDS information) cannot be shared with others without your written permission. 
  • There may be times that you want to share your medical or behavioral health information with other agencies or certain individuals who may be assisting you. In these cases, you can sign an Authorization for the Release of Information (ROI) Form, which states that your medical records, or certain limited portions of your medical records, may be released to the individuals or agencies that you name on the form. For more information about the Authorization for the Release of Information Form, contact Mercy Care at 602-212-4983 or 1-833-711-0776 (TTY 711). 
• Know about limits to confidentiality. There are times when we cannot keep information confidential. The law doesn’t protect the following information:
   
  • If you commit a crime or threaten to commit a crime at the provider’s office or clinic or against any person who works there, the provider must call the police. 
  • If you’re going to hurt another person, we must let that person know so that he or she can protect himself or herself. We must also call the police. 
  • We must also report suspected child abuse to local authorities. 
  • If there is a danger that you might hurt yourself, we must try to protect you. If this happens, we may need to talk to other people in your life or other service providers (e.g., hospitals and other counselors) to protect you. We’ll only share information necessary to keep you safe. 
• Know the other times when providers can share certain health information with family members and others involved in your care. For example, if:
   
  • You verbally agree to share the information.
  • You have an opportunity to object to sharing information, but don’t object. For example, if you allow someone to come into an exam room during an appointment, the provider can assume that you don’t object to sharing information during that visit.
  • It’s an emergency, or you don’t have the capacity to make health care decisions, and the provider believes disclosing information is in your best interest.
  • The provider believes you’re a serious and imminent threat to your health or safety, or someone else’s health and safety.
  • The provider uses the information to notify a family member of the member’s location, general condition or death.
  • The provider is following other laws requiring they share information.
• Know the other times when your information is shared without first getting your written permission to help arrange and pay for your care. These times could include the sharing of information with:
   
  • Physicians and other agencies providing health, social, or welfare services 
  • Your medical primary care provider 
  • Certain state agencies and schools following the law, involved in the child’s care and treatment, as needed 
  • Members of the clinical team involved in the child’s care 
• Know the other times when it may be helpful to share your behavioral health information with other agencies, such as schools or state agencies. This is done within the limits of the applicable regulations. The written permission may be required by your DCS Specialist before your information is shared.

Other rights

You also have the right to:

• Get services provided in a culturally competent manner, with consideration for members with limited English proficiency or reading skills, and those with diverse cultural and ethnic backgrounds as well as members with visual or auditory limitation at no cost.
• Choose a primary care provider (PCP) and primary dental provider (PDP) within the limits of the provider network, and choose other providers as needed from among those affiliated with the network; this also includes the right to refuse care from specified providers. 
• Know about providers who speak languages other than English. 
• Get a second opinion from a qualified health care professional registered with AHCCCS at no cost to the member.
• Receive information on available treatment options and alternatives, in a manner appropriate to the member’s condition and ability to understand. 
• Review his/her medical records in accordance with applicable State and Federal laws. 
• Request annually and receive at no cost a copy of his/her medical records as specified in 45 CFR 164.524. The member’s right of access to inspect and get a copy of his/her medical records may be denied if the information is: 
  
  
  • Psychotherapy notes; 
  • Information compiled for, or in reasonable anticipation of, a civil, criminal or administrative action; or 
  • Protected health information that is subject to the Federal Clinical Laboratory Improvements Amendments of 1988, or exempt pursuant to 42 CFR 493.3(a)(2). An individual may be denied access to read or receive a copy of medical record information without an opportunity for review in accordance with 45 CFR Part 164 (above) if:
     
    
    • The information meets the criteria stated above; 
    • The provider is a correctional institution or acting under the direction of a correctional institution as defined in 45 CFR 164.501; 
    • The information is obtained during the course of current research that includes treatment and the member agreed to suspend access to the information during the course of research when consenting to participate in the research; 
    • The information was compiled during a review of quality of care for the purpose of improving the overall provision of care and services; 
    • The denial of access meets the requirements of the Privacy Act, 5 U.S.C. 552a; or The information was obtained from someone other than a health care provider under the protection of confidentiality, and access would be reasonably likely to reveal the source of the information. 
• Seek review if access to inspect or request for a copy of medical record information is denied when:
   
  • A licensed health care professional has determined the access requested would reasonably be likely to endanger the life or physical safety of the member or another person; or 
  • The protected health information refers to another person and access would reasonably be likely to cause substantial harm to the member or another person. Mercy Care DCS CHP must respond within 30 days to the member’s request for a copy of the records, the response may be the copy of the record or, if necessary to deny the request, the written denial must include the basis for the denial and written information about how to seek review of the denial in accordance with 45 CFR Part 164. 
• Amend or correct his/her medical records as specified in 45 CFR 164.526 (Mercy Care DCS CHP may require the request be made in writing).
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. 
• Get information on beneficiary and plan information. 
• Receive treatment with respect and with recognition of the member’s dignity and need for privacy; the right to privacy includes protection of any identifying information except when otherwise required or permitted by law. 
• Participate in decisions regarding his or her health care, including the right to refuse treatment (42 CFR 438.100), and/or have a representative facilitate care or treatment decisions when the member is unable to do so. 
• Receive information, in a language and format that the member understands, about member rights and responsibilities, the amount, duration and scope of all services and benefits, service providers, services included and excluded as a condition of enrollment, and other information including: 
  
  
  • Provisions for after-hours and emergency health care services, which includes the right to access emergency health care services from a provider without prior authorization, consistent with the member’s determination of the need for such services as prudent; 
  • Information about available treatment options (including the option of no treatment) or alternative courses of care; 
  • Procedures for getting services, including authorization requirements and any special procedures for getting mental health and substance use services, or referrals for specialty services not furnished by the member’s PCP; 
  • Procedures for getting services outside the Mercy Care DCS CHP provider network;
  • Provisions for getting AHCCCS covered services that are not offered or available through Mercy Care DCS CHP, and notice of the right to obtain family planning services from an appropriate AHCCCS registered provider, and 
  • A description of how Mercy Care DCS CHP evaluates new technology for inclusion as a covered benefit.
• Use any hospital or other setting for emergency care [42 CFR 457.1207, 42 CFR 438.10].
• See the criteria used as a basis for decisions.
• Receive information regarding grievances, appeals and requests for a hearing about Mercy Care DCS CHP or the care provided. 
• Request a state fair hearing after Mercy Care DCS CHP has made an adverse determination 
• File grievances and appeals. 
• Receive help filing grievances and appeals. 
• Call Member Services if there are any questions regarding member rights. 

Mercy Care Long Term Care 

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

Your rights as a member 

You have the right to: 

• Exercise your rights. Exercising those rights shall not adversely affect service delivery to you.  
• Know the name of your PCP and/or case manager.  
• Get a copy of the Mercy Care Member Handbook, which includes a description of covered services.  
• Get information about how Mercy Care provides for after-hours and emergency care.  
• File a complaint about Mercy Care or its subcontractors.  
• Request information on the structure and operations of Mercy Care or its subcontractors.  
• Request information about how Mercy Care pays providers, controls costs and uses services. This information includes whether or not Mercy Care has a Physician Incentive Plan (PIP) and a description of the PIP.  
• Know whether stop-loss insurance is required.  
• Receive general grievance results and a summary of member survey results.  
• Know your costs to get services/treatments that are not covered by Mercy Care.  
• Receive information about how to get services, including services requiring authorization.  
• Receive information on how Mercy Care evaluates new technology to include as a covered service.  
• Receive information about changes to your services or what actions to take when your PCP leaves Mercy Care.  
• Receive fair treatment and get covered services without concern about race, ethnicity, national origin (to include those with limited English proficiency), ancestry, marital status, religion, gender, age, mental or physical disability, sexual orientation, genetic information, your ability to pay, or ability to speak English.  
• Receive information about how medical decisions can be made for you when you are not able to make them.  

Confidentiality and confidentiality limitations  

You have the right to: 

• Privacy and confidentiality of your health care information. 
• Talk to health care professionals privately. 
• Know our privacy practices. You will find a copy of the “Privacy Rights” notice in your welcome letter. The notice has information on ways in which Mercy Care uses your records, including information on your health plan activities and payments for services. Your health care information is kept private and confidential. It is given out only with your permission or if the law allows it.  
• Know about health care privacy. (See the “Health plan Notices of Privacy Practices” section.) 
• Know about limits to confidentiality. There are times when we cannot keep information confidential. The law doesn’t protect the following information:
    
  
  • If you commit a crime or threaten to commit a crime at the provider’s office or clinic or against any person who works there, the provider must call the police.  
    
  • If you’re going to hurt another person, we must let that person know so that he or she can protect himself or herself. We must also call the police.  
  • We must also report suspected child abuse to local authorities.  
  • If there is a danger that you might hurt yourself, we must try to protect you. If this happens, we may need to talk to other people in your life or other service providers (e.g., hospitals and other counselors) to protect you. We’ll only share information necessary to keep you safe.  
• Know the other times when providers can share certain health information with family members and others involved in your care. For example, if:
    
  • You verbally agree to share the information. 
  • You have an opportunity to object to sharing information, but don’t object. For example, if you allow someone to come into an exam room during an appointment, the provider can assume that you don’t object to sharing information during that visit. 
  • It’s an emergency, or you don’t have the capacity to make health care decisions, and the provider believes disclosing information is in your best interest. 
  • The provider believes you’re a serious and imminent threat to your health or safety, or someone else’s health and safety. 
  • The provider uses the information to notify a family member of the member’s location, general condition or death. 
  • The provider is following other laws requiring they share information.  
• Know the other times when your information is shared without first getting your written permission to help arrange and pay for your care. These times could include the sharing of information with:  
  • Physicians and other agencies providing health, social, or welfare services 
  • Your medical primary care provider 
  • Certain state agencies and schools following the law, involved in your care and treatment, as needed 
  • Members of the clinical team involved in your care  
• Know the other times when it may be helpful to share your behavioral health information with other agencies, such as schools or state agencies. This is done within the limits of the applicable regulations. Your written permission may be required before your information is shared.  
• Get a second opinion from a qualified health care professional within the network or have a second opinion arranged outside of the network at no cost to you if there are no other in network options. For more information, you can call Mercy Care at 602-263-3000 or 1-800-624-3879 (TTY 711).  
• Receive information on treatment options and alternatives, appropriate to your condition, in a way that you are able to understand. It should also be shared with you in a way that allows you to participate in decisions about your health care.  
• Know about advance directives.  
• Prepare an advance directive and know how to have medical decisions made for you if you are not able to make them for yourself.  

Treatment decisions 

You have the right to: 

• Agree to, or refuse, treatment and to choose other treatment options available to you.  
• Get information on how to get services and authorizations for services. 
• Choose a Mercy Care PCP to plan your health care. 
• Change your PCP.  
• Within the limits of applicable regulations, Mercy Care staff may help manage your health care by working with you, community and state agencies, schools, and your doctor. 
• 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 decisions about your health care.  
• Get information about which medical procedures you will have and who will 
  perform them. 
• Get a second opinion within the Mercy Care network. You can request a second opinion from a doctor outside of Mercy Care’s network, at no cost to you only if there is not adequate in network coverage.  
• Refuse care from a doctor to whom you were referred, and you can ask for a different doctor.  
• Choose someone to be with you for treatments and exams. 
• Have a female in the room for breast and pelvic exams. 
• Know treatment choices or types of care available to you and the benefits and/or drawbacks of each choice. You have the right to have treatment choices presented to you in a way that you can understand. 
• Develop a plan with your caregiver provider agency to decide your preferences when your caregiver is late or does not show up. 
• Develop a plan with your caregiver provider agency to decide your preferences for each service provided when a service is short. 
• Say, “no” to treatments, services and PCPs. You have the right to be informed about what may happen by not having the treatment. Your eligibility or medical care does not depend on your agreement to follow a treatment plan. 
• Say, “no” to tasks that a provider may ask you to perform that are not part of your care plan. 
• Say, “no” to medications or restraints, except for times when your doctor thinks these actions are needed to protect you or others from harm. 
• Transfer or leave a long-term services and supports home because of medical reasons, for your own good or the good of others, or for not paying.  

Your rights under the Home and Community Based Services (HCBS) Rules  

Mercy Care works to ensure that all staff and providers work in a manner consistent with a person-centered approach that respects and enhances a member’s right of choice, integration and autonomy. 

You have the right to:   

• Privacy, dignity and respect, and freedom from coercion and restraint.  
• Make requests in the way your services and supports are delivered.  
• Reside in the least restrictive setting.  
• Actively engage and participate in your community.  
• Get information about creating advance directives. Advance directives tell others how to make medical decisions for you if you are not able to make them for yourself. 

Medical records requests  

• At no cost to you, you have the right to annually request and receive one copy of your medical records and/or inspect your medical records. You may not be able to get a copy of medical records if the record includes any of the following information: psychotherapy notes put together for a civil, criminal or administrative action; protected health information that is subject to the Federal Clinical Laboratory Improvements Amendments of 1988; or protected health information that is exempt due to federal codes of regulation.  
• Mercy Care will reply to your request within 30 days. Mercy Care’s reply will include a copy of the requested record or a letter denying the request. The written denial letter will include the basis for the denial and information on ways to get the denial reviewed.  
• You have the right to request an amendment to your medical records. Mercy Care may ask that you put this request in writing. If the amendment is made, whole or in part, we will take all steps necessary to do this in a timely manner and let you know about changes that are made.  
• Mercy Care has the right to deny your request to amend your medical records. If the request is denied, whole or in part, then Mercy Care will provide you with a written denial within 60 days. The written denial includes the basis for the denial, notification of your right to submit a written statement disagreeing with the denial and how to file the statement.  

Reporting your concerns  

You have the right to: 

• Tell Mercy Care about any complaints or issues you have with your health care services. 
• File an appeal with Mercy Care and get a decision in a reasonable amount of time. 
• Give Mercy Care suggestions about changes to policies and services.  
• Report your concerns about Mercy Care.  

Personal rights  

You have the right to: 

• Choose to share a room with your spouse when appropriate if you live in a nursing facility or an alternative residential facility.  
• Remain in your home if you choose.  
• Manage your own money or choose someone you trust to manage your money on your behalf.  
• Use your rights as a citizen.  
• Choose to speak or not to speak with people.  
• Keep and use your personal clothing and belongings when there is space and no medical reasons not to if you live in a nursing facility or an alternative residential facility. 
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.  
• Receive information on beneficiary and plan information.  

Respect and dignity  

You have the right to: 

• Receive treatment with respect and with due consideration for your dignity and privacy. 
• Participate in decisions regarding your health care, including the right to refuse treatment. 
• Get quality medical services that support your personal beliefs, medical condition and background in a language you understand. You have the right to know about other providers who speak languages other than English. 
• Get interpretation services if you do not speak English. Sign language services are available if you are deaf or have difficulty hearing. You may ask for materials in other formats or languages from Mercy Care Member Services. 
• Get materials in alternative formats (such as large type or audio recording) or in another language.  
• Get notice in writing when any of your health care services are reduced, suspended, terminated or denied. You must follow the instructions in your notification letter. 
• Get the type of information about your treatment that is available to you in a way that helps your understanding given your medical condition.  

Emergency care and specialty services  

You have the right to: 

• Get emergency health care services without the approval of your PCP or Mercy Care when you have a medical emergency. You may go to any hospital emergency room or other setting for emergency care.  
• Get behavioral health services without the approval of your PCP or Mercy Care.  
• See a specialist with a referral from your PCP.  
• Refuse care from a doctor to whom you were referred, and you can ask for a different doctor.  
• Request a second opinion from another Mercy Care doctor.  

Mercy Care Developmental Disabilities 

As a Mercy Care member, you have rights and responsibilities. These rights are listed below. It is important that you read and understand each one. If you have questions, please call Mercy Care Member Services. 

Your rights as a member 

You have the right to exercise your rights. Exercising those rights shall not adversely affect service delivery to you. You have the right to:  

• Know the name of your PCP and/or case manager. 
• Get a copy of the Mercy Care Member Handbook, which includes a description of covered services.  
• Get information about how Mercy Care provides after-hours and emergency care. 
• File a complaint about Mercy Care or its subcontractors. 
• Request information about the structure and operations of Mercy Care or their subcontractors.  
• Get information about how Mercy Care pays providers, controls costs and uses services. This information includes whether or not Mercy Care has Physician Incentive Plans (PIP) and a description of the PIP.  
• Know whether stop loss insurance is required. 
• Know general grievance results and a summary of member survey results. 
• Get information about your costs to get services or treatments that are not covered by Mercy Care.  
• Get information about how to get services, including services requiring authorization. 
• Get information about how Mercy Care evaluates new technology to include as a covered service.  
• Get information about changes to your services or what actions to take when your PCP leaves Mercy Care.  
• Get fair treatment and covered services without concern about race, ethnicity, national origin (to include those with limited English proficiency), religion, gender, age, mental or physical disability, sexual orientation, genetic information, ability to pay, or ability to speak English.  
• Get information about how medical decisions can be made for you when you are not able to make them.  

Confidentiality and confidentiality limitations  

You have the right to: 

• Privacy and confidentiality of your health care information. 
• Talk to health care professionals privately. 
• Get a copy of the “Privacy Rights” notice in your welcome packet. The notice has information on ways Mercy Care uses your records, which includes information on your health plan activities and payments for services. Your health care information will be kept private and confidential. It will be given out only with your permission or if the law allows it.  
• Know about health care privacy. (See the “Health plan Notices of Privacy Practices” section.)  
• Know about limits to confidentiality. There are times when we cannot keep information confidential. The law doesn’t protect the following information: 
   
  • If you commit a crime or threaten to commit a crime at the provider’s office or clinic or against any person who works there, the provider must call the police.  
  • If you’re going to hurt another person, we must let that person know so that he or she can protect himself or herself. We must also call the police.  
  • We must also report suspected child abuse to local authorities.  
  • If there is a danger that you might hurt yourself, we must try to protect you. If this happens, we may need to talk to other people in your life or other service providers (e.g., hospitals and other counselors) to protect you. We’ll only share information necessary to keep you safe. 
• Know the other times when providers can share certain health information with family members and others involved in your care. For example, if:
   
  • You verbally agree to share the information. 
  • You have an opportunity to object to sharing information, but don’t object. For example, if you allow someone to come into an exam room during an appointment, the provider can assume that you don’t object to sharing information during that visit. 
  • It’s an emergency, or you don’t have the capacity to make health care decisions, and the provider believes disclosing information is in your best interest. 
  • The provider believes you’re a serious and imminent threat to your health or safety, or someone else’s health and safety. 
  • The provider uses the information to notify a family member of the member’s location, general condition or death. 
  • The provider is following other laws requiring they share information.  
• Know the other times when your information is shared without first getting your written permission to help arrange and pay for your care. These times could include the sharing of information with:
    
  • Physicians and other agencies providing health, social, or welfare services 
  • Your medical primary care provider 
  • Certain state agencies and schools following the law, involved in your care and treatment, as needed 
  • Members of the clinical team involved in your care  
• Know the other times when it may be helpful to share your behavioral health information with other agencies, such as schools or state agencies. This is done within the limits of the applicable regulations. Your written permission may be required before your information is shared. 
• Get a second opinion from a qualified health care professional within the network or have a second opinion arranged outside of the network at no cost to you if there are no other in network options. For more information, you can call Mercy Care at 602-263-3000 or 1-800-624-3879 (TTY 711).  
• Receive information on treatment options and alternatives, appropriate to your condition, in a way that you are able to understand. It should also be shared with you in a way that allows you to participate in decisions about your health care.  
• Know about advance directives.  
• Prepare an advance directive and know how to have medical decisions made for you if you are not able to make them for yourself.  

Treatment decisions 

You have the right to:   

• Agree to, or refuse, treatment and to choose other treatment options available to you. You can get this information in a way that helps your understanding and is appropriate to your medical condition.  
• Choose a Mercy Care PCP to coordinate your health care.  
• Change your PCP.  
• Talk with your PCP to get complete and current information about your health care and condition. This will help you and/or your family understand your condition and be a part of making decisions about your health care.  
• Within the limits of applicable regulations, Mercy Care staff may help manage your health care by working with you, community and state agencies, schools, and your doctor. 
• Get information about which medical procedures you will have and who will perform them.  
• Get a second opinion from a qualified health care professional within the network.  
• Get a second opinion arranged outside of the network, at no cost to you, only if there is not adequate in network coverage.  
• Know treatment choices or types of care available to you and the benefits and/or drawbacks of each choice.  
• Have treatment choices presented to you in a way that you can understand.  
• Refuse care from a doctor to whom you were referred, and you can ask for a different doctor.  
• Choose someone to be with you for treatments and exams.  
• Have a female in the room for breast and pelvic exams.  
• Say “no” to treatment, services or PCPs. Your eligibility or medical care does not depend on your agreement to follow a treatment plan. You will be informed about what may happen to your health if you do not have the treatment.  
• Receive notice from us in writing when any health care services requested by your PCP are reduced, suspended, terminated or denied. You must follow the instructions in the notification letter sent to you.  

Members who are part of Division of Developmental Disabilities  

• You have the right to develop a plan with their caregiver provider agency to decide your preferences when your caregiver is late or does not show up.  

Your rights under the Home and Community Based Services (HCBS) Rules  

Mercy Care works to ensure that all staff and providers work in a manner consistent with a person-centered approach that respects and enhances a member’s right of choice, integration and autonomy. You have the right to: 

• Privacy, dignity and respect, and freedom from coercion and restraint.  
• Make requests in the way your services and supports are delivered.  
• Live in the least restrictive setting. 
• Actively engage and participate in your community.  

Advance directives  

• You have the right to be provided with information about creating advance directives. Advance directives tell others how to make medical decisions for you if you are not able to make them for yourself.  

Medical records requests  

• At no cost to you, you have the right to annually request and receive one copy of your medical records and/ or inspect your medical records. You may not be able to get a copy of medical records if the record includes any of the following information: psychotherapy notes put together for a civil, criminal or administrative action; protected health information that is subject to the Federal Clinical Laboratory Improvements Amendments of 1988; or protected health information that is exempt due to federal codes of regulation.  
• Mercy Care will reply to your request within 30 days. Mercy Care’s reply will include a copy of the requested record or a letter denying the request. The written denial letter will include the basis for the denial and information on ways to get the denial reviewed.  
• You have the right to request an amendment to your medical records. Mercy Care may ask that you put this request in writing. If the amendment is made, whole or in part, we will take all steps necessary to do this in a timely manner and let you know about changes that are made.  
• Mercy Care has the right to deny your request to amend your medical records. If the request is denied, whole or in part, then Mercy Care will provide you with a written denial within 60 days. The written denial includes the basis for the denial, notification of your right to submit a written statement disagreeing with the denial and how to file the statement.  

Reporting your concerns  

You have the right to: 

• Tell Mercy Care about any complaints or issues you have with your health care services. 
• File an appeal with Mercy Care and get a decision in a reasonable amount of time. 
• Give Mercy Care suggestions about changes to policies and services. 
• Complain about Mercy Care.  

Personal rights  

You have the right to: 

• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.  
• Receive information on beneficiary and plan information.  

Respect and dignity 

You have the right to:  

• Get treatment with respect and with due consideration for your dignity and privacy.  
• Participate in decisions regarding your health care, including the right to refuse treatment. 
• Get quality medical services that support your personal beliefs, medical condition and background. You can get these services in a language you understand. You have the right to know about other providers who speak languages other than English. 
• Get interpretation services if you do not speak English. Sign language services are available if you are deaf or have difficulty hearing. You may ask for materials in other formats or languages from Mercy Care Member Services. 
• Get the type of information about your treatment that is available to you in a way that helps your understanding given your medical condition.  

Emergency care and specialty services  

You have the right to:  

• Get emergency health care services without the approval of your PCP or Mercy Care when you have a medical emergency. You may go to any hospital emergency room or other setting for emergency care.  
• Get behavioral health services without the approval of your PCP or Mercy Care. 
• See a specialist with a referral from your PCP. 
• Refuse care from a doctor you were referred to, and you can ask for a different doctor. 
• Request a second opinion from another Mercy Care doctor. 

Mercy Care Advantage 

As a member of Mercy Care Advantage, you have rights and responsibilities, and they are listed below. If you have any questions, 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.  

SECTION 1: Our plan must honor your rights and cultural sensitivities as a member of the plan 

Section 1.1: We must provide information in a way that works for you and consistent with your cultural sensitivities (in languages other than English, in braille, in large print, or other alternate formats, etc.)  

Debemos proveer información en una forma que funcione para usted (en idiomas distintos inglés, en braille, en letra grande, o en otros formatos alternos, etc.) 

Your plan is required to ensure that all services, both clinical and non-clinical, are provided in a culturally competent manner and are accessible to all enrollees, including those with limited English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds. Examples of how a plan may meet these accessibility requirements include, but are not limited to, provision of translator services, interpreter services, teletypewriters, or TTY (text telephone or teletypewriter phone) connection.  

Se requiere que su plan garantice que todos los servicios, tanto clínicos como no clínicos, se brinden de una manera culturalmente competente y sean accesibles para todos los inscritos, incluidos aquellos con dominio limitado del inglés, habilidades de lectura limitadas, incapacidad auditiva o aquellos con diversos orígenes culturales y étnicos. Los ejemplos de cómo un plan puede cumplir con estos requisitos de accesibilidad incluyen, entre otros, la prestación de servicios de traductor, servicios de intérprete, teletipos o conexión TTY (teléfono de texto o teléfono de teletipo).  

Our plan has free interpreter services available to answer questions from non-English speaking members. We can provide certain written materials in languages other than English and Spanish. We can also give you information in braille, in large print, or other alternate formats at no cost if you need it. We are required to give you information about the plan’s benefits in a format that is accessible and appropriate for you. To get information from us in a way that works for you, please call Member Services.  

Nuestro plan cuenta con personas y servicios de interpretación gratuitos disponibles para contestar preguntas de los miembros discapacitados y de aquellos que no hablan inglés. Nosotros también podemos proveerle información en braille, en letra grande, o en otros formatos alternos sin costo si usted lo necesita. Se requiere que nosotros le proveamos información sobre los beneficios del plan en un formato que sea accesible y apropiado para usted. Para obtener información de nosotros de una manera que funcione para usted, por favor llame a Servicios al Miembro (los números de teléfono aparecen en la contraportada de este folleto).  

Our plan is required to give female enrollees the option of direct access to a women’s health specialist within the network for women’s routine and preventive health care services. 

If providers in the plan’s network for a specialty are not available, it is the plan’s responsibility to locate specialty providers outside the network who will provide you with the necessary care. In this case, you will only pay in-network cost sharing. If you find yourself in a situation where there are no specialists in the plan’s network that cover a service you need, call the plan for information on where to go to obtain this service at in-network cost sharing.  

Nuestro plan es necesario para dar a las mujeres inscritas la opción de acceso directo a un especialista en salud de la mujer dentro de la red para los servicios de atención médica preventiva y de rutina para las mujeres.  

Si los proveedores de la red del plan para una especialidad no están disponibles, es responsabilidad del plan localizar proveedores especializados fuera de la red que le brindarán la atención necesaria. En este caso, solo pagará costos compartidos dentro de la red. Si se encuentra en una situación en la que no hay especialistas en la red del plan que cubran un servicio que necesita, llame al plan para obtener información sobre dónde ir para obtener este servicio a costos compartidos dentro de la red.  

If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711). Representatives are available 8:00 a.m. to 8:00 p.m., 7 days a week. You may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights 1-800-368-1019 or TTY 1-800-537-7697.  

Si tiene usted cualquier problema obteniendo información de nuestro plan en un formato accesible y apropiado para usted, por favor llame a Servicios al Miembro para presentar una queja al 602-586-1730 ó al 1-877-436-5288 (TTY al 711). Los representantes están disponibles de 8:00 a.m. a 8:00 p.m., 7 días de la semana. Usted también puede presentar una queja con Medicare llamando al 1-800-MEDICARE (1-800-633-4227) ó directamente con la Oficina de Derechos Civiles. La información de contacto se incluye en esta Evidencia de Cobertura, o usted puede ponerse en contacto con Servicios al Miembro al 602-586-1730 ó al 1-877-436-5288 (TTY al 711) para información adicional. 

Section 1.2: We must ensure that you get timely access to your covered services and drugs 

You have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services. You also have the right to go to a women’s health specialist (such as a gynecologist) without a referral.  

You have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.  

If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter 9 tells what you can do. 

Section 1.3: We must protect the privacy of your personal health information 

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.  

• Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.  
• You have rights related to your information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice,” that tells about these rights and explains how we protect the privacy of your health information.  

How do we protect the privacy of your health information?  

• We make sure that unauthorized people don’t see or change your records.  
• Except for the circumstances noted below, if we intend to give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you or someone you have given legal power to make decisions for you first.  
• There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law.
    
  • We are required to release health information to government agencies that are checking on quality of care.  
  • Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations; typically, this requires that information that uniquely identifies you not be shared. 

You can see the information in your records and know how it has been shared with others  

You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your health care provider to decide whether the changes should be made.  

You have the right to know how your health information has been shared with others for any purposes that are not routine.  

If you have questions or concerns about the privacy of your personal health information, please call Member Services. 

Notice of Privacy Practices  

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.  

What we mean when we use the words “health information”  

We use the words “health information” when we mean information that identifies you. Examples include your:  

• Name  
• Date of birth  
• Health care you received  
• Amounts paid for your care  

How we use and share your health information  

Help take care of you: We may use your health information to help with your health care. We also use it to decide what services your benefits cover. We may tell you about services you can get. This could be checkups or medical tests. We may also remind you of appointments. We may share your health information with other people who give you care. This could be doctors or drug stores. We may use a private internet website to share your health information with the people who give you care. If you are no longer with our plan, with your okay, we will give your health information to your new doctor.  

Family and friends: We may share your health information with someone who is helping you. They may be helping with your care or helping pay for your care. For example, if you have an accident, we may need to talk with one of these people. If you do not want us to give out your health information call us.  

If you are under eighteen and don’t want us to give your health information to your parents. Call us. We can help in some cases if allowed by state law.  

For payment: We may give your health information to others who pay for your care. Your doctor must give us a claim form that includes your health information. We may also use your health information to look at the care your doctor gives you. We can also check your use of health services.  

Health care operations: We may use your health information to help us do our job. For example, we may use your health information for:  

• Health promotion  
• Case management  
• Quality improvement  
• Fraud prevention  
• Disease prevention 
• Legal matters 

A case manager may work with your doctor. They may tell you about programs or places that can help you with your health problem. When you call us with questions, we need to look at your health information to give you answers.  

Sharing with other businesses  

We may share your health information with other businesses. We do this for the reasons we explained above. For example, you may have transportation covered in your plan. We may share your health information with them to help you get to the doctor’s office. We will tell them if you are in a motorized wheelchair so they send a van instead of a car to pick you up.  

Other reasons we might share your health information  

We also may share your health information for these reasons:  

• Public safety — To help with things like child abuse. Threats to public health.  
• Research — To researchers. After care is taken to protect your information.  
• Business partners — To people that provide services to us. They promise to keep your information safe.  
• Industry regulation — To state and federal agencies. They check us to make sure we are doing a good job.  
• Law enforcement — To federal, state and local enforcement people.  
• Legal actions — To courts for a lawsuit or legal matter.  

Reasons that we will need your written okay  

Except for what we explained above, we will ask for your okay before using or sharing your health information. For example, we will get your okay:  

• For marketing reasons that have nothing to do with your health plan.  
• Before sharing any psychotherapy notes.  
• For the sale of your health information.  
• For other reasons as required by law.  

You can cancel your okay at any time. To cancel your okay, write to us. We cannot use or share your genetic information when we make the decision to provide your health care insurance.  

What are your rights  

You have the right to look at your health information.  

• You can ask us for a copy of it.  
• You can ask for your medical records. Call your doctor’s office or the place where you were treated. 

You have the right to ask us to change your health information.  

• You can ask us to change your health information if you think it is not right.  
• If we don’t agree with the change you asked for. Ask us to file a written statement of disagreement. 

You have the right to get a list of people or groups that we have shared your health information with. 

You have the right to ask for a private way to be in touch with you.  

• If you think the way we keep in touch with you is not private enough, call us.  
• We will do our best to be in touch with you in a way that is more private.  

You have the right to ask for special care in how we use or share your health information.  

• We may use or share your health information in the ways we describe in this notice.  
• You can ask us not to use or share your information in these ways. This includes sharing with people involved in your health care.  
• We don’t have to agree. But we will think about it carefully.  

You have the right to know if your health information was shared without your okay.  

• We will tell you if we do this in a letter.  

Call us toll free at 1-800-624-3879, (TTY 711) to:  

• Ask us to do any of the things above.  
• Ask us for a paper copy of this notice.  
• Ask us any questions about the notice.  

You also have the right to send us a complaint. If you think your rights were violated, write to us at: 

Mercy Care  
Attn: Compliance  
4750 44th Place, Suite 150  
Phoenix, AZ 85040  

You also can file a complaint with the Department of Health and Human Services, Office of Civil Rights. Call us to get the address.  

If you are unhappy and tell the Office of Civil Rights, you will not lose plan membership or health care services. We will not use your complaint against you.  

Protecting your information  

We protect your health information with specific procedures. For example, we protect entry to our computers and buildings. This helps us to block unauthorized entry. We follow all applicable state and federal laws for the protection of your health information. 

Will we change this notice  

By law, we must keep your health information private. We must follow what we say in this notice. We also have the right to change this notice. If we change this notice, the changes apply to all of your information we have or will get in the future. You can get a copy of the most recent notice. 

Section 1.4: We must give you information about the plan, its network of providers, and your covered services 

As a member of Mercy Care Advantage, you have the right to get several kinds of information from us.  

If you want any of the following kinds of information, please call Member Services:  

• Information about our plan. This includes, for example, information about the plan’s financial condition.  
• Information about our network providers and pharmacies. You have the right to get information about the qualifications of the providers and pharmacies in our network and how we pay the providers in our network.  
• Information about your coverage and the rules you must follow when using your coverage. Chapters 3 and 4 provide information regarding medical services. Chapters 5 and 6 provide information about Part D prescription drug coverage.  
• Information about why something is not covered and what you can do about it. Chapter 9 provides information on asking for a written explanation on why a medical service or Part D drug is not covered or if your coverage is restricted. Chapter 9 also provides information on asking us to change a decision, also called an appeal. 

Section 1.5: We must support your right to make decisions about your care 

You have the right to know your treatment options and participate in decisions about your health care 

You have the right to get full information from your doctors and other health care providers. Your providers must explain your medical condition and your treatment choices in a way that you can understand.  

You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:  

• To know about all of your choices. You have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely.  
• To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.  
• The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result.  

You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself  

Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:  

• Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.  
• Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself.  

The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives.  

If you want to use an “advance directive” to give your instructions, here is what to do:  

• Get the form. You can get an advance directive form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also contact Member Services to ask for the forms.  
• Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.  
• Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form who can make decisions for you if you can’t. You may want to give copies to close friends or family members. Keep a copy at home.  

If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. 

• The hospital will ask you whether you have signed an advance directive form and whether you have it with you.  
• If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.  

Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive.  

What if your instructions are not followed?  

If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the Arizona Attorney General’s Office, Civil Rights Division at 602-542-5263 or 1-877-491-5742, TDD 602-542-5002.  

Resources  

There are groups you can contact who will act as an advocate for you. Health advocacy involves direct service to you and your family, which can help promote health and access to health care. An advocate is anyone who supports and promotes your rights.  

There are several advocacy resources listed below.  

Arizona Attorney General’s Office  
2005 N. Central Ave.  
Phoenix, AZ 85004  
602-542-5025
www.azag.gov  

Arizona Attorney General’s Office — Tucson  
400 W. Congress, Ste. 315  
Tucson, AZ 85701  
520-628-6504

Department of Economic Security  
Aging and Adult Administration  
1789 W. Jefferson St.  
Phoenix, AZ 85007  
602-542-4446
https://des.az.gov/  

Your local Area Agency on Aging or your local senior center may also have forms and information.  

The following national organization also provides health care directive forms and information: 

AARP  
601 E. St., N.W.  
Washington, D.C. 20049  
1-888-687-2277
https://states.aarp.org/arizona/  

The following organizations will provide information and answer questions about health care directives and related legal matters:  

Arizona Senior Citizens Law Project  
(Offers assistance to seniors in Maricopa County)  
4146 N 12th St.  
Phoenix, AZ 85014  
602-252-6710

Community Legal Services  
305 S. 2nd Ave.  
Phoenix, AZ 85003  
602-258-3434  
www.clsaz.org

Section 1.6: You have the right to make complaints and to ask us to reconsider decisions we have made 

If you have any problems, concerns, or complaints and need to request coverage, or make an appeal, Chapter 9 of this document tells what you can do. Whatever you do — ask for a coverage decision, make an appeal, or make a complaint — we are required to treat you fairly. 

Section 1.7: What can you do if you believe you are being treated unfairly or your rights are not being respected? 

If it is about discrimination, call the Office for Civil Rights  

If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, sexual orientation, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.  

Is it about something else?  

If you believe you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having:  

• You can call Member Services.  
• You can call the SHIP. For details, go to Chapter 2, Section 3. 
• Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048). 

Section 1.8: How to get more information about your rights 

There are several places where you can get more information about your rights:  

• You can call Member Services.  
• You can call the SHIP. For details, go to Chapter 2, Section 3.  
• You can contact Medicare.  
  • You can visit the Medicare website to read or download the publication “Medicare Rights & Protections.” (The publication is available at: https://www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf.)  
  • Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048). 

SECTION 2: You have some responsibilities as a member of the plan 

Things you need to do as a member of the plan are listed below. If you have any questions, please call Member Services.  

• Get familiar with your covered services and the rules you must follow to get these covered services. Use this Evidence of Coverage to learn what is covered for you and the rules you need to follow to get your covered services.  
  
  
  • Chapters 3 and 4 give the details about your medical services.  
  • Chapters 5 and 6 give the details about your Part D prescription drug coverage.  
• If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Chapter 1 tells you about coordinating these benefits.  
• Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card and your AHCCCS (Medicaid) card whenever you get your medical care or Part D prescription drugs.  
• Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.
    
  • To help get the best care, tell your doctors and other health providers about your health problems. Follow the treatment plans and instructions that you and your doctors agree upon. 
  • Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.  
  • If you have any questions, be sure to ask and get an answer you can understand.  
• Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices.
   
  
• Pay what you owe. As a plan member, you are responsible for these payments:
    
  • You must continue to pay your Medicare premiums to remain a member of the plan. For most of your medical services or drugs covered by the plan, you must pay your share of the cost when you get the service or drug.  
  • If you are required to pay the extra amount for Part D because of your higher income (as reported on your last tax return), you must continue to pay the extra amount directly to the government to remain a member of the plan.  
• If you move within our service area, we need to know so we can keep your membership record up to date and know how to contact you. 
• If you move outside of our plan service area, you cannot remain a member of our plan.  
• If you move, it is also important to tell Social Security (or the Railroad Retirement Board).