How Do I

Here are some answers to our most commonly-asked questions.

How Do I?

How do I find a provider?

If the PCP you have been seeing is already part of our network, you can keep seeing him or her. If you are unsure whether your PCP is part of our network, we can find out for you. You can also use our Find a Provider tool.

If your PCP is not part of our network, you need to choose a new one. You can also ask your Nurse Care Manager for help, or phone Member Services.

How do I change my primary care provider?

You may change your PCP for any reason, at any time. To change your PCP, call Member Services. When you call, be sure to tell them if you are seeing a specialist or getting other covered services that need your PCP’s approval, like home health services or durable medical equipment. Member Services will help make sure you can continue the specialty care and other services you’ve been getting. They’ll also check to be sure the new PCP is accepting new patients. For more details, see Chapter 3 in your Evidence of Coverage.

How do I know what services are covered?

Covered services include all the medical care, health care services, supplies, and equipment that are covered by our plan. As a Medicare health plan, MCC of AZ (HMO SNP) must cover all services covered by Original Medicare and may offer additional services. For a complete list of benefits, review the benefits chart in Chapter 4 of your Evidence of Coverage.

How do I request coverage for prescriptions or services?

For prescriptions: you may complete the Request for Medicare Part D Coverage Form here on our website.

For more information, please see Chapter 5 in your Evidence of Coverage.


For services: You, your doctor, or someone else you appoint to act on your behalf may request a coverage decision. This is a decision we make about your medical benefits and coverage, typically about which services, the quantity of services, and the amount we will pay for them.

You can ask for a coverage decision by phone or in writing:

Call: 1-800-424-4509(TTY 711)

Write to:
MCC of AZ (HMO SNP)
Attn: Member Services
58 Charles Street
Cambridge, MA 02141

What happens next?

When we receive your request, we’ll tell you our decision within 14 working days. If your health requires a fast decision, we’ll answer within 72 hours.

In order to get a fast decision, both of the following must be true:

  • The request is for medical care you have not yet received.
  • Using the standard deadline could cause serious harm to your health or hurt your ability to function.
    • If your doctor tell us your health requires a fast decision, we will automatically answer within 72 hours.
    • If you ask for a fast decision without your doctor’s support, we will decide whether to make a fast decision. If we say no, you can appeal.

Some prescriptions and services may require prior authorization from MCC of AZ (HMO SNP).

What are Medicare Part B drugs?

Medicare Part B covers a small number of outpatient prescription drugs under some conditions. Usually, Part B drugs are medical drugs you wouldn’t give to yourself. They are given at a doctor’s office or hospital outpatient setting.

What is prior authorization?

This means MCC of AZ (HMO SNP) must review your coverage request and determine if it is medically necessary. To find out if your request requires prior authorization from the plan, you or your provider must contact Member Services. This must be done before the health provider performs the service. Health providers can call Provider Services at 1-800-424-4509 if they have questions.

  • If prior authorization is needed for the service, the health provider must download and submit a Prior Authorization Form to MCC of AZ (HMO SNP)’s Utilization Management (UM) department.
  • If prior authorization is not needed from the plan, your PCP may still need to provide a referral for a specialist to see you. Your PCP’s office or Member Services can help you figure this out and schedule the appointment if you need help.

 For more information, please see Chapter 9 in your Evidence of Coverage.

 

Do Part B drugs require prior authorization?

Some of these drugs require prior authorization. You can view the list of drugs requiring prior authorization here.

If your treatment includes any of the medical drugs listed, ask your provider if this change affects you. If so, your provider must:

  •  Submit a Prior Authorization request and fax it to MCC of AZ (HMO SNP) at 1-800-656-2390.
  • Give us supporting documentation with all requests.
  • Provide your treatment history information.
Can my family help me make decisions?

Of course! Your family is important and can be involved if you choose. If you would like to have a family member or friend make requests for you, or ask and receive information about you, we’ll ask you to sign a CMS Appointment of Representative form found here.

How do I find a pharmacy that accepts my plan?

There are several ways to find a pharmacy in our network. For the most up-to-date list, use our Find a Provider search tool or our Pharmacy Locator tool. If you need help, ask your Nurse Care Manager or call Member Services.

How do I find out if a drug is covered?

Please check the Formulary/drug list on our website; it is updated monthly.

How do I ask for reimbursement for a prescription?

If you use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. See Chapter 7 in the Evidence of Coverage to learn how to ask the plan to pay you back.

What do I do if my prescription drug gets recalled?

If this happens, we will immediately remove the drug from the Drug List. If you are taking that drug, we will let you know of this change right away. Your prescriber will also know about this change and can work with you to find another drug for your condition.

For an updated list of recalled drugs, visit our Health & Safety Alerts page.

How do I ask for a new member ID card?

Please phone Member Services at 1-800-424-4509 (TTY 711).

How can I contact my Care Coordination Team?

When you join MCC of AZ (HMO SNP), you’ll receive a welcome call from Member Services. They will give you the contact information you’ll need to reach your team. You can also phone Member Services. They can transfer your call to the Nurse Care Manager or take a message so your NCM can call you back.

What do I do if there’s a national or local emergency?

We will do everything possible to provide you with uninterrupted services. Please see our Health & Safety Alerts page on our website for additional contact information.

How do I report fraud, waste or abuse?

If you think an individual, company, or provider is committing fraud, waste or abuse, please report it. Please see Member Responsibilities to learn more.

How do I appeal a decision you made about my healthcare?

Our members have the right to appeal any decision we make that terminates, suspends, delays, reduces or denies a service. A PCP or family member may file an appeal on the member’s behalf if they have the member’s written consent to do so. To file an appeal:

  • You may phone us at 1-800-424-4509 (TTY 711). If you want someone else to phone us on your behalf, like your PCP or a family member, please complete the CMS Appointment of Representative form found here, along with your appeal form.
  • If you prefer to submit your appeal in writing, download the Medicare Redetermination Request Form – First Level of Appeal found here. Provide the details of the medical care you were denied.
  • Submit it to us by fax at 1-855-838-7998. You may also mail it to us at:

    MCC of AZ (HMO SNP)
    Attn: Appeals
    58 Charles Street
    Cambridge, MA 02141

  • You may ask for a standard appeal, which will be answered in writing within 14 days of the date of receipt.
  • You may ask for a fast appeal if you meet two requirements:

– The request must be for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)

– Using the standard timeframe could cause serious harm to your health or your ability to function.

  • If your doctor tells us that your health requires a fast decision, we will automatically agree. If you ask for a fast decision on your own, without your doctor’s support, we will decide whether your health requires a fast decision. If we say no, we will decide within the standard timeframe.
If the plan denies my appeal, is there anything else I can do?

If your appeal is denied, you have the right to make additional appeals. Learn more about your rights by visiting the CMS web page on making appeals.

For Medicare medical services: we automatically forward a second appeal to a qualified independent contractor of CMS. It will not be decided by MCC of AZ (HMO SNP). You don’t need to submit an appeal form unless you wish to provide additional information.

For Medicare pharmacy matters: you must file an appeal using the Medicare Redetermination Request Form – Second Level of Appeal. Your appeal will be reviewed by a qualified independent contractor of CMS. It will not be decided by MCC of AZ (HMO SNP).

  • This appeal will be reviewed by:

    MAXIMUS Federal Services, Inc.
    3750 Monroe Avenue, Suite 703
    Pittsford, NY 14534-1302
    Fax: 1-585-425-5301
    Phone: 1-877-456-5602

  • See Chapter 9 of the Evidence of Coverage for more details.
How do I file a complaint or a grievance?

You can file a grievance with MCC of AZ (HMO SNP).

A member may file a grievance, or a provider may file a grievance on behalf of a member, at the member’s request. A grievance is a type of complaint you make about a problem or issue you have with our plan or a network provider. Typically, complaints are filed for things like:

  • Problems with the quality of care during a hospital stay
  • Wait times that are too long (for prescriptions, medical appointments, etc.)
  • Dissatisfaction with a provider’s behavior

These complaints do not involve coverage or payment decisions.

You must file your complaint within 60 days of the event or incident. To file a complaint, contact us as soon as possible by phone or in writing.

  • Call Member Services at 1-800-424-4509
  • Write to:
    MCC of AZ (HMO SNP)
    Attn: Member Services
    58 Charles Street
    Cambridge, MA 02141
  • Grievances regarding quality of care will be investigated by the quality department. We’ll notify you and/or your designated representative with our findings within 30 days if you filed a standard grievance. If you requested an expedited grievance, we’ll respond within 24 hours. See Chapter 9 of the Evidence of Coverage for more details.

You can file a complaint with the Quality Improvement Organization.

You don’t have to wait until we answer your complaint. You can also make a complaint to the quality improvement organization, Livanta. To file a complaint with Livanta, call 1-877-588-1123 (TTY 1-855-887-6668) Monday through Friday from 9 a.m. to 5 p.m., and 11 a.m. to 3 p.m. on weekends and holidays.

For more information about Livanta, refer to your Evidence of Coverage.

You may file a complaint with Medicare.

You can give feedback or file a complaint at any time about your MCC of AZ (HMO SNP) plan using the Medicare Complaint Form.  Note: by clicking this link you’ll be leaving the MCC of AZ (HMO SNP) website.

The Centers for Medicare & Medicaid Services values your feedback and will use it to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048).

You may also contact the Office of the Medicare Ombudsman (OMO). The OMO helps you with complaints, grievances and information requests. For more information about the OMO, visit their website at www.medicare.com. (Note: by clicking this link you’ll be leaving the MCC of AZ (HMO SNP) website.)

How do I switch to a different health plan?

You may decide that you want to leave our plan. You can do this for any reason. However, you can change health plans only at certain times during the year.

Medicare’s annual open enrollment period starts on October 15 and lasts through December 7. If you change plans during that time, your membership will be effective on January 1 of the following year.

There is also a Special Election Period (SEP) for individuals who have both Medicare Parts A and B and receive any type of assistance from Medicaid.

The SEP starts the month you become dually-eligible and continues as long as you receive Medicaid benefits. However, there are limits in how often it can be used. The SEP allows an individual to enroll in, or disenroll from, an MA plan once per quarter during the first nine months of the calendar year. That means the SEP can be used one time during each of the following time periods:

January – March
April – June
July – September

When you make a request using the SEP, your enrollment status is effective the first day of the month following receipt of the request. Your enrollment in your new plan will also begin on this day. The SEP is considered used during the month it is requested.

Usually, to end your membership in our plan, you simply enroll in another Medicare plan. However, if you want to switch from our plan to Original Medicare but have not selected a separate Medicare prescription drug plan, you must ask to be disenrolled from our plan.

There are two ways you can ask to be disenrolled:

  • Make a request in writing to:
    MCC of AZ (HMO SNP)
    58 Charles Street
    Cambridge, MA 02141
  • Contact Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY 711) 24 hours a day, 7 days a week

For more information, call Member Services at 1-800-424-4509 (TTY 711).

If you leave our plan, it may take some time for your membership to end and your new coverage to take effect. During this time, you are still a member and must continue to get your care as usual through MCC of AZ (HMO SNP).

If you receive services from providers who are not part of our plan before your membership ends, neither we nor Medicare will pay for these services. However, there are a few exceptions:

  • Urgently needed care
  • Emergency care
  • Care that has been approved by us
  • Hospitalization that begins on the last day of membership (our plan will cover this care until discharge)

For more information, your Evidence of Coverage explains the disenrollment rules and your coverage choices after you leave.

Can MCC of AZ (HMO SNP) end my enrollment?

Yes, in certain situations we will end your enrollment. This is called involuntary disenrollment. There may also be situations where you are required to leave our plan, like permanently moving outside our service area. But we are never allowed to ask you to leave the plan because of your health.

For specific information, visit Member Quality/Member Rights/Involuntary Disenrollment.