Member Resources


The Member Resources page is a categorized list of documents and links to provide you with information related to your benefits and the health plan. Important forms, instructions and general information is also available below.

Members:
This plan is available to anyone who has both Medical Assistance from the State and Medicare. Co-pays may vary based on the level of Extra Help you receive. Please contact the plan for further details.

For information on benefits, co-payments, co-insurance and deductibles please refer to the Summary of Benefits and Evidence of Coverage.  A list of any out-of-network coverage rules can also be found in the Summary of Benefits.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. 

You must continue to pay your Medicare Part B premium. If you are a full dual eligible enrollee your monthly Part B premium is paid for by the State.

This information is available for free in other languages. Please contact our Customer Care Center at (877) 874-3935 for additional information. Esta información esta disponible gratis en otros idiomas. Favor de llamar al Centro de Atención al Cliente al (877) 874-3935 para información adicional.


Clicking a category below will expand the selection to reveal documents, forms and links.
  • 2016 Comprehensive Drug Formulary & Requirements
  • 2016 Member Materials
    • Annual Notice of Change (ANOC)
      If you are currently enrolled as a member of Maricopa Care Advantage you will be receiving the Annual Notice of Change. This booklet tells about the changes there will be to the plan's costs and benefits from 2015 to 2016. (Updated 01/2016)...open
    • Aviso Anual de Cambios (Annual Notice of Change)
      Usted está actualmente inscrito como miembro de Maricopa Care Advantage. El próximo año, habrá algunos cambios a los beneficios y costos del plan. Este librete le indica los cambios del 2015 al 2016. Actualizado 01/2016...open
    • Evidence of Coverage
      This booklet gives you the details about your Medicare and Arizona Health Care Cost Containment System or AHCCCS (Medicaid) health care and prescription drug coverage from January 1 – December 31, 2016. It explains how to get coverage for the health care services and prescription drugs you need as well as a list of any out-of-network coverage rules. Updated 01/2016...open
    • Evidencia de Cobertura (Evidence of Coverage)
      La Evidencia de Cobertura contiene detalles sobre su cobertura de Medicare, AHCCCS y recetas medicas, effectivo el 1 de enero hasta el 31 de diciembre del 2016. Explica cómo obtener la cobertura de los servicios de atención médica y medicamentos recetados que necesita, así como una lista de las reglas de cobertura fuera de la red. Actualizado 01/2016...open
    • Resumen de Beneficios (Summary of Benefits)
      Maricopa Care Advantage es un plan de HMO SNP con un contrato de Medicare y un contrato con el programa de Arizona Medicaid. Inscripción en Maricopa Care Advantage depende de la renovación del contrato. Actualizado 10/2015...open
    • Summary of Benefits
      This document tells you some features of our plan effective January 1, 2015 for members in Maricopa County. It doesn’t list every service we cover or list every limitation or exclusion. Maricopa Care Advantage is an HMO SNP plan with a Medicare contract and a contract with the Arizona Medicaid program. Enrollment in Maricopa Care Advantage depends on contract renewal. Updated 10/2015...open
  • Best Available Evidence Policy
    • This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate.
    • Best Available Evidence Policy
      Best Available Evidence Policy...open
  • Clinical Practice Guidelines
  • Fraud, Waste and Abuse
      • MCA is committed to preventing Fraud, Waste and Abuse (FWA). If you suspect a provider or member of fraud and abuse, please contact us at any of the following:
        » Customer Care Department: 1-877-874-3935
        » Confidential and Anonymous Compliance Hotline: 1-888-747-7989
        » U.S. Mail: The University of Arizona Health Plans
             Compliance and Audit Department
             2701 E. Elvira Rd.
             Tucson, AZ 85756
        » Secure Fax: (520) 874-7072
        » Compliance and Audit Department: (520) 874-5075

        Examples of Member Fraud and Abuse include but are not limited to:
        • Lending or selling your AHCCCS Identification Card to anyone.
        • Changing prescriptions written by any MCA provider.
        • Giving incorrect information on your AHCCCS application.
        • Providing false materials or documents.
        • Leaving out important information.

        Examples of Provider Fraud and Abuse include but are not limited to:
        • Use of the Medicaid system by someone who is inappropriate, unqualified, unlicensed or has lost their license.
        • Providing unnecessary medical services leading to unnecessary costs to the program.
        • Charging for medical services not rendered.
        • Not meeting professional standards for health care.

    • For more information on Fraud, Waste, and Abuse, please visit: https://www.medicare.gov/forms-help-and-resources/report-fraud-and-abuse/fraud-and-abuse.html.
  • Grievances
    • Why should you file a grievance?
      You should file a grievance if you were unhappy with any aspect of care that you have received from Maricopa Care Advantage, whether or not remedial action is requested.

      Who can file a grievance?
      You or your authorized representative may file a grievance. You may file in person, by phone or in writing (mail, email, or fax) using the contact information provided below.

      There are two types of grievances:

      1) Grievance. All grievances (which includes complaints, concerns or disputes) which do not meet criteria for an expedited or “fast” grievance will be processed in this category. We will respond to you within 30 calendar days regarding grievances within this classification. If we need more information or the delay will benefit you, we can take up to 14 days more to answer your complaint.

      2) Expedited or “fast” grievance. If you have asked Maricopa Care Advantage to give you a “fast” or expedited response for a coverage determination or a redetermination (appeal) and we have said no, you can make a “fast” or expedited grievance. We must also review as a “fast” or expedited grievance if we extend a review timeframe for a determination and you do not agree with this decision. “Fast” or expedited grievance means we will provide a response to you within 24 hours.

      When should a grievance be filed?
      Your grievance must be made within 60 days after you experience the problem.  For quality of care complaints, you may file your grievance or complaint with Maricopa Care Advantage at the address below and/or directly with the Quality Improvement Organization.  You are not required to file quality of care grievances within the 60-day time period.

      Quality Improvement Organization
      There is a Quality Improvement Organization for each state. For Arizona, it's called Livanta. Livanta has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. Livanta, LLC is an independent organization. It is not connected with our plan.

      Contact information for Livanta, LLC is:
      Livanta, LLC
      9090 Junction Drive, Suite 10
      Anapolis Junction, MD 20701

      CALL           877-588-1123
      TTY              855-887-6668
      FAX             Appeals: 855-694-2929   Other reviews: 844-420-6672
      WEBSITE    www.BFCCQIOAREA5.com

      Where should a grievance be filed or status of one be checked?
      In order to provide you with the quickest response time to your grievance, please file your grievance or check the status of such with the Grievance & Appeals department of Maricopa Care Advantage:

      Maricopa Care Advantage
      Attn: Grievance & Appeals Department
      2701 E. Elvira Road
      Tucson, AZ 85756
      1 (877) 874-3935
      TTY users call 711
      (Fax) 1-866-465-8340
      UAHNGrievanceMailbox@bannerhealth.com

      What happens after filing a grievance?
      Upon receipt of your grievance, Maricopa Care Advantage will send you an acknowledgement notice to let you know that we have received your grievance and we are beginning the investigation process into your complaint. We contact each party involved and request additional information (this may include notes, statements from others present during the event, police reports, etc.). At any time during our investigation, you may submit additional information and/or evidence regarding your grievance. We record each grievance separately and maintain all records related to each by a case number which is assigned upon receipt. If corrective action is required, we work with the appropriate areas, vendors, contractors, and/or subcontractors to remedy the actions. We will provide notification to all concerned parties at the closure of the investigation. Maricopa Care Advantage’s Grievance & Appeals Department
      responds to each grievance in writing regardless of how it was received.

    • Appointment of Representative Form (English)
      To appoint a representative, you can do one of two things. Fill out the CMS Appointment of Representative Form (CMS Form-1696) or create a document in your own words that contains all the elements of CMS Form-1696. We will accept both. Then send either option to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision. ...open
    • Nombramiento de Representante
      To appoint a representative, you can do one of two things. Fill out the CMS Appointment of Representative Form (CMS Form-1696) or create a document in your own words that contains all the elements of CMS Form-1696. We will accept both. Then send either option to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision....open
  • Language Interpretation Services
    • We have free interpreter services to answer any questions you may have about our health or prescription drug plan. To get an interpreter, please call us at 1-877-874-3935.

  • Medicare Plan Star Ratings
    • The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans. 

      Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • Member Rights and Responsibilities
  • Notice of Privacy Practices
    • This notice describes how health information about you may be used and shared.  It also tells you how you can get this information.  Please read it carefully.
  • Over-the-Counter Loyalty Card Program
  • Prescription Drug Transition Policy and Letters
  • Provider & Pharmacy Directory