1. You will receive care that meets your needs in a way that doesn’t judge race, gender, religious beliefs, values, language, how much a person is able to do, age, handicap, or ability to pay.
2. You will be treated with respect and dignity. We understand your need for privacy and confidentiality including protection of any information that identifies you.
3. You will be treated in a safe, supportive and smoke-free environment.
4. You have the right to information about Maricopa Health Plan’s services, health care providers, admission, transfer, discharge, billing policies, and members’ rights and responsibilities.
5. You have the right to choose your primary care physician within the limits of the Maricopa Health Plan network.
6. The law states that you have the right to read or get copies of your medical records at no cost to you. However, your right to access medical records may be denied if the information is psychotherapy notes, compiled for, or in a reasonable anticipation of a civil, criminal or administrative action, protected health information subject to the Federal Clinical Laboratory Improvement Amendments of 1988 or exempt pursuant to 42 CFR 493.3(a)(2).
   • You have the right to have MHP amend or correct your medical records.
   • You have the right to review your medical records if you are denied access to inspect or obtain a copy.
7. You have the right to help in decision making about your health care and Advance Directives (decisions about what kind of care you would like to receive if you become unable to make medical decisions).
8. You have the right to complain about Maricopa Health Plan and/or care provided.
9. You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
10. Your wishes are important. You have the right to the information needed to help you make informed decisions. Here is a list of some, but not all of your rights:
    • You can accept or refuse any treatment. You will be informed of any consequences of refusing treatment.
    • You can receive information on available treatment options and alternatives.
    • You can make Advance Directives and appoint someone to make healthcare decisions for you. You or your representative can change your Advance Directives at any time.
    • You or someone who represents you can take part in resolving problems about your care decisions.
11. You have the right to the following:
    • You can be told about Physician Incentive Plans that affect referral services.
    • You have the right to know that MHP is required to participate in a stop-loss insurance program.
    • You can be told the types of plans Maricopa Health Plan uses for compensation.
    • You can get a summary of member survey results.
12. You have the right to know of providers who speak a language other than English.
13. You have the right to have a list of available PCPs.
14. You have the right to a second opinion from a qualified health care professional within MHP’s network. If an in-network second opinion is not available, you have the right to have a second opinion arranged outside of the MHP network at no cost to you.
15. You have the right to request a copy of the Notice of Privacy Practices at no cost to you. The notice describes Maricopa Health Plan’s privacy practices and how we use health information about you and when we may share that health information with others.

1. It is your responsibility to provide, to the best of your knowledge, information to help the Maricopa Health Plan staff care for you.
2. It is your responsibility to follow instructions and guidelines given by those providing health care.
3. It is your responsibility to know the name of your assigned PCP.
4. It is your and your family members’ responsibility to be considerate of the rights and property of patients and staff. This includes smoking and visitation policies.
5. It is your responsibility to pay your co-payments for care received as soon as possible.
6. It is your responsibility to schedule appointments during medical office hours whenever possible before using urgent care.
7. It is your responsibility to arrive on time and to let the medical office know in advance when you can’t keep an appointment.
8. It is your responsibility to bring immunization records to every appointment for children under 21 years of age.
9. It is your responsibility to watch over children with you at all times.
10. It is your responsibility to cancel your ride when you cancel your appointment.
11. It is your responsibility to NOT behave in a way that disrupts and/or does not allow a doctor to serve you or another patient in a safe way.

Q. What if l have questions, problems or complaints about Maricopa Health Plan?
A. Call Member Services if you have a specific grievance or dissatisfaction with any aspect of your care. For example, this can be a letter called notice of action, or a denial of service by MHP. Interpretation and translation services are available in any language at no cost to you. You may call Member Services to file a grievance (complaint). You may also file your grievance in writing by mailing it to the address listed below. Your grievance will be reviewed and a response will be provided no longer than 90 days from the date that you contact us. Examples of grievances are: service issues, transportation issues, quality of care issues, provider office issues. A grievance does not include any “action” or denial by MHP.
You can mail your grievance to:


Q. Who may file a grievance?
A. All applicants, members, or their authorized representatives, including those enrolled in an AHCCCS Health Plan or fee-for-service program may file a formal grievance. The representative must be authorized in writing.

Appeal and Request for Fair Hearing

Q. What if l disagree with a denied service?
A. If you are dissatisfied with an “action” or denial of services by MHP you may file an “appeal”. An appeal must be filed in writing within 60 days from MHP’s Notice of Action letter.

Q. Who may file an appeal?
A. All applicants, members, or their authorized representatives, including those enrolled in an AHCCCS Health Plan or fee-for-service program, may appeal a decision. The representative must be authorized in writing.

Q. What can I file an appeal for?
A. The reasons you may file an appeal are:

• denial or limited authorization of a requested service, including the type or level of service
• reduction, suspension, or termination of a previously authorized service
• denial, in whole or in part, of payment for a service
• failure to provide services in a timely manner
• failure to act within the timeframe required for standard and expedited resolution of appeals and standard disposition of grievances
• the denial of a rural enrollee’s request to obtain services outside the contractor’s network under 42CFR 438.52 (b)(2)(ii), when the contractor is the only contractor in the rural area

Q. How do I file an appeal?
A. You may write to the MHP Appeals Department, 2701 E. Elvira Road, Tucson, AZ 85756, or you may call and ask to speak to an Appeals Department representative. You may also fax in your request to 1-866-465-8340. Maricopa Health Plan will provide you with a written decision within 30 days of filing the appeal.

Q. What is an Expedited Appeal?
A. You may file an expedited appeal, or it may be filed on your behalf by your provider. It will be approved if MHP determines that the time to process a standard appeal would seriously jeopardize your health, life or ability to attain, maintain or regain maximum function. If an expedited appeal request is not approved, MHP will notify you promptly with oral notice and in writing within two (2) days.

Q. If I am currently receiving the services requested, can I continue to receive them during the appeal process?
A. Yes, but the request must be in writing and be received by MHP within 10 days of the receipt of the notice of action letter. However, you may be responsible for payment of those services if MHP upholds the denial.

Q. How do I request a State Fair Hearing?
A. If you are not satisfied with the appeal decision, you may file a request for State Fair Hearing with MHP. This request must be made in writing to MHP within 30 days of the date of receipt of the appeal decision. MHP will send your appeal file to AHCCCS and a hearing date will be scheduled for you to attend. You may submit your request for hearing to: MHP Appeals Department, 2701 E. Elvira Road, Tucson, AZ 85756. You may also fax in your request to 1-866-465-8340. Additionally, there are Legal Services Programs in your area that may be able to help you with the hearing process. General legal information about your rights can also be found on the internet at the following website: www.azlawhelp.org.

At Maricopa Health Plan (MHP) we care about our members and we value all of the cultural differences that our members possess. Beliefs about the cause, prevention and treatment of illness vary among cultures. These beliefs need to be respected in the practices used to maintain MHP members' health.

At MHP, we know the importance of communication and strive to meet all of our members' needs. MHP can provide interpretative services at no charge.

MHP provides member materials to you in a language or format that may be easier for you to understand.

Call MHP Member Services at 1-800-582-8686 for interpretive services, to find a doctor who understands your cultural needs or for materials in another language or format. These services are provided at no cost to you.

Coordination of Benefits (COB) If you are a member with “other insurance” or are “dual eligible” (which means that you also have Medicare coverage), please take a moment to call Member Services to let us know. When you call us, we will make sure we have the other insurance listed in our system. You may also call the AHCCCS eligibility office to let them know. AHCCCS will then pass the information on to us. Remember, this also includes insurance coverage by divorce or if your child had insurance that is paid by your former spouse.

Sometimes, members with other types of insurance such as Tricare or other commercial plans are approved for AHCCCS. Maricopa Health Plan is responsible for making any co-payment, coinsurance or deductibles, even if the services are provided outside of the Maricopa Health Plan Plan Network.

If a third party insurer (other than Medicare) requires the member to pay any co-payment, coinsurance or deductible, MHP is responsible for making these payments, even if the services are provided outside of the network. MHP is not responsible for paying coinsurance and deductibles that are more than MHP would have paid for the entire service per the contract with the provider performing the service, or the AHCCCS equivalent.

Special Information for our Members who have Medicare Coverage:
If you are a “dual eligible” member, it often means that you have additional benefits that may not be covered under AHCCCS. When we know about your other insurance, it helps us coordinate the care you receive with the other plan. If you have Medicare coverage and you see a doctor that is not on our plan, the charges may not be covered. If you choose to do that without our approval, Maricopa Health Plan may not pay for those services because they were done by a doctor that is not on our plan. It is important that you work with your PCP to be referred to the right doctors. (This does not include emergency services.) Maricopa Health Plan will not cover co-pays or deductibles for services provided outside of the network without authorization. So why should you call Member Services and let us know? Because it will help you get the maximum benefits from both insurance plans!

    NOTE: If you are on a Medicare HMO and have Maricopa Health Plan (MHP), you MUST choose a PCP that is contracted with both plans in order for medical services to be covered.

The law requires doctor and health care facilities to inform you, in writing, of your right to create “Advance Directives” relating to your medical care. Advanced Directives are used to allow you to make medical decisions about yourself should you no longer be able to do so. The two most common Advanced Directives are the Living Will and the Durable Power of Attorney.

The Living Will gives information about whether you want or don’t want life sustaining procedures if you have a condition that cannot be cured or improved.

A Medical Power of Attorney allows you to name a person you trust to decide what type of treatment you will receive if you are unable to decide for yourself.

Even though you have made Advanced Directives, your PCP may still choose whether or not to follow your wishes. You cannot be denied care without these documents, but without written instructions, a judge may have to make a personal and medical decision for you. Tell your family and PCP where you keep your Advance Directives. Ask your PCP to make the Advance Directive a part of your medical record.

Moving Away from the Service Area
If you move out of the country or state of Arizona, you will not be eligible for any AHCCCS plans. Before you move, tell:

• Your health plan, Maricopa Health Plan, by calling Member Services.
• Your PCP.
• The AHCCCS eligibility office.
• Your SSI office, if you are receiving SSI benefits.
• DES, if you receive TANF, food stamps or are on SOBRA.
• For KidsCare (Title XXI) members, please call AHCCCS at 602-417-5437 or the toll-free statewide number, 1-877-764-5437.

You could lose your care paid for by AHCCCS if you do not tell these offices you are moving.

Call Member Services if you have questions about your enrollment or call AHCCCS at 602-417-4000.

If you move to another county you should:

• Tell the eligibility office.
• Call the AHCCCS office to choose a new plan if you are AHCCCS-eligible.
• Call your new plan and choose a provider.

Call Member Services if you have any questions about what to do or call AHCCCS at 602-417-4000.

Definitions:

Abuse by a Provider: Actions that are not wise business or medical practices and result in:

• unnecessary costs to the program
• payment for services that are not medically necessary
• not meeting professional standards for health care

Abuse by a Member: Unnecessary costs to the program because of:

• providing false materials or documents
• leaving out important information

Fraud: Any lie told on purpose that results in you or some other person receiving unnecessary benefits. This includes any act of fraud defined by Federal or State law.

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 Maricopa Health Plan provider.
• Giving incorrect information on your AHCCCS application.

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.
• Not meeting professional standards for health care.

How to Report Fraud and Abuse:
If you suspect a Maricopa Health Plan provider or member of fraud and abuse, please call MHP Member Services or AHCCCS at 1-800-962-6690 to report it.

Penalties:
A person who is suspected of fraud and/or abuse of the AHCCCS system will be reported to AHCCCS. Penalties for people involved in fraud and/or abuse may be both civil and criminal.