With Mercy Care Advantage (HMO SNP), members pay No ...
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With Mercy Care Advantage (HMO SNP), members pay No Monthly Plan Premiums Covered Benefts Plan Benefts Amount you pay Ofce Visits $0 Emergency Care (U.S. Only) $0 Urgently Needed Care (U.S. Only) $0 Ambulance Services (Medicare-Covered) $0 Inpatent Hospital Care $0 Home Health Care $0 Outpatent Services/Surgery $0 Inpatent Hospital Care $0 X-Ray/Lab Services $0 Flu/Pneumonia Vaccines $0 Wellness Exam (1 routne exam per year) $0 Covered Benefts Plan Benefts Amount you pay Transportaton 36 one‑way routne rides per calendar year to MCA supplemental benefts $0 Vision Up to 1 supplemental routne eye exam every calendar year. $400 limit every 2 years for supplemental eyewear $0 Preventve Dental Up to 1 oral exam; cleaning; and fuoride treatment every 6 months $0 Dental X-Ray 1 per calendar year. 1 full mouth/Panorex X-Ray every 3 years $0 Comprehensive Dental $4,800 limit per calendar year for comprehensive dental benefts $0 Hearing Aids $1,900 limit every 2 years for supplemental hearing aids $0 Podiatry Services Up to 1 supplemental routne visit every 3 months $0 Chiropractc Services Up to 12 supplemental routne visits per year $0 Over-the-Counter (OTC) Items Up to $80 per month for OTC items and personal health and wellness products $0 Health/Wellness Classes Nutritonal training, smoking cessaton, diabetc educator $0 Telehealth Online doctors for a variety of medical conditons $0 Nursing Hotline Afer‑hours health line available to talk with a registered nurse $0 Meals 28 home-delivered meals upon each hospital discharge $0 Mercy Care Advantage includes coverage for Part D Prescription Drugs. Copay amounts are based on the level of “Extra Help” you receive from Medicare to help pay for the costs of your Medicare prescription drug coverage. For the AHCCCS Complete Care (ACC) Medicaid program our service area is Gila, Maricopa and Pinal counties; for ALTCS Medicaid our service area is Gila, Maricopa, Pima, and Pinal counties. For the Arizona Division of Developmental Disabilities, our service area is all counties in the State of Arizona. Medicare and AHCCCS Medicaid eligibility are verified at the time of enrollment. You must receive all routine care from Mercy Care Advantage plan providers, except in an emergency or urgently needed care situation or for kidney dialysis services received from a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cost sharing amounts are based on your level of Medicaid eligibility. Mercy Care Advantage is an HMO SNP with a Medicare contract and a contract with the Arizona Medicaid Program. Enrollment in Mercy Care Advantage depends on contract renewal. Got AHCCCS? ¿Tiene AHCCCS? Got Medicare? ¿Tiene Medicare? 2022 Benefts at a Glance Vistazo a los Benefcios www.MercyCareAZ.org
Transcript of With Mercy Care Advantage (HMO SNP), members pay No ...
With Mercy Care Advantage (HMO SNP), members pay No Monthly Plan PremiumsCovered Benefits Plan Benefits Amount you pay
Office Visits $0
Emergency Care (U.S. Only) $0
Urgently Needed Care (U.S. Only) $0
Ambulance Services (Medicare-Covered) $0
Inpatient Hospital Care $0
Home Health Care $0
Outpatient Services/Surgery $0
Inpatient Hospital Care $0
X-Ray/Lab Services $0
Flu/Pneumonia Vaccines $0
Wellness Exam (1 routine exam per year) $0
Covered Benefits Plan Benefits Amount you pay
Transportation 36 one‑way routine rides per calendar year to MCA supplemental benefits $0
Vision Up to 1 supplemental routine eye exam every calendar year. $400 limit every 2 years for supplemental eyewear $0
Preventive Dental Up to 1 oral exam; cleaning; and fluoride treatment every 6 months $0
Dental X-Ray 1 per calendar year. 1 full mouth/Panorex X-Ray every 3 years $0
Comprehensive Dental $4,800 limit per calendar year for comprehensive dental benefits $0
Hearing Aids $1,900 limit every 2 years for supplemental hearing aids $0
Podiatry Services Up to 1 supplemental routine visit every 3 months $0
Chiropractic Services Up to 12 supplemental routine visits per year $0
Over-the-Counter (OTC) Items Up to $80 per month for OTC items and personal health and wellness products $0
Health/Wellness Classes Nutritional training, smoking cessation, diabetic educator $0
Telehealth Online doctors for a variety of medical conditions $0
Nursing Hotline After‑hours health line available to talk with a registered nurse $0
Meals 28 home-delivered meals upon each hospital discharge $0
Mercy Care Advantage includes coverage for Part D Prescription Drugs. Copay amounts are based on the level of “Extra Help” you receive from Medicare to help pay for the costs of your Medicare prescription drug coverage. For the AHCCCS Complete Care (ACC) Medicaid program our service area is Gila, Maricopa and Pinal counties; for ALTCS Medicaid our service area is Gila, Maricopa, Pima, and Pinal counties. For the Arizona Division of Developmental Disabilities, our service area is all counties in the State of Arizona. Medicare and AHCCCS Medicaid eligibility are verified at the time of enrollment. You must receive all routine care from Mercy Care Advantage plan providers, except in an emergency or urgently needed care situation or for kidney dialysis services received from a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Cost sharing amounts are based on your level of Medicaid eligibility.
Mercy Care Advantage is an HMO SNP with a Medicare contract and a contract with the Arizona Medicaid Program. Enrollment in Mercy Care Advantage depends on contract renewal.
Got AHCCCS?
¿Tiene AHCCCS?
Got Medicare?
¿Tiene Medicare?
2022 Benefits at a Glance Vistazo a los Beneficios
www.MercyCareAZ.org
Con Mercy Care Advantage (HMO SNP), los miembros No Pagan Primas Mensuales del Plan
Beneficios Cubiertos Beneficios del Plan Cantidad que usted paga
Visitas al Consultorio $0
Atención de Emergencia (Sólo E.U.A.) $0
Cuidado Urgentemente Necesario (Sólo E.U.A.)
$0
Servicios de Ambulancia (Cubiertos por Medicare)
$0
Cuidado de Hospital como Paciente Interno
$0
Cuidado de la Salud en el Hogar $0
Servicios/Cirugía como Paciente Externo $0
Cuidado de la Salud Mental como Paciente Interno
$0
Rayos X/Servicios de Laboratorio $0
Vacunas Contra la Influenza/Gripa/ Neumonía
$0
Examen de Bienestar (1 examen de rutina al año)
$0
Beneficios Cubiertos Beneficios del Plan Cantidad que usted paga
Transporte 36 viajes sencillos (de ida o de vuelta) de rutina por año de calendario para los beneficios suplementarios de MCA $0
Cuidado de la Vista Hasta 1 examen suplementario de rutina de los ojos cada año de calendario. Límite de $400 cada 2 años para anteojos suplementarios $0
Cuidado Dental Preventivo Hasta 1 examen oral; limpieza; y tratamiento con fluoruro cada 6 meses $0
Rayos X Dentales 1 por año de calendario. 1 toma de rayos x Panorex de toda la boca cada 3 años $0
Cuidado Dental Completo Límite de $4,800 por año de calendario en beneficios dentales integrales $0
Aparatos Auditivos Límite de $1,900 cada 2 años para aparatos auditivos suplementarios $0
Servicios de Podiatría Hasta 1 visita suplementaria de rutina cada 3 meses $0
Servicios de Quiropráctico Hasta 12 visitas suplementarias de rutina por año $0
Artículos Sin Prescripción “OTC” Hasta $80 al mes para artículos sin prescripción para la salud y el bienestar personal $0
Clases de Salud/Bienestar Capacitación nutricional, ayuda para dejar de fumar, educación sobre la diabetes $0
Telesalud Doctores en línea para una variedad de condiciones médicas $0
Línea Directa de Enfermería Línea de salud disponible en horas no laborales para hablar con una enfermera registrada $0
Comidas 28 comidas de entrega a domicilio cada vez que se le dé de alta del hospital $0
Mercy Care Advantage incluye cobertura de los Medicamentos de Prescripción de la Parte D. Las cantidades del copago están basadas en el nivel de “Ayuda Extra” que usted reciba de Medicare para ayudar a pagar por los costos de su cobertura de Medicare para los medicamentos de prescripción. Para el programa AHCCCS Complete Care (ACC) de Medicaid nuestra área de servicio son los condados Gila, Maricopa y Pinal; para ALTCS de Medicaid nuestra área de servicio son los condados Gila, Maricopa, Pima y Pinal. Para la División de Discapacidades del Desarrollo de Arizona, nuestra área de servicio son todos los condados en el Estado de Arizona. La elegibilidad a Medicare y AHCCCS de Medicaid es verificada en el momento de la inscripción. Usted debe recibir toda la atención de rutina de los proveedores del plan Mercy Care Advantage, excepto en una situación de emergencia o de atención urgentemente necesaria o para los servicios de diálisis del riñón recibidos de una instalación de diálisis certificada por Medicare cuando usted se encuentre temporalmente fuera del área de servicio del plan. El formulario, la red de farmacias, y/o la red de proveedores pueden cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario. Las cantidades del costo compartido se basan en su nivel de elegibilidad a Medicaid. Mercy Care Advantage es una organización HMO SNP bajo contrato con Medicare y un contrato con el Programa Medicaid de Arizona. La inscripción en Mercy Care Advantage depende de la renovación del contrato.
Call today for more information or to speak with a representative!
602-414-7630 or 1-866-571-5781 (TTY 711)
8:00 a.m. - 8:00 p.m., 7 days a week
¡Llame hoy para más información o para hablar con
un representante!
602-414-7630 ó 1-866-571-5781 (TTY al 711)
8:00 a.m. - 8:00 p.m., 7 días de la semana
Mercy Care Advantage 4500 E. Cotton Center Blvd.
Phoenix, AZ 85040
www.MercyCareAZ.org H5580_22_028_M
