Member Information

As a recipient of Medicare and as a member of Health Choice Generations, you are entitled to certain rights and also share certain responsibilities with us which are explained below.

You have the right to:

• Be treated with Fairness and Respect
• The Privacy of your Medical Records and Personal Health Information (PHI)
• See plan providers, get covered services and get prescriptions filled within a reasonable period of time
• Know your treatment choices and participate in decisions about your healthcare
• Use Advance Directives, such as a Living Will or Power of Attorney
• Make complaints
• Get information about your healthcare coverage and costs
• Get information about Health Choice , Health Choice Generations, plan providers your drug coverage and costs

How to get More Information About Your Rights

If you have questions or concerns about your rights and protections, please call Health Choice Generations Member Services, 8 am – 8 pm, 7 days a week (except holidays), at 1-800-656-8991 (TTY: 711) or you may receive free help and information from:

DES Aging and Adult Administration
State Health Insurance and Assistance Program
1789 W. Jefferson, St., 950A
Phoenix, AZ 85007.

In addition, the Medicare program has written a booklet called Your Medicare Rights and Protections. To get a free copy, call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) 24 hours a day/7 days a week. Or you can visit the Medicare website at www.medicare.gov to order this booklet or print it directly from your computer.

To learn more about your rights and responsibilities upon disenrollment, please review the Evidence of Coverage document.

Evidence of Coverage
Evidence of Coverage (Spanish)

What can you do if you think you have been treated unfairly or Your Rights are not being respected?

If you think you have been treated unfairly or your rights have not been respected, what you should do depends on your situation. If you think you have been treated unfairly due to your race, color, national origin, disability, age or religion, please let us know. Or, you can call the Office for Civil Rights in your area at:

Phoenix Office
275 W. Washington St., Phoenix, AZ 85007
602-542-5263
TDD: 602-542-5002
Toll free: 1-877-491-5742
Toll free TDD: 1-877-624-8090

Tucson Office
400 W. Congress, Ste, S215, Tucson, AZ 85701
520-628-6500
TDD: 520-628-6872
Toll free: 1-877-491-5740
TDD toll free: 1-877-881-7552

For any other kind of concern or problem related to your Medicare rights and protections described in this section, you can call Member Services at 800-656-8991. You can also get help from Arizona’s SHIP.

Your Responsibilities as a Member of Health Choice Generations

As a member of Health Choice Generations, you also have responsibilities.

Your responsibilities include the following:

• To get familiar with your coverage and the rules you must follow to obtain care as a member. You may use your Evidence of Coverage and Summary of Benefits and other information we provide to you to learn about your coverage, what you have to pay, and the rules you need to follow. Please call Health Choice Generations Member Services, 8 am – 8 pm, 7 days a week (except holidays), at 1-800-656-8991 (TTY: 711) if you have any questions.
• To give your doctor and other providers the information they need to care for you, and to follow the treatment plans and instructions that you and your doctors agree upon. Be sure to ask your doctors and other providers if you have any questions.
• To act in a way that supports the care given to other patients and helps the smooth running of your doctor’s office, hospitals and other offices.
• To pay any co-payments you may owe for the covered services you receive. You must also pay for any other financial responsibilities you may incur.

To let us know if you have any questions, concerns, problems, or suggestions.

What are Fraud, Waste, and Abuse?

FRAUD is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/her or some other person. It includes any act that constitutes fraud under applicable Federal or State law.

WASTE is unintentional misuse of Medicare funds through inadvertent error, most frequently incorrect coding and billing.

ABUSE (of member) means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the health plan, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes recipient practices that result in unnecessary cost to the health plan.

For potential Fraud-Waste-Abuse complaints, you may call our Hotline

Examples of fraud, waste, and abuse include letting someone use your ID card to get medical care; a provider who bills for services that you did not receive; getting a prescription that was not prescribed by a licensed and appropriate medical provider; and/or a medical provider physically abusing a Health Choice Generations member.

All organizations that provide Medicare Advantage Plans, like Health Choice Generations, must obey federal laws against retaliation. If you report a fraud, waste, and abuse to Health Choice Generations, it will not affect the medical care you receive.

If you witness any misuse of any ID card, or any other instances of Medicare fraud, waste or abuse, please contact Health Choice Generations FWA Alertline, toll-free at 1-888-677-3720 or TTY – Arizona Relay Service 711. You can call this number any time and leave a confidential message.

Please leave a detailed message regarding the reason for your call and the following information:

• Your name – please state whether you are a member, provider or employee of Health Choice Generations. If you are a member or provider, please provider you Health Choice Generations plan ID number.
• Telephone number.
• The best time to reach you.

You may remain anonymous. You call will receive the same attention whether you identify yourself or not.

Reporting Services Not Provided
Identity Theft Prevention
Prevent Fraud When Changing Plans
Online Pharmacies Fraud Preventions

Sometimes, people need assistance to help them make decisions, ask questions or to help them interpret the rules and regulations of a plan. If this happens, you have the right to ask someone such as a family member or friend to help you with decisions about your healthcare.

There is a special form called an “Appointment of Representative” to give someone you trust the legal authority to make decisions for you about claims, organization determinations, reconsiderations, other appeals and grievances, should you be unable to make decisions for yourself.

If you decide that you want to appoint someone to speak on your behalf, please fill out the form below and return to Health Choice Generations by either faxing to (480) 784-2933 or by mail to: Health Choice Generations, 410 N. 44th Street, Ste. 900 Phoenix, AZ 85008.

Note:
Please make sure you make a copy and retain for your records before mailing or faxing to Health Choice Generations.

If you have further questions, about appointing someone to speak or make healthcare decisions on your behalf contact Health Choice Generations Member Services, 8 am – 8 pm, 7 days a week (except holidays), at 1-800-656-8991 (TTY users call 711).

Appointment of Representative Form
Appointment of Representative Form (Spanish)

As an adult, you can express your wishes about the type of medical treatment you would like to have through a document known as an Advance Medical Directive for Healthcare.

Simply stated, it provides directions in the event of an accident or illness which results in your inability to communicate your wishes yourself. An Advance Directive can also allow you to designate a person (a proxy) who will make healthcare decisions for you.

An advance directive may be used to accept or refuse any procedure or treatment, including life-sustaining treatment. You should discuss your options with your physicians, loved ones, clergy and/or close friends.

There are different types of advanced directives and different names for them. Documents called “Living Will” and “Power of Attorney for Healthcare” are two examples.

If you decide that you want to have an Advance Directive, there are several ways to get this type of form; from your lawyer, a social worker or from some office supply stores. To make it easier for our members, Health Choice has posted the Living Will and Power of Attorney for Healthcare forms along with instructions on how to fill out the form.

If you should have any questions, please call Health Choice Member Services at 1-800-322-8670 (Outside Maricopa County) or (480) 968-6866 (Inside Maricopa County). TTY users should call 711.

Instructions for Completing the Health Care Directive or Writing a Living Will

1. Print your name on the first blank line. “I, MY NAME, want everyone who cares for me to know what health care I want when I cannot let others know what I want.”
2. Think about the statement, “A quality of life that is unacceptable to me means” and check each item from the list below that applies.
   This means that if you are in the condition described, you would want your family and doctors to stop or withdraw treatment. You would not want to continue to live in that condition.
   You may add any words you want on the blank lines to further describe the conditions when you would not want to continue to receive treatment.
3. Think about the statement, “There are some procedures that I do not want under any circumstances.”
   If you have decided that you would never want a treatment listed, check that box. If you have not decided yet, or if you would want your doctor to try these treatments, leave the box blank.
4. Think about the statement, “When I am near death, it is important to me that.” When writing a living will, you can write anything you like on these lines. Some people say, “I want hospice care.”, “I want to die at home.”, or “I want my family near me.” You may leave these lines blank if you wish.
5. You must sign this form on the reverse side and you must have your signature witnessed.
   The witness cannot be related to you by blood, marriage or adoption, cannot be a beneficiary to your estate, and cannot be directly involved in your healthcare.
   In Arizona, it is not necessary to have this form notarized, but there is a space for a notary if you desire.
6. After writing a living will, give a copy of it to your Health Care (Medical) Power of Attorney, to your family and close friends, and to your doctor. Keep a copy to take to the hospital or clinic if you become ill and need treatment.

Health Care Directive

Instructions for Completing the Health Care (Medical) Power of Attorney

1. Print your name in the first blank line.
   “I, MY NAME, as principal, designate . . .
2. Print the name of the person you have chosen to be your Health Care (Medical) Power of Attorney on the next blank line.
   “OTHER PERSON’S NAME, as my agent for all matters relating to my health care . . . “
3. Print the address and phone number of the person you have chosen to be your Health Care (Medical) Power of Attorney on the next blank line.
   “Print agent ADDRESS and PHONE”
4. You may name an alternate person to be your Health Care (Medical) Power of Attorney. This second person would take over if the first person you named is not available or is unable to make decisions for you.
   “If my agent is unwilling or unable to serve or continue to serve, I hereby appoint SECOND PERSON’S NAME as my agent.”
5. If you choose a second person as an alternate, complete the next blank line with the second person’ s address and phone number. If you do not choose a second person as an alternate, leave this last line blank.
6. You must sign this form in front of a witness.
   The witness cannot be related to you by blood, marriage or adoption, cannot be a beneficiary to your estate, and cannot be directly involved in your healthcare.
   In Arizona, it is not necessary to have this form notarized, but there is a space for a notary if you desire.

Give a copy of this form to your Health Care (Medical) Power of Attorney, to your family and close friends, and to your doctor. Keep a copy to take to the hospital or clinic if you become ill and need treatment.

How can I get care during a disaster?

If the Governor or Arizona, the U.S Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to receive care from Health Choice Generations.

In the event of an emergency declaration you may be able to receive services from an out of network provider or hospital.

If you are unable to fill your prescriptions at a network pharmacy during a disaster, you may be able to fill your prescriptions at an out of network pharmacy. If you had to leave your home without your medications because they were damaged or lost because of the disaster, you can contact us for a location of a nearby pharmacy.

If you your ID card was lost or damaged due to the disaster, you can request a new card by calling Member Services.

If you have any questions as to whether or not you are in a disaster area, or if coverage rules have changed during a disaster, please call Member Services at 1-800-656-8991 (TTY 711), 8:00 a.m. – 8:00 p.m., 7 days a week.

The Health Choice Generations Provider Directory

The Health Choice Generations Provider Directory lists our network providers. Providers who accept both AHCCCS (Medicaid) and Health Choice Generations are indicated in the Provider directory. If you have any questions regarding your provider, please contact member services.

What are “network providers”?

Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and any plan cost-sharing as payment in full. We have arranged for these providers to deliver covered services to members in our plan.

Why do you need to know which providers are part of our network?

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Health Choice Generations authorizes use of out-of-network providers. Please see the Evidence of Coverage document for more specific information aboutemergency, out-of-network, and out-of-area coverage.

It is also important to know who is a participating AHCCCS (Medicaid) provider so that your care may be coordinated between Medicare and AHCCCS (Medicaid). If you don’t have your copy of the Health Choice Generations Provider Directory, you can request a copy from Member Services. You may ask Member Services for more information about our network providers, including their qualifications. You can also search for providers online website by clicking here.