Summary of Benefits – English

Summary of Benefits – Spanish

Evidence of Coverage: Florida Complete Care

Evidence of Coverage: Florida Complete Care – Spanish

Evidence of Coverage: Florida Complete Care – In The Community

Evidence of Coverage: Florida Complete Care – In The Community – Spanish

LIS Premium Summary Form – English

LIS Premium Summary Form – Spanish

Coverage Determination Request Form – English

Coverage Determination Request Form – Spanish

Star Ratings – English

Star Ratings – Spanish

Notice of Privacy Practices – English

Notice of Privacy Practices – Spanish

Appointment of Representative Form – English

Appointment of Representative Form – Spanish

Over the Counter Benefits Catalog

For assistance, please call or write to Florida Complete Care (HMO I-SNP) Member Services. We will be happy to help you.

Please contact our Member Services number at 1-833-FC2-PLAN for additional information. (TTY users should call 711). Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

Member Services – Contact Information

CALL 1-833-FC2-PLAN
Calls to this number are free. Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Our automated system is available any time for self-service options. You can also leave a message after hours and on weekends and holidays. Please leave your phone number and the other information requested by our automated system. A representative will return your call by the end of the next business day.

Member Services also has free language interpreter services available for non-English speakers.

TTY 711

Calls to this number are free. Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

For written correspondence see P.O. Box below:
Florida Complete Care
PO Box 667870
Miami, Florida 33166

How to file an appeal?

An appeal is the action you or your authorized representative can take if you disagree with a decision Florida Complete Care (HMO I-SNP) Health Plan has made on an Organization Determination.

When we have completed the review, we will provide you, our decision.

There are five successive levels to the appeals process:

• Level 1: Reconsideration by the health plan.
• Level 2: Review by the Independent Review Entity (IRE)
• Level 3: Hearing by an Administrative Law Judge (ALJ)
• Level 4: Review by the Medicare Appeals Council (MAC)
• Level 5: Review by a Federal District Court.

A decision may be appealed to the next level of appeal when the lower appeal entity issues a decision that is unfavorable to the member. Each unfavorable decision letter will provide instructions on how to move to the next level of appeal.

You or your authorized representative can request a first level appeal by requesting Florida Complete Care plan review an unfavorable organization decision. Reconsideration/appeal requests must be filed with the health plan within 60 calendar days from the date of the notice of the organization determination decision letter. You may file an expedited reconsideration requests orally or in writing. Standard reconsideration requests must be made in writing.

If you or your legal representative requires assistance in preparing and submitting your written Reconsideration request, please contact the Florida Complete Care Member Services department and a Case Manager Assistant (CMA) will assist you.

Once the request is received by Florida Complete Care we will decide and provide notice of our decision as quickly as your health requires, but no later than 72 hours for expedited requests, 30 calendar days for (Pre-Service) standard requests, or 60 calendar days for (Claim denial) requests. If the decision is unfavorable, you or your authorized representative can request further review.

After the first level of appeal, all following levels of appeal will be reviewed by an entity that is contracted with the Medicare Program, or the federal court system. This will help ensure a fair and impartial decision.

By phone:

CALL 1-833-FC2-PLAN

Calls to this number are free. Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

TTY 711

Calls to this number are free. Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

Appeals Requests can be mailed, faxed or emailed to the addresses below:

Florida Complete Care- Appeals
PO Box 668170
Miami, Florida 33166

FAX: 1-800-765-3695

Email: Appeals@FC2healthplan.com

You can also file a complaint at medicare.gov website

Note: You can also use this contact information to follow up on the status of an appeal, or obtain an aggregate number of appeals filed with the plan.

How to file a grievance?

What do I do if I have a complaint?

Our members are very important to Florida Complete Care (HMO I-SNP). We work hard to ensure all our members are satisfied with us. If you have any issues, calling our Member Services department is the first step. Member Services will assist you and let you know if you need to do anything else. You can call our Member Services department at 1-833-FC2-PLAN, TTY 711, from 8 a.m. to 8 p.m. seven days a week from Oct. 1 – March 31 and 8 a.m. to 8 p.m. Monday-Friday from April 1 – Sept. 30. If you do not wish to call, you can submit your complaint in writing and send it to us. You may submit your written Grievance request to the Florida Complete Care Grievance & Appeals department at the following address or fax number:

Florida Complete Care – Grievances
PO Box 668800
Miami, Florida 33166
FAX: 1-800-887-2838
Email: Grievance@FC2healthplan.com

You can also file a complaint at medicare.gov website

Note: You can also use this contact information to follow up on the status of a complaint or obtain an aggregate number of grievances filed with the plan.

How to file a grievance?

A Grievance is a complaint or dispute that expresses dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers.

Some examples of why you or your authorized representative might file a grievance include the following:

• Benefit design (copays);
• Difficulty getting an appointment or having a long wait time for an appointment;
• Disrespectful or rude behavior by doctors, nurses, pharmacist or another plan clinic,
• hospital staff and plan staff;
• Failure to provide you a decision within the required time frame;
• Issues/concerns with the services you received;
• Issues/concerns with the medical care you received;
• If you believe our notices and other written materials are hard to understand.

You may request an expedited grievance if:

• We deny your request for an expedited organization/coverage determination;
• We deny your request for an expedited reconsideration/Part C appeal and/or redetermination/Part D appeal;
• You disagree with our decision to extend the timeframe to make an initial organization or expedited reconsideration/Part C appeal

When filing a written grievance, please provide the following information: Your name, address, member identification number (listed on your Member ID card), your signature or that of your authorized representative, date, summary of the issue, any previous contact with us, and a statement of action requested.

You or your authorized representative may file a grievance with Florida Complete Care orally or in writing no later than 60 days after the occurrence. If you or your authorized representative require help in preparing and submitting your written grievance, please contact the Florida Complete Care Member Services department and a Member Services Representative will help you. Florida Complete Care will notify you or your authorized representative of the decision about your grievance as quickly as your case requires based on your health status, but not later than 30 calendar days after receiving your complaint. In some cases, we may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. We will notify you of our decision about an expedited Grievance within 24 hours.

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services.

Below is how to contact us to request a coverage decision.

Coverage Decisions For Medical Care – Contact Information

CALL 1-833-FC2-PLAN

Calls to this number are free. Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

TTY 711

Calls to this number are free. Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

For written correspondence see P.O. Box below:
Florida Complete Care
PO Box 667870
Miami, Florida 33166

Note: You can also use this contact information to follow up on the status of a coverage decision, or obtain an aggregate number of coverage decisions filed with the plan.