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

Enrollment Form – English

Enrollment 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

An appeal is a formal way of asking us to review and change a coverage decision we have made.

Below is how to contact us to file an appeal.

Appeals 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.

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

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

Email: Appeals@FC2healthplan.com

FAX: 1-800-765-3695 (Expedited Appeals Only)

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.

You can make a complaint, which is sometimes called a grievance, about us or one of our network providers, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan’s coverage or payment, you should look at the section above about making an appeal.)

Below is how to contact us to file a complaint.

Complaints About 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 – Grievance
PO Box 668800
Miami, Florida 33166

Email: Grievance@FC2healthplan.com

FAX: 1-800-887-2838 (Expedited Grievances Only)

MEDICARE WEBSITE

You can also submit a complaint about Florida Complete Care (HMO I-SNP) directly to Medicare. To submit an online complaint to Medicare go to www.medicare.gov/MedicareComplaintForm/home.aspx.

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.

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.