MEMBER RIGHTS

As a Member (Commercial or Senior), you have the right to:

1.      Be treated with respect and dignity.

2.      Be provided with comprehensible information about MHIPA, its services, providers and the health care service delivery process.  This information includes instructions on how to obtain care with various providers and at varied facilities (e.g., primary care, specialty care, behavioral health services, hospital services.)  Additionally, information will be included on how to obtain services outside the MHIPA system or service area.

3.      Be informed of emergent and non-emergent benefit coverage and cost of care, and receive an explanation of the member’s financial obligations as appropriate, prior to incurring the expense (including co-payments, deductibles, and co-insurance).

4.      Be provided with information on how to obtain care after normal office hours and how to obtain emergency care including when to directly access emergency care or use 911 services.

5.      Examine and receive an explanation of bills generated for services delivered to the member.

6.      Be provided with information on how to submit a claim for covered services.

7.      Be informed of the name and qualifications of the physician who has primary responsibility for coordinating the member’s care; and be informed of the names, qualifications, and specialties of other physicians and non-physicians who are involved in the member's care.

8.      Have 24-hour access to the member’s primary care physician (or covering physician).

9.      Receive complete information about any test results, diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, and prospects for recovery in terms that are understandable to the member, in order to give informed consent or to refuse that course of treatment.

10.  Candidly discuss appropriate or medically necessary treatment options for the member’s condition, regardless of cost or benefit coverage.  No incentives are offered to encourage denials of coverage of service.

11.  Actively participate in decisions regarding the member’s health care and treatment plan.  To the extent permitted by law, this includes the right to refuse any procedure or treatment.  If the recommended procedure or treatment is refused, an explanation will be given addressing the effect that this will have on the member’s health.

12.  Privacy and confidential handling of all information regarding your medical conditions and health.

13.  Receive a timely response to requests for services, including evaluations and referrals.

14.  Voice a complaint about your health plan or the care you receive through your health plan’s appeals and grievance procedures, and to receive a timely response to any complaints or inquiries regarding your benefits or care.

15.  Make recommendations regarding MHIPA’s member’s rights and responsibilities policies.

16.  Openly discuss advance directives with your doctor.

As a Senior Member, you also have the right to:

1.      Discuss (and complete) an advance directive, living will or other health care directive with your health care provider.

2.      Receive a second opinion when deemed medically necessary.

3.      Receive, on request, the names, specialties, and titles of the professionals responsible for your care.

4.      Candidly discuss treatment options for your conditions, regardless of cost or coverage.

5.      Receive emergency services when you, a prudent layperson, acting reasonably would have believed that an emergency medical condition existed.  Payment will not be withheld in such cases.

6.      Receive urgently needed services when traveling outside the service area or in the service area when unusual or extenuating circumstances prevents you from obtaining care from your contracting facilities.

7.      Not be discouraged when enrolling, or be directed to enroll in any particular plan.

MEMBER RESPONSIBILITIES

As a Member (Commercial or Senior), you have the responsibility to:

1.      Be familiar with the benefits and exclusions of your health plan coverage.

2.      Provide your health care provider with complete and accurate information, which is necessary for your care.

3.      Be on time for all appointments and notify the provider’s office as far in advance as possible for appointment cancellation or rescheduling.

4.      Report changes in your condition according to provider instructions.

5.      Inform providers of your inability to understand the information given to you.

6.      Carry out the treatment plan, which has been developed and agreed upon by you and your health care provider.

7.      Contact your primary care physician (or covering physician) for any care, which is needed after that physician’s normal office hours.

8.      Treat the health care providers and staff with respect.

9.      Obtain an authorized referral from your primary care physician for a visit to a specialist and/or to receive any specialty care.

10.  Be familiar and comply with Memorial HealthCare IPA Member Services Department or your Health Plan Member Services Department regarding questions and assistance.

11.  Contact the Memorial HealthCare IPA Member Services Department or your Health Plan Member Services Department regarding questions and assistance.

12.  Respect the rights, property and environment of all physicians and Memorial HealthCare IPA providers, staff and other members.

13.  Have all of these responsibilities apply to the person who has the legal responsibility to make health care decisions for you.

Department of Managed Healthcare

www.dmc.ca.gov

For Consumer HMO Complaints:    Voice (888) HMO-2219

Fax (916) 229-0465

TDD (877) 688-9891

E-mail: helpline@dmhc.ca.gov