Medicaid : Rights And Responsibilities

As an ‘Ohana member, you have the right:

• To get information about the plan, its services and its providers.
• To get information about your rights and responsibilities.
• To know the names and titles of the providers who take care of you.
• To be treated with respect.
• To be treated with dignity.
• To decide with your provider on the care you get.
• To talk about the care you need for particular health conditions. This includes the
• choices and risks involved, regardless of the cost or benefit coverage. You must get this information in a way you understand.
• To know about your health care needs after you get out of the hospital or leave a provider’s office.
• To take part in decisions regarding your health care, including the right to refuse treatment.
• To not take part in any medical research.
• To complain about the plan or the care it provides. And to know that if you do, it will not affect how you are treated.
• To be free from any form of restraint or seclusion as a means of force, discipline, convenience or retaliation.
• To request and get a copy of your medical records. (Requests must be received in writing from you or the person you choose to represent you. The records will be provided at no cost. They will be sent within 14 days of receipt of the request.)
• To request to amend or correct your medical records.
• To have your records (medical and personal) kept private.
• To make your health care wishes known by using advance directives.
• To have input in the plan’s member rights.
• To use these rights no matter your sex, age, race, ethnicity, income, education or religion.
• To have all plan employees honor your rights.
• To get health care services that are accessible, comparable in amount, duration and scope to those provided under Medicaid FFS and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished.
• To get appropriate services that are not denied or cut back just because of diagnosis, type of illness or medical condition.
• To get all information in a way that you can easily understand, in alternative formats and in a manner that takes into consideration your special needs. (Materials will be written at a 6th grade reading level and made available in English, Ilocano, Tagalog, Mandarin Chinese and Korean.)
• To get help in understanding the rules and benefits of the plan.
• To get oral translation and sign language services at no cost. This is for all non-English languages, not just those that are most common.
• To be told that oral translation and sign language services are available to you. And how to get this service.
• To get information about:
  
  −−The basic features of managed care
  
  −−Who may or may not join the program
  
  −−The plan’s responsibilities for coordination of care in a timely manner in order to make an informed choice (potential members)
• To get a complete description of your right to leave the plan at least once a year.
• To get a notice of any major change in benefits. You must get this at least 30 days before the change is to go into effect.
• To get full information about emergency and after-hours services.
• To get the plan’s policy on referrals for specialty care and other benefits that are not provided by the member’s PCP.
• To have all these rights apply to the person whom you legally appoint to make decisions about your health care.
• To freely exercise your rights, including those related to filing a grievance or appeal, and that the exercise of these rights will not adversely affect the way you are treated.
• To have direct access to a women’s health specialist within the network.
• To receive a second opinion at no cost to you.
• To receive services out-of-network if the health plan is unable to provide them in-network for as long as the health plan is unable to provide them in-network, and not
• pay more than you would have if services were provided in-network.
• To receive services according to the appointment waiting-time standards.
• To receive services in a culturally competent manner.
• To receive services in a coordinated manner.
• To have your privacy protected.
• To be included in care plan development.
• To have direct access to specialists (if you have a special health care need).
• To not have services arbitrarily denied or reduced in amount, duration or scope solely because of diagnosis, type of illness or condition.
• To choose between institutional care and HCBS (if determined cost-neutral by the health plan).
• To receive a description of cost-sharing responsibilities, if any.
• To not be held liable for:
  
  −−The health plan’s debts in the event of insolvency;
  
  −−The covered services provided to the member by the health plan for which the DHS does not pay the health plan;
  
  −−Covered services provided to the member for which the DHS or the health plan does not pay the health care provider that furnishes the services;
  
  −−Payments of covered services furnished under a contract, referral or other arrangement to the extent that those payments are in excess of the amount the member would owe if the health plan provided the services directly.

You also have responsibilities as a member:

• To give information that the plan and its providers need to give care.
• To follow plans and instructions for care that you have agreed on with your PCP.
• To understand your health problems.
• To help set treatment goals that you and your PCP agree to.
• To read the member handbook to understand how the plan works.
• To always carry your member ID card.
• To always carry your Medicaid card.
• To show your ID cards to each provider.
• To notify ‘Ohana if you lose your member ID card.
• To schedule appointments for all nonemergency care through your PCP.
• To get a referral from your PCP for specialty care.
• To cooperate with the people providing your health care.
• To be on time for appointments.
• To notify the provider’s office if you need to cancel or change an appointment.
• To respect the rights of all providers.
• To respect the property of all providers.
• To respect the rights of other patients.
• To not be disruptive in any provider’s office.
• To know the medicines you take, what they are for and how to take them the right way.
• To make sure your PCP has copies of all of your previous medical records.
• To let the plan know within 48 hours, or as soon a possible, if you are admitted to the hospital or get emergency room care.
• To call ‘Ohana to get information or get your questions answered. Call Customer Service at 1-888-846-4262 (TTY/TDD: 1-877-247-6272).