Rights and Responsibilities

Know Your Rights as a QUEST Integration Member.

As an 'Ohana member, you have the right:

  • Receive information pursuant to the plan;
  • Be treated with respect and with due consideration for the member's dignity and privacy;
  • Have all records and medical and personal information remain confidential;
  • Receive information on available treatment options and alternatives, presented in a manner appropriate to the member's condition and ability to understand;
  • Participate in decisions regarding his or her health care, including the right to refuse treatment;
  • Be free from any form of restraint or seclusion as a means of coercion, discipline, convenience or retaliation, as specified in federal regulations on the use of restraints and seclusion;
  • Request and receive a copy of his or her medical records, and request to amend or correct the record as specified by the plan;
  • Be furnished health care services in accordance with the plan;
  • Freely exercise his or her rights, including those related to filing a grievance or appeal, and that the exercise of these rights shall not adversely affect the way the member is treated;
  • Have direct access to a women's health specialist within the network;
  • Receive a second opinion at no cost to the member;
  • 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 he or she would have if services were provided in-network;
  • Receive services according to the appointment waiting time standards;
  • Receive services in a culturally competent manner;
  • Receive services in a coordinated manner;
  • Have his or her privacy protected;
  • Be included in service plan development, if applicable;
  • Have direct access to specialists (if he or she has a special healthcare need);
  • Not have services arbitrarily denied or reduced in amount, duration or scope solely because of diagnosis, type of illness, or condition;
  • 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 healthcare provider that furnishes the services; and
    • 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; and
  • Only be responsible for cost sharing in accordance with the plan.

NOTE:If 'Ohana Health Plan objects to providing a service on moral or religious grounds, the Health Plan must furnish information about the services it does not cover:

  1. To the DHS within 120 days of adopting the policy
  2. To members before and during enrollment
  3. To members within 90 days of adopting the policy with respect to any particular service

Know Your Responsibilities as a QUEST Integration Member.

As an 'Ohana member, you have the responsibility to:

  • 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 non-emergency 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 as 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 toll-free at 1-888-846-4262 (TTY 711).