Member Rights, Protections and Responsibility

To ensure members are aware and guaranteed their rights and protections. Member rights include but are not limited to, those rights and protections provided by 42 CFR 438.10, 42 CFR 422 Subpart C and the CFAM-MOU These are:

  1. Right to be treated with dignity and respect.
  2. Right to be afforded privacy and confidentiality in all aspects of care for all health care information, unless otherwise required by law.
  3. Right to be provided copy of his or her medical records, upon request, and to request corrections or amendments to these records
  4. Members are not discriminated against in the delivery of health care services consistent with the benefits covered in their policy based on race, ethnicity, national origin, religion, sex, age, medical condition (including mental and/or physical illness or disability), sexual orientation, genetic information, medical history, receipt of health care, claims history or source of payment
  5. Right to have all plan options, rules, and benefits fully explained, including through use of a qualified interpreter if needed.
  6. Right to access to an adequate network of primary and specialty providers who are capable of meeting the member needs with respect to physical access, and communication and scheduling needs, and are subject to on-going assessment of clinical quality including required reporting.
  7. Right to choose a plan and provider at any time and have that choice be effective the first calendar day of the following month.
  8. Right to participation in all aspects of care and to exercise all rights to appeal. This includes but is not limited to the right to freely exercise his or her rights without adverse effect on the way a provider or its contractors treat the member.
  9. Right to file an Appeal if services are denied that the member feels are medically indicated and to have an independent rnal system of review.
  10. Right to receive medical and non-medical care from a team that meets the member’s needs in a manner that is sensitive to the member’s language and culture in an appropriate care setting including the home and community.
  11. Members have a responsibility to be fully involved in maintaining their health and making decisions about their health care, including the right to refuse treatment if desired, and must be appropriately informed and supported to this end.
  12. Receive a comprehensive health risk assessment upon date of coverage in a plan and to participate in the implementation of an Individualized Care Plan. The assessment must include considerations of social, functional, medical, behavioral, wellness and prevention domains, including an evaluation of the members strengths and weaknesses, and a plan for managing and coordinating the member’s care. A member or their designated representative, also have a right to request re-assessment by an interdisciplinary care team, and be fully involved in any such reassessment.
  13. Right to be provided information on all programs services and health care options, including available treatment options and alternatives, presented in a culturally appropriate manner, and in consideration of member’s condition and ability to understand.
  14. Right to translation of services available to make information appropriately accessible.
  15. Right to elect a representative and/or caregiver and/or family member in treatment discussions and decisions.
  16. Right to receive advance notice, in writing, of any transfer to another treatment setting and the justification for transfer.
  17. Right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  18. Right to receive information timely regarding plan changes. This includes but is not limited to, the right to request and obtain information listed in the orientation materials once a year and the right to receive notice of any significant change in the information provider in the orientation materials at least 30 days prior to the intended effective date of a change.
  19. Right to be protected from liability for payment of any fees that are the obligation of the plan or Medical Group which the member is assigned.
  20. Right to not be charged any cost sharing for Medicare Part A and B services, when applicable.
  21. The unconditional and exclusive right to hire, fire, and supervise his or her In Hone Support Services provider, where applicable.
  22. Right to receive their Medicare and/or Medi-Cal appeals rights in a format and language that is easily understood and accessible.
  23. For CalMediConnect members, the right to opt out at any time, beginning at the first of the following month.