Member Rights

• Members or their legal guardians have a right to receive information about Molina Healthcare, Molina Healthcare’s policies and procedures regarding products, services, its contracted practitioners and providers, grievance procedures, benefits provided and Members' rights and responsibilities.
• Members have a right to be treated with courtesy and consideration, equitably and with respect and recognition of their dignity and right and need to for privacy.
• Members or their legal guardians have a right to choose a primary care practitioner within the limits of the covered benefits, and plan network, and the right to refuse care of specific practitioners.
• Members or their legal guardians have a right to receive from the Member's practitioner/provider, in terms that the Member or legal guardian(s) understands, an explanation of his or her complete medical condition, and recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of the health care insurer's or Molina Healthcare’s position on treatment options. If the Member is not capable of understanding the information, the explanation shall be provided to his or her next of kin, guardian, agent or surrogate, if available, and documented in the Member’s medical record.
• Members have a right to receive health care services in a non-discriminatory fashion.
• Members who do not speak English as their first language have the right to access translator services at no cost for communication with Molina Healthcare.
• Members who have a disability have the right to receive information in an alternative format in compliance with the Americans with Disabilities Act.
• Members or their legal guardians have a right to participate with their health care practitioner/provider in decision making in all aspects of their health care, including the treatment plan development, acceptable treatments and the right to refuse treatment.
• Members or their legal guardians shall have the right to informed consent.
• Members or their legal guardians shall have the right to choose a surrogate decision-maker to be involved as appropriate, to assist with care decisions.
• Members or their legal guardians shall have the right to seek a second opinion by another provider in the Molina Healthcare network when Members need additional information regarding recommended treatment or believe the provider is not authorizing requested care.
• Members have a right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
• Members or their legal guardians have a right to voice complaints, grievances or appeals about Molina Healthcare, the handling of grievances, or the care provided and make use of Molina Healthcare’s grievance process and the Human Service Department (HSD) hearings process, at no cost, without fear of retaliation.
• Members or their legal guardians have a right to file a complaint, grievance or appeal with Molina Healthcare or, the HSD Administrative Hearings Bureau, for Medicaid Members, and to receive an answer to those complaints, grievances or appeals within a reasonable time.
• Members or their legal guardians have a right to choose from among the available practitioners and providers within the limits of Molina Healthcare’s network and its referral and prior authorization requirements.
• Members or their legal guardians have a right to make their decisions known through advance directives regarding health care decisions (i.e., living wills, right to die directives, "do not resuscitate" orders, etc) consistent with federal and state laws and regulations.
• Members or their legal guardians have a right to privacy of medical and financial records maintained by Molina Healthcare and its providers, in accordance with existing law.
• Members or their legal guardians have a right to access the Member's medical records in accordance with the applicable federal and state laws and regulations.
• Members have the opportunity to consent to or deny the release of identifiable medical or other information by Molina Healthcare, except when such release is required by law.
• Members have a right to request an amendment to their Protected Health Information (PHI) if the information is believed to be incomplete or wrong.
• Members or their legal guardians have a right to receive information about Molina Healthcare, its health care services, how to access those services, the network practitioners and providers i.e., title and education and the Patient Bill of Rights.
• Members or their legal guardians have a right to be provided with information concerning Molina Healthcare’s policies and procedures regarding products, services, practitioners and providers, appeal procedures, obtaining consent for use of Member medical information, allowing Members access to their medical records, and protecting access to Member medical information, and other information about Molina Healthcare and benefits provided.
• Members or their legal guardians have a right to know upon request of any financial arrangements or provisions between Molina Healthcare and its practitioners and providers which may restrict referral or treatment options or limit the services offered to Members.
• Members or their legal guardians have a right to be free from harassment by Molina Healthcare or its network practitioners or providers in regard to contractual disputes between Molina Healthcare and practitioners or providers.
• Members or their legal guardians have a right to available and accessible services when medically necessary as determined by the primary care practitioner or treating provider in consultation with Molina Healthcare, twenty-four (24) hours per day, seven (7) days per week for urgent or emergency care services, and for other health care services as defined by the contract or evidence of coverage.
• Members have a right to adequate access to qualified health professionals near where the Member lives or works within the service area of Molina Healthcare.
• Members have a right to affordable health care, with limits on out-of-pocket expenses, including the right to seek care from a non-participating Provider, and an explanation of a Member's financial responsibility when services are provided by a non-participating provider/ or non-participating practitioner, or provided without required pre-authorization.
• Members or their legal guardians have a right to prompt notification of termination or changes in benefits, services or Provider network.
• Members have a right to seek care from a non-participating provider and be advised of their financial responsibility if they receive services from a non-participating provider, or receive services without required Prior Authorization.
• Members have the right to continue an ongoing course of treatment for a period of at least thirty (30) days. This shall apply if the Member's provider leaves the Provider network, or if a new Member's provider is not in the Provider network.
• Members have the right to make recommendations regarding the organization's Member Rights and Responsibilities policy.
• Members have a right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion.
• Members or their legal guardians shall have the right to select an MCO and exercise switch enrollment rights without threats or harassment.
• Members have a right to detailed information about coverage, maximum benefits and exclusions of specific conditions, ailments or disorders, including restricted benefits and all requirements that an enrollee must follow for prior approval and utilization review.
• Members or their legal guardians have all the rights afforded by law, rule, or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Member understands.
• Members or their legal guardians have the right to a complete explanation of why care is denied, an opportunity to appeal the decision to Molina Healthcare’s internal review, the right to a secondary appeal, and the right to request the superintendent’s or HSD’s assistance as applicable.

Member Responsibilities

• Members or their legal guardians have a responsibility to provide, to the extent possible, information that Molina Healthcare and its practitioners and providers need in order to care the Member.
• Members or their legal guardians have a responsibility to understand the Member’s health problems and to participate in developing mutually agreed upon treatment goals.
• Members or their legal guardians have a responsibility to follow the plans and instructions for care that they have agreed on with their practitioner/provider.
• Members or their legal guardians have a responsibility to keep, reschedule or cancel an appointment rather than to simply not show up.
• Members or their legal guardians have a responsibility to review their Member Handbook or Evidence of Coverage and if there are questions contact the Member Services Department for clarification of benefits, limitations and exclusions. The Member Services telephone number is located on the Member’s Identification Card.
• Members or their legal guardians have a responsibility to follow Molina Healthcare’s policies, procedures and instructions for obtaining services and care.
• Members or their legal guardians have a responsibility to show your Member Identification Card each time you go for medical care and to notify Molina Healthcare immediately of any loss or theft of their ID card.
• Members or their legal guardians have a responsibility to advise a participating provider of coverage with Molina Healthcare at the time of service. Members may be required to pay for services if they do not inform the participating provider of their coverage.
• Members or their legal guardians have a responsibility to pay for all services obtained prior to the effective date with Molina Healthcare and subsequent to termination or cancellation of coverage with Molina Healthcare.
• Notify your ISD Caseworker if there is a change in your name, address, telephone number, or any changes in your family.
• Notify HSD and Molina Healthcare if you get medical coverage other than through Molina Healthcare.
• Members or their legal guardians have a responsibility to pay for all required co-payments and/or coinsurance at the time services are rendered.

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