As a Molina Medicare member, you have certain rights and responsibilities. Molina
Medicare has listed them below. They help you to know what to expect from your health
care. They can also help you to get the most out of your health care.
Your right to be treated with dignity, respect and fairness
You have the right to be treated with dignity, respect, and fairness at all times.
Our Plan must obey laws that protect you from discrimination or unfair treatment.
We don’t discriminate based on a person’s race, disability, religion, sex, sexual
orientation, health, ethnicity, creed, age, or national origin. If you need help
with communication, such as help from a language interpreter, please call Member Services.
Member Services can also help if you need to file a complaint about access (such
as wheel chair access). You may also call the Office for Civil Rights at (800) 368-1019
(800) 537-7697, or your local Office for Civil Rights.
Your right to the privacy of your medical records and personal health information
There are federal and state laws that protect the privacy of your medical records
and personal health information. We protect your personal health information under
these laws. Any personal information that you give us when you enroll in this plan
is protected. We will make sure that unauthorized people don’t see or change your
records. Generally, we must get written permission from you (or from someone you
have given legal power to make decisions for you) before we can give your health
information to anyone who isn’t providing your care or paying for your care. There
are exceptions allowed or required by law, such as release of health information
to government agencies that are checking on quality of care. The Plan will release
your information, including your prescription drug event data, to Medicare, which
may release it for research and other purposes that follow all applicable Federal
statutes and regulations.
The laws that protect your privacy give you rights related to getting information
and controlling how your health information is used. We are required to provide
you with a notice that tells about these rights and explains how we protect the
privacy of your health information. You have the right to look at medical records
held at the Plan, and to get a copy of your records (there may be a fee charged
for making copies). You also have the right to ask us to make additions or corrections
to your medical records (if you ask us to do this, we will review your request and
figure out whether the changes are appropriate). You have the right to know how
your health information has been given out and used for non-routine purposes. If
you have questions or concerns about privacy of your personal information and medical
records, please call Member Services
Your right to see network providers, get covered services, and get your prescriptions
filled within a reasonable period of time
As explained in this booklet, you will get most or all of your care from network
providers, that is, from doctors and other health providers who are part of our
Plan. You have the right to choose a network provider (we will tell you which doctors
are accepting new patients). You have the right to go to a women’s health specialist
in our Plan (such as a gynecologist) without a referral You have the right to timely
access to your providers and to see specialists when care from a specialist is needed.
“Timely access” means that you can get appointments and services within a reasonable
amount of time
You have the right to timely access to your prescriptions at any network pharmacy,
your right to know your treatment options and participate in decisions about your
You have the right to get full information from your providers when you go for medical
care, and the right to participate fully in decisions about your health care. Your
providers must explain things in a way that you can understand. Your rights include
knowing about all of the treatment options that are recommended for your condition,
no matter what they cost or whether they are covered by our Plan. This includes
the right to know about the different Medication Therapy Management Programs we
offer and in which you may participate. You have the right to be told about any
risks involved in your care. You must be told in advance if any proposed medical
care or treatment is part of a research experiment, and be given the choice of refusing
You have the right to receive a detailed explanation from us if you believe that
a provider has denied care that you believe you were entitled to receive or care
you believe you should continue to receive. In these cases, you must request an
initial decision called an organization determination or a coverage determination.
Organization determinations and coverage determinations are discussed in Section
You have the right to refuse treatment. This includes the right to leave a hospital
or other medical facility, even if your doctor advises you not to leave. This includes
the right to stop taking your medication. If you refuse treatment, you accept responsibility
for what happens as a result of your refusing treatment.
Your right to get information about our Plan
You have the right to get information from us about our Plan. This includes information
about our financial condition, and how our Plan compares to other health plans.
To get any of this information, please call Member Services
Your right to get information in other formats
You have the right to get your questions answered. Our plan must have individuals
and translation services available to answer questions from non-English speaking
beneficiaries, and must provide information about our benefits that is accessible
and appropriate for persons eligible for Medicare because of disability. If you
have difficulty obtaining information from your plan based on language or a disability,
call (800) MEDICARE (633-4227). TTY users should call (877) 486-2048, 24 hours a
day, 7 days a week.
Your right to get information about our network pharmacies and providers
You have the right to get information from us about our network pharmacies, providers
and their qualifications and how we pay our doctors. To get this information, please
call Member Services
Your right to get information about your prescription drugs, Part C medical care
or services, and costs
You have the right to an explanation from us about any prescription drugs or Part
C medical care or service not covered by our Plan. We must tell you in writing why
we will not pay for or approve a prescription drug or Part C medical care or service,
and how you can file an appeal to ask us to change this decision. See Section 5
for more information about filing an appeal. You also have the right to this explanation
even if you obtain the prescription drug, or Part C medical care or service from
a pharmacy and/or provider not affiliated with our organization. You also have the
right to receive an explanation from us about any utilization-management requirements,
such as step therapy or prior authorization, which may apply to your plan. Please
review our formulary website or please call Member Services
Your right to make complaints
You have the right to make a complaint if you have concerns or problems related
to your coverage or care. See Section 4 and Section 5 for more information about
complaints. If you make a complaint, we must treat you fairly (i.e., not retaliate
against you) because you made a complaint. You have the right to get a summary of
information about the appeals and grievances that members have filed against our
Plan in the past. To get this information, call Member Services
How to get more information about your rights
If you have questions or concerns about your rights and protections, you can
- Please call Member Services
- Get free help and information from your State Health Insurance Assistance Program
(SHIP) at (800) 434-0222.
- Visit www.medicare.gov to view
or download the publication "Your Medicare Rights & Protections."
- Call (800) MEDICARE (633-4227). TTY users should call (877) 486-2048, 24 hours a
day, 7 days a week
What can you do if you think you have been treated unfairly or your rights are not
If you think you have been treated unfairly or your rights have not been respected,
you may call Member Services or :
- If you think you have been treated unfairly due to your race, color, national origin,
disability, age, or religion, you can call the Office for Civil Rights at (800)
368-1019 or TTY/TDD (800) 537-7697, or call your local Office for Civil Rights.
- If you have any other kind of concern or problem related to your Medicare rights
and protections described in this section, you can also get help from your SHIP.
You have the right to make a complaint if we end your membership in our plan
If we disenroll you from our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can file a grievance or make a complaint about our decision to end your membership. For more information about how to make a complaint please visit How to File a Grievance.
Your responsibilities as a member of our Plan include:
- Getting familiar with your coverage and the rules you must follow to get care as
a member. You can use this booklet to learn about your coverage, what you have to
pay, and the rules you need to follow. Please call Member Services
if you have questions.
- Using all of your insurance coverage. If you have additional health insurance coverage
or prescription drug coverage besides our Plan, it is important that you use your
other coverage in combination with your coverage as a member of our Plan to pay
your health care or prescription drug expenses. This is called “coordination of
benefits” because it involves coordinating all of the health or drug benefits that
are available to you.
- You are required to tell our Plan if you have additional health insurance
or drug coverage. Please call Member Services.
- Notifying providers when seeking care (unless it is an emergency) that you are enrolled
in our Plan and you must present your plan membership card to the provider.
- Giving your doctor and other providers the information they need to care for you,
and following the treatment plans and instructions that you and your doctors agree
upon. Be sure to ask your doctors and other providers if you have any questions
and have them explain your treatment in a way you can understand.
- Acting in a way that supports the care given to other patients and helps the smooth
running of your doctor’s office, hospitals, and other offices.
- Paying your coinsurance or co-payment for your covered services. You must pay for
services that aren’t covered.
- Notifying us if you move. If you move within our service area, we need to keep your
membership record up-to-date. If you move outside of our plan service area, you
cannot remain a member of our plan, but we can let you know if we have a plan in
- Letting us know if you have any questions, concerns, problems, or suggestions. If
you do, please call Member Services.