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Members

Member Rights and Responsibilities

You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:

  • Be treated fairly and with respect; and
  • Know that your medical records and discussions with your providers will be kept private and confidential.

You have the opportunity to choose a health care plan and primary care provider. This is the doctor or health care provider you will see most of the time. He or she will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to:

  • Be told how to choose and change health plans and primary care provider;
  • Choose any health plan you want that is available in your area; and
  • Choose your primary care provider from the plan; and
  • Change your primary care provider; and
  • Change your health plan without penalty;
  • Be told how to change your health plan or your primary care provider.

Get information you can understand about your health plan, doctors and other providers. This includes the right to:

  • Get information about the health care services you can get and how to get them.
  • Get more information on these member rights and responsibilities and let us know if you can think of ways to change them.

You have the right to ask questions and get answers about anything you do not understand. That includes the right to:

  • Have your provider explain your health care needs to you; and
  • Have your provider talk to you about the different ways your health care problems can be treated even if the care or treatment is not a covered service or benefit; and
  • To know that your health plan cannot prevent providers from giving you this information; and
  • Get accurate, easy to understand information to help you make good choices about your health plan, services, doctors, hospitals and other providers.
  • Be told why care or services were denied and not given.

You have the right to consent to or refuse treatment and actively participate in treatment decisions. That includes the right to:

  • Work as part of a team with your doctor in deciding what health care is best for you; and
  • Say yes or no to the care recommended by your provider.

You have the right to voice complaints and appeals about the health plan or the care it provides. That includes the right to:

  • Make a complaint to your health plan or to the state about your health care, your provider or your health plan;
  • Get a timely answer to your complaint,appeal or fair hearing;
  • Use the plan's appeal process and be told how to use it; and
  • Ask for a fair hearing from the state and request information about how that process works.

To timely access to care that does not have any communication or physical access barriers. That includes the right to:

  • Have telephone access to a medical professional 24 hours a day, 7 days a week in order to get any emergency or urgent care you need; and
  • Get medical care in a timely manner; and
  • Be able to get in and out of a health care provider's office. This includes barrier free access for persons with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act; and
  • Have interpreters, if needed, during appointments with your providers and when talking to your health plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information; and
  • Get information you can understand about your health plan rules;
  • Get information about the health care services you can get and how to get them; and
  • You have the right to not be restrained or secluded when it is for someone else's convenience, or is meant to force you to do something you don't want to do, or is to punish you.

You Have the Responsibility to:

To learn and understand each right you have under the Medicaid program. That includes the responsibility to:

  • Learn and understand your rights under the program;
  • Ask questions if you don't understand your rights; and
  • Learn what choices of health plans are available in your area.

To abide by the health plan policies and procedures. That includes the responsibility to:

  • Learn and follow your health plan and Medicaid rules;
  • Follow plans and instructions for care that you have agreed on with your doctors;
  • Choose your health plan and primary care provider quickly;
  • Make any changes in your health plan and primary care provider in ways established by the health plan;
  • Keep your scheduled appointments;
  • Cancel visits in advance when you can't keep them;
  • Always contact your primary care provider first for non-emergency medical needs;
  • Be sure you have approval from your primary care provider before going to a specialist; and
  • Understand when you should and should not go to the emergency room.

To share information about your health with your primary care provider and other providers and learn about services and treatment options. That includes the responsibility to:

  • Tell your primary care provider, other providers and your health plan about your health so they can provide the care that they need for you;
  • Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated; and
  • Work with your health plan's doctors and other providers to understand your health problems. Pick treatment goals that you have all agreed on; and
  • Help your providers get your medical records.

You must be involved - and take part in decisions relating to service and treatment options and agreed upon goals. Make personal choices, and take action to maintain your health. That includes the responsibility to:

  • Work as a team with your provider in deciding what health care is best for you; and
  • Understand how the things you do can affect your health; and
  • Follow plans and instructions for care that you have agreed on with your doctors and other providers; and
  • Do the best you can to stay healthy; and
  • Treat providers and staff with respect.

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