Member Rights and Responsibilities

 

To find the Member Rights and Responsibilities, please click here.

This section explains the rights and responsibilities of Molina Healthcare of New Mexico, Inc. (Molina Healthcare) Members as written in the Molina Healthcare Evidence of Coverage. New Mexico state law requires that health care practitioners/providers or health care facilities recognize Member rights while they are receiving medical care and that Members respect the health care provider's or health care facility's right to expect certain behavior on the part of patients. 
Below are the Member Rights and Responsibilities:

Members have the right to:

  • Be treated with respect and recognition of your dignity by everyone who works with Molina Healthcare;
  • Get information about Molina Healthcare and our products, participating providers, appeals procedures, services, policies and procedures;
  • Available and accessible services when covered under this EOC and Medically Necessary, including urgent care services and emergency services 24 hours a day, 7 days a week and for other Covered Services as defined by this EOC;
  • Choose your Primary Care Practitioner (PCP) from Molina Healthcare’s list of participating providers and to refuse care of specific health care professionals;
  • Receive from your treating practitioners/providers information about your health in terms you can understand;
  • Be told by your treating practitioners/providers about all treatment options and risks regardless of cost or benefit coverage if you have an illness;
  • Have all your questions about your health answered by your treating practitioners/providers; 
  • All rights under law, rule or regulation as patient in a licensed Health Care Facility, including  the right to refuse medication and treatment after having the consequences explained to you by a practitioner/provider in a language that you can understand and other rights as a patient;
  • Privacy of your medical and financial records maintained by Molina Healthcare and its participating providers, in accordance with applicable state and federal law;
  • Complain about Molina Healthcare or your care from participating providers.  You can call, fax, e-mail or write to Molina Healthcare’s Customer Support Center;
  • Complain or appeal Molina Healthcare’s decisions to Molina Healthcare or to the Superintendent of Insurance, and to receive an answer to those complaints in accordance with law;
  • Prompt notification, as required by applicable law, of termination or changes in benefits, services, or participating providers.
  • Request and receive information about any financial arrangements or provisions between Molina Healthcare and its participating providers that may restrict referral or treatment options or limit the services offered to Members;
  • Adequate access to qualified health professionals for the provision of Covered Services near where you work or live in the Molina Healthcare service area;
  • Detailed information about coverage, maximum benefits, and exclusions of specific services, including restricted prescription benefits, and all requirements to obtain prior authorization for services;
  • Affordable health care, with limits on out-of-pocket expenses, including the right to seek care from a non-participating provider (care provided by a non-participating provider is not covered unless expressly stated in this EOC), and an explanation of your financial responsibility when services are provided by a non-participating provider, or provided without required prior authorization;
  • A complete explanation of why Molina Healthcare has denied coverage for certain services, an opportunity to appeal Molina Healthcare’s decision, the right to a secondary appeal, and the right to request the superintendent’s assistance;
  • Ask for and get materials in other formats such as, larger size print, audio and Braille upon request and in a timely fashion appropriate for the format being requested and in accordance with state laws;
  • Get a copy of Molina Healthcare’s list of approved drugs on the Drug Formulary upon request;
  • Not to be treated poorly by Molina Healthcare or your practitioners/providers for acting on any of these rights; and
  • Make recommendations regarding Molina Healthcare’s Member rights and responsibilities policies.

 

Members have the responsibility to:

  • Learn and ask questions about your health benefits. If you have a question about your benefits, call Member Services Department toll-free at  (888) 295-7651;
  • Give information to your doctor, provider, or Molina Healthcare that is needed to care for you;
  • Be active in decisions about your health care;
  • Follow the care plans for you that you have agreed on with your doctor(s);
  • Build and keep a strong patient-doctor relationship.  Cooperate with your doctor and staff.  Keep appointments and be on time.  If you are going to be late or cannot keep your appointment, call your doctor’s office;
  • Give your Molina Healthcare card when getting medical care.  Do not give your card to others.  Let Molina Healthcare know about any fraud or wrong doing; and
  • Understand your health problems and participate in developing mutually agreed-upon treatment goals as you are able.

 

If a Member does not agree with their practitioner’s/provider’s plan of care, they have the right to request a second opinion from another practitioner/provider.  Members should call Member Services to find out how to get a second opinion.  Second opinions may require prior authorization.