Member Rights and Responsibilities
Our members have rights and responsibilities. Our Member Services representatives serve as their advocates. Below are the rights and responsibilities of members.
Members have the right to:
Privacy:
- Be treated with respect and with due consideration for their dignity and privacy.
- Expect that we will treat their records, including medical and personal information as well as communications, confidentially.
- Request and receive a copy of their medical records at no cost to the member and request that the records be amended or corrected.
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation as specified in federal regulations.
Take part in decisions regarding their health care:
- Receive information on available treatment options and alternatives, presented in a manner appropriate to the member’s condition and ability to understand.
- Engage in candid discussions of appropriate or medically necessary treatment options for their conditions regardless of cost or benefit coverage.
- Receive the appropriate services that are not denied or reduced solely because of medical condition.
- Refuse health care (to the extent of the law) and understand the consequences of such action.
- Make a living will so they can decide ahead of time the type of care they want if they become sick, injured or seriously ill.
- Be able to make decisions about their children’s health care if members are younger than age 18 and married, pregnant or have children.
Grievances, disputes and fair hearings:
- Pursue resolution of grievances and disputes about the health plan or care provided.
- Freely exercise filing a grievance or a dispute without adversely affecting the way they are treated.
- Continue to receive benefits pending the outcome of a dispute or a fair hearing under certain circumstances.
Clear Health Alliance (CHA) information:
- Receive the necessary information to be a CHA member in a manner and format they can easily understand.
- Receive a current member handbook and a provider directory.
- Receive a copy of the member handbook and/or provider directory by request by calling Member Services at 1-844-406-2398, TTY-711.
- Receive assistance from CHA in understanding the requirements and benefits of the plan.
- Receive notice of any significant changes in the benefit package at least 30 days before the intended effective date of the change.
- Make recommendations about our rights and responsibilities policies.
- Know how we pay our providers.
Medical care:
- Choose their PCPs from our network of providers.
- If appropriate, choose any CHA network specialist after getting a referral from their PCPs.
- Be referred to health care providers for ongoing treatment of chronic disabilities.
- Have access to their PCPs or backups 24 hours a day, 365 days a year for urgent or emergency care.
- Get care right away from any hospital when their symptoms meet the definition of an emergency medical condition.
- Get post-stabilization services following an emergency medical condition in certain circumstances.
- Be free from discrimination and receive covered services without regard to race, color, creed, gender, religion, age, national origin ancestry, marital status, sexual preference, health status, income status, program membership, or physical or behavioral disability, except where medically indicated.
Members have the responsibility to:
Respect their health care providers:
- Treat their doctors, their doctors’ staff and employees with respect and dignity.
- Not be disruptive in the doctor’s office.
- Make and keep appointments, and be on time.
- Call if they need to cancel an appointment, change an appointment time or if they will be late.
- Respect the rights and property of all providers.
Cooperate with the people providing health care:
- Tell their providers about their symptoms and problems, and ask questions.
- Supply providers with the information needed for providers to deliver care.
- As much as they are able to, understand their specific health problems and participate in developing mutually agreed upon treatment goals.
- Discuss problems they may have with following their providers’ directions.
- Follow the plans and instructions for the care they have agreed to with their practitioners.
- Consider the outcome of refusing treatment recommended by a provider.
- Discuss grievances, concerns and opinions in an appropriate and courteous way.
- Help their providers obtain medical records from their previous providers, and help their providers complete new medical records as necessary.
- Secure referrals from their PCPs when specifically required before going to another health care provider, unless they have a medical emergency.
- Know the correct way to take medications.
- Go to the emergency room when they have an emergency.
- Notify their PCPs as soon as possible after they receive emergency services.
- Tell their doctor who they want to receive their health information.
Follow policies outlined in the member handbook:
- Provide us with proper identification during enrollment.
- Carry their CHA and Medicaid ID cards at all times and report any lost or stolen cards.
- Contact us if information on their ID cards is wrong or if there are changes to their name, address or marital status.
- Call us and change their PCP before seeing the new PCP.
- Tell us about any doctors they are currently seeing.
- Notify us if a member or family member who is enrolled in CHA has died.
- Report suspected fraud and abuse.