Member Rights and Responsibilities

As a patient, you have the right to:

• Be treated with respect, consideration and without judgment by all staff and volunteers.
• Actively participate in your health care, including decision making, treatment options, and ethical decisions.
• Be given care and service that respects your values and belief system.
• Have your privacy, confidentiality and dignity respected.
• Be provided care and service in a safe, secure, comfortable and clean environment.
• Choose your primary care clinic, request a primary care provider, and change providers as often as once a month.
• Receive materials and have information about your health care and your health plan explained to you in a language you understand.
• Have language interpreters and interpreters for the deaf or hard of hearing available during health care visits and when dealing with the health plan.
• Know the name, title and qualifications of the providers and staff who care for you.
• Tell us your complaints about your health care or the health plan without being afraid that this will affect your health care status in the future.
• Be informed about the complaint process and to receive an answer in a timely manner.
• File a grievance with the Health Care Authority if you are not satisfied with the response to a complaint.
• Have your medical record and information regarding your health care treated confidentially, except when sharing such information is authorized by law or when you have given written permission.
• Receive proper and timely health care, 24 hours a day, 7 days a week, including emergency services, without discrimination of any kind.
• Receive information about the health care services available to you, including when and how to obtain these services.
• Be informed about your health status, treatment options and risks involved regardless of cost or benefit coverage and to be given the opportunity to provide informed consent.
• Receive a second opinion from another provider of the health plan when you request it.
• Refuse treatment and to be informed of the possible results of refusal.
• Refuse to participate in experimental research.
• Be informed and educated about the opportunity to express your wishes concerning future care, including: choosing a person to make medical decisions for you if you are unable to do so through advance directives by giving durable power of attorney, and/or preparing a living will.
• Change health plans during the open enrollment period or if your plan leaves your area.
• Convert to an individual plan when you retire.
• Review your medical record with a staff member present.
• Receive an explanation of any charges for services.
• Seek care, if you are female, from a Community Health Plan provider specializing in women’s health care services for women’s health care needs, without a referral from your primary care provider.
• Participate in member advisory work groups.
• Request written information about other health care options available from Community Health Plan.
• Expect that Community Health Plan will protect the privacy of your personal information. Included in your new member information packet is a copy of the Community Health Plan document, “Notice of our information privacy policies and practices”.
• Know that state and federal laws establish standards to ensure safe and effective pharmacy services. You have the right to know what drugs are covered under this plan, and what limitations have been placed on your coverage by the terms of your contract. For information on the drug coverage policies under this plan, please refer to benefit detail 22, Prescription Drugs, Insulin and Diabetic Supplies. If you have additional questions, please contact Community Health Plan Customer Service at 1-800-440-1561.
• Request information about many different aspects of Community Health Plan administration. If you would like information about any of the items listed below, contact Customer Service at 1-800-440-1561.

1. In your member handbook there may be references to documents, instruments or other information. You may request of copy of these documents, instruments or other information.
2. You must have an approved referral from your primary care provider before you see a specialist for most health care services. You may request a description of the things you must do before you see a provider other than your primary care provider, and if your primary care provider, Community Health Plan Medical Director, or any one else must authorize the referral.
3. Some health care services require a prior authorization from Community Health Plan in order for them to be covered under your policy. You may request a description of what you must do, if anything, to obtain prior authorization for health care services.
4. Community Health Plan pays physicians and facilities for health care services in a variety of ways. You may request a general description of these payment methods, including reasons for any incentives or penalties that are intended to encourage providers to withhold services or minimize or avoid referrals to specialists.
5. You may request an annual accounting of all payments made by Community Health Plan that have been counted against any payment limitations, visit limitations, or other overall limitation on your coverage under your policy.
6. You may request a copy of Community Health Plan’s grievance policy. This policy will tell you how to file an appeal with us if you don’t agree with one of our decisions or you are dissatisfied with the care you received from a provider.
7. Community Health Plan tracks its health care effectiveness performance using the health employer data information set (HEDIS®). You may request a description of how we publicly report our results and how you can see the HEDIS® data.

As a member of Community Health Plan you have the responsibility to:

• Provide complete and accurate information regarding your health history, current medical status, and changes in your symptoms and medical condition.
• Participate in decision making about your health care and to make informed decisions about treatments and procedures before they are performed.
• Follow the treatment plan that you and your provider agree to.
• Inform your provider if you do not understand your treatment plan and what is expected of you, or if you believe you cannot follow through with the treatment plan.
• Accept the risks that have been explained to you, if you decide to refuse recommended treatment.
• Treat health care professionals, staff, other members, and the health Primary Care Center’s property in a considerate and respectful manner.
• Seek medical services only through your chosen primary care provider except in a life threatening emergency.
• Make and keep appointments for non-emergency care and to notify the primary care center if you are going to be late or need to cancel an appointment.
• Receive proper authorization from your primary care provider before going to a specialist.
• Fulfill your financial obligations, if any, for the health care services provided to you.
• Notify staff if you do not understand how your health plan works.
• Tell us about your suggestions for improvements, concerns and complaints.
• Identify yourself as a member of Community Health Plan when you seek care and to carry your identification cards with you.