The member has the right to:

1. Exercise these rights without regard to gender, sexual orientation or cultural, economic, educational or religious background.

2. Be provided with comprehensible information about our medical group, services, providers and the healthcare service delivery process. This information includes instructions about how to obtain care with various providers and at varied facilities (e.g., primary care, specialty care, behavioral health services, and hospital services). Additionally, information will be included about how to obtain services outside the IPA system or service area.

3. Be informed of emergent and non-emergent benefit coverage and cost of care, and receive an explanation of the member’s financial obligations as appropriate, prior to incurring the expense (including co-payments, deductibles and co-insurance).

4. Be provided with instructions in accordance with prudent layperson standards and address the needs of non-English speaking members with information about how to obtain care after normal office hours and how to obtain emergency care including when to directly access emergency care or use 911 services.

5. Receive and examine an explanation of bills generated for services delivered to the member.

6. Be provided with information on how to submit a claim for covered services.

7. Be informed of the name and qualifications of the physician who has primary responsibility for coordinating the member’s care; and be informed of the names, qualifications and specialties of other physicians and non-physicians who are involved in the member’s care.

8. Have 24-hour, 7 days a week access to the member’s primary care physician (or covering physician).

9. Receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, and prospects for recovery in terms that are understandable to the member, to give informed consent or to refuse that course of treatment.

10. Candidly discuss appropriate or medically necessary treatment options for the member’s condition, regardless of cost or benefit coverage.

11. Actively participate in decisions regarding the member’s healthcare and treatment to the extent permitted by law. This includes the right to refuse any procedure or treatment. If the recommended procedure or treatment is refused, an explanation will be given addressing the effect that this will have on the member’s health.

12. Be treated with respect and dignity.

13. Receive considerate and respectful care with full consideration of the member’s privacy.

14. Receive confidential treatment of all member information and records used for any purpose.

15. Be informed of applicable rules in the various health care settings regarding member conduct.

16. Express opinions or concerns about our medical group or the care provided and offer recommendations for change in the healthcare service delivery process by contacting the Member Services Department.

17. Be informed of the member complaint/grievance and appeal process including how to express a complaint or appeal.

18. Be informed of the termination of a primary care provider or practice site and receive assistance in selecting a new primary care provider or site in this situation.

19. Change primary care physicians by contacting the Member Services Department at your health plan.

20. Be provided information on how we evaluate with health plans, new technology for inclusion as a covered benefit.

21. Receive reasonable continuity of care and be given timely and sensible responses to questions and requests made for service, care and payment (including complaints and appeals).

22. Be informed of continuing healthcare requirements following office visits, treatments, procedures and hospitalizations.

23. Have all member rights apply to the person who has the legal responsibility to make healthcare decisions for the member.

24. To make available and or assist Limited English Proficiency (LEP) members access to their contracted health plan interpreter services or when requested at any scheduled or unscheduled or unscheduled visits at provider offices, including ancillary providers, specialty service providers, diagnostic testing facilities, and urgent care at no cost to the member.

25. Right to make recommendations regarding  member rights and responsibilities policies.

26. Request enrollment in, or to decline or disenroll from, case management and/or disease management programs.

27. For any member denial the member will be able to contact the Medical Group and request a copy of the criteria used to make the decision on a denial that the group has made.