DCS Comprehensive Health Plan

Member Rights & Responsibilities

Policy Statement

This policy outlines the rights and responsibilities of members enrolled with the Department of Child Safety Comprehensive Health Plan (DCS CHP), and the manner those rights and responsibilities are communicated to members and providers.

Definitions

AHCCCS: The Arizona Health Care Cost Containment System, which is the State’s program for medical assistance available under Title XIX of the Social Security Act and state public insurance statutes, A.R.S. Title 36, Chapter 29.

Member: An eligible individual who is enrolled in AHCCCS, as specified in ARS 36-2931, 36-2901, 36-2901.01 and ARS 36-2981. Also referred to as Title XIX/XXI member or Medicaid member.  When applicable, MEMBER may also or alternatively refer to an enrolled individual's health care decision maker (HCDM) or designated representative (DR).

Provider: A person, institution, or group engaged in the delivery of services, or ordering and referring those services, who has an agreement with AHCCCS to provide services to AHCCCS members.

Policy

DCS CHP upholds all member rights and responsibilities and shares this information with both members and participating providers. It is the duty of organizational departments and participating providers to guarantee that members’ rights are honored and safeguarded.

DCS CHP, through its subcontracted MCO, is responsible for publishing Member Rights and Responsibilities in its Member Handbook, the health plan website, providing new members with information about their rights and responsibilities in the New Member Information Packets, and an annual notice to members about where they can find information about their rights and responsibilities.

DCS CHP, through its subcontracted MCO, is also responsible for publishing Member Rights and Responsibilities in the Provider Manual and posting the Provider Manual in the provider sections of the health plan website.

Information outlining Member Rights and Responsibilities, prepared by AHCCCS or the Centers for Medicare and Medicaid Services (CMS), is disseminated to DCS CHP members and subcontractors. DCS CHP is responsible for all costs related to dissemination of the information.

Procedure

DCS CHP complies with all Federal and State laws including:

• Title VI of the Civil Rights Act of 1964 as implemented by Regulations at 45 CFR Part 80;

• Age Discrimination Act of 1975 as implemented by Regulations at 45 CFR Part 91;

• Rehabilitation Act of 1973;

• Title IX of the Education Amendments of 1972 (regarding education programs and activities);

• Titles II and III of the Americans with Disabilities Act; and

• Section 1557 of the Patient Protection and Affordable Care Act.

Privacy Rights

The “Privacy Rights” notice provides detailed information regarding the manner DCS CHP and its subcontracted MCO utilize member records, including health plan activities and payment information. Members’ health care data is maintained with strict confidentiality and disclosed only with their consent or as permitted by law. Members are entitled to request and receive, annually, one copy of their medical records and/or review their medical records at no cost. However, access may be restricted if the records contain psychotherapy notes prepared for civil, criminal, or administrative proceedings; protected health information governed by the Federal Clinical Laboratory Improvements Amendment of 1988; or protected health information exempt under federal regulations.

 

Members have the following rights:

• The right to exercise his or her rights, and that exercising those rights will not negatively affect service delivery to the member;

• The right to file a complaint about DCS CHP and/or its subcontracted MCO;

• The right to request information about the structure and operations of DCS CHP and its contracted MCO or their subcontractors;

• The right to know whether stoploss insurance is required; and

• The right to be treated fairly and get covered services without concern about race, ethnicity, national origin (including those with limited English proficiency), religion, gender, age, mental or physical disability, sexual orientation, genetic information, or ability to pay or speak English.

 

Members have the right to the following information:

• The name of their Primary Care Physician (PCP) and/or Mercy Care care manager;

• A copy of the Member Handbook, which includes a description of covered services;

• Provision of after-hours and emergency care by DCS CHP;

• The methods by which DCS CHP and its subcontracted MCO compensate providers, manage expenses, and utilize services—along with an indication of whether Physician Incentive Plans (PIP) are implemented and a description of such plans;

• General grievance results and a summary of member survey results;

• Their costs to get services or treatments that are not covered by DCS CHP;

• Mechanisms to get services, including those requiring authorization;

• How DCS CHP and its subcontracted MCO evaluates new technology to include as a covered service; and

• Changes to their services or what actions to take when their PCP leaves the provider network.

Confidentiality and Privacy

Members have the following rights related to confidentiality and privacy:

• Confidentiality of their health care information.

• Private discussion with their health care professionals.

• Receive a copy of the “Privacy Rights” notice with information on ways DCS CHP and its subcontracted MCO uses their records, which includes information on their health plan activities and payments for services. Their health care information will be kept private and confidential. It will be given out only with their permission or if the law allows it.

Treatment Decisions

Members have the following rights related to treatment decisions:

• Agree to, or refuse, treatment and to choose other treatment options available to them. They can get this information in a way that helps their understanding and is appropriate to their medical condition.

• Choose a PCP to coordinate their health care.

• Change their PCP.

• Talk with their PCP to get complete and current information about their health care and condition. This will help the members and/or their caregiver understand their condition and be a part of making decisions about their health care.

• Within the limits of applicable regulations, DCS CHP and its subcontracted MCO may help manage their health care by working with them, community and state agencies, schools, and their doctor.

• Receive information on which procedures they will have and who will perform them.

• Receive a second opinion from a qualified health care professional within the network. They can get a second opinion arranged outside of the network, at no cost to the member, only if there is not adequate in-network coverage.

• Know treatment choices or types of care available to them and the benefits and/or drawbacks of each choice.

• Have treatment choices presented to them in a way that they can understand.

• Decide who they want to be with them for treatments and exams.

• Have a female in the room for breast and pelvic exams.

• Their eligibility or medical care does not depend on their agreement to follow a treatment plan. They can say “no” to treatment, services or PCPs. They will be informed about what may happen to their health if they do not have the treatment.

• Receive, in writing from DCS CHP and/or its subcontracted MCO, when any health care services requested by their PCP are reduced, suspended, terminated or denied. Members must follow the instructions in the notification letter sent to them.

Advance Directives

• Members have the right to be provided with information about creating advance directives. Advance directives tell others how to make medical decisions for the member if they cannot make them for themselves.

Medical Records Requests

• At no cost to the member, they have the right to annually request and receive one copy of their medical records and/or inspect their medical records. They may not be able to get a copy of medical records if the record includes any of the following information: psychotherapy notes put together for a civil, criminal or administrative action; protected health information that is subject to the Federal Clinical Laboratory Improvements Amendments of 1988; or protected health information that is exempt due to federal codes of regulation.

• DCS CHP and/or its subcontracted MCO shall respond to their request within 30 days. The reply will include a copy of the requested record or a letter denying the request. The written denial letter will include the basis for the denial and information on ways to get the denial reviewed.

• Members have the right to request an amendment to their medical records. DCS CHP and/or its subcontracted MCO may ask that the member put this request in writing. If the amendment is made, whole or in part, the health plan takes necessary steps to complete in a timely manner and notify the member about changes that are made.

• DCS CHP and/or its subcontracted MCO has the right to deny their request to amend their medical records. If the request is denied, whole or in part, then DCS CHP and/or its contracted MCO will provide the member with a written denial within 60 days. The written denial includes the basis for the denial, notification of their right to submit a written statement disagreeing with the denial and how to file the statement.

Reporting Concerns

• Members are encouraged to tell DCS CHP and/or its subcontracted MCO about any complaints or issues they have with their health care services.

• They may file an appeal with DCS CHP and/or its subcontracted MCO and get a decision in a reasonable amount of time.

• They can give DCS CHP and/or its subcontracted MCO suggestions about changes to policies and services.

• They have the right to complain about DCS CHP and/or its subcontracted MCO.

Personal Rights

• Members have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.

• They have the right to receive information on beneficiary and plan information.

Respect and Dignity

Members have the right to be treated with respect and with due consideration for their dignity and privacy as well as the following rights:

• Participate in decisions regarding their health care, including the right to refuse treatment.

• Receive quality medical services that support their personal beliefs, medical condition and background.

• Receive these services in a language they understand and know about other providers who speak languages other than English.

• Receive interpretation services if they do not speak English. Sign language services are available if they are deaf or have difficulty hearing. They may ask for materials in other formats or languages from Member Services.

• Know that their Information about their treatment plan is available to them in a way that helps their understanding given their medical condition.

Emergency Care and Specialty Services

Members can get emergency health care services without the approval of their PCP, DCS CHP and/or its subcontracted MCO when they have a medical emergency.

Members:

• May go to any hospital emergency room or other setting for emergency care.

• May get behavioral health services without the approval of their PCP, DCS CHP and/or its subcontracted MCO.

• Can see a specialist with a referral from their PCP.

• Can refuse care from a provider they were referred to, and they can ask for a different provider.

• May request a second opinion from another network provider.

Member Responsibilities

All DCS CHP Members and their caregivers have the following responsibilities:

Respect

• Respect the doctors, other providers, pharmacists, staff and all people providing services to them.

• Protect their member ID card, including not losing it or sharing it with anyone.

Share Information

• Show their member ID card, or identify themselves as a DCS CHP member, to health care providers before getting services. If they have other insurance in addition to DCS CHP, members need to show their doctor or pharmacist their other insurance ID card as well.

• If they do not understand their health condition or treatment plan, they should ask their PCP to explain.

• Tell their PCP the name of other insurance plans they may have. Apply for benefits for which they may be eligible through their additional insurance.

• Give their PCP all the facts about their health problems: past illnesses, hospital stays, all medications, shots and other health concerns. Let their PCP and/or their Mercy Care care manager know about any changes in their condition.

• Notify DCS CHP and/or its subcontracted MCO any time a provider or another member is not using their health plan benefits correctly.

• Report changes that could affect their eligibility such as address, telephone number and/or assets and other matters to the interviewer at the office where they applied for AHCCCS.

Follow Instructions

• Know the name of their assigned PCP.

• Members or their caregiver should know the name of their case manager if they have one.

• Follow the treatment instructions that the member and their PCP have agreed on, including the instructions from nurses and other health care professionals.

• Bring any available immunization/medical records for the child in their care to PCP visits.

Provider Appointments

• Schedule appointments during office hours instead of using urgent or emergency care.

• Go to their appointments on time and keep them. The member or their caregiver should call their PCP’s office ahead of time when they cannot keep their appointment.