Member Rights and Responsibilities

Members have certain rights and responsibilities. They are listed below.

MEMBERS HAVE THE RIGHT TO:

Be treated with respect and dignity.
Get covered benefits or services regardless of gender, race, ethnicity, age, religion, national origin, sexual orientation, physical or mental disability, type of illness or condition, ability to pay or ability to speak English.
Pick a doctor who works with DPCI’s provider network.
Not have your medical records shown to others without your approval, unless allowed by law.
Privacy when you are at an office visit, getting treatment or talking to the health plan.
Get information about DPCI, the services we cover, the doctors who provide care, and the Member Rights and Responsibilities.
Have your doctor tell how he or she plans to treat you. The doctor should tell you if other treatments can be used and the risks for each one, no matter how much they cost or if DPCI will pay for it.
Know the cost to you if you choose to get a service that DPCI does not cover.
Be involved in deciding on the kind of care you want or do not want.
Get a second opinion from an appropriately qualified participating health care professional at no cost to you. If a DPCI provider is not available, DPCI will help you to get a second opinion from a non-participating provider at no cost to you.
Find out what is in your medical records, as allowed by law and request a copy of your records.
You can ask that changes be made to your medical records.
You can ask for a list of people who have been given a copy of your medical records.
To be free from any form of restraint and/or seclusion used as a means of coercion, discipline, convenience or retaliation.
Get interpretation services if you do not speak English or have a hearing impairment to help you get the medical services you need. You may ask for materials to be presented in a manner or language that you understand at no cost to you.
Voice your complaints and grievances about DPCI and the care you get from your doctor.
Use the methods listed in this handbook to share questions and concerns about your health care or DPCI.
Tell us ways to improve DPCI’s policies and procedures, including the Member Rights and Responsibilities.
Develop Advance Directives or a Living Will, which tell how to have medical decisions made for you if you are not able to make them for yourself.
Know how DPCI pays providers, controls costs and uses services.
Get emergency health care services without the approval of your PCP or DPCI when you have a true medical emergency.
Say no to treatment, services or PCPs and be told what may happen if you do not have the treatment. You can continue to get Medicaid and medical care even if you say no to treatment.
Refuse care from a doctor you were referred to and ask for a referral to a different doctor.
Be told in writing by DPCI when any of your health care services requested by your PCP are reduced, suspended, terminated or denied. You must follow the instructions in your notification letter.

YOU HAVE A RESPONSIBILITY TO:

Read this handbook. It tells you about our services and how to file a complaint or grievance.
Follow DPCI rules.
Know the name of your assigned PCP.
Show your ID card to each doctor before getting health services.
Get approval from your PCP before you get treatment from other doctors. This does not include self-referral services or emergency treatment.
Protect your member ID card. Do not lose or share it with others.
Use the emergency room (ER) for true emergencies only.
Make and keep appointments with your doctors. If you need to cancel an appointment, it must be done at least 24 hours before your scheduled visit.
Treat the doctors, staff and people providing services to you with respect.
Give all information about your health to DPCI and your doctor. This includes immunization records for members under age 21.
Tell your doctor if you do not understand what they tell you about your health so that you and your doctor can make plans together about your care.
Follow what you and your doctor agree to do. Make follow-up appointments. Take medicines and follow your doctor’s care instructions.
Schedule wellness check-ups. (Members under 21 years of age need to follow the Early Periodic Screening Diagnosis and Treatment (EPSDT) schedule.)
Get care as soon as you know you are pregnant. Keep all prenatal appointments.
Tell DPCI and the Department of Social Services (DSS) when your address changes. Tell them about changes in your family that might affect eligibility or enrollment.
Tell DPCI if you have other health insurance, including Medicare.
Give your doctor a copy of your Living Will and/or Advance Directive.