Member Rights and Responsibilities

Members have the right to expect a certain level of service from their health care providers. Members are also responsible for cooperating with providers in obtaining health care services. These member rights and responsibilities apply to member's relationships with Health Net, and all participating providers responsible for member care. In addition to member rights and responsibilities, medical services must be provided in a culturally competent manner without regard to race, color, national origin, ancestry, religion, gender, marital status, sexual orientation, age, health status, physical or mental disability.

Health Net members are notified of their rights and responsibilities via the annual member mailing and Cal MediConnect Member Handbook. The actual statements of member rights and responsibilities are in accordance with the Centers for Medicare and Medicaid Services (CMS) and Department of Health Care Services (DHCS) and may vary slightly from what is listed below. Providers should direct Health Net members who have questions regarding their rights and responsibilities to reference materials specific to their plan.

Members have the responsibility for:

• Being aware of their benefits and services and how to obtain them
• Supplying information (to the extent possible) that the health plan and its providers need in order to provide care
• Following plans and instructions for care that they may have agreed on with their providers
• Understanding their health problems and participating in developing mutually agreed-upon treatment goals, to the degree possible

Members have the right to:

• Receive information about the organization (including all enrollment notices, informational and instructional materials), its services, its practitioners and providers and member rights and responsibilities in a manner and format that may be easily understood
• Be treated with respect and recognition of their dignity and right to privacy
• Participate in decisions regarding their health care, including the right to refuse treatment
• A candid discussion of appropriate of medically necessary treatment options for their conditions, regardless of cost or benefit coverage
• Voice complaints or appeals about the organization or the care it provides
• Make recommendations regarding the organization's member rights and responsibilities policy
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation
• Have access to personal medical records, and where legally appropriate, receive copies of, amend or correct their medical record
• Reasonable accommodations
• Be treated with dignity and respect
• Privacy and confidentiality in all aspects of care and for all health care information, unless otherwise required by law
• Be provided a copy of their medical records, upon request, and to request corrections or amendments to these records
• Not be discriminated against based on race, ethnicity, national origin, religion, gender, age, sexual orientation, medical or claims history, mental or physical disability, genetic information, or source of payment
• Have all plan options, rules and benefits fully explained, including through use of a qualified interpreter if needed
• Access an adequate network of primary and specialty providers who are capable of meeting their needs with respect to physical access, and communication and scheduling needs, and are subject to ongoing assessment of clinical quality, including required reporting
• Choose a plan and provider at any time and have that choice be effective the first calendar day of the following month
• Participate in all aspects of care and to exercise all rights of appeal. Members have a responsibility to be fully involved in maintaining their health and making decisions about their health care, including the right to refuse treatment if desired, and be appropriately informed and supported to this end. Specifically, members must:
  • Receive a comprehensive health risk assessment upon date of coverage in a plan and to participate in the development and implementation of an individualized care plan (ICP). The assessment must include considerations of social, functional, medical, behavioral, wellness and prevention domains, an evaluation of their strengths and weaknesses, and a plan for managing and coordinating their care. Members, or their designated representative, also have the right to request a reassessment by the interdisciplinary team, and be fully involved in any such reassessment. Enrollees or their authorized representative must have the opportunity to review and sign the ICP and any of its amendments. 
    
    
    • Health Net or the participating provider group, when delegated to do so, must provide enrollees with copies of the ICP and any of its amendments. The ICP must be made available in alternative formats and in an enrollee's preferred written or spoken language.  
    • Enrollees or their authorized representative must have the opportunity to review and sign the ICP and any of its amendments

  Receive complete and accurate information on their health and functional status by the interdisciplinary team

  • Be provided information on all program services and health care options, including available treatment options and alternatives, presented in a culturally appropriate manner, taking into consideration their condition and ability to understand. A participant who is unable to participate fully in treatment decisions has the right to designate a representative. This includes the right to have translation services available to make information appropriately accessible. Information must be available:
    • Before enrollment
    • At enrollment
    • At the time needs necessitate the disclosure and delivery of such information in order to allow members to make an informed choice
  • Be encouraged to involve caregivers or family members in treatment discussions and decisions
  • Receive reasonable advance notice, in writing, of any transfer to another treatment setting and justification for the transfer
  • Be afforded the opportunity to file an appeal if services are denied that they think are medically indicated, and to be able to ultimately take that appeal to an independent external system of review
• Receive medical and non-medical care from a team that meets their needs in a manner that is sensitive to their language and culture, and in an appropriate care setting, including the home and community
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation
• Freely exercise these rights and that the exercise of those rights does not adversely affect the way Health Net and its providers or the DHCS treats them
• Receive timely information about plan changes. This includes the right to request and obtain the information listed in the orientation materials at least once per year, and the right to receive notice of any significant change in the information provided in the orientation materials at least 30 days prior to the intended effective date of the change
• Be protected from liability for payment of any fees that are Health Net's obligation
• Not to be charged any cost sharing for Medicare Parts A and B services
• The unconditional and exclusive right to hire, fire and supervise their in-home supportive services (IHSS) provider
• Receive their Medicare and Medi-Cal appeals rights in a format and language understandable and accessible to them
• Opt out of Cal MediConnect at any time, beginning the first of the following month

In addition:

• Members shall not be balance billed by a provider for any service
• Members are free to exercise their rights without negative consequences