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Overview

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Sacramento
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

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 members' relationships with Health Net, and all participating providers responsible for member care.

Health Net members are notified of their rights and responsibilities via the annual member mailing and the Evidence of Coverage (EOC). The following text is take directly from the Health Net Medi-Cal member's handbook.

Health Net members have these responsibilities:

  • Act courteously and respectfully. You are responsible for treating your doctor and all Providers and staff with courtesy and respect. You are responsible for being on time for your visits or calling your doctor's office at least 24 hours before the visit to cancel or reschedule.
  • Give up-to-date, accurate and complete information. You are responsible for giving correct information and as much information as you can to all of your Providers, and to Health Net. You are responsible for getting regular check-ups and telling your doctor about health problems before they become serious.
  • Follow your doctor's advice and take part in your care. You are responsible for talking over your health care needs with your doctor, developing and agreeing on goals, doing your best to understand your health problems, and following the treatment plans and instructions you both agree on.
  • Use the Emergency Room only in an emergency. You are responsible for using the emergency room in cases of an emergency or as directed by your doctor. Emergency Care is a service that you reasonably believe is necessary to stop or relieve sudden serious illnesses or symptoms, and injury or conditions requiring immediate diagnosis and treatment.
  • Report wrong doing. You are responsible for reporting health care fraud or wrong doing to Health Net Community Solutions. You can do this without giving your name by calling Health Net Fraud and Abuse Hotline toll-free at 1-800-977-3565.

Health Net members have these rights:

  • To be treated with respect, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information.
  • To be provided with information about the plan its services, including Covered Services its practitioners and providers and member rights and responsibilities.
  • To be able to choose a primary care provider within the Contractor's network.
  • To participate in decision making regarding your own health care, including the right to refuse treatment.
  • To a candid discussion appropriate or medically necessary treatment options for conditions, regardless of cost or benefit coverage.
  • To make recommendations regarding the plan's member rights and responsibilities policy.
  • To voice grievances, either verbally or in writing, about the organization or the care received.
  • To receive care coordination.
  • To request an appeal of decisions to deny, defer, or limit services or benefits.
  • To receive oral interpretation services for their language.
  • To receive free legal help at your local legal aid office or other groups.
  • To formulate advance directives.
  • To have access to family planning services, Federally Qualified Health Centers, Indian Health Service Facilities, sexually transmitted disease services and Emergency Services outside the Contractor's network pursuant to the federal law.
  • To request a State Hearing, including information on the circumstances under which as expedited hearing is possible.
  • To have access to, and where legally appropriate, receive copies of, amend or correct your Medical Record.
  • To disenroll upon request. Beneficiaries that can request expedited disenrollment include, but not are limited to, beneficiaries receiving services under the Foster Care, or Adoption Assistance Programs; and members with special health care needs.
  • To access Minor Consent Services.
  • To receive written member informing materials in alternative formats (including braille, large-size print, and audio format) upon request and in a timely fashion appropriate for the format being requested and in accordance with W & I Code Section 14182 (b)(12).
  • To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • To receive information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand.
  • To receive a copy of your medical records, and request that they be amended or corrected, as specified in 45 CFR §164.524 and 164.526.
  • Freedom to exercise these rights without adversely affecting how you are treated by the Contractor, providers or the State.

CalViva Health members have these responsibilities:

  • Act courteously and respectfully. You are responsible for treating your doctor and all providers and staff with courtesy and respect. You are responsible for being on time for your visits or calling your doctor's office at least 24 hours before the visit to cancel or reschedule.
  • Give up-to-date, accurate and complete information. You are responsible for giving correct information and as much information as you can to all of your providers, and to our plan. You are responsible for getting regular check-ups and telling your doctor about health problems before they become serious.
  • Follow your doctor's advice and take part in your care. You are responsible for talking over your health care needs with your doctor, developing and agreeing on goals, doing your best to understand your health problems, and following the treatment plans and instructions you both agree on.
  • Use the Emergency Room only in an emergency. You are responsible for using the emergency room in cases of an emergency or as directed by your doctor. Emergency Care is a service that you reasonably believe is necessary to stop or relieve sudden serious illnesses or symptoms, and injury or conditions requiring immediate Diagnosis and treatment.
  • Report wrong doing. You are responsible for reporting health care fraud or wrong doing to CalViva Health. You can do this without giving your name by calling the CalViva Health Fraud and Abuse Hotline toll-free at 1-866-863-2465.

CalViva Health members have these rights:

  • To be treated with respect, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information.
  • To be provided with information about the plan its services, including Covered Services its practitioners and providers and member rights and responsibilities.
  • To be able to choose a primary care provider within the plan's network.
  • To participate in decision making regarding your own health care, including the right to refuse treatment.
  • To a candid discussion of appropriate or medically necessary treatment options for conditions, regardless of cost or benefit coverage.
  • To make recommendations regarding the plan's member rights and responsibilities policy.
  • To voice grievances, either verbally or in writing, about the organization or the care received.
  • To receive care coordination.
  • To request an appeal of decisions to deny, defer, or limit services or benefits.
  • To receive oral interpretation services for their language.
  • To receive free legal help at your local legal aid office or other groups.
  • To formulate advance directives.
  • To have access to family planning services, Federally Qualified Health Centers, Indian Health Service Facilities, sexually transmitted disease services and Emergency Services outside the Contractor's network pursuant to the federal law.
  • To request a State Hearing, including information on the circumstances under which an expedited hearing is possible.
  • To have access to, and where legally appropriate, receive copies of, amend or correct your Medical Record.
  • To disenroll upon request. Beneficiaries that can request expedited disenrollment include, but not are limited to, beneficiaries receiving services under the Foster Care, or Adoption Assistance Programs; and members with special health care needs.
  • To access Minor Consent Services.
  • To receive written member informing materials in alternative formats (including braille, large-size print, and audio format) upon request and in a timely fashion appropriate for the format being requested and in accordance with W & I Code Section 14182 (b)(12).
  • To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • To receive information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand.
  • To receive a copy of your medical records, and request that they be amended or corrected, as specified in 45 CFR §164.524 and 164.526.
  • Freedom to exercise these rights without adversely affecting how you are treated by the plan, providers or the State.

1 The actual statements of member rights and responsibilities are in accordance with the National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS) and may vary slightly from what is listed. In addition to member rights and responsibilities, medical services must be provided in a culturally competent manner without regard to race, color, national origin, creed, ancestry, religion, language. sex, marital status, sexual orientation, gender identity, age, health status, physical or mental disability, or any identification with any other persons or groups defined in Penal Code 422.56.

Last Updated: 11/04/2019