Member Rights and Responsibilities
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
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. Health Net developed member rights and responsibilities statements in accordance with the National Committee for Quality Assurance (NCQA) and the Centers for Medicare and Medicaid Services (CMS). 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, sex, marital status, sexual orientation, age, health status, physical or mental handicap, or disability.
Health Net members are notified annually of their rights and responsibilities via the member's Evidence of Coverage (EOC) or Certificate of Insurance (COI) and are listed below for reference. The actual statements of member rights and responsibilities may vary slightly from what is included in the EOC or COI. Health Net members with questions regarding their rights and responsibilities should be directed to their specific member materials.
Members have the right to:
- Receive information about their rights and responsibilities.
- Receive information about their Plan, the services their Plan offers the member, and the health care providers available to care for the member.
- Make recommendations regarding the Plan’s member rights and responsibilities policy.
- Receive information about all health care services available to the member, including a clear explanation of how to obtain them and whether the Plan may impose certain limitations on those services.
- Know the costs for their care, and whether their deductible or out-of-pocket maximum has been met.
- Choose a health care provider in their Plan’s network, and change to another doctor in their Plan’s network if the member is not satisfied.
- Receive timely and geographically accessible health care.
- Have a timely appointment with a health care provider in their Plan's network, including one with a specialist.
- Have an appointment with a health care provider outside of their Plan’s network when their Plan cannot provide timely access to care with an in-network health care provider.
- Certain accommodations for their disability, including:
- Equal access to medical services, which includes accessible examination rooms and medical equipment at a health care provider’s office or facility.
- Full and equal access, as other members of the public, to medical facilities.
- Extra time for visits if the member needs it.
- Taking their service animal into exam rooms with them.
- Purchase health insurance or determine Medi-Cal eligibility through the California Health Benefit Exchange, Covered California.
- Receive considerate and courteous care and be treated with respect and dignity.
- Receive culturally competent care, including but not limited to:
- Trans-inclusive health care, which includes all medically necessary services to treat gender dysphoria or intersex conditions.
- To be addressed by their preferred name and pronoun
- Receive from their health care provider, upon request, all appropriate information regarding their health problem or medical condition, treatment plan, and any proposed appropriate or medically necessary treatment alternatives. This information includes available expected outcomes information, regardless of cost or benefit coverage, so the member can make an informed decision before the member receives treatment.
- Participate with their health care providers in making decisions about their health care, including giving informed consent when the member receives treatment. To the extent permitted by law, the member also has the right to refuse treatment.
- A discussion of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage.
- Receive health care coverage even if the member has a pre-existing condition.
- Receive medically necessary treatment of a mental health or substance use disorder.
- Receive certain preventive health services, including many without a co-pay, co-insurance, or deductible.
- Have no annual or lifetime dollar limits on basic health care services.
- Keep eligible dependent(s) on your Plan.
- Be notified of an unreasonable rate increase or change, as applicable.
- Protection from illegal balance billing by a health care provider.
- Request from their Plan a second opinion by an appropriately qualified health care provider.
- Expect their Plan to keep the member’s personal health information private by following its privacy policies, and state and federal laws.
- Ask most health care providers for information regarding who has received their personal health information.
- Ask your Plan or your doctor to contact them only in certain ways or at certain locations.
- Have their medical information related to sensitive services protected.
- Get a copy of their records and add their own notes. The member may ask their doctor or health plan to change information about them in their medical records if it is not correct or complete. The member’s doctor or health plan may deny their request. If this happens, the member may add a statement to their file explaining the information.
- Have an interpreter who speaks their language at all points of contact when the member receives health care services.
- Have an interpreter provided at no cost to the member.
- Receive written materials in their preferred language where required by law.
- Have health information provided in a usable format if the member is blind, deaf, or has low vision.
- Request continuity of care if their health care provider or medical group leaves the member’s Plan or the member is a new Plan member.
- Have an advanced health care directive.
- Be fully informed about their Plan’s grievances procedure and understand how to use it without fear of interruption to their health care.
- File a complaint, grievance, or appeal in their preferred language about:
- Their Plan or health care provider.
- Any care the member receives, or access to care the member seeks.
- Any covered service or benefit decision that their Plan makes.
- Any improper charges or bills for care.
- Any allegations of discrimination on the basis of gender identity or gender expression, or for improper denials, delays, or modifications of trans-inclusive health care, including medically necessary services to treat gender dysphoria or intersex conditions.
- Not meeting their language needs.
- Know why their Plan denies a service or treatment.
- Contact the Department of Managed Health Care if the member is having difficulty accessing health care services or have questions about their Plan.
- To ask for an independent medical review if their Plan denied, modified, or delayed a health care service.
As a Plan member, members have the responsibility to:
- Treat all health care providers, health care provider staff, and Plan staff with respect and dignity.
- Share the information needed with their Plan and health care providers, to the extent possible, to help get appropriate care.
- Participate in developing mutually agreed-upon treatment goals with their health care providers and follow the treatment plans and instructions to the degree possible.
- To the extent possible, keep all scheduled appointments, and call their health care provider if the member may be late or need to cancel.
- Refrain from submitting false, fraudulent, or misleading claims or information to their Plan or health care provider.
- Notify their Plan if they have any changes to their name, address, or family members covered under their Plan.
- Timely pay any premiums, copayments, and charges for non-covered services.
- Notify their Plan as soon as reasonably possible if the member is billed inappropriately.