Rights and Responsibilities as a Member of IEHP DualChoice
As an IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) Member, you have the right to:
- Receive information about your rights and responsibilities as an IEHP DualChoice Member.
- Be treated with respect and courtesy. IEHP DualChoice recognizes your dignity and right to privacy.
- Receive services without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment.
- Receive information about IEHP DualChoice, its programs and services, its Doctors, Providers, health care facilities, and your drug coverage and costs, which you can understand.
- Have a Primary Care Physician who is responsible for coordination of your care.
- If your Primary Care Physician changes, your IEHP DualChoice benefits and required co-payments will stay the same.
- Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments.
- Request a second opinion about a medical condition.
- Receive emergency care whenever and wherever you need it.
- See plan Providers, get covered services, and get your prescription filled timely.
- Receive information about clinical programs, including staff qualifications, request a change of treatment choices, participate in decisions about your health care, and be informed of health care issues that require self-management.
- If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period.
- If you are under a Doctor’s care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. To make this request, or if you have any concerns about your continuity of care, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347)
- Receive Member informing materials in alternative formats, including Braille, large print, and audio.
- Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members.
- IEHP DualChoice will honor authorizations for services already approved for you. If you have any authorizations pending approval, if you are in them idle of treatment, or if specialty care has been scheduled for you by your current Doctor, contact IEHP to help you coordinate your care during this transition time. Call IEHP DualChoice Member Services at 1-877-273-IEHP (4347).
- Review, request changes to, and receive a copy of your medical records in a timely fashion.
- Receive interpreter services at no cost.
- Notify IEHP if your language needs are not met.
- Make recommendations about IEHP DualChoice Members’ rights and responsibilities policies.
- Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws.
- Decide in advance how you want to be cared for in case you have a life-threatening illness or injury.
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation
- Complain about IEHP DualChoice, its Providers, or your care. IEHP DualChoice will help you with the process. You have the right to choose someone to represent you during your appeal or grievance process and for your grievances and appeals to be reviewed as quickly as possible and be told how long it will take.
- Have grievances heard and resolved in accordance with Medicare guidelines;
- Request quality of care grievances data from IEHP DualChoice.
- Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment, or reduction of services. This includes denial of payment for a service after the service has been rendered (post-service) or denial of service prior to the service being rendered (pre-service).
- Request expedited reconsideration;
- Request and receive appeal data from IEHP DualChoice;
- Receive notice when an appeal is forwarded to the Independent Review Entity (IRE);
- Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part;
- Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more;
- Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part;
- Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more;
- Make a quality of care complaint under the QIO process;
- Request QIO review of a determination of noncoverage of inpatient hospital care;
- Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities;
- Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information;
- Challenge local and national Medicare coverage determination.
As an IEHP DualChoice Member, you have the responsibility to:
- Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits
- Inform your Doctor about your medical condition, and concerns.
- Follow the plan of treatment your Doctor feels is necessary
- Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment.
- Learn about your health needs, and leading a healthy lifestyle.
- Make every effort to participate in the health care programs IEHP DualChoice offers you.
For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook.
IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
Information on this page is current as of September 30, 2016