Member Rights and Responsibilities

As a member of Optima Health Community Care, you have certain rights. You have the right to:

  • Be treated with respect and dignity;
  • Receive timely access to care and services;
  • Take part in decisions about your healthcare, including your right to choose your providers from Optima Health Community Care network and your right to refuse treatment;
  • Choose to receive long-term services and supports in your home or community or in a nursing facility;
  • Confidentiality and privacy about your medical records and when you get treatment;
  • Receive information and discuss available treatment options and alternatives presented in a manner and language you understand;
  • Get information in a language you understand—you can get oral translation services free of charge;
  • Receive reasonable accommodations to ensure you can effectively access and communicate with providers, including auxiliary aids, interpreters, flexible scheduling, and physically accessible buildings and services;
  • Receive information necessary for you to give informed consent before the start of treatment;
  • Get a copy of your medical records and ask that the records be amended or corrected;
  • Participate in decisions regarding your healthcare, including the right to refuse treatment;
  • Be free from restraint or seclusion unless ordered by a physician when there is an imminent risk of bodily harm to you or others, or when there is a specific medical necessity. Seclusion and restraint will never be used as a means of coercion, discipline, retaliation, or convenience;
  • Get care in a culturally competent manner including without regard to disability, gender, race, health status, color, age, national origin, sexual orientation, marital status or religion;
  • Be informed of where, when, and how to obtain the services you need from Optima Health Community Care, including how you can receive benefits from out-of-network providers if the services are not available in the Optima Health Community Care network;
  • Complain about Optima Health Community Care to the State. You can call the CCC Plus Helpline at 1-844-374-9159 or TTY 1-800-817-6608 to make a complaint about us;
  • Appoint someone to speak for you about your care and treatment and to represent you in an Appeal;
  • Make advance directives and plans about your care in the instance that you are not able to make your own health care decisions. See Section 17 of the Member Handbook for information about Advance Directives;
  • Change your CCC Plus health plan once a year for any reason during open enrollment or change your MCO after open enrollment for an approved reason. Reference Section 2 of the Member Handbook or call the CCC Plus Helpline at 1-844-374-9159 or TTY 1-800-817-6608 or visit the website at cccplusva.com for more information;
  • Appeal any adverse benefit determination (decision) by Optima Health Community Care that you disagree with that relates to coverage or payment of services. See Your Right to Appeal in Section 15 of the Member Handbook for more information;
  • File a complaint about any concerns you have with our customer service, the services you have received, or the care and treatment you have received from one of our network providers. See Your Right to File a Complaint in Section 15 of the Member Handbook for more information;
  • Receive information from us about our plan, your covered services, providers in our network, and about your rights and responsibilities; and
  • Make recommendations regarding our member rights and responsibility policy.

You also have certain responsibilities as a member of Optima Health Community Care. These include the responsibility to:

  • Present your Optima Health Community Care member ID card whenever you seek medical care;
  • Provide complete and accurate information to the best of your ability on your health and medical history;
  • Participate in your care team meetings, develop an understanding of your health condition, and provide input in developing mutually agreed upon treatment goals to the best of your ability;
  • Keep your appointments. If you must cancel, call as soon as you can;
  • Receive all of your covered services from the Optima Health Community Care network,
  • Obtain authorization from Optima Health Community Care prior to receiving services that require a service authorization review;
  • Call Optima Health Community Care whenever you have a question regarding your membership or if you need assistance toll-free;
  • Tell Optima Health Community Care when you plan to be out of town so we can help you arrange your services;
  • Use the emergency room only for real emergencies;
  • Call your PCP when you need medical care, even if it is after hours;
  • Tell Optima Health Community Care when you believe there is a need to change your plan of care;
  • Tell us if you have problems with any healthcare staff. Call member services at the number located on the back of your member ID card; and
  • Call member services at the number located on the back of your member ID card about any of the following:
    • If you have any changes to your name, your address, or your phone number. Report these also to your case worker at your local Department of Social Services;
    • If you have any changes in any other health insurance coverage, such as from your employer, your spouse’s employer, or workers’ compensation;
    • If you have any liability claims, such as claims from an automobile accident;
    • If you are admitted to a nursing facility or hospital;
    • If you get care in an out-of-area or out-of-network hospital or emergency room;
    • If your caregiver or anyone responsible for you changes; and
    • If you are part of a clinical research study.

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