Member Rights and Responsibilities

What Are My Rights?

Medicaid is a voluntary program. This means that you agree to be part of the Medicaid program and to follow the rules issued by Medicaid and Optima Family Care.

Privacy. You Have The Right To

• Be sure your medical record is kept private and that your records will not be given out without your doctor’s permission or your written approval. In the case of a minor, release of information is allowed only by the permission of the legal guardian.
• Be treated with respect, dignity, and privacy.

Take Part In Making Decisions About Your Healthcare. You Have The Right To

• Pick or change doctors from the list of doctors in the health plan’s Provider network.
• Get in touch with your doctor.
• Decide about your healthcare and give permission before the start of any treatment or surgery.
• Refuse treatment to the extent permitted by law. To be told of the possible medical consequences if you do so.
• Ask for a second opinion.
• Discuss your medical record with your doctor. You may receive a copy of that record as required under State law. You may request that the record be amended or corrected.

Receive Care Without Restraint. You Have The Right To

• Be free from being discriminated against due to race, national origin, religion, sex, age, mental or physical disability or the need for healthcare services.
• Be told of appropriate or medically necessary treatment options for your illness regardless of the cost or benefit coverage.

Have Access To Healthcare Services. You Have The Right To

• Get care right away if you have a medical emergency.
• Go to any Medicaid doctor or clinic for birth control or family planning services.

Receive All Information In A Manner That Is Easily Understood. You Have The Right To

• Be told about your illness or medical condition and the best way to treat in terms you can reasonably be expected to understand.
• Be informed of the Plan’s policies and procedures regarding services, benefits, doctors, and other Providers.
• Be told about your rights and responsibilities. To be told of any significant changes in those policies and procedures.
• Ask for a copy of the health Plan’s Practice Guidelines.
• Ask for information on how the Plan pays providers.

Get Information On Emergency And After-Hours Coverage. You Have The Right To

• Be told that emergency services do not require pre-authorization.
• Use any hospital or other setting for emergency care.
• Be told what constitutes an emergency medical condition, emergency services, and post-stabilization services.

Get Oral Interpretation Services. You Have The Right To

• Receive oral interpretation services free of charge for all non-English languages.
• Be told about these services and how to get them.

Exercise Your Rights Without Adverse Effects. You Have The Right To

• Be free from being coerced into making decisions about treatment.
• Report any complaint about your doctor or your medical care and receive a response.
• File an appeal if your medical services are reduced or denied based on medical criteria.
• Have a fair hearing.
• Make recommendations about your rights and responsibilities as a Member.
• Exercise your Member rights and responsibilities without any negative effect by the Plan or its Providers.

Receive Information On Optima Family Care Services. You Have The Right To

• Be told at the time of enrollment, and at least once per year, of your right to disenroll from Optima Family Care.
• Get a Member Handbook that tells you about:
  • Covered benefits
  • Benefits not covered by Optima Family Care
  • Carved-out Services
  • How to get pre-authorization for benefits and services
  • How to get benefits and services including transportation
  • How to get emergency care and services
  • Areas served by Optima Family Care
• Get a Provider Directory that tells you about:
  • The name, address and phone number of network Providers that include:
    • Primary Care Providers
    • Specialists
    • Hospitals

What Are My Responsibilities?

Medicaid is a voluntary program. This means that you agree to be part of the Medicaid program and to follow the rules issued by Medicaid and Optima Family Care rules.

Learn And Follow Optima Family Care And Medicaid Rules. It Is My Responsibility To

• Carry your ID cards at all times when getting care and services
• Keep scheduled appointments. To arrive on time. Let your doctor’s office know if you must cancel or come late.
• Treat Providers and staff with respect.
• Express your opinions, concerns or complaints in a helpful manner.
• Read and be aware of your health plan’s policies and procedures about your services and benefits, and to follow those policies and procedures when receiving care.
• Tell the health plan of any changes that might affect your coverage such as address, marriage, divorce, birth, income or insurance coverage.
• Report any suspected fraud, waste and/or abuse.

Tell Your Providers About Your Healthcare Needs. It Is My Responsibility To

• Work with your doctor to establish the proper patient/doctor relationship.
• Work with your doctor or other care coordinators as needed. Make sure that all of our Providers work with each other to give you all the medical and social support you need.
• Tell your doctor or other Provider about any insurance you have.
• Give as many facts as you can to help your doctor or other healthcare Provider take care of you.

Take Part In Making Decisions About Your Health. It Is My Responsibility To

• Ask any questions and understand the answers about your illness or treatment.
• Get and carefully consider all information necessary to give permission for a procedure or treatment.
• Consider what will happen if you refuse to follow your doctor’s instructions or recommendations.
• Follow the plans and instructions for care that you agreed on with your doctor.