Members Rights and Responsibilities

The Member Bill of Rights and Responsibilities assures that all members are treated in a manner consistent with the Plan’s mission, goals and objectives and assures that members are aware of their obligations and responsibilities upon joining the Plan and throughout their membership with the Plan.

Member Notice:

As a member of the Plan, you are entitled to all covered benefits; however, you must learn how the Plan works, follow the proper procedures, and use the proper network – doctors, hospitals, mental health providers and other health care specialists – participating with the Plan.

Member Rights:

Be treated in a manner reflecting respect for your privacy and dignity as a person.
Be informed regarding your diagnosis, treatment and prognosis in terms you can
reasonably be expected to understand.
Receive sufficient information to enable you to give informed consent prior to the initiation of any procedure and/or treatment.
Participate with practitioners in decision-making about your health care and refuse treatment to the extent permitted by law, and be made aware of the potential medical consequences of such action.
A candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
Expect that all communications and records pertaining to your health care will be treated as confidential. Any data shared with employers is not implicitly or explicitly member identifiable unless specific consent has been obtained. No records will be released without your written authorization to protect access to your medical information. In the case of a minor, release of information is allowed only by authorization of a legal guardian or court order.
Select a Primary Care Physician (PCP) and expect the physician to provide, arrange for, and coordinate, all the care you require.
Express complaints or appeals to the Plan about the managed care organization or care provided, and expect a response to that complaint or appeal within a reasonable period of time.
Reasonable access to necessary medical services.
Be informed of the Plan’s policies and procedures regarding services, benefits, practitioners and providers, and member rights and responsibilities, and be notified of any significant changes in those policies and procedures.
Discuss your medical record with your physician and receive, upon request, a summary of that record (at a nominal charge) as required under State law. The Plan’s staff can only release records with your physician’s approval and signed consent.
Obtain from the Plan a certificate of creditable coverage which shows prior, continuous coverage. With the certificate, you may be able to receive coverage under your next health plan with either no waiting period for pre-existing conditions or a reduced waiting period.
Make recommendations regarding member rights and responsibilities.

Member Responsibilities

You also have responsibilities to:

Work with your Primary Care Physician (PCP) to help establish the proper patient/physician relationship.
Schedule appointments and arrive on time for those appointments or notify the primary care physician’s office if you must cancel or come late for a scheduled appointment. Charges for missed appointments are not covered by the Plan.
Meet the financial obligations regarding member premiums and copays when services are rendered.
Ask any questions and understand the answers about your illness and/or treatment.
Obtain prior authorization from your Primary Care Physician (PCP) before seeking consultation or other medical services, except in potentially life-threatening situations.
Get and carefully consider all information necessary to give informed consent for a procedure or treatment.
Weigh the potential consequences of any refusal to comply with physician instructions or recommendations.
Follow the plans and instructions for care that you have agreed on with your
practitioners.
Be courteous, considerate and cooperative in dealing with your Primary Care physician (PCP), his/her office staff, and employees of the Plan, and to respect the rights of fellow Plan members.
Express opinions, concerns or complaints in a constructive manner to avoid similar problems in the future.
Read and be aware of all material distributed by the Plan explaining policies and procedures regarding services and benefits, and to follow those policies and procedures when receiving care.
Provide the Plan and providers with complete and accurate information necessary to care for you, for your medical record and for Plan membership records. This includes notifying the Plan of any changes in status such as phone number, address, and number of dependents (i.e., birth, marriage, divorce, etc.), and information regarding other health insurance coverage for coordination of benefits purposes.
Assist the Plan in compiling a complete medical record by providing, or by authorizing the Plan to obtain, necessary medical information. Ultimately, it is your responsibility to furnish the Plan with any medical records needed to process a complaint, grievance or appeal of a denied claim when the Plan has been unable to obtain this information.

Optima Family Care Member Rights and Responsibilities

What Are My Rights?

As a member of Optima Family Care, you are entitled to all the benefits outlined in your Evidence of Coverage. With your plan, you have the right to:

Be treated in a manner reflecting respect for your privacy and dignity as a person. While receiving health care services there will be no discrimination based on race, ethnicity, national origin, religion, sex, age and mental or physical disability.
Be informed regarding your diagnosis, treatment and prognosis in terms you can reasonably be expected to understand.
Receive enough information to enable you to give informed consent prior to the beginning of any procedure and/or treatment.
Participate with practitioners in decision-making about your health care and refuse treatment to the extent permitted by law, and be made aware of the potential medical consequences of such action.
A candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
Expect that all communications and records about your health care will be treated as confidential. Any data shared is not member specific. No records will be released without your written authorization. In the case of a minor, release of information is allowed only by the authorization of the legal guardian.
Express complaints or appeals to the Plan about Family Care or care provided and expect a response. The Plan will respond to all complaints within 30 days. To file an appeal for denied services, see Section 9 (Complaints and Appeals Procedure) of the Evidence of Coverage for details.
Reasonable access to necessary medical services.
Be informed of the Plan’s policies and procedures regarding services, benefits, practitioners and providers, and your rights and responsibilities, and be notified of any significant changes in those policies and procedures. Upon request, receive a copy of the Plan’s Practice Guidelines.
Discuss your medical record with your doctor and receive, upon request, a copy of that record as required under State law and request that the record be amended or corrected. The Plan’s staff can only release records with your doctor’s approval and your signed consent.
Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
Obtain from the Plan information on how providers are paid.
The MCO and its employees are prohibited from providing incentives for denials, limiting or discontinuing medical services.
Make recommendations regarding member rights and responsibilities.
Freedom to exercise your member rights and expect that you will not be negatively affected by the Plan and its providers by exercising those rights.

What Are My Responsibilities?

As a member of Optima Family Care, you also have responsibilities to:

Work with your doctor to help establish the proper patient/doctor relationship.
Schedule appointments and arrive on time for those appointments or notify the doctor’s office if you must cancel or come late for a scheduled appointment.
Ask any questions and understand the answers about your illness and treatment.
Get and carefully consider all information necessary to give informed consent for a procedure or treatment.
Follow the plans and instructions for care that you have agreed on with your doctors.
Weigh the possible consequences of your refusal to follow doctor’s instructions or recommendations.
Be courteous, considerate and cooperative in dealing with your doctor, his/her office staff, and employees of Family Care, and to respect the rights of fellow plan members.
Express opinions, concerns or complaints in a constructive manner to avoid similar problems in the future.
Read and be aware of all material distributed by the Plan explaining policies and procedures regarding services and benefits, and follow those policies and procedures when receiving care.
Provide Family Care and your doctor with complete and accurate information. This includes notifying the Plan of any changes in status such as phone number, address and number of dependents (example: birth, marriage, divorce, etc), and information regarding other health insurance coverage you may have. You must also contact your Medicaid/FAMIS Plus caseworker at your local Department of Social Services with this information.
Help the Plan to gather your complete medical record by providing, or by authorizing your Plan to obtain necessary medical information. Ultimately, it is your responsibility to furnish your Plan with any medical records needed to process a complaint, grievance or appeal of a denied claim if your Plan has been unable to obtain this information.
Obtain prior authorization from your PCP before seeking consultation or other medical services except in potentially life-threatening situations.