Rights and Responsibilities

The Member has the right to:

  1. Be informed about the IPA, its services and participating providers and the health care service delivery process.
  2. Be treated with respect and dignity without regard to race, ethnicity, national origin, sexual orientation or cultural, economic,educational, religion, sex, age, mental or physical disability or medical condition, such as ESRD, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), genetic information, or source of payment…”; requirement not met.
  3. Be provided with information on how to obtain care after normal office hours and how to obtain emergency care including when to directly access emergency care or use 911 services.
  4. Be informed of the name and qualifications of the physician who has primary responsibility for coordinating the member’scare; and be informed of the names, qualifications, and specialties of other physicians and non-physicians who are involved in the member’s care.
  5. Have 24-hour access to the member’s primary care physician (or covering physician).
  6. Receive comprehensive health assessment, including preventive healthcare.
  7. Receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, and prospects for recovery in terms that are understandable to the member, in order to give informed consent or to refuse that course of treatment.
  8. Be informed of appropriate or medically necessary treatment options for the member’s condition, regardless of cost or benefit coverage.
  9. Have access to their entire medical records and health information in accordance with the state and federal law and kept them confidential, and to request that the medical records be amended or corrected.
  10. Be informed that they have a right to transfer to any provider in the IPA network.
  11. Change his/her primary care physicians to another PCP who participates in the IPA network by contacting the health plan’s Member Services Department.
  12. Be informed of continuing health care requirements following office visits, treatments, procedures and hospitalizations and receive reasonable continuity of care.
  13. Be informed of the termination of a primary care provider or practice site and receive assistance in selecting a new primary care provider or site in this situation.
  14. Seek a second opinion from another specialist within Superior Choice Medical Group.
  15. Be informed of the member complaint/grievance and appeal process including how to express a complaint and/or file a regular or expedited appeal.
  16. Receive free language interpretation services by phone or by person and/or right to refuse a free telephone or free face-to-face interpreter services.
  17. Have educational brochures and other materials for the purpose of understanding the member’s disease condition.
  18. Access or referred to community resources for health education.
  19. Received information and be informed of the methods by which advance directive is executed.
  20. Not to be discriminated against when an advance directive has been completed or refused.
  21. Be informed of emergent and non-emergent benefit coverage and cost of care, and receive an explanation of the member’s financial obligations as appropriate, prior to incurring the expense (including co-payments, deductibles, and co-insurance).
  22. Examine and receive an explanation of bills generated for services delivered to the member.
  23. Be provided with information on how to submit a claim for covered services.
  24. IPA has policy and procedure that establishes members rights and protections, and assures that the member is free to exercise those rights without negative consequences, consistent with CMS and California regulations.
  25. To be treated with respect and due consideration for his/her dignity and privacy; receive information on available treatment options and alternative, presented in a manner appropriate to the members condition and ability to understand.
  26. Participate in decisions regarding his/her health care, including the right to refuse treatment
  27. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.

Members Responsibilities: As a member you have the responsibility to:

  1. Be on time for all appointments and notify the provider’s office as far in advance as possible for appointment cancellation or rescheduling.
  2. Provide your health care provider with complete and accurate information, which is necessary for the care of the member.
  3. Contact your primary care physician or on call physician for any care that you may need after normal office hours. If it is an emergency call 911 or go to the nearest emergency department.
  4. Carry out the treatment plan, which has been developed and agreed upon by you and your health care provider.
  5. Obtain an authorized referral from your primary care physician for a visit to a specialist and/or to receive any specialty care.
  6. Report any changes in your condition according to provider instructions.
  7. Inform your health care provider if you are unable to understand the information given to you.
  8. Treat your health care providers, staff and members with respect.
  9. Be familiar with and follow the rules of the IPA’s health care service delivery system regarding your access to routine, urgent and emergent care.
  10. Contact the IPA Member Services Department or the member’s Health Plan Member Services Department regarding questions and assistance you may need with coordinating your care.