Rights & Responsibilities

Your rights under Medi-Cal managed care

As a member of Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”), you have certain rights and responsibilities. This chapter explains these rights and responsibilities. This chapter also includes legal notices that you have a right to as a member of Health Plan.

Your rights
These are your rights as a member of Health Plan:

• To be treated with respect and dignity, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information.
• To receive sensitive services or submit a claim for sensitive services without obtaining the primary subscribers or other enrollees’ authorization.
• To have the right to request the communication of sensitive services you’ve received go to another address, phone number, or email for confidentiality purposes. These forms are available at https://www.hpsj.com/compliance/
• To be provided with information about the plan and its services, including covered services, practitioners, and member rights and responsibilities.
• To make recommendations about Health Plan’s  member rights and responsibilities policy.
• To be able to choose a primary care provider within Health Plan’s network.
• To have timely access to network providers.
• To participate in decision making regarding your own health care, including the right to refuse treatment.
• To voice grievances, either verbally or in writing, about the organization or the care you got.
• To get care coordination.
• To ask for an appeal of decisions to deny, defer or limit services or benefits.
• To get no-cost interpreting services for your language.
• To get free legal help at your local legal aid office or other groups.
• To formulate advance directives.
• To ask for a State Hearing if a service or benefit is denied and you have already filed an appeal with Health Plan and are still not happy with the decision, or if you did not get a decision on your appeal after 30 days, including information on the circumstances under which an expedited hearing is possible.
• To disenroll from Health Plan and change to another health plan in the county upon request.
• To access minor consent services.
• To get no-cost written member information in other formats (such as braille, large-size print, audio and accessible electronic formats) upon request and in a timely fashion appropriate for the format being requested and in accordance with Welfare & Institutions Code Section 14182 (b)(12).
• To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
• To truthfully discuss information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand, regardless of cost or coverage.
• To have access to and get a copy of your medical records, and request that they be amended or corrected, as specified in 45 Code of Federal Regulations §164.524 and 164.526.
• Freedom to exercise these rights without adversely affecting how you are treated by Health Plan, your providers or the State.
• To have access to family planning services, Freestanding Birth Centers, Federally Qualified Health Centers, Indian Health Clinics, midwifery services, Rural Health Centers, sexually transmitted infection services and emergency services outside Health Plan’s network pursuant to the federal law.

Your responsibilities
Health Plan members have these responsibilities:

• Be familiar with and ask questions about your health plan coverage. If you have questions you should contact Customer Service at 1-888-936-7526 (PLAN) TTY 711.
• Follow the advice and care procedures indicated by your doctors, Health Plan and the program.
• Request interpreter services at least five (5) business days before your scheduled appointment.
• Call your doctor or pharmacy at least three (3) days before you run out of medication.
• Treat your doctors and all their staff with respect. This includes being on time to appointments and calling to reschedule or cancel.
• Understand that your doctor’s office may have limited seating for patients and caregivers only.
• Give accurate information to the professional staff, following instructions, and cooperating with the providers, Health Plan, your doctor’s office, and any other doctor in order to receive the best care possible.
• Understand your health problems and work with your doctor to develop mutually agreed upon treatment goals.
• Ask your doctor questions if you do not understand what they are saying.
• Care for your own health. Live a healthy lifestyle, exercise, eat a good diet, and don’t smoke.
• Avoid knowingly spreading disease to others.
• Report any wrongdoing or fraud to Health Plan.
• Understand that there are risks in receiving health care and limits to what can be done for you medically.
• Understand that it is a health care doctors duty to be efficient and fair in caring for you as well as other patients.