CHIP / STAR Member Rights & Responsibilities

FOR CHIP / STAR MEMBERS AND CHIP PERINATE NEWBORN MEMBERS

MEMBER RIGHTS

You have the right to respect, dignity, privacy, confidentiality, and non-discrimination. That includes the right to:

  1. Be treated fairly and with respect.
  2. Know that your medical records and discussions with your providers will be kept private and confidential.

You have the right to a reasonable opportunity to choose a health care plan and primary care provider. This is the doctor or health care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to:

  1. Be told how to choose and change your health plan and your primary care provider.
  2. Choose any health plan you want that is available in your area and choose your primary care provider from that plan.
  3. Change your primary care provider.
  4. Change your health plan without penalty.
  5. Be told how to change your health plan or your primary care provider.

You have the right to ask questions and get answers about anything you do not understand. That includes the right to:

  1. Have your provider explain your health care needs to you and talk to you about the different ways your health care problems can be treated.
  2. Be told why care or services were denied and not given.

You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to:

  1. Work as part of a team with your provider in deciding what health care is best for you.
  2. Say yes or no to the care recommended by your provider.

You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid, and get a timely response to complaints, appeals and fair hearings. That includes the right to:

  1. Make a complaint to your health plan or to the state Medicaid program about your health care, your provider or your health plan.
  2. Get a timely answer to your complaint.
  3. Use the plan’s appeal process and be told how to use it.
  4. Ask for a fair hearing from the state Medicaid program and get information about how that process works.

You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to: 

  1. Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need.
  2. Get medical care in a timely manner.
  3. Be able to get in and out of a health care provider’s office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act.
  4. Have interpreters, if needed, during appointments with your providers and when talking to your health plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information.
  5. Be given information you can understand about your health plan rules, including the health care services you can get and how to get them.

You have the right to not be restrained or secluded when it is for someone else’s convenience, or is meant to force you to do something you do not want to do, or is to punish you.

You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment.  Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

You have a right to know that you are not responsible for paying for covered services.  Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services.

You also have the right to:

  1. Receive coverage for the medical benefits and treatment that is available when you need it and is handled in a way that respects your privacy and dignity.
  2. Receive information about your health benefit plan, services, practitioners and providers, member rights and responsibilities, including information about services that are covered and not covered and any costs that you will be responsible for paying.
  3. Have a discussion and participate with your health care professional in health decisions and have your health care professional give you information about your medical condition and your treatment options, regardless of coverage or cost. You have the right to receive this information in terms and language you understand.
  4. Voice complaints and appeals about Sendero or any practitioner or provider. Our process is designed to hear and act on your complaint or concern about Sendero and/or the quality of care you received from health care professionals and the various places you receive care in our network; provide a courteous, prompt response and guide you through our grievance process if you do not agree with our decision.
  5. Make recommendations regarding our policies that affect your rights and responsibilities. If you have recommendations or concerns, please call Customer Services at the toll-free number on your ID card.

MEMBER RESPONSIBILITIES

You must learn and understand each right you have under the Medicaid program. That includes the responsibility to:

  1. Learn and understand your rights under the Medicaid program.
  2. Ask questions if you do not understand your rights.
  3. Learn what choices of health plans are available in your area.

You must abide by the health plan’s and Medicaid’s policies and procedures. That includes the responsibility to:

  1. Learn and follow your health plan’s rules and Medicaid rules.
  2. Choose your health plan and a primary care provider quickly.
  3. Make any changes in your health plan and primary care provider in the ways established by Medicaid and by the health plan.
  4. Keep your scheduled appointments.
  5. Cancel appointments in advance when you cannot keep them.
  6. Always contact your primary care provider first for your non-emergency medical needs.
  7. Be sure you have approval from your primary care provider before going to a specialist.
  8. Understand when you should and should not go to the emergency room.

You must share information about your health with your primary care provider and learn about service and treatment options. That includes the responsibility to:

  1. Tell your primary care provider about your health.
  2. Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated.
  3. Help your providers get your medical records.

You must be involved in decisions relating to service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility to:

  1. Work as a team with your provider in deciding what health care is best for you.
  2. Understand how the things you do can affect your health.
  3. Do the best you can to stay healthy.
  4. Treat providers and staff with respect.
  5. Talk to your provider about all of your medications.

You also have the responsibility to:

  1. Review and understand the information you receive about your health benefit plan. Please call Customer Service when you have questions or concerns.
  2. Follow the plans and instructions for care that have been agreed upon by you and your practitioner.
  3. Supply information to Sendero and its practitioners and providers in order to provide care to you.

If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019.   You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.