Provisions of health care services are
not influenced by member race, ethnicity, national origin,
religion, sex, age, mental or physical disability, sexual
orientation, genetic information, or source of payment.
Services are provided in a culturally competent and non-discriminatory
manner to all members, including those with limited English
proficiency or reading skills, the sensory impaired, and
those with diverse cultural or ethnic backgrounds. Choice
Medical Group provides auxiliary aids and interpreter
services, printed materials available in large print and
Braille formats or recorded cassettes for visually impaired.
Member Rights and Responsibilities Program
A. Member Rights and Responsibilities Policy Statement [C, M; HMO, PPO] - The Provider Group must have a policy statement that includes the following member rights and responsibilities:
- Right to receive information about the Provider Group, its services, its practitioners and providers, and members’ rights and responsibilities [NCQA RR 1.A.1; 42 CFR § 438.100(b)(2)(i)]
- Right to be treated with respect and recognition of their dignity and right to privacy [NCQA RR 1.A.2; 42 CFR § 438.100(b)(2)(ii)]
- Right to participate with practitioners in decision-making regarding their health care [NCQA RR 1.A.3; 42 CFR § 438.100(b)(2)(iv), § 422.206(a)]
- Right to a candid and unrestricted discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage [NCQA RR 1.A.4; 42 CFR § 438.100(b)(2)(iii), § 422.112(a)(6)(iii), § 438.102(a)(i-iv), § 422.206(a)(i)]
- Right to voice grievances/complaints or appeals about the Provider Group or the care provided [NCQA RR 1.A.5; 42 CFR § 422.111(b)(8), § 422.562(b)(1)]
- Right to make recommendations regarding the Provider Group’s member rights and responsibilities policies [NCQA RR 1.A.6; CA Health & Safety Code § 1369]
- Responsibility to supply information (to the extent possible) that the Provider Group and its practitioners and providers need in order to care for them [NCQA RR 1.A.7]
- Responsibility to follow the plans and instructions for care that they have agreed on with their practitioners [NCQA RR 1.A.8]
- Responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible [NCQA RR 1.A.9]
B. Distribution of Member Rights and Responsibilities Policy Statement [C, M; HMO, PPO]
Reviewer Note:
- The Provider Group must have a mechanism for notifying members and practitioners of policy revisions as they occur.
- If the Provider Group utilizes the Internet, written information on the availability of the information must be mailed to all participating practitioners and members upon enrollment and annually thereafter. A paper copy of the statement of the member’s rights and responsibilities posted on the Internet must be available upon request.
- Note in comments the method by which the Provider Group distributes this policy to its members and practitioners.
There must be evidence of the following:
- Distribution of the member rights statement to new and/or existing members (e.g., via member newsletters, brochures, postings, Internet) [NCQA RR 2.A.1-2]
- Distribution of the member rights statement to new and/or existing practitioners (e.g., via provider/practitioner newsletters, brochures, postings, Internet) [NCQA RR 2.A.3-4]
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