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Important Information about Your Plan
Members' Rights and Responsibilities | Understanding CHP's Health Care Decision-Making | Improving Services For Members | Safer Health Care | Privacy Of Personal Health Information
Capital Health Plan Member's Rights and Responsibilities
Capital Health Plan (CHP) is committed to provide and/or arrange for the provision of quality health care in a cost-effective manner. Consistent with our commitment, the following statement of Member's Rights and Responsibilities has been adopted. For a complete, definitive description of your rights and responsibilities as a member of CHP, please refer to your Member Handbook* or the master policy or contract provided to your employer.
You Have a Right To:
- Receive information about CHP, the services, benefits, member rights and responsibilities, and participating practitioners and facilities that provide care.
- Receive medical care and treatment from practitioners and providers who have met the credentialing standards of CHP.
- Expect CHP participating practitioners to permit you to participate in decision-making about your health care consistent with legal, ethical, and relevant patient-practitioner relationship requirements. If you are unable to fully participate in treatment decisions you have a right to be represented by your parents, guardians, family members, health care surrogates or other conservators to the extent permitted by applicable laws.
- Expect health care practitioners who participate with CHP to provide treatment with courtesy, respect, and with recognition of your dignity and right to privacy.
- Communicate complaints or appeals about CHP or the care provided through the established appeal or grievance procedures found in your Member Handbook and the master policy or contract provided to your employer.
- Have candid discussion with practitioners about the best treatment options for you no matter what the cost of the treatment or your benefit coverage.
- Refuse treatment if you are willing to accept the responsibility and consequences of that decision.
- Have access to your medical records, request amendments to your records, and have confidentiality of these records and member information protected and maintained in accordance with State and Federal law and CHP policies.
- Make recommendations regarding CHP’s member rights and responsibilities policies.
- Call or write us anytime with helpful comments, questions and observations, whether concerning something you like about our plan, or something you feel is a problem area. Expect to receive a timely response from CHP staff.
QIMT Approval: 12/92, 8/95, 6/97, 8/98, 6/99, 3/00, 3/01, 1/10/02, 2/6/03, 3/5/03, 6/26/03, 2/19/04, 2/3/05, 1/19/06, 2/1/07, 1/31/08
You Have a Responsibility To:
- Seek all non-emergency care through your primary care physician (PCP), obtain a referral from your PCP for medical services by a specialist, and cooperate with those providing care and treatment.
- Be courteous; respect the rights, needs and privacy of other patients, office staff and providers of care.
- Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care for you.
- Understand your health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
- Follow the plans and instructions for care that you have agreed to with your practitioners.
- Ask questions and seek clarification to enable you to participate fully in your care.
- Pay co-payments and provide current information concerning your CHP membership status to any CHP participating practitioner or provider.
- Follow established procedures for filing a complaint, appeal or grievance concerning medical or administrative decisions that you feel are in error.
- Review and understand the benefit structure, both covered benefits and exclusions, as outlined in the Member Handbook*. Cooperate and provide information that may be required to administer benefits.
- Seek access to medical and member information through your Primary Care Physician, CHP Connect or through CHP Member Services.
- Follow the coverage access rules in your Member Handbook*.
*Note: Capital Health Plan’s Member Handbook is intended to highlight the Plan and does not constitute a contract. The precise benefits will be controlled by the master policy or contract.
UNDERSTANDING CHP'S HEALTH CARE DECISION-MAKING
CHP makes health care decisions to achieve quality treatment and efficient use of resources. CHP and its participating physicians coordinate preventive care, evaluate new technologies, and develop clinical treatment tools to guide the care of members. This is called "utilization management."
CHP and its participating physicians use clinical review standards to determine when a member needs health care services and supplies, and which services and supplies are suitable. The requested services and supplies must support the diagnosis and treatment of the member's condition and standards of good medical practice. The review process may be pre-service (before services are provided), concurrent (based on an urgent request to continue a hospital stay), or post-service (after services are provided).
If you have questions about utilization management procedures, decisions or your benefits, you can contact our Member Services Department at (850) 383-3311 or toll-free at 1-877-247-6512, Monday through Friday from 8:00 am through 5:00 pm. The TDD number for the hearing impaired is (850) 383-3534. If you call after hours or on a weekend, you can call (850) 383-3333 or toll-free (800) 390-1434. The after-hours number for the Florida State Relay, for the hearing impaired is (800) 955-8771.
CHP safeguards confidential information and makes disclosures only when allowed under state and federal law, including HIPAA. Information used in the decision-making process is protected by CHP staff members who must use the information.
CHP's policy statement for utilization management decisions:
- Utilization management decisions are based only on the appropriateness of care and services, and the existence of benefit coverage.
- CHP does not reward reviewers or provide financial incentives to deny coverage or services.
- CHP does not offer incentives to encourage decisions that result in underutilization.
A member, physician, or a person authorized by a member may request a re-evaluation of a utilization management decision as follows:
- By sending to CHP's Grievance Department a written request for reconsideration, which is known as a grievance. Staff collects any necessary documents, and the member request is reviewed by a group of senior managers and physicians. CHP notifies the member in a timely manner of the review group's decision.
- By requesting an expedited grievance decision. Expedited decisions are those made when a delay in a grievance decision for care that has not occurred would harm the member's health. A call to Member Services at (850) 383-3311 alerts CHP to make an expedited grievance decision. Staff will then notify the member when the decision has been made.
- By asking for an evaluation by an organization outside of CHP if still dissatisfied with the second grievance decision. An "Independent review organization" evaluates the request, and has no financial or business ties to CHP. Members pay nothing for independent reviews, and CHP must accept decisions made by independent review organizations. The letter that notifies the member of the second-level grievance decision explains how to request an independent review.
Improving Services For Members
CHP constantly works to improve services for our practitioners and members. Our program of quality improvement uses information from many sources to identify services that could be improved. For example, we use feedback from our practitioners and members that we obtain from satisfaction surveys, complaints, and grievances. Changes are implemented to improve the identified services. We then monitor future information to make sure that we are better meeting the needs of our practitioners and members.
CHP appreciates your feedback; we are listening and working to respond to your needs. If you know of an area in which we can improve, or you would like additional information about the quality improvement program at CHP, please call us at one of the telephone numbers listed on this page.
Steps for Safer Health Care: What You Can Do
Health care, like any human endeavor, is not immune to mistakes. In fact, as medicine advances—as treatments become more various and sophisticated—care necessarily entails additional possibility for error. Patient safety is a continual concern at Capital Health Plan. One important method we use for safeguarding members is education. How can you help ensure that your care is safe and effective?
- Medications. Make sure both your doctor and pharmacist know all of the medicines that you take, including over-the-counter medications (aspirin, etc.), vitamins, and supplements. Tell them of any drug allergies. Ask your doctor to spell out the name of a prescribed drug and specify the dose. Write this down, so that you can check it against the label on the pharmacy bottle. Either from your doctor or the pharmacist, find out exactly what the drug is for, how to take it (empty or full stomach; time of day), what to avoid while taking it (foods, beverages, or activities), and possible side effects. Read any written information provided about the medicine.
- Tests.Find out the results of any test or diagnostic procedure. When tests are ordered or done (even routine tests) ask when and how you will get the results. If the results are late, call your doctor's office to inquire. When you have results, ask what they mean for your care.
- Physician-Patient Communication. You should feel comfortable talking with your doctor about your health and treatment. If you have any questions or concerns, express them. Don't hesitate to ask for a simpler explanation or to take notes. Especially to understand a serious condition, you may want a family member or a friend to accompany you.
- Surgery. Be sure you understand what will happen before and after any surgery. Ask the surgeon what he or she will be doing, how long it will take, and what recovery will be like. If the surgery requires hospitalization, ask whether the surgeon or another physician will take charge of your care after the procedure. Before the procedure, clearly specify to the anesthesiologist or nurse any drug allergies or bad reactions to anesthesia.
Privacy Of Personal Health Information
All CHP member health information is confidential. Disclosures (such as to employers) for purposes other than treatment, payment, or health care operations are made only when CHP receives a member's Authorization for Release of Health Information. CHP does not accept requests to disclose personal information to plan sponsors (organizations that pay for an employee's health benefits) with the exception of summary health information, enrollment and disenrollment information.
CHP safeguards oral, written, and electronic information. Confidentiality agreements are signed with any contracted parties that receive a member's confidential personal, financial, or health information. Access to this information is restricted to those employees who use the information to provide services for members.
CHP's privacy program conforms to all state and federal laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). CHP's website, www.capitalhealth.com, contains links to member privacy rights and HIPAA, (see the lower right corner of the website home page).
CHP sends every new member a Notice of Privacy Practices. A copy is posted in CHP health centers, and is available as a pamphlet. The Notice includes explanations, instructions, and examples of:
- the content of a member's medical record
- member rights regarding health information
- CHP's responsibilities to maintain privacy of your health information
- routine uses of health information for treatment, payment, and health operations and
- how to contact CHP with questions or concerns
Members have a right to:
- view, inspect, copy, and amend their health records
- request limits on certain uses of their health information
- get an accounting of health information disclosures
- request communications of their health information by alternative means or at alternative locations and
- revoke their authorization to use health information, except when action already has been taken
Members can enter information on CHP's secure website. This information is accessed and used by the Member Services Department to assist members. Members can enter information to do the following:
- select a new, or change a primary care physician
- register for classes provided by CHP
- request a replacement of a CHP ID card
- submit questions to CHP's Member Services department
If you have questions or would like additional information about CHP's privacy practices, please call Member Services at (850) 383-3311.