Member Rights and Responsibilities

Capital Health Plan Member's Rights and Responsibilities

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 who 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.

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 copayments 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.

January, 2008