Member Rights
Each IPA member has the right to:
- Exercise these rights without regard to gender, sexual orientation, or cultural, economic, educational, or religious background.
- Be provided with comprehensible information about the IPA, its services, providers and the health care service delivery process. This information includes instructions on how to obtain care with various providers and at varied facilities (e.g., primary care, specialty care, behavioral health services, and hospital services.) Additionally, information will be included on how to obtain services outside the IPA system or service area.
- Be informed of emergent and non-emergent benefit coverage and cost of care, and receive an explanation of the member’s financial obligations as appropriate, prior to incurring the expense (including co-payments, deductibles, and co-insurance).
- Be provided with information on how to obtain care after normal office hours and how to obtain emergency care including when to directly access emergency care or use 911 services.
- Be informed of the name and qualifications of the physician who has primary responsibility for coordinating the member’s care; and be informed of the names, qualifications, and specialties of other physicians and non-physicians who are involved in the member’s care.
- Have 24-hour access to their primary care physician (or covering physician).
- Receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, and prospects for recovery in terms that are understandable to the member, in order to give informed consent or to refuse that course of treatment.
- Candidly discuss appropriate or medically necessary treatment options for the member’s condition, regardless of cost or benefit coverage.
- Actively participate in decisions regarding the member’s health care and treatment plan. To the extent permitted by law, this includes the right to refuse any procedure or treatment. If the recommended procedure or treatment is refused, an explanation will be given addressing the effect that this will have on the member’s health.
- Be treated with respect and dignity. Receive considerate and respectful care with full consideration of the member’s privacy.
- Receive confidential treatment of all member information and records used for any purpose.
- Be afforded the opportunity to consent or deny the release of identifiable medical or other information except when such release is required by law. This activity includes nonmember-identifiable data shared with employers
- Express opinions or concerns about the IPA or the care provided and offer recommendations for change in the health care service delivery process by contacting the IPA Member Services Department.
- Be informed of the member complaint/grievance and appeal process. Be able to express a complaint, grievance, or appeal in writing or by phone.
- May be offered the opportunity to be represented by someone of their choosing at any level of appeal and at a minimum the opportunity for representation, including an attorney, at the second level of appeal.
- Review of first or second level appeal of a clinical issue by at least one actively participating practitioner from the same or a similar specialty who typically treats the medical condition or provides the procedure or treatment in question.(NCQA considers a practitioner “actively participating” if he or she provides direct member care)
- Be informed of the availability of providers, termination of a primary care provider or practice site and receive assistance in selecting a new primary care provider or site in this situation.
- Change primary care physicians by contacting the Member Services Department of health plan.
- Be provided with information on potential health plan restrictions incorporated in the operational procedures, how the IPA implements new technology for inclusion as a covered benefit.
- Receive reasonable continuity and coordination of care and be given timely and sensible responses to questions and requests made for service, care, covered benefits, non-covered services, and payment (including complaints and appeals).
- Be informed of continuing health care requirements following office visits, treatments, procedures, and hospitalizations.
- Have all member rights apply to the person who has the legal responsibility to make health care decisions for the member.
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Copyright© 2004
EXCEL MSO, LLC
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