Complex Care Management Rights and Responsibilities

Your Rights and Responsibilities

I.  It is the enrollee’s and family’s right to:

1. Be treated in a caring and respectful manner by HSCSN staff.
2. Get information yearly about HSCSN services, providers and rights and responsibilities.
3. Know the names of all healthcare staff and providers involved in their care.
4. Share their thoughts about enrollee rights and responsibilities.
5. Be informed in writing yearly or 30 days before any changes are made to membership or benefits.
6. Choose or change providers in network or ask for a change in Care Manager to meet their needs.
7. Know their health needs and agree to treatment before it is given.
8. Know how to get authorization for services before they are given (authorization is not needed for emergency services).
9. Know how and when to call 911.
10. Know what the emergency medical conditions are and follow-up treatment or services available.
11. To have an open discussion of right or medically needed treatment options for their conditions, no matter the cost or benefit coverage.
12. Be a part of the decision-making process about the enrollee’s health care. You have the right to say yes or no to treatment before it is given to the enrollee. Enrollees have the right to get a second opinion and/or refuse offers for treatment.
13. Have HSCSN arrange for a second opinion outside the network at no charge to the enrollee if there is not a provider in network.
14. Be transported to all medically necessary appointments.
15. HSCSN’s policies should be given in a language that you understand to help you make decisions.
16. Voice concerns and complaints to HSCSN staff and receive a timely response.
17. Contact the Department of Health Care Finance (DHCF) Ombudsman to voice your concerns, or complaints at any time without fear of revenge. Receive a Fair Hearing and get help from HSCSN or DHCF staff if needed.
18. Have Advance Directives about the child or young adult’s care in case there is danger of death stating what you want done if you are unable to make your own medical choices, if you are 18 years of age or older; provide enrollees with information about changes in state law no later than 90-days after date of the change.
19. Have the child or young adult’s medical records kept confidential and released generally only with written permission from a parent, legal guardian, or emancipated minor.
20. Be able to request and receive a copy of his or her medical records, and request that they be amended or corrected as specified in 45C.F.R. sec. 164.524 and 164.526.
21. Be informed in writing within 10 days when information about your child’s care has been released due to a legal request.
22. Have the child or young adult receive considerate health care with privacy during treatment, interviews, and any care planning meetings.
23. Have access to HSCSN’s health care services for the child or young adult 24 hours a day, every day of the year.
24. Enrollees/Caregivers have the right not to be coerced or judged for any reason.
25. Enrollees who are non-English speaking will receive translation services.
26. Enrollees will have documents translated in other languages and formats.
27. An enrollee with LEP has the right to file a complaint if oral translation services are not provided in a timely manner.
28. To be free from restraints as a means of discipline or revenge.
29. Know of HSCSN’s financial status. Enrollees will not be at fault for HSCSN’s debts or wealth; and will not be liable for payment for covered services.
30. Know of HSCSN’s prescription drug program, the program’s policy, and the enrollee’s right to have a prescription filled while a prescription is under a Grievance or in Appeals process.
31. A description of HSCSN’s Physician Incentive Plans (PIPs).
32. Summaries of any enrollee satisfaction survey based on the requirements found at 42 C.F.R. sec. 438.10(i)(3)(iv).
33. Get Family Planning Services and supplies from all Health Care Finance providers in the District of Columbia.
34. Get a copy of this Enrollee Handbook and a Provider Directory.

II. It is the enrollee’s and family’s responsibility to:

1. Treat HSCSN staff and providers with kindness and respect when receiving healthcare or care coordination services.
2. Work with the enrollee’s providers and care managers to create and follow plans and instructions for care as agreed on.
3. Know your or your child’s health problems and be part of planning on how to treat them.
4. Let your worker and doctor know if you would like to make a change in the care plan.
5. Show your HSCSN card and shot record when getting health care.
6. Go to all health visits and let your doctor and HSCSN know if you need to cancel.
7. Be on time for when HSCSN takes you to your child’s health visits.
8. Have a grown-up with your child under 18 years old when going to office visits.  The grown-up must stay with the child during the ride and while seeing the doctor.
9. Be ready for your child when HSCSN brings them back from a health visit or program.
10. If you are not able to be there, make sure a grown-up you know is there to get your child.
11. Give HSCSN releases of consent forms (ROI) when asked.
12. Let HSCSN know right away of any changes in name, address, telephone number, or emergency numbers.
13. Let HSCSN know if you or your child is pregnant or has had a child while with HSCSN.
14. Let HSCSN know if a parent or caretaker or your child has passed away, if they lost SSI, if they are not living at home, if in jail, or anything else that will help us when we call you.
15. Give doctors and HSCSN the information they need.  This helps doctors give you quality care.  It helps us give you the right service.
16. Share your thoughts about you and your child’s care.
17. All new medications and treatment must be approved.
18. Go to the Emergency Room if you are feeling sick.
19. Help your doctor get records from your prior doctors.
20. Tell Income Maintenance Administration (IMA) and HSCSN if you or a family member has other health insurance.
21. Ask questions about you and your child’s care and HSCSN services.  This helps doctors learn about you and your child’s health problems.
22. Not engage in fraud or abuse in dealing with your doctors and /or HSCSN.