UPMC Health Plan
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HealthChoices
Members

Membersí Rights and Responsibilities

All members served by Community Care have certain rights and responsibilities.  It is the obligation and responsibility of every Community Care staff person and provider to be informed of these rights and responsibilities and to support them in daily operations.

Members Rights read as follows:

Confidentiality:
Community Care will not disclose information about a member’s care without permission, except when:

  1. It is required for the monitoring activities of Community Care, the Counties and/or the State.
  2. Required by law.

Members have the right to ask for a copy of the following information:

  1. The names, addresses, and phone numbers of providers who speak other languages.
  2. The names, addresses, and phone numbers of providers of service who are not accepting new patients.
  3. Any reasons why they could not choose a provider of service.  For example, Community Care will not provide referral information for treatment services that are not generally recognized by doctors.
  4. Member rights and responsibilities.
  5. Information about grievances and fair hearing procedures.
  6. The benefits available to members, in detail.
  7. How to learn about additional benefits from the State of Pennsylvania.
  8. The steps that one needs to take to receive services.
  9. The steps that must be taken to use a provider of service who is not in the network.
  10. The emergency benefits available to you, including:
  11. What is an emergency.
  12. The steps for getting emergency service, including calling 911.
  13. The names, addresses, and phone numbers of emergency providers of service.
  14. That emergency services do not require approval.
  15. That any hospital can be used when there is an emergency.
  16. How emergency transportation is provided.

Members also have the right:

  1. To receive information about Community Care, its services, its providers and the member rights and responsibilities.
  2. To receive proper treatment regardless of race, color, religion, lifestyle, disabilities national origin, age, gender, or income.
  3. To be treated in a considerate and respectful manner with recognition of one’s dignity.
  4. To receive services where privacy is protected.
  5. To an open discussion of appropriate or medically necessary treatment options for conditions, regardless of cost or benefit coverage.
  6. To choose any provider from the Community Care provider list.  Members are free to change providers if you are unhappy.
  7. To have information kept private and confidential.
  8. To know the name and the qualifications of any provider.
  9. To voice complaints or grievances about Community Care or the care received and to see how Community Care responds to member complaints and grievances.  Members have the right to a fair process that is easy to follow.
  10. To make recommendations about Community Care’s member rights and responsibilities.
  11. To receive a copy of the information that Community Care uses when we decide what care members should receive.
  12. To know about the services one is receiving, why one is receiving them and what to expect.
  13. To know everything needed to make decisions about one’s care.
  14. To work with providers or interpreters who understand members and their community.
  15. To get information about Community Care that is clear and easy to understand.
  16. To tell us if they are unhappy about any decision made by us or one of our providers.  You have the right to a fair process that is easy to follow.
  17. To know about the qualifications of Community Care providers and staff.
  18. To receive information about options for treatment.  You have the right to receive this information in way that is easy to understand.
  19. To play a part in the decisions about one’s care.  You also have the right to refuse treatment.
  20. To not be restrained (tied down or locked in) or left alone – as a way for someone giving treatment to bully, punish, or as a way for that person to take a break.
  21. To ask for a copy of one’s medical record.  You have a right to correct information inside your record.
  22. To know members’ rights and to not be treated differently because you do.
  23. To a second opinion.
  24. To ask and learn more about “Advance Directives”.

Members’ Responsibilities read as follows:

It is important for members to:

  1. Give Community Care and their provider the information needed to provide care.
  2. Tell their provider everything they know about their physical and mental health.  Also, tell this person what medicines are being taking, including over-the-counter (store bought) medicine(s). 
  3. Tell their family doctor or PCP (primary care physician) about any counseling treatment.
  4. Carry one’s ACCESS, Physical Health Plan, and Community Care ID cards with him/her.
  5. Go to a Community Care participating hospital in an emergency, if possible.    Call us within 24 hours if they have been seen for an emergency at a hospital that is not in our provider network.
  6. Keep appointments.  Call ahead to cancel if they must.
  7. Understand their health problems and work together with their provider on an agreed-upon treatment plan.
  8. Follow the treatment plan they have agreed upon with their provider.
  9. Tell their provider if they want to stop or change treatment.
  10. Tell Community Care and their provider about any other insurance they have.
  11. Tell their provider and Community Care right away if their Medicaid status changes. 
  12. Tell their provider and Community Care right away if they move.

 

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