Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-08.3 - Managed care: member rights

Current through all regulations passed and filed through July 1, 2024
(A)
								
								A managed care entity (MCE)
			 must develop and implement written policies in accordance with
			 42 C.F.R. 438.100
			 (October 1, 2021), as applicable, to
			 ensure each member has and is informed of his or her right to:
(1) Receive all services the
			 
									MCE is
			 required to provide pursuant to the terms of 
									the MCE
			 provider agreement or contract, as applicable,
			 with the Ohio department of medicaid (ODM).
(2) Be treated with respect and with due
			 consideration for their dignity and privacy.
(3) Be ensured of confidential handling of
			 information concerning their diagnoses, treatments, prognoses, and medical and
			 social history.
(4) Be provided
			 information about their health. Such information should also be made available
			 to the individual legally authorized by the member to have such information or
			 the person to be notified in the event of an emergency when concern for a
			 member's health makes it inadvisable to give him/her such
			 information.
(5) Be given the
			 opportunity to participate in decisions involving their health care.
(6) Receive information on available
			 treatment options and alternatives, presented in a manner appropriate to the
			 member's condition and ability to understand.
(7) Maintain auditory and visual privacy
			 during all health care examinations or treatment visits.
(8) Be free from any form of restraint or
			 seclusion used as a means of coercion, discipline, convenience, or
			 retaliation.
(9) Request and
			 receive a copy of their medical records, and to be able to request that their
			 medical records be amended or corrected.
(10) Be afforded the opportunity to approve
			 or refuse the release of information except when release is required by
			 law.
(11) Be afforded the
			 opportunity to refuse treatment or therapy. Members who refuse treatment or
			 therapy will be counseled relative to the consequences of their decision and
			 documentation will be entered into the medical record accordingly.
(12) Be afforded the opportunity to file
			 grievances, appeals, or state hearings pursuant to the provisions of rule
			 5160-26-08.4 of the Administrative Code.
(13) Be provided written member information
			 from the MCE:
(a) At no cost
			 to the member,
(b) In the prevalent
			 non-English languages of members specified by ODM,
			 and
(c) In alternative formats and
			 in an appropriate manner that takes into consideration the special needs of
			 members.
(14) Receive
			 necessary oral interpretation and oral translation services at no
			 cost.
(15) Receive necessary
			 services of sign language assistance at no cost.
(16) Be informed of specific student
			 practitioner roles and the right to refuse student care.
(17) Refuse to participate in experimental
			 research.
(18) Formulate advance
			 directives and to file any complaints concerning noncompliance with advance
			 directives with the Ohio department of health.
(19) Change primary care providers (PCPs) no
			 less often than monthly. The MCO must mail written confirmation to the member of
			 his or her new PCP selection prior to or on the effective date of the
			 change.
(20) Appeal to or file
			 directly with the United States department of health and human services office
			 of civil rights any complaints of discrimination on the basis of race, color,
			 national origin, age or disability in the receipt of health services.
(21) Appeal to or file directly with the ODM
			 office of civil rights any complaints of discrimination on the basis of race,
			 color, religion, gender, gender identity, sexual orientation, age, disability,
			 national origin, military status, genetic information, ancestry, health status
			 or need for health services in the receipt of health services.
(22) Be free to exercise their rights and to
			 be assured that exercising their rights does not adversely affect the way the
			 MCE, the
			 
									MCE's
			 providers, or ODM treats the member.
(23) Be assured the
			 
									MCE must
			 comply with all applicable federal and state laws and other laws regarding
			 privacy and confidentiality.
(24)
			 Choose his or her health professional to the extent possible and
			 appropriate.
(25) For female
			 members, to obtain direct access to a woman's health specialist within the
			 network for covered care necessary to provide women's routine and preventive
			 health care services. This is in addition to a member's designated PCP if the
			 PCP is not a woman's health specialist.
(26) Be provided a second opinion from a
			 qualified health care professional within the MCO'snetwork. If
			 such a qualified health care professional is not available within the
			 MCO'snetwork, the 
									MCO must arrange for a second opinion outside the
			 network, at no cost to the member.
(27) Receive information on their
			 MCE.