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Member Rights and Responsibilities

CMS Health Plan members have the right to:

  • Be treated with courtesy and respect
  • Have dignity and privacy respected at all times
  • Receive a quick and useful response to questions and requests
  • Know who is providing medical services and who is responsible for the care
  • Know what member services are available, including whether an interpreter is available if a member does not speak English
  • Know what rules and laws apply to conduct
  • Be given information about a diagnosis, the needed treatment, choices of treatments, risks, and how these treatments will help members receive care
  • Say no to any treatment, except as otherwise provided by law
  • Be given full information about other ways to help pay for healthcare
  • Know if the provider or facility accepts the Medicare assignment rate
  • To be told prior to getting a service how much it may cost
  • Get a copy of a bill and have the charges explained
  • Get medical treatment or special help for people with disabilities, regardless of race, national origin, religion, handicap, or source of payment
  • Receive treatment for any health emergency that will get worse if a member does not get treatment
  • Know if medical treatment is for experimental research and to say yes or no to participating in such research
  • Make a complaint when members rights are not respected
  • Ask for another doctor when a parent or guardian does not agree with a doctor (second medical opinion)
  • Get a copy of a medical record and ask to have information added or corrected, if needed
  • Have medical records kept private and shared only when required by law or with a parent or guardian’s approval
  • Decide how medical decisions should be made if member can’t make decisions themselves (advance directive)
  • Decide how you want medical decisions made if you can’t make them yourself (advance directive)
  • To file a grievance about any matter other than a plan’s decision about services.
  • To appeal a plan’s decision about the services
  • Receive services from a provider that is not part of our plan (out-of-network) if we cannot find a provider that is part of our plan
  • Speak freely about your health care and concerns without any bad results
  • Freely exercise your rights without the plan or its network providers treating you badly
  • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation
  • Request and receive a copy of your medical records and ask that they be amended or corrected

Member and Parents and/or Guardians Responsibilities

A CMS Health Plan member or parent/guardian of a CMS member have the responsibility to:

  • Give accurate information about members health to the plan and providers
  • Tell a provider about unexpected changes in a member’s health condition
  • Talk to providers to understand a course of action and what is expected from parents and/or guardians
  • Listen to a provider, follow instructions and ask questions
  • Keep a appointments or notify a provider if an appointment cannot be kept
  • Be responsible for actions if treatment is refused or if healthcare provider's instructions are not followed
  • Make sure payment is made for non-covered services that members receive
  • Follow healthcare facility conduct rules and regulations
  • Treat healthcare staff with respect
  • Tell us if members or parents and/or guardians have problems with any healthcare staff
  • Use the emergency room only for real emergencies
  • Notify your child’s care manager about change in information (address, phone number, etc.)
  • Have a plan for emergencies and access this plan if necessary for member safety
  • Report fraud, abuse and overpayment