Member Rights and Responsibilities

• You have a right to get information in a way that meets your needs.
• We must treat you with respect, fairness, and dignity at all times.
• We must ensure that you get timely access to covered services and drugs.
• We must protect your personal health information.
• You have a right to see your medical records.
• We must give you information about our plan, our network providers, and your covered services.
• Network providers cannot bill you directly.
• You have the right to leave our Community Advantage Plus (HMO D-SNP), a Medicare Medi-Cal Plan, during certain parts of the year.
• You have a right to make decisions about your health care.
• You have the right to know your treatment options and make decisions about your health care.
• You have the right to say what you want to happen if you are unable to make health care decisions for yourself.
• You have the right to make complaints and to ask us to reconsider decisions we have made.
• You have the right to choose a Primary Care Provider (PCP) in our network. A network provider is a provider who works with us.
  • Call Member Services or look in the Provider and Pharmacy Directory to learn which doctors are accepting new patients.
• Women have the right to go to a gynecologist or another women’s health specialist without getting a referral. A referral is a written order from your primary care provider.
• You have the right to get covered services from network providers within a reasonable amount of time.
  • This includes the right to get timely services from specialists.
• You have the right to get emergency services or care that is urgently needed without prior approval.
• You have the right to get your prescriptions filled at any of our network pharmacies without long delays.
• You have the right to know when you can see an out-of-network provider. To learn about out-of-network providers see the Member Handbook.
• When you first join our plan, you have the right to keep your current providers and service authorizations for up to 12 months if certain conditions are met. To learn more about keeping your providers and service authorizations, see the Member Handbook.
• You have the right to hire, fire, and manage your In-Home Supportive Services provider.
• You have the right to self-direct care with help from your care team and Personal Care Coordinator.

You also have responsibilities as a member of the plan.

As a member of the plan, you have a responsibility to do the things that are listed below. If you have any questions, please call our Member Services Department at 1-888-484-1412 (TTY: 711). Community Advantage Plus representatives are available 24 hours a day, 7 days a week, including holidays.

• Read the Member Handbook to learn what is covered and what rules you need to follow to get covered services and drugs.
• Tell us about any other health or prescription drug coverage you have.
• Tell your doctor and other health care providers that you are enrolled in our plan.
• Help your doctors and other health care providers give you the best care.
• Be considerate.
• Pay what you owe.
• Tell us if you move.
• Call Member Services for help if you have questions or concerns.

Rights and Responsibilities Upon Disenrollment

Ending your membership in our Plan may be voluntary (your own choice) or involuntary (not your own choice):

• You might leave our Plan because you have decided that you want to leave.
• There are also limited situations where we are required to end your membership. For example, if you move permanently out of our geographic service area.

We cannot ask you to leave our Community Advantage Plus Plan for any reason related to your health.

If you feel that you are being asked to leave our plan for a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may call 24 hours a day, seven days a week.

You have the right to make a complaint if we end your membership in our plan.

If we end your membership in Community Advantage Plus, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership. You can also see Chapter 9 for information about how to make a complaint.

Until your membership ends in our Community Advantage Plus, you will keep getting your medical services and drugs through our plan.

If you leave our Plan, it may take some time for your membership to end and your new way of getting Medicare to take effect. While you are waiting for your membership to end, you are still a member and must continue to get your medical care and prescription drugs through our Plan.

• You should use our network pharmacies to get your prescriptions filled. Usually, your prescription drugs are covered only if they are filled at a network pharmacy including through our mail-order pharmacy services.

If you are hospitalized on the day that your membership ends, your hospital stay will usually be covered by our Community Advantage Plus until you are discharged. This will happen even if your new health coverage begins before you are discharged.

For full information on Community Advantage Plus benefits, please call our Member Services Department at 1-888-484-1412 (TTY: 711). Community Advantage Plus representatives are available 24 hours a day, 7 days a week, including holidays.