Member Rights
& Responsibilities.

1.1 — We must provide information in a way that works for you

Imperial Insurance Companies, Inc. has people and free interpreter services available to answer questions from disabled and non-English speaking members. We can also give you information in braille, in large print, or other alternate formats at no cost if you need it. We are required to give you information about the plan's benefits in a format that is accessible and appropriate for you.

To get information from us in a way that works for you, please call Member Services at 1-800-595-0619 (TTY: 711):

• November 1 – January 15: Monday – Sunday, 6:00 AM – 8:00 PM PST
• January 16 – October 31: Monday – Friday, 6:00 AM – 8:00 PM PST

These rights and responsibilities are for all members, regardless of race, sex, culture, economic, educational, or religious background.

If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with Member Services at 1-800-595-0619 (TTY: 711). You may also file a complaint directly with the Office for Civil Rights — contact information is included in your Evidence of Coverage.

1.2 — We must ensure that you get timely access to your covered services and drugs

As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan's network to provide and arrange for your covered services. Call Member Services to learn which doctors are accepting new patients. You also have the right to go to a women's health specialist (such as a gynecologist) without a referral.

As a plan member, you have the right to get appointments and covered services from the plan's network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.

If you think that you are not getting your medical care or prescription drugs within a reasonable amount of time, call 1-800-595-0619 (TTY: 711) and discuss your options. If we have denied coverage for your medical care or drugs and you don't agree with our decision, your Evidence of Coverage tells you what you can do.

1.3 — We must treat you with respect, dignity, and protect your privacy

You will always be treated with respect and dignity. Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

Your "personal health information" includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information. The laws that protect your privacy give you rights related to getting information and controlling how your health information is used.

Imperial is a "Covered Entity" under HIPAA

A "covered entity" is defined in federal regulation as a health plan, a health care clearinghouse, or a health care provider who transmits health information electronically in connection with certain transactions. Imperial, hospital organizations, physician practices and clinics, pharmacies, and some laboratory companies are examples of covered entities. Organizations that are not health care providers, clearinghouses, or Imperial itself — such as fitness or wellness apps — are generally not covered by HIPAA, even if they hold health-related data about you.

How we protect your health information

• We make sure that unauthorized people don't see or change your records.
• In most situations, if we give your health information to anyone who isn't providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.
• There are certain exceptions allowed or required by law. For example, we are required to release health information to government agencies checking on quality of care. Because you are a member of our plan through the individual marketplace-health care exchange, we are required to give CMS or state regulators your health information if requested. Any release of your information for research or other uses is done according to federal or state statutes and regulations.

Your right to see and correct your records

You have the right to look at your medical records held at the plan and to get a copy of your records. We are allowed to charge a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made.

You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your personal health information, please call Member Services at 1-800-595-0619 (TTY: 711).

Protecting your own health information

HIPAA protects your health information when it's held by Imperial and your doctor or hospital — but those protections don't apply if you share your health information yourself with an organization that isn't covered by HIPAA, such as posting on a health-related message board or online community. Simple steps like using passwords on your devices, verifying a source before sharing personal or medical information, and shredding old insurance forms or prescriptions can help protect you from medical identity theft. The Federal Trade Commission's ReportFraud.ftc.gov has more information on protecting yourself.

How to file a complaint

If you believe your information was used or shared in a way not allowed under HIPAA, or you weren't able to exercise your privacy rights, you can file a complaint with Imperial, your provider, the U.S. Department of Health and Human Services Office for Civil Rights, or your state's Attorney General's Office.

1.4 — We must give you information about the plan, its network, and your covered services

As a member of Imperial Insurance Companies, Inc., you have the right to get several kinds of information from us. If you want any of the following, please call Member Services at 1-800-595-0619 (TTY: 711):

• Information about our plan — including the plan's financial condition and the number of appeals made by members.
• Information about our network providers and pharmacies — including the qualifications of providers in our network and how we pay them. For a list of providers and pharmacies, see the provider/pharmacy directory sent to you upon enrollment or visit imperialhealthplan.com.
• Information about your coverage and the rules you must follow — your Evidence of Coverage (EOC) explains what medical services are covered for you, any restrictions to your coverage, and what rules you must follow to get your covered medical services.
• Information about why something is not covered and what you can do — if a medical service or prescription drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation, even if you received the service or drug from an out-of-network provider or pharmacy. If you disagree with a decision, you have the right to make an appeal.

1.5 — We must support your right to make decisions about your care

Your right to know your treatment options and participate in decisions

You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand. Your rights include:

• To know about all of your choices — including all treatment options recommended for your condition, no matter what they cost or whether they are covered by our plan, and about programs our plan offers to help members manage medications and use drugs safely.
• To know about the risks — you have the right to be told about any risks involved in your care, and must be told in advance if any proposed care is part of a research experiment. You always have the choice to refuse experimental treatments.
• The right to say "no" — you have the right to refuse any recommended treatment, including the right to leave a hospital or other medical facility even if your doctor advises you not to leave, and the right to stop taking your medication. If you refuse treatment, you accept full responsibility for what happens as a result.
• To receive an explanation if you are denied coverage — you have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision.

Your right to give instructions about future care — advance directives

Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means you can:

• Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.
• Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself.

The legal documents used to give your directions in advance are called "advance directives." Documents called "living will" and "power of attorney for health care" are examples of advance directives.

If you want to use an advance directive:

• Get the form — from your lawyer, a social worker, or some office supply stores. The plan cannot advise you on how to complete the form.
• Fill it out and sign it — it is a legal document; consider having a lawyer help you prepare it.
• Give copies to appropriate people — your doctor, the person named on the form to make decisions for you, and close friends or family members. Keep a copy at home.

If you know ahead of time that you'll be hospitalized and you've signed an advance directive, take a copy with you. If you're admitted to the hospital without one, they will ask whether you have signed one and offer you a form if you'd like to. It's always your choice whether to fill one out.

1.6 — You have the right to make complaints and ask us to reconsider decisions

If you have any problems or concerns about your covered services or care, your Evidence of Coverage gives the details about how to deal with all types of problems and complaints. What you need to do depends on the situation — you might need to ask our plan to make a coverage decision for you, make an appeal to change a coverage decision, or make a complaint. Whatever you do, we are required to treat you fairly.

You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, call Member Services at 1-800-595-0619 (TTY: 711).

1.7 — What can you do if you believe you are being treated unfairly or your rights are not being respected?

If it is about discrimination

If you believe you have been treated unfairly, or your rights have not been respected, due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, call the Department of Health and Human Services' Office for Civil Rights at 1-800-368-1019 (TTY: 1-800-537-7697), or your local Office for Civil Rights. You may file a complaint by mail (Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F HHH Bldg., Washington, D.C. 20201), by email (OCRComplaint@hhs.gov), or via the OCR Complaint Portal. A complaint must be filed within 180 days of when you knew the act or omission occurred; OCR may extend this period if you can show good cause.

If it is about something else

If you believe you've been treated unfairly or your rights haven't been respected, and it isn't about discrimination, call Member Services at 1-800-595-0619 (TTY: 711) for help.

1.8 — How to get more information about your rights

If you need more information about your rights, call Member Services at 1-800-595-0619 (TTY: 711).

1.9 — You have the right to make recommendations regarding this Policy

Send your comments to:

Imperial Health Plan of California, Inc.
Attention: Member Experience
P.O. Box 60874
Pasadena, CA 91116

2.1 — What are your responsibilities?

Things you need to do as a member of the plan are listed below. If you have any questions, call Member Services at 1-800-595-0619 (TTY: 711). We're here to help.

Get familiar with your covered services and rules

Use the Evidence of Coverage booklet sent to you when you enrolled to learn what is covered for you and the rules you need to follow to get your covered services. Your EOC is also posted at imperialhealthplan.com.

Show your plan membership card

Tell your doctor and other health care providers that you are enrolled in our plan, and show your plan membership card whenever you get medical care or prescription drugs. Your ID card was sent to you with your EOC when you enrolled.

Help your doctors and providers help you

• Learn as much as you can about your health problems and give your providers the information they need about you and your health.
• Follow the treatment plans and instructions that you and your doctors agree upon.
• Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.
• If you ask a question and you don't understand the answer you are given, ask again.
• Make every effort to understand your health problems and participate in developing mutually agreed-upon treatment goals.

Be considerate

We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor's office, hospitals, and other offices.

Tell us if you move

If you are going to move, it's important to tell us right away. Call Member Services at the number listed in your EOC.

• If you move outside of our plan service area, you cannot remain a member of our plan. Your EOC describes our service area, and we can help you determine whether you're moving outside it. If you're leaving the service area, you'll have a Special Enrollment Period to join any plan available in your new area — we can let you know if we have a plan there.
• If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you.

Call Member Services for help

We welcome any suggestions you may have for improving our plan. Phone numbers and calling hours for Member Services are listed in Section 1.1 above. For more information on how to reach us, including our mailing address, see your EOC.