Member Rights & Responsibilities

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

Our plan 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 1-800-838-8271:

• October 1 – March 31: Monday – Sunday, 8:00 AM – 8:00 PM PST
• April 1 – September 30: Monday – Friday, 8:00 AM – 8:00 PM PST

These rights and responsibilities are for all members, regardless of race, sex, culture, economic, educational, or religious background. Refer to Chapter 8: Rights and Responsibilities in your Evidence of Coverage.

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 1-800-838-8271. You may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights.

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. Your Evidence of Coverage (EOC), Chapter 3 explains more about this. 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 Part D drugs within a reasonable amount of time, your EOC Chapter 9, Section 10 explains what you can do. If we have denied coverage for your medical care or drugs and you don't agree with our decision, your EOC Chapter 9, Section 4 tells 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.

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 through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs.

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.

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

As a member of Imperial Health Plan of California, Inc., you have the right to get several kinds of information from us. If you want any of the following, please call Member Services:

• Information about our plan — including the plan's financial condition, number of appeals made by members, and the plan's Star Ratings.
• 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 EOC Chapters 3 and 4 explain what medical services are covered, any restrictions, and what rules you must follow. EOC Chapters 5 and 6 cover Part D prescription drug coverage.
• Information about why something is not covered and what you can do — if a medical service or Part D drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. If you disagree with a decision, you have the right to make an appeal. See your EOC Chapter 9 for details.

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.
• 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.
• 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.
• 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.

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, some office supply stores, or by calling Member Services.
• 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 to make decisions for you, and close family members. Keep a copy at home.

If you are admitted to the hospital, they will ask whether you have signed an advance directive. No one can deny you care or discriminate against you based on whether or not you have signed one.

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

If you have a concern regarding a person, a service, the quality of care, contractual benefits, or a rescission of coverage, your EOC Section 9 tells what you can do. It gives details about how to deal with all types of problems and complaints. 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, please call Member Services.

1.7 — What can you do if you believe you are being treated unfairly?

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, age, or national origin, you should call the Department of Health and Human Services' Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.

If it is about something else

If you believe you have been treated unfairly or your rights have not been respected, and it's not about discrimination, you can:

• Call Member Services at 1-800-838-8271
• Call the State Health Insurance Assistance Program (SHIP) — see your EOC Chapter 2, Section 3 for details
• Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

1.8 — How to get more information about your rights

• Call Member Services at 1-800-838-8271
• Call the SHIP — see your EOC Chapter 2, Section 3 for contact details
• Visit medicare.gov to read or download "Medicare Rights & Protections"
• Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week

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, please call Member Services. We're here to help.

Get familiar with your covered services and rules

Use your EOC booklet to learn what is covered for you and the rules you need to follow. EOC Chapters 3 and 4 give the details about your medical services. EOC Chapters 5 and 6 give the details about your Part D prescription drug coverage.

Tell us if you have other coverage

If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Call Member Services at 1-800-838-8271. We are required to follow rules set by Medicare to coordinate your benefits.

Show your plan membership card

Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card whenever you get medical care or Part D prescription drugs.

Help your doctors and providers help you

• Learn as much as you are able to about your health problems and give 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.

Pay what you owe

• To be eligible for our plan, you must have Medicare Part A and Medicare Part B. Most plan members must pay a premium for Medicare Part B to remain a member.
• For most of your covered medical services or drugs, you must pay your share of the cost — a copayment (fixed amount) or coinsurance (percentage of the total cost). Your EOC Chapter 4 tells you what you must pay for medical services; Chapter 6 for Part D prescription drugs.
• If you get medical services or drugs that are not covered by our plan or other insurance, you must pay the full cost.
• If you disagree with our decision to deny coverage, you can make an appeal. See your EOC Chapter 9.

Tell us if you move

If you are going to move, it's important to tell us right away. Call Member Services at 1-800-838-8271.

• If you move outside of our plan service area, you cannot remain a member. We can help you determine whether you are moving outside our service area. If you are leaving, you will have a Special Enrollment Period to join any Medicare plan available in your new area.
• If you move within our service area, we still need to know so we can keep your membership record up to date.
• If you move, it is also important to tell Social Security (or the Railroad Retirement Board).

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 Chapter 2.