Member Rights and Responsibilities

Purpose
To ensure that members of High Desert Primary Care have available access to information regarding their rights and responsibilities.

Policy:
It is the policy of High Desert Primary Care Medical Group to ensure that members have access to information regarding their rights and responsibilities, the role of the practitioner advocating on behalf of members, members rights to participate into the input of proposed treatment plans, to ensure members of confidentiality of member information and records, the establishment of criteria to report complaints and appeals, and information on how a member can obtain primary and specialty care.

Procedures:
Members rights and responsibilities will be posted on the HDPC Internet website for all members to review along with a poster posted in the lobby area of the facility. The following notice will be made public to the members: The member has the:

• Right to receive information about HDPC, its services, its practitioners and providers, and member’s rights and responsibilities.
  
  
• Right to be treated with respect and recognition of their dignity and right to privacy.
  
  
• Right to participate with practitioners in decision making regarding their healthcare.
  
  
• Right to candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
  
  
• Right to voice complaints or appeals about HDPC or the care provided.
  
  
• Responsibility to provide, to the extent possible, information that HDPC and its practitioners and providers need in order to care for them.
  
  
• Responsibility to follow the plans and instructions for care that they have agreed on with their practitioners.
  
  
• Utilization criteria is available to our practitioners, members and the public upon request by contacting the Utilization Management Department at (760) 956-4159 or contact us through www.hdpcmg.com.
  
  1. Members and practitioners can obtain UM criteria used to
  make decisions free of charge by calling (760) 956-4159 or contact us through www.hdpcmg.com.
  
  2. UM staff is available 8 hours a day during normal business
  hours for inbound calls regarding UM issues.
  
  3. Collect calls regarding UM issues will be accepted by UM
  staff if necessary by calling (760) 956-4159 or contact us through www.hdpcmg.com.
  
  
• Members have the right to make recommendations regarding High Desert Primary Care's member rights and responsibilities policies.
  

Members have the right to be assured that services are provided in a culturally competent and non-discriminatory manner.

• HDPC will assure that services are provided in a culturally competent manner to all members, including those with limited English proficiency or reading skills (i.e., translator and interpreter services will be available upon request) and those with diverse cultural or ethnic backgrounds.
  
  
• HDPC will assure that member race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment does not influence the provision of health services.
  
  
• The method by which HDPC monitors compliance and the processes implemented if allegations of discrimination are made by a member or a practitioner will be investigated by the Quality Management Committee and steps will be taken to provide a corrective action plan immediately.
  
  
• HDPC will make public declarations (e.g., via posters, member handbooks, newsletters, mission statement, Internet) indicating that health services are provided in a non-discriminatory manner.
  
  
• The primary goal for profiling health care entities and physicians is to assess and improve the quality and value of the health care services provided. Under no circumstances is the profiling made in conjunction with decisions of the appropriateness of a referral and/or the level of care that a member receives. Medical decisions made by the provider and/or committee shall be based on medical necessity only. There shall be no fiscal restraints or incentives put in place by administrative management as required by Health and Safety Code Section 13679g).

Practitioners are not prohibited from advocating on behalf of members or advising a member on medical care. HDPC allows open practitioner-member communication regarding appropriate treatment alternatives and does not penalize practitioners for discussing medically necessary or appropriate care for the member. Interference with health care practitioners’ advice to members is prohibited.

Members have the right to have input into proposed treatment plans.

• Practitioner will inform member of treatment options (without regard to plan coverage), risks, benefits and consequences of treatment or non-treatment.
  
  
• Practitioner will consider member input in the proposed treatment plan, member’s rights to refuse medical treatment, and to self-determination in treatment plans.
  
  
• Members have the right to be represented by parents, guardians, family members or other conservators for those who are unable to fully participate in their treatment decisions.
  
  
• Education includes communication to practitioners that they are expected to:
  
  1. Educate members regarding their health needs.
  
  2. Share findings of history and physical examinations.
  
  3. Discuss potential treatment options (without regard to plan coverage), side effects of treatment, management of symptoms.
  
  4. Recognize that the member has final determination in the course of action among clinically acceptable choices.
  
  5. Distribution of educational communication will be via newsletter, posters, committee minutes, and/or internet.
  
  

Privacy and Confidentiality procedures will be implemented and adhered to by all HDPC employees and providers at all times. The following are expectations that HDPC will adhere to:

• Contracts with practitioners and providers explicitly state expectations about the confidentiality of member information and records, including policies for members who lack the ability to give informed consent.
  
  
• Members are afforded the opportunity to consent to or deny the release of identifiable medical or other information except as required by law. Medical information may not be disclosed without the consent of member.
  
  
• HDPC informs members, practitioners, and providers of its policies and procedures on obtaining consents for use of member medical information, allowing members access to their medical records, and protecting access to member medical information.
  
  
• HDPC will designate an internal committee to create and review confidentiality policies and to review practices regarding the collection, use and disclosure of medical information.
  
  
• HDPC will maintain the medical information and records are stores in a anonymous manner.
  
  
• HDPC will dispose of, or destroy members’ medical information and records in such a way that the information is not identifiable.
  
  
• HDPC will maintain that no provider of health care shall disclose medical information regarding a member to any person or entity that is not engaged in providing direct health care services without first obtaining an authorization, except as provided by law. The following will apply:
  

1. HDPC will prohibit negligent disposal or destruction of medical information.
   
   
2. HDPC will prohibit intentional sharing, sale, or use of medical information for any purpose not necessary to provide health care services to the member, except as otherwise authorized.
   
   
3. HDPC will prohibit practitioners from requiring a member, as a condition to receiving health care services, to sign an authorization, release, consent, or waiver permitting the disclosure of any medical information subject to confidentiality protections.
   
   
4. HDPC will prohibit physicians or health care professionals from releasing medical information on a member’s psychotherapy outpatient treatment to a requesting agent without a written request to the practitioner (specifying what the information will be used for and how long it will be kept) and a notice to the member (unless the member has signed a waiver of this notice requirement).
   
   
5. Anyone requesting medical information related to a member’s psychotherapy treatment shall send a copy of the written request to the member within 30 calendar days of receiving the information, unless the member signs a letter waiving notification.
   
   
6. HDPC shall allow any adult member who inspects their medical record(s) shall have the right to provide to the health care provider a written addendum with respect to any item or statement in his or her record(s) that the member believes to be incomplete or incorrect. The addendum shall be limited to 250 words per alleged incomplete or incorrect item and shall clearly indicate in writing that the member wishes the addendum to be made
   

HDPC will provide the following criteria to provide member with written information on how to obtain primary and specialty care:

1. HDPC will provide member with information that is easy to read, easily understood at 8th grade level, and in language that is consistent with major population groups. If 10% of population speaks a language other than English, member materials will be provided in that language. Member information will include the method for obtaining the following health care services:
   
   
2. Practitioners contracted with HDPC.
   
   
3. Primary care services, including points of access.
   
   
4. Specialty care and hospital service.
   
   
5. Care after normal office hours.
   
   
6. Emergency care, including HDPC’s policy on when to directly access emergency care of use 911 services.
   
   

Member rights and responsibilities corrective action plan submission and implementation will be submitted within 30 calendar days of request from any contracted health plan. HDPC will provide a corrective action plan that addresses all areas of identifiable deficiencies and will set appropriate time parameters that will include measurable goals, actions to correct all deficiencies, responsible person, and timeframe for corrective action plan implementation.