What Are My Member Rights and Responsibilities?

Rights

• Receive information about Partners in a way that is easily understood in accordance with 42 C.F.R. § 438.10. The information will include, but not limited to its health care services, its providers and practitioners, and the rights and responsibilities of members, including the right to receive oral interpreter services at no cost.
• Be free to exercise their rights, and that by doing so will not change the way the Contractor, its network providers, or the State Medicaid agency treats the member (42 CFR §438.100).
• Make recommendations about Partners policies and procedures, including the Member Rights and Responsibilities policy.
• Be treated with respect, without regard for health status, sex, race, color, religion, national origin, age, marital status, sexual orientation or gender identity.
• Be treated with respect and with due consideration for his or her dignity and privacy by Partners’ staff, network providers and others who are part of their health team.
• Not be subjected to any unlawful discrimination specified in the Contract, as well as any other applicable federal and state laws and regulations prohibiting discrimination against recipients in the course of obtaining or receiving services from any network provider of the health plan.
• Express freedom of speech and freedom of religious expression.
• Be free of influence, limitations, or any interference with their decision to exercise their rights.
• Receive information on available treatment options and alternatives, presented in a manner appropriate to the member’s condition and ability to understand.
• Participate in decisions about their health care, including the right to refuse treatment and advance directives for Medicaid and State-funded services.
• Connect to providers in Partners’ network to get the health care services they need.
• Get treatment in the most natural, age-appropriate, and independent setting as possible.
• Receive health care services that meet requirements for timely access and medically necessary coordinated care (42 CFR §438.206 through 42 CFR §438.210).
• Get information about changes in benefits, health care services or providers. Partners will notify members in writing of any important changes to programs or health care services.
• Be furnished, consistent with the scope of services of the Contract, health care services in accordance with 42 C.F.R. §§ 438.206-438.210.
• Be informed of the availability of Medicaid transportation services at no cost.
  • Have the transportation policy explained, including how to request or cancel a trip, limitations on transportation, personal conduct, and no-show rules.
  • Be transported to medical appointments if unable to arrange or pay for transportation:
    • Have the transportation policy explained, including how to request or cancel a trip, limitations on transportation, personal conduct, and no-show rules.
    • Be transported to medical appointments if unable to arrange or pay for transportation:
      • By means appropriate to circumstances.
      • To arrive at the medical provider in time for their scheduled appointment.
      • Be informed that a member under the age of eighteen (18) does not have to ride alone and that member and/or attendants can ride at no additional cost.
      • Request a hearing if the request for transportation assistance is denied.
      • Receive assistance in filling out forms or paperwork needed to assure their rights.
  • Make suggestions to us about our policies and health care services by calling the toll-free PartnersACCESS Member and Recipient services line at 1-888-235-HOPE (4673) (for deaf or hard of hearing, NC Relay 711; TTY: 1-800-735-2962-English; 1-888-825-6570-Spanish) or 704-884-2729, Member Engagement.
    • If members would prefer to email their suggestions, they can be sent to the Member Engagement department at memberquestions@partnersbhm.org or by completing our feedback form online at https://www.partnersbhm.org/feedback/.
    • Medicaid members may contact the State Medicaid Ombudsman program 1-855-723-7283 to assist, if needed, with resolution of issues and questions about their rights.
      • The Ombudsman program provides free and confidential support about the rights and responsibilities members have under NC Medicaid.
      • The call center offers free interpretation in over 150 languages.
    • Prepare Advance Directives and share with their providers. These are instructions for your care if, in the future, you are unable to make decisions about your care.
    • Ask questions when you do not understand your care or what you are expected to do.
    • Have an open discussion with service providers or practitioners on appropriate or medically necessary treatment options for their conditions, regardless of cost or what their health benefits cover.
      • Members may need to decide among related treatment options, risks, benefits, and consequences, including their right to refuse treatment and to express their preferences about future treatment decisions regardless of limits of what their benefits cover.
    • Receive health care services from a provider even if they cannot pay required copayment—a fee they pay when they get certain healthcare services or a prescription. There are NO copays for the following members or health care services:
      • Under age 21
      • Pregnant
      • Receiving hospice care
      • Federally recognized tribal members
      • North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) beneficiaries
      • Children in foster care
      • People living in an institution who are receiving coverage for cost of care
      • For questions on copayments, members may contact the PartnersACCESS service line at 1-888-235-HOPE (4673) (for deaf or hard of hearing, (for deaf or hard of hearing, NC Relay 711; TTY: 1-800-735-2962-English; 1-888-825-6570-Spanish)
    • Voice concerns or complaints about us or the care they receive. Members may voice their concerns in a confidential and secure way by filing a grievance in the following ways:
      • Telephone: 1-888-235-HOPE (4673).
      • Mail: Partners Health Management, c/o Grievances, 901 S. New Hope Road, Gastonia, NC 28054.
      • Email: Grievances@partnersbhm.org.
      • Online feedback form: https://www.partnersbhm.org/feedback/.
      • In person: every employee at Partners can take their grievance or concern.
    • Request and receive a copy of their medical records and request a change to it, as specified in 45 C.F.R. §§ 164.524 and 164.526. For medical records and any other health and enrollment information that identifies a particular member, Partners uses and discloses individually identifiable health information in accordance with the privacy requirements in 45 CFR parts 160 and 164, subparts A and E (HIPAA), to the extent that these requirements are applicable (42 CFR §438.224).
    • Be free from any form of restraint (e.g., physical or chemical) or seclusion used as a means of coercion, discipline, convenience or retaliation.
      • A member’s rights can only be restricted by their treatment team for reasons related to their care or treatment.
      • They must be part of their own treatment team and must be involved in making decisions. They have the right to have an advocate or someone they trust involved.
      • The Human Rights Committee must approve the plan to restrict their rights.
      • Any restriction is documented and kept in their medical record.
    • Receive a second opinion from a qualified behavioral health professional, within the Partners’ network out of network, at no cost to the member.
    • Disagree with what is written in their medical records.
      • If members disagree, they have the right to compose a statement to be placed in their file.
        However, the original notes will also stay in the record until the time for retention ends, according to the MH/DD/SAS retention schedule (11 years for adults; 12 years after a minor reaches the age of 18; 15 years for DUI records).
      • You have the right to appeal if you disagree with our decision to deny, reduce, suspend, or terminate a service. An appeal is a request for review. Your provider and care coordinator can help you file a request by calling or emailing the Appeals department at 704-884-2650 or Appeals@PartnersBHM.org.
      • Have a state-level Fair Hearing.

• Freely exercise their appeal and grievance rights and resolve issues efficiently with minimal burden to them or their authorized representative.
  • Receive education on their rights and provide reasonable assistance with understanding and navigating the appeals and grievances process (Utilization Management appeals staff assist with filling out paperwork).
  • Request a reconsideration review by Partners staff if they disagree with our decision to deny, reduce, suspend, or terminate a service and receive assistance.
  • If the decision is upheld, request a State Fair Hearing to appeal.
  • Appoint someone to speak on their behalf (including providers, legal guardian, or other concerned person), with their written consent, including requesting an appeal or filing a grievance on their behalf. 42 C.F.R.§ 438.402.
• Take part in creating a written, health care or person-centered treatment plan that builds on their needs, strengths, and choices.
  • A treatment or care plan must be put into action within 30 days after health care services start.
  • Participate in the creation of an Individual Support Plan (ISP) to request services specific to people with IDD or a Person-Centered Plan for other services.
  • Help create and update your treatment plan or ISP and consent to treatment goals in that plan.
  • If you live in an Adult Care Home, you have the right to report any suspected violation of your rights to the North Carolina Division of Health Service Regulation, who oversees licensed facilities in our state. You may contact them by phone at 1-800-624-3004 or 1-919-855-4500.
• Ensure that minors, per North Carolina state law, have the right to treatment for the following conditions without the consent of a parent or guardian:
  • Sexually transmitted diseases.
  • Pregnancy.
  • Use of controlled substances or alcohol.
  • Emotional disturbances.

Rights of Minors

Under NC state law, minors have the right to treatment for the following conditions without the consent of a parent or guardian:

• Venereal diseases
• Pregnancy
• Use of controlled substances or alcohol
• Emotional disturbances

Do I have additional rights if I have an intellectual or developmental disability?

Information about rights for individuals living with an intellectual or developmental disability is found in the Mental Health, Developmental Disabilities, and Substance Abuse Act of 1985. (1985, c. 589, s.2; 1989, c. 625, ss. 1, 2.), available on the internet at

http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/ByChapter/Chapter_122C.html

What are my rights if I am in a 24-hour facility?

Members who live in a 24-hour facility have the right to:

• Receive necessary medical care if they are sick. If their insurance does not cover the cost, then they will be responsible for payment.
• Send and receive unopened mail and have access to writing materials, postage and staff assistance, if requested.
• Contact and consult with the Grievance/Member Rights Coordinator at 1-888-235-HOPE (4673).
• Contact and see a lawyer, their own doctor and other private professionals. This will be at their own expense, not at the expense of the facility.
• Contact and consult with their parent or legal guardian at any time as indicated.
• Make and receive confidential telephone calls. All long-distance calls will be at their expense, not at the expense of the facility.
• Have visitors between 8 a.m. and 9 p.m. Visiting hours must be available at least six hours each day. Two of those hours must be after 6 p.m. If the member is under the age of 18, visitors cannot interfere with school or treatment.
• Communicate and meet with other individuals. These meetings and communications may be supervised if their treatment team feels it is necessary.
• Make visits outside the facility unless their person-centered plan states otherwise.
• Have access to outside facilities and equipment for physical exercise several times per week.
• Have individual storage space for their private belongings.
• Keep personal possessions and clothing, except items prohibited by law.
• Keep and spend a responsible sum of their own money.
• Participate in religious worship if they choose.
• Retain a driver’s license unless they are prohibited from doing so by a court of law.
• If members live in an Adult Care Home or Nursing Home, they have the right to report any suspected violation of their rights to Partners Consumer Rights Officer via email at iris@partnersbhm.org or by calling 704-884-2698. Reports may also be made to the Office of the State Long Term Care Ombudsman that assists residents of long-term care facilities in exercising their rights and attempts to resolve grievances between residents, families and facilities. Members can contact them by phone at 1-919-855-3400. They may also contact the Division of Health Service Regulation, which oversees licensed facilities in North Carolina. Members may contact them by phone at 1-800-624-3004 or 1-919-855-4500.

Additionally, Partners ensures that no referrals to publicly supported health care resources are made to avoid costs for covered benefits and services.

Additional rights for members with an intellectual and/or developmental disability are detailed in the NC Innovations Member Handbook.

MEMBER RESPONSIBILITIES

Members are encouraged to improve their care by taking on the following responsibilities:

• Understanding their health benefits and plan before receiving care.
  • Reading, or having read to them, written notices from Partners and their providers about changes in benefits, health care services or providers.
  • Understanding the roles of the service providers and professionals who deliver their health care services or treatment.
  • Understanding their health and taking part, as much as they can, in creating treatment goals.
• Always carrying their Medicaid or other insurance card with them.
  • Call the numbers on the back of the card when they need health care services or help.
  • Contacting their provider or physician when they have a concern or need help.
• Paying for health care services if payment is included in their established agreement.

Sharing the information needed for their care.

• • Telling the clinician, doctor or nurse about any changes in their health.
  • Following the plans and instructions for care they have agreed to with their providers.
  • Asking questions when they do not understand their care or what they are expected to do.

• Keeping all the scheduled appointments, as able.
  • Cancelling an appointment at least 24 hours in advance if they cannot keep it.
• Calling their primary care physician (PCP) when they need medical care, even if it is after hours.
  • Using emergency room services only for injuries and illnesses that require immediate treatment.
• Inviting people who will be helpful and supportive to be included in creating their treatment plan.
• Seeking additional resources and support services in their community as needed.
• Use available transportation resources appropriately and efficiently.
  • Travel to the requested location and receive a Medicaid covered service.
  • Make timely requests for transportation assistance.
  • Be ready and at the designated place and time for transportation pick up.
  • Cancel transportation services that are no longer needed.
  • Follow the instructions of the driver.
  • Maintain the health and safety of drivers and other passengers.
  • Respect and not violate the rights of other passengers or the driver.
  • This includes not creating a disturbance or engaging in threatening language or behavior.
• Taking medications as they are prescribed for their care.
  • Telling their doctor if they are having unpleasant side effects from their medications, or if their medications are not helping them feel better.
• Telling their provider if they do not agree with their suggestions.
• Telling their provider when or if they want to end treatment.
  • Requesting a discharge plan when they leave a provider; making sure they understand it and being committed to following it.
• Respecting the rights, health and property of other members and provider staff.
  • Respecting other members’ needs for privacy.
  • Informing staff of any medical condition that is contagious.

You also have the right and responsibility to give Partners input on policies and services.

The best way to give this input is to:

• Complete Partners Needs Assessment Survey every year
• Attend Consumer and Family Advisory Committee or Human Rights Committee meetings
• Committee and meeting information can be found at www.PartnersBHM.org/consumer-family-advisory-committee/ or www.PartnersBHM.org/human-rights-committee/
• Attend a Partners Board Meeting
• Meeting information can be found at www.PartnersBHM.org/partners-board-directors/
• Submit a formal grievance/complaint
• Visit www.PartnersBHM.org/feedback and choose the submission method you prefer

Partners looks forward to your suggestions for how we can treat you, your family, and your community better. If you have questions or would like more information, call 1-888-235-HOPE (4673).

Can my rights be restricted?

Your rights can only be restricted by your treatment team for reasons related to your care or treatment. You must be part of your own treatment team and must be involved in making the decision. You have the right to have an advocate or someone you trust involved. A Human Rights Committee must approve the plan to restrict your rights. Any restriction will be documented and kept in your medical record.

What if my rights have been violated?

If you feel that your rights have been violated, Partners wants to hear from you! Please call 1-888-235-HOPE (4673), or follow the instructions on page 10 of the Member Handbook.

Exercising Your Rights

You are free to exercise all these rights. Exercising these rights will not negatively impact your access to services or the way that Partners or our network providers treat you.

RESPONSIBILITIES

In addition to your rights as a member, you can reach the best results for yourself by taking on the following responsibilities:

• Understanding your benefits and plan before receiving care.
• Always carrying your Medicaid or other insurance card with you.
• Understanding the roles of the providers and professionals who deliver your services or treatment.
• Contacting your provider when you have a concern or need help.
• Sharing the information needed for your care.
• Following the plans and instructions for care that you have agreed to with your providers.
• Using emergency room services only for injuries and illnesses that require immediate treatment.
• Understanding your health problems and taking part, as much as you can, in creating treatment goals.
• Telling the doctor or nurse about any changes in your health.
• Asking questions when you do not understand your care or what you are expected to do.
• Inviting people who will be helpful and supportive to you to be included in creating your treatment plan.
• Respecting the rights and property of other members and of provider staff
• Respecting other members’ needs for privacy.
• Working on the goals of your person-centered plan.
• Keeping all the scheduled appointments that you can.
• Canceling an appointment at least 24 hours in advance, if you cannot keep it.
• Paying for services, if payment is included in your established agreement.
• Informing staff of any medical condition that is contagious.
• Taking medications as they are prescribed for you.
• Telling your doctor if you are having unpleasant side effects from your medications, or if your medications are not helping you feel better.
• Telling your provider if you do not agree with their suggestions.
• Telling your provider when or if you want to end treatment.
• Cooperating with those trying to care for you.
• Being considerate of other members and family members.
• Seeking additional support services in your community.
• Reading, or having read to you, written notices from Partners about changes in benefits, services or providers.
• Requesting a discharge plan when you leave a provider; being sure you understand it and being committed to following it.
• Contacting our Access to Care Call Center, Monday-Saturday, 7 a.m. to 6 p.m. if you feel that your rights have been violated at 1-888-235-HOPE (4673). You may also email Member Engagement Department at memberquestions@partnersbhm.org . If you prefer to contact someone other than Partners, you may contact the NC DHHS Customer Service Center at 1-800-662-7030.

Regulatory References include but are not limited to–

• Rules/Regulations: NCGS 122C, NCGS 131E-117, 42 CFR, 45 CFR
• NCQA Health Plan Accreditation Member Engagement Standard 1
• DHB Contract: Section 6.15
• DMH/DD/SAS Contract
• Tailored Plan Contract
• Medicaid Direct Prepaid Inpatient Health Plan Contract
• MCO P, P &Ps