La. Admin. Code tit. 50 § I-3109

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-3109 - Member Rights and Responsibilities

A. The MCO members rights shall include, but are not limited to the right to:

1. receive information in accordance with federal regulations and as described in the contract and department issued guides;

2. receive courteous, considerate and respectful treatment provided with due consideration for the members dignity and privacy;

3. receive information on available treatment options and alternatives in a manner appropriate to the members condition and ability to understand;

4. participate in treatment decisions, including the right to:

a. refuse treatment;

b. complete information about their specific condition and treatment options including, but not limited to the right to receive services in a home or community setting or in an institutional setting if desired;

c. seek second opinions;

d. information about available experimental treatments and clinical trials and how such research can be accessed; and

e. assistance with care coordination from the PCPs office;

5. be free from any form of restraint or seclusion as a means of coercion, discipline, retaliation or convenience;

6. express a concern about their MCO or the care it provides, or appeal an MCO decision, and receive a response in a reasonable period of time;

7. receive a copy of their medical records, including, if the HIPAA privacy rule applies, the right to request that the records be amended or corrected as allowed in federal regulations;

8. be furnished health care services in accordance with federal regulations governing access standards;

9. implement an advance directive as required in federal regulations:

a. the MCO must provide adult enrollees with written information on advanced directive policies and include a description of applicable state law. The written information must reflect changes in state law as soon as possible, but no later than 90 days after the effective date of change;

b. members have the right to file a grievance concerning noncompliance with the advance directive requirements to the department or other appropriate licensing or certification agency as allowed in federal regulations;

10. choose his/her health professional to the extent possible and appropriate in accordance with federal regulations; and

11. be furnished health care services in accordance with all other applicable federal regulations.

B. Members shall have the freedom to exercise the rights described herein without any adverse effect on the members treatment by the department or the MCO, or its contractors or providers.

C. The MCO members responsibilities shall include, but are not limited to:

1. informing the MCO of the loss or theft of their MCO identification card;

2. presenting their identification card when using health care services;

3. being familiar with the MCOs policies and procedures to the best of his/her abilities;

4. contacting the MCO, by telephone or in writing (formal letter or electronically, including email), to obtain information and have questions clarified;

5. providing participating network providers with accurate and complete medical information;

6. following the prescribed treatment of care recommended by the provider or letting the provider know the reasons the treatment cannot be followed, as soon as possible;

7. making every effort to keep any agreed upon appointments and follow-up appointments and contacting the provider in advance if they are unable to do so; and

8. accessing preventive care services.

La. Admin. Code tit. 50, § I-3109

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 37:1576 (June 2011), amended LR 40:311 (February 2014), LR 41:931 (May 2015), LR 41:2365 (November 2015).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.