5160-26-08.3 Managed health care programs: member rights.

(A) MCPs must develop and implement written policies which ensure that members have and are informed of the following rights:

(1) To receive all services that the MCP is required to provide pursuant to the terms of their provider agreement with ODM.

(2) To be treated with respect and with due consideration for their dignity and privacy.

(3) To be ensured of confidential handling of information concerning their diagnoses, treatments, prognoses, and medical and social history.

(4) To be provided information about their health. Such information should also be made available to the individual legally authorized by the member to have such information or the person to be notified in the event of an emergency when concern for a member's health makes it inadvisable to give him/her such information.

(5) To be given the opportunity to participate in decisions involving their health care unless contraindicated.

(6) To receive information on available treatment options and alternatives, presented in a manner appropriate to the member's condition and ability to understand.

(7) To be assured of auditory and visual privacy during all health care examinations or treatment visits.

(8) To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.

(9) To request and receive a copy of their medical records, and to be able to request that their medical records be amended or corrected.

(10) To be afforded the opportunity to approve or refuse the release of information except when release is required by law.

(11) To be afforded the opportunity to refuse treatment or therapy. Members who refuse treatment or therapy will be counseled relative to the consequences of their decision, and documentation will be entered into the medical record accordingly.

(12) To be afforded the opportunity to file grievances, appeals, or state hearings pursuant to the provisions of rules 5101:3-26-08.4 and 5101:3-26-08.5 of the Administrative Code.

(13) To be assured that all written member information provided by the MCP is available:

(a) At no cost to the member,

(b) In the prevalent non-English languages of members in the MCP's service area, and

(c) In alternative formats and in an appropriate manner that takes into consideration the special needs of members including but not limited to visually-limited and LRP members.

(14) To be assured that oral interpretation and oral translation services are available at no cost to members.

(15) To be assured that the services of sign language assistance are available to hearing impaired members.

(16) To be informed of specific student practitioner roles and the right to refuse student care.

(17) To refuse to participate in experimental research.

(18) To formulate advance directives and to file any complaints concerning noncompliance with advance directives with the Ohio department of health.

(19) To change PCPs no less often than monthly. MCP's must mail written confirmation to the member of their new PCP selection prior to or on the effective date of the change.

(20) To appeal to or file directly with the United States department of health and human services office of civil rights any complaints of discrimination on the basis of race, color, national origin, age or disability in the receipt of health services.

(21) To appeal to or file directly with the ODM office of civil rights any complaints of discrimination on the basis of race, color, religion, gender, sexual orientation, age, disability, national origin, veteran's status, ancestry, health status or need for health services in the receipt of health services.

(22) To be free to exercise their rights and to be assured that exercising their rights does not adversely affect the way the MCP, the MCP's providers, or ODM treats the member.

(23) To be assured that the MCP must comply with all applicable federal and state laws and other laws regarding privacy and confidentiality.

(24) To choose his or her health professional to the extent possible and appropriate.

(25) To be assured that female members have direct access to a woman's health specialist within the network for covered care necessary to provide women's routine and preventive health care services. This is in addition to the member's designated PCP if the PCP is not a woman's health specialist.

(26) To be provided a second opinion from a qualified health care professional within the MCP's panel. If such a qualified health care professional is not available within the MCP's panel, the MCP must arrange for a second opinion outside the network, at no cost to the member.

(27) To receive information on their MCP.

(B) MCPs must advise members via the member handbook of the member rights specified in paragraph (A) of this rule.

Effective: 07/01/2013
R.C. 119.032 review dates: 04/16/2013 and 07/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.16 , 5111.17
Rule Amplifies: 5111.01 , 5111.02 , 5111.16 , 5111.17
Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 2/1/90, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 7/1/00, 7/1/01, 7/1/03, 1/1/08