Skip to main content
Back To Top Top Back To Top
This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Rule 5160-26-08.3 | Managed care: member rights.


(A) A managed care entity (MCE) must develop and implement written policies in accordance with 42 C.F.R. 438.100 (October 1, 2021), as applicable, to ensure each member has and is informed of his or her right to:

(1) Receive all services the MCE is required to provide pursuant to the terms of the MCE provider agreement or contract, as applicable, with the Ohio department of medicaid (ODM).

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

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

(4) 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) Be given the opportunity to participate in decisions involving their health care.

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

(7) Maintain auditory and visual privacy during all health care examinations or treatment visits.

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

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

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

(11) 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) Be afforded the opportunity to file grievances, appeals, or state hearings pursuant to the provisions of rule 5160-26-08.4 of the Administrative Code.

(13) Be provided written member information from the MCE:

(a) At no cost to the member,

(b) In the prevalent non-English languages of members specified by ODM, and

(c) In alternative formats and in an appropriate manner that takes into consideration the special needs of members.

(14) Receive necessary oral interpretation and oral translation services at no cost.

(15) Receive necessary services of sign language assistance at no cost.

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

(17) Refuse to participate in experimental research.

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

(19) Change primary care providers (PCPs) no less often than monthly. The MCO must mail written confirmation to the member of his or her new PCP selection prior to or on the effective date of the change.

(20) 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) Appeal to or file directly with the ODM office of civil rights any complaints of discrimination on the basis of race, color, religion, gender, gender identity, sexual orientation, age, disability, national origin, military status, genetic information, ancestry, health status or need for health services in the receipt of health services.

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

(23) Be assured the MCE must comply with all applicable federal and state laws and other laws regarding privacy and confidentiality.

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

(25) For female members, to obtain 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 a member's designated PCP if the PCP is not a woman's health specialist.

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

(27) Receive information on their MCE.

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

Last updated September 1, 2023 at 1:09 PM

Supplemental Information

Authorized By: 5167.02
Amplifies: 5162.03, 5164.02, 5167.03, 5167.10
Five Year Review Date: 9/27/2027
Prior Effective Dates: 4/1/1985, 5/2/1985, 10/1/1987, 2/15/1989 (Emer.), 5/8/1989, 11/1/1989 (Emer.), 2/1/1990, 5/1/1992, 5/1/1993, 11/1/1994, 7/1/1996, 7/1/1997 (Emer.), 9/27/1997, 7/1/2000, 7/1/2001, 7/1/2003, 1/1/2008, 7/1/2013, 2/1/2015, 1/1/2018