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Member Rights and Responsibilities

As a member of Commonwealth Care Alliance, you have the rights and responsibilities described below.

  • 1. Right to be informed of your rights and protections

    a. We have established member rights and protections which you are free to exercise without fear of negative consequences.

    b.  We notify you of your rights and protections at least annually, in a manner appropriate to your condition and ability to understand. You have the right to receive information including all enrollment notices, informational materials, and instructional materials in a manner and format that may be easily understood. Alternative formats include but are not limited to materials printed in larger font and interpreted into different languages.

    c. You have the right to have all plan options, rules, and benefits fully explained, including through use of a qualified interpreter if needed.

    d. You are informed about changes or updates to your rights and protections at least 30 days prior to the intended effective date of the change.

    e. You have the right to have a voice in the governance and operation of the integrated system, provider or health plan.

    f. You have the right to disenroll from the plan at any time and have that choice be effective the first calendar day of the following month.

    g. You have the right to receive the information required pursuant to the Contract.

  • 2. Right to be treated with fairness and respect

    a. You have the right to be treated with dignity, respect and fairness at all times and with due consideration for your dignity and privacy.

    b. We do not discriminate against you due to medical condition (including physical and mental illness), claims experience, source of payment, receipt of health care, medical history, genetic information, evidence of insurability, race, ethnicity, age, gender, sexual orientation, religion, national origin or any disability.

    c. You have the right to receive medical and non-medical care from a team that meets your needs, in a manner that is sensitive to your language and culture, and in an appropriate care setting, including the home and community.

    d. If you need assistance with communication, such as a language interpreter or a document translation, you should call our Member Services department.

    e. You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • 3. Right to privacy of medical records, and access to and disclosure of your personal health information

    a. You have the right to be afforded privacy and confidentiality in all aspects of care and for all health care information, unless otherwise required by law.

    b. Federal and state laws protect the privacy of your medical records and personal health information.

    c. Any personal information provided to us upon enrollment and thereafter is protected.

    d. The laws that protect your privacy provide rights related to receiving information and the manner in which information is used.

    e. You have the right to request and receive a copy of your medical records including in a legally compliant electronic form.

    f. You may request that your medical records be amended or corrected, as specified in 45 Code of Federal Regulations, part 164.
  • 4. Right to see plan providers, receive covered services and have prescriptions filled within a reasonable period of time

    a. You have the right to have access to an adequate network of primary and specialty providers who are appropriately qualified and capable of meeting your needs with respect to physical access, and communication and scheduling needs, and are subject to ongoing assessment of clinical quality including required reporting, as well as access to an ongoing source of primary care.

    b. You have the right to choose a plan provider. We inform you on which providers are accepting new patients.

    c. You have the right to visit a women’s health specialist without a referral.

    d. You have the right to access your providers in a timely manner and to see specialists when care from a specialist is needed.

    e. You have the right to receive a second opinion on a medical procedure and have us pay for the second opinion consultation visit.

    f. You have the right to timely access to prescriptions at any network pharmacy.

    g. Timely access means that you may receive an appointment or services within a reasonable amount of time.
  • 5. Right to know treatment choices and participate in decisions about your healthcare

    a. You must receive an in-person Comprehensive Assessment upon enrollment in a plan and to participate in the development and implementation of an Individualized Care Plan. The assessment must include considerations of social, functional, medical, behavioral, wellness and prevention domains, an evaluation of your strengths and weaknesses, and a plan for managing and coordinating your care. You, or your designated representative, also have the right to request a reassessment by the interdisciplinary team, and be fully involved in any such reassessment.

    b. You must be provided information on all program services and health care options, including available treatment options and alternatives, presented in a culturally appropriate manner, taking into consideration your functional status, and language and cultural needs. If you are unable to participate fully in treatment decisions, you have the right to designate a representative. This includes the right to have translation services available to make information appropriately accessible to you or your representative. Information must be available before and at enrollment and at the time your needs necessitate the disclosure and delivery of such information in order to allow you to make an informed choice.

    c. You have the right to receive full information from your providers presented in a manner appropriate to your condition, functional status, and language needs.

    d. You have the right to participate fully in decisions regarding your healthcare.

    e. Your rights include being fully informed of the recommended treatment choices, irrespective of cost or coverage by Commonwealth Care Alliance. This includes the right to be informed of the different Medication Management Treatment Programs we offer.

    f. You have the right to be informed about any risks involved in your care.

    g. You must be told in advance if any proposed medical care or treatment is part of a research experiment and be given the choice of refusing experimental treatments.

    h. You must receive reasonable advance notice, in writing, of any transfer to another treatment setting and the justification for the transfer.

    i. You have the right to receive a detailed explanation from us if you believe that a plan provider has denied care that you believe you are entitled to receive.

    j. You have the right to refuse treatment including the right to leave a hospital or other medical facility, even if a doctor advises you not to leave. If you refuse treatment, you accept responsibility for your health as a result of refusing treatment.

    k. You have the right to information regarding the resources and options available for personal care supports and to voluntarily choose between a self-directed or agency model for services.
  • 6. Right to use advance directives

    a. You have the right to ask someone, such as a family member or friend, to assist you with decisions about your healthcare.

    b. You have the right to have advanced directives explained and to give your doctors written instructions about how you wish them to handle your medical care if you become unable to make decisions.

    c. If you decide that you do not want to use Massachusetts’ Medical Order for Life Sustaining Treatment (MOLST) form as the advance directive, there may be several other avenues to pursue creating an advanced directive. You should contact appropriate legal services for advice.

    d. According to the law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. If you have signed an advance directive and you believe that a doctor or hospital has not followed the instructions, you may file a complaint with the Massachusetts Department of Public Health, Office of Patient Protection.

  • 7. Right to make complaints

    a. You have the right to make a complaint if you have concerns or problems related to the coverage or care received.

    b. We will treat you fairly, even if you make a complaint.

    c. You have the right to receive a summary of information about the appeals and grievances that you have filed against Commonwealth Care Alliance.

  • 8. Right to receive information on grievance and appeal rights

    a. You are informed, at least once a year, about your grievance and appeal rights.

    b. You are afforded the opportunity to file an appeal if services are denied that you think are medically indicated, and are able to ultimately take that appeal to an independent external system of review.

  • 9. Right to receive information about your healthcare coverage

    a. The Evidence of Coverage (EOC) and Summary of Benefits (SB) provide information regarding the medical services we cover.

  • 10. Right to be informed that you will not be billed

    a. Upon enrollment, we inform you about your right not to be balance-billed by a provider for any service.

    b. You have the right to be protected from liability for payment of any fees that are our obligation.

    c. You have the right not to be charged any cost sharing for Medicare Parts A and B services.

  • 11. Right to receive information about Commonwealth Care Alliance,
    Senior Care Options, One Care, plan providers, drug coverage, and costs

    a. You have the right to request and receive information from us regarding Commonwealth Care Alliance, the Senior Care Options or One Care program including information about the financial condition, health care providers and their qualifications, and about how Senior Care Options and One Care compare to other health plans. You have the right to know about the manner in which our providers are reimbursed.

    b. You have the right to request and receive information regarding the Part D program including information about our network pharmacies.

    c. In order to receive this information in alternate formats, you may call Member Services.
  • 12. Right to reasonable accommodation

    a. We inform you of your right to reasonable accommodation as provided by law and make reasonable accommodation means available to you.

    b. Steps to be taken if you feel that you have been treated unfairly or rights have not been respected, depending on the situation:

    i. If you think that you have been treated unfairly due to medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, race, color, national origin, gender, sexual orientation, disability, age or religion, you should contact the Commonwealth Care Alliance Americans with Disabilities Act Officer by calling 866-610-2273 (TTY 711) or call the Department of Health and Human Services Office for Civil Rights at 800-368-1019 (TTY 1-800-537-7697).

    ii. For other concerns or problems, you may call Member Services.

     

  • 13. Along with rights, you have some responsibilities, including:

    a. To become familiar with coverage and rules that you must follow;

    b. To give your doctor and other providers the information needed to provide care to you and to follow treatment plans and instructions you receive;

    c. To act in a way that supports the care given to other patients and helps the smooth running of your doctor’s office, hospitals and other offices;

    d. To inform Member Services of any questions, concerns, problems or suggestions that you may have; and

    e. To act collectively, cooperatively, and in good faith to ensure that we are able to meet our obligation of providing care and support.

The Commonwealth Care Alliance staff receives training about members’ rights and is responsible for implementing relevant procedures.

  • If you are treated unfairly or your rights are not respected
    • If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697).
    • If you believe you have been treated unfairly or your rights have not been respected, and it is not about discrimination, you can get help dealing with the problem by contacting:
      • Commonwealth Care Alliance Member Services at 1-866-610-2273 (TTY 711)
      • Serving the Health Information Needs of Elders (SHINE) at 1-800-243-4636 (TTY 1‑800‑872‑0166)
      • Medicare at 1-800-633-4227 (TTY 1-877-486-2048), 24 hours a day, 7 days a week or contacting Medicare/Medicaid by using their online form*

Notice of Privacy Practices             

 

For a detailed description of our policies and practices concerning the privacy of your medical information, please use the link below.

Notice of Privacy Practices

Disenrollment

Ending your membership may be voluntary or involuntary. You can end your membership at any time by:

Making a request in writing to:

Commonwealth Care Alliance
Member Services
30 Winter Street
Boston, MA 02108
 

Contacting Member Services at 866-610-2273 (TTY 711). We are available 8 am to 8 pm, 7 days a week.

Contacting MassHealth Customer Service at 800-841-2900.

 

Voluntary disenrollment becomes effective on the first day of the month after Commonwealth Care Alliance receives the written request. You are required to continue to obtain all services through Commonwealth Care Alliance and our contracted network of providers and facilities until your disenrollment becomes effective.

 

Commonwealth Care Alliance must end your membership in certain situations, such as if you are no longer eligible for MassHealth and/or Medicare, if you move out of our service area, or if you become incarcerated (go to prison). We cannot ask you to leave our plan for any reason related to your health.

Call Member Services at 866-610-2273 (TTY 711) for help if you have questions or concerns. For detailed information on your rights and responsibilities upon disenrollment, see your Member Handbook.
 

Potential for Contract Termination

 

Senior Care Options

The Senior Care Options Program’s contract with Centers for Medicare & Medicaid Services (CMS)* is renewed annually and availability of coverage beyond the end of the current year is not guaranteed.

Commonwealth Care Alliance Senior Care Options Program is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts/Executive Office of Health and Human Services. Enrollment in Commonwealth Care Alliance, Senior Care Options Plan depends on contract renewal. Enrollment is voluntary.

 

One Care

The One Care program’s contract with the Centers for Medicare & Medicaid Services (CMS)* is renewed annually and availability of coverage beyond the end of the current year is not guaranteed.

Commonwealth Care Alliance One Care plan is a Medicare-Medicaid health plan that contracts with both Medicare and MassHealth to provide benefits of both programs to enrollees.
 

Appointing a Representative


If you need someone to file a grievance, coverage determination, or appeal on your behalf, you can name a relative, friend, advocate, doctor, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

If you're requesting a coverage determination through an appointed representative, you should download form CMS-1696 (pdf)*, complete it, and mail it to:

Commonwealth Care Alliance
Member Services
30 Winter Street
Boston, MA 02108

Fax: (617) 426-1311

If you have any questions about naming your appointed representative, you can call us at 866‑610‑2273 (TTY 711).


 
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