Each managed care organization (MCO) participating in the Texas
Medicaid program must provide to each member an easy-to-read, written
document, which must include the following:
(1) Member responsibilities for members of health care
MCOs:
(A) You must learn and understand each right you have
under the Medicaid program. That includes the responsibility to:
(i) Learn and understand your rights under the Medicaid
program.
(ii) Ask questions if you do not understand your rights.
(iii) Learn what choices of managed care organizations
(MCOs) are available in your area.
(B) You must abide by the MCO's and Medicaid's policies
and procedures. That includes the responsibility to:
(i) Learn and follow your MCO's rules and Medicaid
rules.
(ii) Choose your MCO and a primary care provider (PCP)
quickly.
(iii) Make any changes in your MCO and PCP in the ways
established by Medicaid and by the MCO.
(iv) Keep your scheduled appointments.
(v) Cancel appointments in advance when you cannot
keep them.
(vi) Always contact your PCP first for your non-emergency
medical needs.
(vii) Be sure you have approval from your PCP before
going to a specialist.
(viii) Understand when you should and should not go
to the emergency room.
(C) You must share information about your health with
your PCP and learn about service and treatment options. That includes
the responsibility to:
(i) Tell your PCP about your health.
(ii) Talk to your providers about your health care
needs and ask questions about the different ways your health care
problems can be treated.
(iii) Help your providers get your medical records.
(D) You must be involved in decisions relating to service
and treatment options, make personal choices, and take action to keep
yourself healthy. That includes the responsibility to:
(i) Work as a team with your provider in deciding what
health care is best for you.
(ii) Understand how the things you do can affect your
health.
(iii) Do the best you can to stay healthy.
(iv) Treat providers and staff with respect.
(v) Talk to your provider about all of your medications.
(E) If you think you have been treated unfairly or
discriminated against, call the U.S. Department of Health and Human
Services (HHS) toll-free at 1-800-368-1019. You also can view information
concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.
(2) Member responsibilities for members of dental MCOs:
(A) You and the MCO both have an interest in seeing
your child's dental health improve. You can help by assuming these
responsibilities.
(i) You and your child must try to follow healthy habits,
such as encouraging your child to exercise, to stay away from tobacco,
and to eat a healthy diet.
(ii) You must become involved in the dentist's decisions
about you and your child's treatments.
(iii) You must work together with the MCO's dentists
and other providers to pick treatments for your child that you have
all agreed upon.
(iv) If you have a disagreement with the MCO, you must
try first to resolve it using the MCO's complaint process.
(v) You must learn about what the MCO does and does
not cover. You must read your Member Handbook to understand how the
rules work.
(vi) If you make an appointment for your child, you
must try to get to the dentist's office on time. If you cannot keep
the appointment, be sure to call and cancel it.
(vii) You must report misuse by dental and health care
providers, other members, the MCO, or other dental or medical plans.
(B) If you think you have been treated unfairly or
discriminated against, call the U.S. Department of Health and Human
Services (HHS) toll-free at 1-800-368-1019. You also can view information
concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.
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| Source Note: The provisions of this §353.203 adopted to be effective February 28, 1997, 22 TexReg 1799; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective March 1, 2012, 37 TexReg 1283 |
