Member Rights & Responsibilities
As an HPSJ Member, you have rights and responsibilities. Your rights include:
- Ask for and receive information about HPSJ, our services, participating practitioners, providers, Member rights and responsibilities, and how to use HPSJ benefits.
- Be treated in a courteous and respectful manner that reflects recognition of your privacy and dignity as a person.
- Wait no more than 30 seconds to speak to a customer service representative during HPSJ’s normal business hours.
- Upon request receive information about HPSJ’s staff and staff qualifications for health management programs.
- Receive information on how to reach Health Management staff and to discuss any problems regarding Health Management.
- Receive interpreter services at no cost to you. You also have the right not to use family members or friends as interpreters. Minors should not be used as interpreters unless it is a medical emergency.
- Receive medically necessary covered services without regard to race, religion, age, gender, national origin, disability, sexual identity or orientation, family composition or size, or medical condition or stage of illness.
- Receive family planning services, services at Federally Qualified Health Centers (FQHC) or Indian Health Centers, sexually transmitted disease (STD) services, and emergency services outside the HPSJ network as stated in Federal law.
- Receive emergency or urgently needed services outside the HPSJ network or when authorized by the plan.
- Receive emergency care whenever necessary and wherever you need it.
- Receive sensitive services such as family planning or mental health care in a confidential way.
- Access minor consent services
- Choose a primary care doctor (PCP) within the HPSJ network.
- Receive information from HPSJ that you can understand.
- Upon request receive member information materials in alternative formats including Braille, large print, and audio.
- Make recommendations about HPSP’s Member rights and responsibilities policies.
- Participate with your doctors and other practitioners in decision making about your own health care.
- Talk openly with your doctor and other practitioners about your medical condition and appropriate or medically necessary treatment options for your condition regardless of the cost or what your benefits are.
- Decide about your care, including the decision to stop treatment or services, or stop participating in health management programs.
- Decide in advance how you want to be cared for in case you have a life-threatening illness or injury.
- Be informed by HPSJ regarding advance directives and to receive information from HPSJ regarding any changes to that law. The information shall reflect changes in state law regarding advance directives as soon as possible, but no later than 90 days after the effective date of change.
- Review, request corrections to, and receive a copy of your medical records (your doctor may charge a fee for copies of records and other forms).
- Keep your personal and medical information and records confidential, unless you say differently, and know how HPSJ keeps your information confidential.
- Make complaints and appeals without discrimination about HPSJ, our providers, or your care. HPSJ will help you with the complaint and appeal process. You have the right to choose someone to represent you during the grievance process and for your complaints and appeals to be reviewed as quickly as possible and be told how long it will take. Medi-Cal Members have the right to request a State Fair Hearing or an expedited State Fair Hearing for urgent cases. Call the Department of Social Services Public Inquiry and Response Unit at 1-800-952-5253 or TDD 1-800-952-8349.
- Request an Independent Medical Review (IMR) from the Department of Managed Health Care (DMHC) if you disagree with HPSJ’s decision to deny, delay, or modify a service that your doctor or other practitioner requests.
- Request an External Independent Review if a service or therapy was denied on the basis that it was considered experimental or investigational. If you have any questions about these procedures, call HPSJ Customer Service at 1-888-936-PLAN (7526) or (209) 942-6320.
- Have HPSJ act as your patient advocate.
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
- Disenroll from HPSJ.
- Request a second opinion about a medical condition.
- File a grievance with HPSJ if your language needs are not met.
- If you are a Native American Indian, you have the right to not enroll in a plan, not be restricted by a plan in your right to access Indian Health Facilities, and to disenroll from a plan without cause.
As an HPSJ Member, you have a responsibility to:
- Be familiar with and ask questions about your health plan coverage. If you have a question about your coverage, call HPSJ Customer Service at 1-888-936-PLAN (7526), or (209) 942-6320.
- Follow the advice and care procedures indicated by your doctor, HPSJ, and the program. If you have a question about these procedures, call HPSJ Customer Service at 1-888-936-PLAN (7526), or (209) 942-6320.
- Request interpreter services at least 5 working days before a scheduled appointment.
- Call your doctor or pharmacy at least 3 days before you run out of medicine.
- Cooperate with your doctor and staff and treat them with respect. This includes being on time for your visits or calling your doctor if you need to cancel or reschedule an appointment.
- Understand that your doctor’s office may have limited seating for patients and caregivers only.
- Give accurate information (to the extent possible) to HPSJ, your doctor and any other provider in order to help you receive the best care possible.
- Understand your health problems and work with your doctor and other practitioners in developing mutually agreed-upon treatment goals, to the extent possible.
- Ask your doctor questions if you do not understand what they are saying to you.
- Work with your doctor to make plans for your health care.
- Follow the plans and instructions for care that you have agreed on with your doctors and other practitioners.
- Notify HPSJ and your doctor and other practitioners if you want to stop the plans and instruction you have agreed on or want to stop participating in health management programs
- Immunize your children by age two (2) and always keep your children’s immunizations up to date.
- Call your doctor when you need routine or urgent health care.
- Care for your own health. Live a healthy lifestyle, exercise, eat a good diet, and don’t smoke.
- Avoid knowingly spreading disease to others.
- Use the HPSJ grievance process to file a complaint. Call HPSJ Customer Service at 1-888-936-PLAN (7526), or (209) 942-6320 to file a complaint.
- Report any wrong doing or fraud to HPSJ by calling HPSJ Customer Service at 1-888-936-PLAN (7526), or (209) 942-6320 or the proper authorities.
- Understand that there are risks in receiving health care and limits to what can be done for you medically.
- Understand that it is a health care provider’s duty to be efficient and fair in caring for you as well as other patients.
- To have a confidential relationship with your doctor.
- To be able to choose a Primary Care Provider (PCP) from the Provider Directory and to change PCPs.
- To receive information about the Health Plan and how to get health care services.
- To participate in decisions about your own health care, including refusing treatment.
- To voice complaints about HPSJ or the care provided to you and to ask for a State Fair Hearing.
- To have advance directives (such as a living will).
- To see your medical records.
- To have your Medi-Cal eligibility and medical record information kept private. Call HPSJ Customer Service Department at (209) 942-6320 if you want to know how we keep this information private.
- To have access to an interpreter, either face-to- face or through the language line when you receive medical care, at no cost to you.
- To receive Member materials in other formats including large print, audio tape, or Braille.
- To be treated by any qualified provider for medical emergencies.
- To have full access to family planning services, Federally Qualified Health Centers (FQHC), Indian Health Centers, confidential HIV testing and counseling services, and treatment for sexually transmitted disease (STD). These services are discussed later in this booklet.
- To get confidential and sensitive services if you are a minor.
- To disenroll from HPSJ at any time.
Your responsibilities include:
1. To work with your health care providers by:
- Making positive health choices and to get health services when you need them.
- Following his or her instructions.
- Taking all medications you are asked to take.
2. Giving correct information to your doctors and to us.
3. To keep appointments that you or your doctor have made.
Posted on June 16th, 2015 and last modified on August 6th, 2015.