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8.1.9 Client Rights and Responsibilities
8.1.9.1 Client Rights
In Texas, Medicaid managed care clients have defined rights and responsibilities. Each health plan and primary care provider share the responsibility to ensure and protect client rights and to assist clients in understanding and fulfilling their responsibilities as plan clients.
Medicaid managed care clients have the right to:
• Be treated fairly and with dignity and respect.
•Know that their medical records and discussions with their providers will be kept private and confidential.
•Request changes to their medical records (if incorrect).
•A reasonable opportunity to choose a health-care plan and primary care provider (the doctor or health-care provider they will see most of the time and who will coordinate their care) and to change to another plan or provider in a reasonably easy manner. These opportunities include the right to:
•Be informed of available health plans and primary care providers in their areas.
•Be informed of how to choose and change health plans and primary care providers.
•Choose any health plan that is available in their area and choose a primary care provider.
•Change their primary care provider.
•Change health plans without penalty.
•Be educated about how to change health plans or primary care providers.
•Know that doctors, hospitals, and others who provider care can advise clients about their health status, medical care, and treatment. The health plan cannot prevent them from giving clients this information, even if the care or treatment is not a covered service."
•Know that clients are not responsible for paying for covered services. Doctors, hospitals, and others cannot require clients to pay copayments or any other amounts for covered services.
•Ask questions and get answers about anything the client doesn't understand, and that includes the right to:
•Have their provider explain their health-care needs to them and talk to them about the different ways their health-care problems can be treated.
•Be told why care or services were denied and not given.
•Consent to or refuse treatment and actively participate in treatment decisions, and that includes the right to:
•Work as part of a team with their provider in deciding what health care is best for them.
•Say yes or no to the care recommended by their provider.
•Utilize each available complaint and appeal process through the MCO and through Medicaid, receive a timely response to complaints, appeals, and fair hearings. These processes include the right to:
•Make a complaint to their health plan or to the state Medicaid program about their health-care, provider, or health plan.
•Receive a timely answer to their complaint.
•Access the health plan appeal process and the procedures for doing so.
•Request a fair hearing from the state Medicaid program and request information about the process for doing so.
•Timely access to care that does not have any communication or physical access barriers. They have the right to:
•Have telephone access to a medical professional 24 hours a day, 7 days a week in order to obtain any needed emergency or urgent care.
•Receive medical care in a timely manner.
•Be able to get in and out of a health-care provider's office, including barrier free access for persons with disabilities or other conditions limiting mobility, in accordance with the Americans with Disabilities Act.
•Have interpreters, if needed, during appointments with their providers and when talking to their health plan. Interpreters include people who can speak in their native language, assist with a disability, or help them understand the information.
•Be given an explanation they can understand about their health plan rules, including the health-care services they can get and how to get them.
•Not be restrained or secluded when doing so is for someone else's convenience, or is meant to force them to do something they are unwilling to do, or to punish them.
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