Our Members Rights & Responsibilities
Good health care starts with having a good relationship with your doctors, their staff and your health plan.
As a CenCal Health member, you have many rights that we want you to know about. You also have responsibilities and both are very important for you to know and understand. In the sections on this page, we have outlined your rights as a CenCal Health member and just as importantly, your responsibilities.
To download a copy of Members Rights and Responsibilities click here.
You as a CenCal Health Member, Have the Right to:
To be treated with respect and recognition of their dignity, giving due consideration to the Member’s right to privacy and the need to maintain confidentiality of the Member’s protected health information (PHI) and private information (PI).
To be provided with information about CenCal Health’s organization, its practitioners and providers, Member rights and responsibilities, and all services available to Members.
To be able to choose their Primary Care Provider (PCP) within CenCal Health’s network unless the PCP is unavailable or is not accepting new patients.
To participate with practitioners in decision making regarding their health care, including the right to refuse treatment.
- To submit grievances, either verbally or in writing, about CenCal Health, providers, care received, and any other expression of dissatisfaction not related to an Adverse Benefit Determination.
- To request an appeal of an Adverse Benefit Determination within 60 calendar days from the date on the notice of Adverse Benefit Determination (NABD) and how to continue benefits during the in-plan appeal process through the State Fair Hearing, when applicable.
- To request a State Fair Hearing, including information on the circumstances under which an expedited State Fair Hearing is available.
- To receive interpretation services and written translation of critical informing materials in their preferred threshold language, including oral interpretation and American Sign Language.
- To have a valid Advance Directive in place, and an explanation to Members of what an Advance Directive is.
- To have access to family planning services, sexually transmitted disease services, from a provider of their choice, without referral or prior authorization, either in or outside of CenCal Health’s network. To have Emergency Services provided in or outside of CenCal Health’s network, as required pursuant to federal law.
- To have access to Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Service Facility (IHS) Programs outside of CenCal Health’s network, pursuant to federal law.
- To have access to, and receive a copy of, their medical records, and request that they be amended or corrected, as specified in 45 CFR sections 164.524 and 164.526.
- To change Medi-Cal managed care plans upon request, if applicable.
- To access Minor Consent Services.
- To receive written Member informing materials in alternative formats, including braille, large size print no smaller than 20-point font, accessible electronic format, and audio format upon request and in accordance with 45 CFR sections 84.52(d), 92.102, and 42 CFR 438.10.
- To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
- To receive information and/or have a candid discussion on available treatment options and alternatives that are appropriate and medically necessary and presented in a manner appropriate for the Member’s condition and ability to understand available treatment options and alternatives, regardless of cost or benefit coverage.
- To freely exercise these Member rights without retaliation or any adverse conduct by CenCal Health, subcontractors, downstream subcontractors, Network Providers, or the State.
- To make recommendations regarding CenCal Health’s Member rights and responsibilities policy.
You as a CenCal Health Member, Have the Responsibility to:
- To learn how to use the CenCal Health plan and supply information (to the extent possible) that CenCal Health and its practitioners and providers need in order to provide the best care possible.
- To follow plans, treatment plans, and instructions for care that they have agreed to with their practitioners.
- To understand their health problems and participate in developing a mutually agreed-upon treatment plan and goals, to the degree possible.
- To cooperate with their providers and treat their providers and CenCal Health staff with courtesy and respect.
- To always present their CenCal Health ID card when getting services.
- To help CenCal Health keep correct records by providing timely information regarding changes in address, family status, and other health care coverage.
- To notify CenCal Health as soon as possible if a provider bills them inappropriately.