Alliance Member Rights and Responsibilities

What are my rights and responsibilities as an Alliance member?

As a member of the Alliance, you have certain rights and responsibilities.

These are your rights a Medi-Cal member of the Alliance: 

• To be treated with respect and dignity, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information such as medical history, mental and physical condition or treatment, and reproductive or sexual health.
• To be provided with information about the health plan and its services, including covered services, practitioners, and member rights and responsibilities. 
• To get fully translated written member information in your preferred language, including all grievance and appeals notices. 
• To make recommendations about the Alliance’s member rights and responsibilities policy.
• To be able to choose a primary care provider within the Alliance’s network.
• To have timely access to network providers.
• To participate in decision making with providers regarding your own health care, including the right to refuse treatment.
• To voice grievances, either verbally or in writing, about the organization or the care you got.
• To know the medical reason for the Alliance’s decision to deny, delay, terminate (end) or change a request for medical care.
• To get care coordination.
• To ask for an appeal of decisions to deny, defer or limit services or benefits.
• To get free interpreting and translation services for your language.
• To get free legal help at your local legal aid office or other groups.
• To formulate advance directives.
• To ask for a State Hearing if a service or benefit is denied and you have already filed an appeal with the Alliance and are still not happy with the decision, or if you did not get a decision on your appeal after 30 days, including information on the circumstances under which an expedited hearing is possible.
• To disenroll (drop) from the Alliance in Mariposa and Santa Cruz counties and change to another health plan in the county upon request.
• To access minor consent services.
• To get no-cost written member information in other formats (such as braille, large-size print, audio, and accessible electronic formats) upon request and in a timely fashion appropriate for the format being requested and in accordance with Welfare and Institutions (W&I) Code section 14182 (b)(12).
• To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
• To truthfully discuss information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand, regardless of cost or coverage.
• To have access to and get a copy of your medical records, and request that they be amended or corrected, as specified in 45 Code of Federal Regulations (CFR) sections 164.524 and 164.526.
• Freedom to exercise these rights without adversely affecting how you are treated by the Alliance, your providers or the state.
• To have access to family planning services, Freestanding Birth Centers, Federally Qualified Health Centers, Indian Health Clinics, midwifery services, Rural Health Centers, sexually transmitted infection services, and emergency services outside the Alliance’s network pursuant to the federal law.

Alliance Medi-Cal members have these responsibilities:  

• Know the Alliance’s rules and follow them.
• Tell your doctor about your health conditions, both now and in the past.
• To follow plans and have instructions for care that they have agreed to with their practitioners.
• To understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
• Keep your appointments. If you have to cancel an appointment, let the office know 24 hours before you were scheduled to see the doctor.
• Be kind and polite to your doctors, their staff and to Alliance staff.
• Keep your Alliance ID and Medi-Cal BIC cards with you at all times and show your cards when you get care.
• Follow the rules of any other health insurance you have.
• Use the emergency room only for emergency care.
• Call your county Medi-Cal office if you move or change your phone number. If you receive Supplemental Security Income (SSI), call the local Social Security Office.
• Call your local county services office to update any other health insurance you have or no longer have. To update other insurance information by phone, call:
  Mariposa County
  1-800-549-6741
  1-209-966-2000
  Merced County
  1-855-421-6770
  1-209-385-3000
  Monterey County
  1-877-410-8823
  San Benito County 
  1-831-636-4180
  Santa Cruz County
  1-888-421-8080

  To update other insurance information online, go to the California Department of Health Care Services (DHCS) website: https://www.dhcs.ca.gov/services/Pages/TPLRD_OCU_cont.aspx 

Alliance IHSS members have the following rights:

• Receive information about your rights and responsibilities.
• Receive information about your Plan, the services your Plan offers you, and the Health Care Providers available to care for you.
• Make recommendations regarding the Plan’s member rights and responsibilities policy.
• Receive information about all health care services available to you, including a clear explanation of how to obtain them and whether the Plan may impose certain limitations on those services.
• Know the costs for your care, and whether your deductible or out-of-pocket maximum have been met.
• Choose a Health Care Provider in your Plan’s network, and change to another doctor in your Plan’s network if you are not satisfied.
• Receive timely and geographically accessible health care.
• Have a timely appointment with a Health Care Provider in your Plan's network, including one with a specialist.
• Have an appointment with a Health Care Provider outside of your Plan’s network when your Plan cannot provide timely access to care with an in-network Health Care Provider.
• Certain accommodations for your disability, including:
  • Equal access to medical services, which includes accessible examination rooms and medical equipment at a Health Care Provider’s office or facility.
  • Full and equal access, as other members of the public, to medical facilities.
  • Extra time for visits if you need it.
  • Taking your service animal into exam rooms with you.
• Purchase health insurance or determine Medi-Cal eligibility through the California Health Benefit Exchange, Covered California.
• Receive considerate and courteous care and be treated with respect and dignity.
• Receive culturally competent care, including but not limited to:
  • Trans-Inclusive Health Care, which includes all Medically Necessary services to treat gender dysphoria or intersex conditions.
  • To be addressed by your preferred name and pronoun.
• Receive from your Health Care Provider, upon request, all appropriate information regarding your health problem or medical condition, treatment plan, and any proposed appropriate or Medically Necessary treatment alternatives. This information includes available expected outcomes information, regardless of cost or benefit coverage, so you can make an informed decision before you receive treatment.
• Participate with your Health Care Providers in making decisions about your health care, including giving informed consent when you receive treatment. To the extent permitted by law, you also have the right to refuse treatment.
• A discussion of appropriate or Medically Necessary treatment options for your condition, regardless of cost or benefit coverage.
• Receive health care coverage even if you have a pre-existing condition.
• Receive Medically Necessary Treatment of a Mental Health or Substance Use Disorder.
• Receive certain preventive health services, including many without a co-pay, co-insurance, or deductible.
• Have no annual or lifetime dollar limits on basic health care services.
• Be notified of an unreasonable rate increase or change, as applicable.
• Protection from illegal balance billing by a Health Care Provider.
• Request from your Plan a second opinion by an Appropriately Qualified Health Care Provider.
• Expect your Plan to keep your personal health information private by following its privacy policies, and state and federal laws.
• Ask most Health Care Providers for information regarding who has received your personal health information.
• Ask your Plan or your doctor to contact you only in certain ways or at certain locations.
• Have your medical information related to sensitive services protected.
• Get a copy of your records and add your own notes. You may ask your doctor or health plan to change information about you in your medical records if it is not correct or complete. Your doctor or health plan may deny your request. If this happens, you may add a statement to your file explaining the information.
• Have an interpreter who speaks your language at all points of contact when you receive health care services.
• Have an interpreter provided at no cost to you.
• Receive written materials in your preferred language where required by law.
• Have health information provided in a usable format if you are blind, deaf, or have low vision.
• Request continuity of care if your Health Care Provider or medical group leaves your Plan or you are a new Plan member.
• Have an Advanced Health Care Directive.
• Be fully informed about your Plan’s grievances procedure and understand how to use it without fear of interruption to your health care.
• File a complaint, grievance, or appeal in your preferred language about:
• Your Plan or Health Care Provider.
  • Any care you receive, or access to care you seek.
  • Any covered service or benefit decision that your Plan makes.
  • Any improper charges or bills for care.
  • Any allegations of discrimination on the basis of gender identity or gender expression, or for improper denials, delays, or modifications of Trans-Inclusive Health Care, including Medically Necessary services to treat gender dysphoria or intersex conditions.
  • Not meeting your language needs.
• Know why your Plan denies a service or treatment.
• Contact the Department of Managed Health Care if you are having difficulty accessing health care services or have questions about your Plan.
• To ask for an Independent Medical Review if your Plan denied, modified, or delayed a health care service.

Alliance IHSS members have the following responsibilities: 

• Treat all Health Care Providers, Health Care Provider staff, and Plan staff with respect and dignity.
• Share the information needed with your Plan and Health Care Providers, to the extent possible, to help you get appropriate care.
• Participate in developing mutually agreed-upon treatment goals with your Health Care Providers and follow the treatment plans and instructions to the degree possible.
• To the extent possible, keep all scheduled appointments, and call your Health Care Provider if you may be late or need to cancel.
• Refrain from submitting false, fraudulent, or misleading claims or information to your Plan or Health Care Providers.
• Notify your Plan if you have any changes to your name, address, or family members covered under your Plan.
• Timely pay any premiums, copayments, and charges for non-covered services.
• Notify your Plan as soon as reasonably possible if you are billed inappropriately.