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Member rights and responsibilities

Rights

As a member of Santa Clara Family Health Plan (SCFHP), you have the right to:

  • Be treated with respect and courtesy regardless of your gender, culture, language, appearance, sexual orientation, race, disability, or source of payment.
  • Be told in a clear way about all healthcare services available and how to get them.
  • Receive written member materials in English, Spanish, Vietnamese, Chinese, or Tagalog (depending on the plan you are enrolled in) or alternative formats, including braille, large print, and audio, upon request.
  • Select a healthcare provider or clinic as your primary care provider (PCP). Your PCP will provide or arrange for all the healthcare you need.
  • Receive needed and appropriate medical care, including preventive health services and health education.
  • Access family planning services, Federally Qualified Health Centers, Indian Health Service facilities, sexually transmitted disease services, and emergency services outside of the SCFHP network according to federal law.
  • Access minor consent services.
  • Know and understand your medical condition as diagnosed by your healthcare provider, know what the healthcare provider plans to do to treat the condition, know what results to expect, and know what effects the treatment may have on your daily life.
  • Actively take part in decisions about your medical care. If permitted by law, you have the right to refuse or stop treatment.
  • Formulate advance directives.
  • Have the meaning and limits of confidentiality explained to you.
  • Have your health records kept confidential, except when disclosure is required by law or permitted in writing by you. With adequate notice, you have the right to see your protected health information (PHI), as allowed by law.
  • Know that if you must be moved or transferred from one hospital to another, you may receive information about why you need to be moved and about any other choices you may have.
  • Receive a second opinion from another plan physician about your diagnosis, the proposed plan of treatment, and other available treatment options.
  • Know how to get help and solve problems, know how to file a grievance or appeal with SCFHP, and know how to ask for a State Fair Hearing. Understand how to use the grievance or State Fair Hearing process without risk of interruption or loss of healthcare or retaliation.
  • Take part in establishing SCFHP's public policy by attending or joining the SCFHP Consumer Advisory Committee and attending any SCFHP Governing Board meeting.
  • Have an interpreter who speaks your language (including sign language) available 24 hours a day, 7 days a week, at no cost to you.
  • File a grievance if your accessibility, cultural, or linguistic needs are not met.
  • Disenroll from SCFHP.
  • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
  • Exercise these rights without adversely affecting how you are treated by SCFHP, plan providers, or the state.

Note: Members who are American Indians and Alaska Natives (AIANs) have the right to choose to receive primary care services at Indian Health Service facilities or Federally Qualified Health Centers (FQHCs) or from any other plan provider within SCFHP's geographic service area (Santa Clara County). AIANs also have the right to stay in regular Medi-Cal and not enroll in a managed care plan.

Responsibilities

As an SCFHP member, you have the responsibility to:

  • Carefully read all SCFHP materials as soon as you enroll so you understand how to use our services.
  • Ask questions when you do not understand something about your coverage or medical care.
  • Follow the rules of SCFHP membership as explained in your plan's Evidence of Coverage document.
  • Be responsible for your own health and the health of your children.
  • Talk to your healthcare provider so you can develop a strong relationship based on trust and cooperation.
  • Call your healthcare provider when you need routine or urgent healthcare.
  • Report unexpected changes in your health to your PCP.
  • Ask questions about your medical condition. Make sure you understand the answers, and what you are supposed to do.
  • Follow the treatment plan your healthcare provider gives you, and know what might happen if you do not follow the treatment plan.
  • Make and be on time for medical appointments. Let your healthcare provider know at least 24 hours before your scheduled appointment if you need to cancel.
  • Tell SCFHP about any changes in your address; phone number; family status, such as marriage, divorce, etc.; and changes in any other healthcare coverage you might have. Tell us about these changes within 10 days.
  • Call or write SCFHP as soon as possible if you feel you were improperly billed or if the bill is wrong.
  • Treat all SCFHP personnel and healthcare providers with respect and courtesy.
  • Submit requests for claims reimbursement for covered services within the required time period.
  • Be honest in your dealings with SCFHP and its plan providers. Do not commit fraud or theft or do anything that threatens the property of SCFHP or the property or safety of any of its representatives, plan providers, plan providers' employees, or agents.