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Member rights and responsibilities

As a member of SCFHP, you have certain rights and responsibilities. Rights are what you can expect to receive, including needed treatment and information. Responsibilities are what we expect you to do as an SCFHP member. The next two lists explain these rights and responsibilities.

Member Rights

SCFHP members have these rights:

  • To receive needed and appropriate medical care, including preventive health services and health education.
  • To be treated with respect, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information.
  • To be provided with information about the plan and its services, including Covered Services.
  • To be able to choose a primary care provider within SCFHP’s
  • To participate in decision making 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 received.
  • To receive care coordination.
  • To request an appeal of decisions to deny, defer or limit services or benefits.
  • To receive oral interpretation services for their language.
  • To receive free legal help at your local legal aid office or other groups.
  • To formulate advance directives.
  • To request a State Hearing, including information on the circumstances under which an expedited hearing is possible.
  • To disenroll upon request. Members that can request expedited disenrollment include, but are not limited to, those receiving services under the Foster Care or Adoption Assistance Programs and those with special health care needs.
  • To access Minor Consent Services.
  • To receive written member-informing materials in alternative formats (such as braille, large-size print and audio format) upon request and in a timely fashion appropriate for the format being requested and in accordance with Welfare & Institutions 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 receive information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand.
  • To have access to and receive a copy of your medical records, and request that they be amended or corrected, as specified in 45 Code of Federal Regulations §164.524 and 164.526.
  • Freedom to exercise these rights without adversely affecting how you are treated by SCFHP, your providers or the State.
  • To have access to family planning services, Freestanding Birth Centers, Federally Qualified Health Centers, Indian Health Service Facilities, midwifery services, Rural Health Centers, sexually transmitted disease services and Emergency Services outside SCFHP’s networks pursuant to the federal law.
  • To take part in establishing SCFHP’s public policy, by attending and/or joining the SCFHP Consumer Advisory Committee and attending any SCFHP Governing Board meeting.

Member Responsibilities

SCFHP members have these responsibilities:

  • To carefully read all SCFHP materials as soon as you enroll so you understand how to use SCFHP’s services.
  • To carry your SCFHP ID card with you at all times and show it to all providers and pharmacies when getting services.
  • To ask questions when you do not understand something about your coverage or medical care.
  • To follow the rules of SCFHP membership as explained in this Member Handbook.
  • To be responsible for your and your children’s health.
  • To talk to your health care provider so you can develop a strong relationship based on trust and cooperation.
  • To call your health care provider when you need routine or urgent health care.
  • To report unexpected changes in your health to your PCP.
  • To ask questions about your medical condition. Make sure you understand the answers, and what you are supposed to do.
  • To follow the treatment plan you and your health care provider create together, and know what might happen if you do not follow the treatment plan.
  • To make and be on time for medical appointments. Let your health care provider know at least 24 hours before your scheduled appointment if you need to cancel.
  • To tell SCFHP about any changes in: address; phone number; family status, such as marriage, divorce, etc.; and changes in any other health care coverage you might have. Tell SCFHP about these changes as soon as you know them or within 10 days of these changes.
  • To call or write SCFHP as soon as possible if you feel you were improperly billed or if the bill is wrong.
  • To treat all SCFHP personnel and health care providers with respect and courtesy.
  • To submit requests for claims reimbursement for covered services within the required time period.
  • To 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.
  • To report wrongdoing. You are responsible for reporting health care fraud or wrongdoing to SCFHP. You can do this without giving your name by calling the SCFHP Compliance Hotline at 1-408-874-1450, go to www.scfhp.com, or you can call the California Department of Health Care Services (DHCS) Medi-Cal Fraud and Abuse Hotline toll-free at 1-800-822-6222.