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Benefits and Coverage

Member Rights and Responsibilities

As a member, you have the right to:

  • Get the services you need 24 hours a day, seven days a week. This includes emergencies.
  • Be told about your health problems.
  • Get information about treatments, your treatment choices, and how they will help or harm you.
  • Refuse treatment and get information about what might happen if you refuse treatment.
  • Refuse care from specific providers.
  • Know that we will keep your records private according to law.
  • File a grievance or appeal with us. You can also file a complaint with the Minnesota Department of Health.
  • Request a state fair hearing with the Minnesota Department of Human Services (also referred to as “the state”). You may request a state fair hearing before or at any time during our appeal process. You do not have to file an appeal with us before you request a state fair hearing.
  • Receive a clear explanation of covered home care services.
  • Request and receive a copy of your medical records. You also have the right to ask to correct the records.
  • Get notice of our decisions if we deny, reduce, or stop a service, or deny payment for a service.
  • Participate with providers in making decisions about your health care.
  • Be treated with respect, dignity, and consideration for privacy.
  • Give written instructions that inform others of your wishes about your health care. This is called a “health care directive.” It allows you to name a person (agent) to decide for you if you are unable to decide, or if you want someone else to decide for you.
  • Be free of restraints or seclusion used as a means of: coercion, discipline, convenience, or retaliation.
  • Choose where you will get family planning services, diagnosis of infertility, sexually transmitted disease testing and treatment services, and AIDS and HIV testing services.
  • Get a second opinion for medical, mental health, and chemical dependency services.
  • Request a copy of your Evidence of Coverage at least once a year.
  • Get the following information from us, if you ask for it.
    • Whether we use a physician incentive plan that affects the use of referral services
    • The type(s) of incentive arrangement used
    • Whether stop-loss protection is provided
    • Results of a member survey if one is required because of our physician incentive plan
    • Results of an external quality review study from the state
    • The professional qualifications of health care providers
  • Make recommendations about our rights and responsibilities policy.
  • Exercise the rights listed here.

As a member, you have the responsibility to:

  • Read this Evidence of Coverage and know which services are covered under the Plan and how to get them.
  • Show your health plan ID card and your Minnesota Health Care Program (ID) card every time you get health care. Also show the cards of any other health coverage you have, such as Medicare or private insurance.
  • Establish a relationship with a Plan network primary care doctor before you become ill. This helps you and your primary care doctor understand your total health condition.
  • Give information asked for by your doctor and/or health plan so the right care or services can be provided to you. Share information about your health history.
  • Work with your doctor to understand your total health condition. Develop mutually agreed-upon treatment goals when possible. If you have questions about your care, ask your doctor.
  • Know what to do when a health problem occurs, when and where to seek help, and how to prevent health problems.
  • Practice preventive health care. Have tests, exams and shots recommended for you based on your age and gender.

Contact Medica Customer Service if you have any questions, concerns, problems or suggestions..

Date: 12/15/2017 2:02:41 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CMSWEB01