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Your Rights as a Patient

Kaiser is all about profit. Physicians are employed by the Permanente Medical Group, a for-profit entity described as "independent" from the Kaiser Foundation Health Plan and Kaiser Foundation Hospitals in Kaiser's IRS Form 990. Payments to the Permanente Medical Group are made by the Kaiser Foundation Health Plan as an expense item and, hence, obscured from public scrutiny. Kaiser physicians are shareholders in the Permanente Medical group. Physicians are offered significant incentive compensation and dividends based in large part on ability to control costs. This can and does, in many cases, translate to denial of care.

 

Apparently there are three sets of Patient Rights in California - all different versions. Two are somewhat similar. I guess that no one knows what Rights Patients in California actually have.  I suggest if you are interested that you read through all three sets of statements by The California Department of Managed Health Cares to try to understand what rights if any that patients actually have with an HMO.  Apparently in 2005 patients don't have many rights left.

The recently promoted one by the DMHC is incredibly diluted.  It has been removed from the DMHC web site. It was at:
http://www.dmhc.ca.gov/gethelp/healthrights.asp

What Are My Health Care Rights?

    * You have the right to receive quality health care in a timely manner.
      An appointment should be available when you need one.

      Care should be provided by qualified medical personnel.

      Services should be provided with courtesy and respect.
 

    * You have the right to be in charge of your health care.
      Know and understand your diagnosis, available treatments, and associated risks.

      When you have a question, ask your doctor or other healthcare professional; reliable information is very valuable.

      The choice to accept or refuse treatment is yours.
 

    * You have the right to be informed.
      To understand the benefits and rights under your health plan, ask for a copy of your health plan's Evidence of Coverage.

      If you do not understand the Evidence of Coverage, call your health plan and ask for clarification.

      Request written information regarding your diagnosis, available treatments, and associated risks for future reference.

      Remember your physician and other healthcare professionals are vital source of information.

      For additional information contact an organization in your community or contact our Consumer Help Line at (888) HMO-2219 or TDD (877) 688-9891.
 

    * You have the right to choose a primary care provider. This is frequently a physician but, in some plans, you may also choose a nurse practitioner as your primary care provider.
      One of the most important health care choices you will make is the selection of your primary care provider.

      Being a member of a managed care health plan does not eliminate this choice.

      Your health plan will provide you with a list of physicians and other healthcare professionals to choose from.

      Feel free to ask about the professional's education, background, and experience.

      If you do not like your provider, ask your plan for a Provider Directory and select a new one.
 
 

What Are My Responsibilities as a Consumer?

    * Read and understand your health plan's Evidence of Coverage.
      If you do not have a copy of your plan's Evidence of Coverage, call and request one.

      If you have questions, call your plan's Member Services for clarification.

    * Keep good records.
      Maintain an appointment log.

      Organize and file medical billings.

      Retain diagnosis and treatment information.

      Record your medical history.

    * Make healthy lifestyle choices.
      Access and use preventive health care services.

    * Remember you are your own best advocate.
      The best way to ensure you receive quality health care is to be an active participant.

Your Rights and Responsibilities as a HMO Patient from the Department of Managed Health Care in California -as originally Posted at and removed from site at: http://www.dmhc.ca.gov
and verified by this newspaper article at the DHMC web site: at:http://www.dmhc.ca.gov/press/news/sfgate/20010128.asp

There is also the DMHC RIGHTS as an HMO Patient from their Annual Report of 2004 at:
http://www.dmhc.ca.gov/library/reports/complaint/2004.pdf

Your RIGHTS as an HMO Patient:
You have the right to see a primary care physician who is located near you.
Your HMO must assign you to a primary care physician who is located within 15 miles (or a 30-minute drive) of your
home or workplace.
You have the right to a second opinion.
If you disagree with the diagnosis or the way your doctor proposes to treat you, and have discussed the matter with your doctor, you may request to see another physician for a second opinion. In many cases the HMO must pay for a second opinion.
You have the right to be referred to a specialist when medically necessary.
Your HMO must provide a referral to a qualified specialist when it is medically necessary for you to see one.
You have the right to select an obstetrician/gynecologist as your primary care physician.
If you are a woman, your HMO must permit you to see a participating obstetrician/gynecologist without obtaining
a referral from your primary care physician.
You have the right to a quick response when requesting authorization for a medical referral.
In most cases your HMO must provide an answer to your physician's request for a treatment authorization within five
business days of the HMO's receipt of the request (or 72 hours if the request is urgent).
You have the right to file a grievance with your HMO.
If you are dissatisfied with the health care that you received from your HMO, you have the right to file a grievance with
your HMO. The HMO must resolve the grievance within 30 days (or within three days if the grievance is urgent).
You have the right to receive emergency care without prior authorization.
If you reasonably believe that you need immediate care to avoid placing your health at serious risk, you may seek
emergency care by dialing "911" or by going to the nearest emergency facility without seeking prior authorization
from your HMO.
You have the right to uninterrupted health care.
If you have to change HMOs or your doctor is no longer under contract with your HMO during the course of
treatment, your HMO must have policies in place to guarantee that you will not suffer from an interruption in
medically necessary care.
You have the right to inspect your medical records kept by your provider.
You can ask to review your own medical records. If you believe that they are incomplete or incorrect, you have
the right to add a written addendum with respect to any item or statement in your records. There may be a fee to
review your medical records.
You have the right to contact the California Department of Managed Health Care's HMO Help Center for
assistance, toll free at 1-888-HMO-2219, or TDD 1-877-688-9891 if you can't resolve a problem with your HMO.
Your RESPONSIBILITIES as an HMO Patient:
The following suggestions, while not required by law, can help you obtain the highest quality of care from your HMO:
 Read and understand your HMO Evidence of Coverage/Contract and keep it handy for easy reference.
 Always be prepared to discuss your healthcare problems during your visit with your doctor.
 Ask your doctor questions if you are not clear about your diagnosis or treatment plan.
 Demand appropriate, necessary care.
 Keep good records of your medical history, including diagnosis and treatment information.
 Know about and use preventive health care services offered by your HMO.
 Be an active participant: ask questions, read, and inquire.
 Learn how to become your best advocate.
 Keep your membership card handy.
 Know the phone number of your HMO Member Services.

Your RIGHTS as a HMO Patient
    • You have the right to see a primary care physician who is located near you.Your HMO must assign you to a primary care physician who is located within 15 miles     (or a 30-minute drive) of your home or workplace.
    • You have the right to a second opinion.
    • If you disagree with the diagnosis or the way your doctor proposes to treat you, and have discussed the matter with your doctor, you may request to see another physician for a second opinion. In many cases the HMO must pay for a second opinion.
    • You have the right to be referred to a specialist when medically necessary.
    • Your HMO must provide a referral to a qualified specialist when it is medically necessary for you to see one.
    • You have the right to select an obstetrician/gynecologist as your primary care physician.
    • If you are a woman, your HMO must permit you to see a participating obstetrician/gynecologist without obtaining a referral from your primary care physician.
    • You have the right to a quick response when requesting authorization for a medical referral.
    • In most cases your HMO must provide an answer to your physician's request for a treatment authorization within 5 business days of the HMO's receipt of the request (or 72 hours if the request is urgent).
    • You have the right to file a grievance with your HMO.
    • If you are dissatisfied with the health care that you received from your HMO, you have the right to file a grievance with your HMO. The HMO must resolve the grievance within 30 days (or within three days if the grievance is urgent).
    • You have the right to receive Emergency Care without prior authorization.
    • If you reasonably believe that you need immediate care to avoid placing your health at serious risk, you may seek emergency care by dialing "911" or by going to the nearest emergency facility without seeking prior authorization from your HMO.
    • You have the right to uninterrupted health care.
    • If you have to change HMOs or your doctor is no longer under contract with your HMO during the course of treatment, your HMO must have policies in place to guarantee that you will not suffer from an interruption in medically necessary care.
    • You have the right to inspect your medical records kept by your provider.
    • You can ask to review your own medical records. If you believe that they are incomplete or incorrect, you have the right to add a written addendum with respect to any item or statement in your records. There may be a fee to review your medical records.
    • You have the right to contact the Department of Managed Health Care's California HMO Help Center for assistance, toll free, at 1-888-HMO-2219, or TDD 1-877-688-9891 if you can't resolve a problem with your HMO.
Your RESPONSIBILITIES as an HMO Patient
    • The following suggestions, while not required by law, can help you obtain the highest quality of care from your HMO:
    • Read and understand your HMO Evidence of Coverage/Contract and keep it handy for easy reference.
    • Always be prepared to discuss your healthcare problems during your visit with your doctor.
    • Ask your doctor questions if you are not clear about your diagnosis or treatment plan.
    • Demand appropriate, necessary care.
    • Keep good records of your medical history, including diagnosis and treatment information.
    • Know about and use preventive health care services offered by your HMO.
    • Be an active participant: ask questions, read, and inquire.
    • Learn how to become your best advocate.
    • Keep your membership card handy.
    • Know the phone number of your HMO Member Services.


In contrast the following is the Kaiser Rights: 
From the Kaiser Permanente HealthWise Handbook

You Have the Right to:

* Receive information about your Health Plan. 
* Participate in a candid discussion of all available treatment options. 
* Express your wishes about future care. 
* Receive personal medical records and/or information so you can participate in your 
   health care. 
* Receive information about the people who provide your health care. 
* Request an interpreter in your primary language.
* Receive care with dignity and respect. 
* Have impartial access to treatment.
* Be assured of privacy and confidentiality. 
* Have a safe, secure, clean, and accessible health care environment. 
* Participate in physician selection. 
* Know and use member satisfaction resources

California Law says that your HMO has rights also:
  1375.7. 
Health Care Providers' Bill of Rights

  1375.7.             
Health Care Providers' Bill of Rights

(a) This section shall be known and may be cited as the Health Care Providers' Bill of Rights.

(b) No contract issued, amended, or renewed on or after January 1, 2003, between a plan and a health care provider for the provision of health care services to a plan enrollee or subscriber shall contain any of the following terms:

(1)(A) Authority for the plan to change a material term of the contract, unless the change has first been negotiated and agreed to by the provider and the plan or the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. If a change is made by amending a manual, policy, or procedure document referenced in the contract, the plan shall provide 45 business days' notice to the provider, and the provider has the right to negotiate and agree to the change. If the plan and the provider cannot agree to the change to a manual, policy, or procedure document, the provider has the right to terminate the contract prior to the implementation of the change. In any event, the plan shall provide at least 45 business days' notice of its intent to change a material term, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. However, if the parties mutually agree, the45-business day notice requirement may be waived. Nothing in this subparagraph limits the ability of the parties to mutually agree to the proposed change at any time after the provider has received notice of the proposed change.

(B) If a contract between a provider and a plan provides benefits to enrollees or subscribers through a preferred provider arrangement, the contract may contain provisions permitting a material change to the contract by the plan if the plan provides at least 45 business days' notice to the provider of the change and the provider has the right to terminate the contract prior to the implementation of the change.

(C) If a contract between a noninstitutional provider and a plan provides benefits to enrollees or subscribers covered under the Medi-Cal or Healthy Families program and compensates the provider on a fee-for-service basis, the contract may contain provisions permitting a material change to the contract by the plan, if the following requirements are met:

(i) The plan gives the provider a minimum of 90 business days' notice of its intent to change a material term of the contract.

(ii) The plan clearly gives the provider the right to exercise his or her intent to negotiate and agree to the change within 30 business days of the provider's receipt of the notice described in clause (i).

(iii) The plan clearly gives the provider the right to terminate the contract within 90 business days from the date of the provider's receipt of the notice described in clause (i) if the provider does not exercise the right to negotiate the change or no agreement is reached, as described in clause (ii).

(iv) The material change becomes effective 90 business days from the date of the notice described in clause (i) if the provider does not exercise his or her right to negotiate the change, as described in clause (ii), or to terminate the contract, as described in clause (iii).
 

(2) A provision that requires a health care provider to accept additional patients beyond the contracted number or in the absence of a number if, in the reasonable professional judgment of the provider, accepting additional patients would endanger patients' access to, or continuity of, care.

(3) A requirement to comply with quality improvement or utilization management programs or procedures of a plan, unless the requirement is fully disclosed to the health care provider at least 15 business days prior to the provider executing the contract. However, the plan may make a change to the quality improvement or utilization management programs or procedures at any time if the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. A change to the quality improvement or utilization management programs or procedures shall be made pursuant to paragraph (1).

(4) A provision that waives or conflicts with any provision of this chapter. A provision in the contract that allows the plan to provide professional liability or other coverage or to assume the cost of defending the provider in an action relating to professional liability or other action is not in conflict with, or in violation of, this chapter.

(5) A requirement to permit access to patient information in violation of federal or state laws concerning the confidentiality of patient information.

(c)(1) When a contracting agent sells, leases, or transfers a health provider's contract to a payor, the rights and obligations of the provider shall be governed by the underlying contract between the health care provider and the contracting agent.

(2) For purposes of this subdivision, the following terms shall have the following meanings:

(A) "Contracting agent" has the meaning set forth in paragraph (2) of subdivision (d) of Section 1395.6.

(B) "Payor" has the meaning set forth in paragraph (3) of subdivision (d) of Section 1395.6.

(d) Any contract provision that violates subdivision (b) or (c) shall be void, unlawful, and unenforceable.

(e) The department shall compile the information submitted by plans pursuant to subdivision (h) of Section 1367 into a report and submit the report to the Governor and the Legislature by March 15 of each calendar year.

(f) Nothing in this section shall be construed or applied as setting the rate of payment to be included in contracts between plans and health care providers.

(g) For purposes of this section the following definitions apply:

(1) "Health care provider" means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by the state to deliver or furnish health services.

 (2) "Material" means a provision in a contract to which a reasonable person would attach importance in determining the action to be taken upon the provision.
 

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