In Copyright Since September 11, 2000
Help for Kaiser Permanente Patients on this public service web site.
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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.
one by the DMHC is incredibly diluted. It has been removed
from the DMHC web site. It was at:
What Are My Health Care Rights?
* You have the right to receive quality health care
in a timely manner.
Care should be provided by qualified medical personnel.
Services should be provided with courtesy
* You have the right to be in charge of your health
When you have a question, ask your doctor or other healthcare professional; reliable information is very valuable.
The choice to accept or refuse treatment
* You have the right to be informed.
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
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.
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
If you have questions, call your plan's Member Services for clarification.
* Keep good records.
Organize and file medical billings.
Retain diagnosis and treatment information.
Record your medical history.
* Make healthy lifestyle choices.
* Remember you are your own best advocate.
Responsibilities as a HMO Patient from the Department
of Managed Health Care in California -as originally Posted at and
from site at: http://www.dmhc.ca.gov
DMHC RIGHTS as an HMO Patient from their Annual
Report of 2004 at:
RIGHTS as an HMO
Your RIGHTS as a HMO Patient
You Have the Right to:
* Receive information about your Health
that your HMO has rights also:
(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).
change becomes effective 90 business days from the
date of the notice described in clause (i) if the provider does not
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.