1 Tex. Admin. Code § 353.202

Current through Register Vol. 49, No. 48, November 29, 2024

Section 353.202 - Member Bill of Rights

Each managed care organization (MCO) participating in the Texas Medicaid program must provide to each member an easy-to-read, written document describing the member's rights, which must include the following:

(1) Member rights for members of health care MCOs:

(A) You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:

(i) Be treated fairly and with respect.

(ii) Know that your medical records and discussions with your providers will be kept private and confidential.

(B) You have the right to a reasonable opportunity to choose a managed care organization (MCO) and primary care provider. This is the doctor or health care provider you will see most of the time and who will coordinate your care. You have the right to change to another MCO or provider in a reasonably easy manner. That includes the right to:

(i) Be told how to choose and change your MCO and your primary care provider.

(ii) Choose any MCO you want that is available in your area and choose your primary care provider from that plan.

(iii) Change your primary care provider.

(iv) Change your MCO without penalty.

(v) Be told how to change your MCO or your primary care provider.

(C) You have the right to ask questions and get answers about anything you do not understand. That includes the right to:

(i) Have your provider explain your health care needs to you and talk to you about the different ways your health care problems can be treated.

(ii) Be told why care or services were denied and not given.

(D) You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to:

(i) Work as part of a team with your provider in deciding what health care is best for you.

(ii) Say yes or no to the care recommended by your provider.

(E) You have the right to use each complaint and appeal process available through the MCO and through Medicaid, and get a timely response to complaints, appeals and fair hearings. That includes the right to:

(i) Make a complaint to your MCO or to the Texas Medicaid program about your health care, your provider or your MCO.

(ii) Get a timely answer to your complaint.

(iii) Use the MCO's appeal process and be told how to use it.

(iv) Ask for a fair hearing from the Texas Medicaid program and get information about how that process works.

(F) You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to:

(i) Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need.

(ii) Get medical care in a timely manner.

(iii) Be able to get in and out of a health care provider's office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act.

(iv) Have interpreters, if needed, during appointments with your providers and when talking to your MCO. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information.

(v) Be given information you can understand about your MCO's rules, including the health care services you can get and how to get them.

(G) You have the right to not be restrained or secluded when it is for someone else's convenience, or is meant to force you to do something you do not want to do, or is to punish you.

(H) You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your MCO cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

(I) You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services.

(2) Member rights for members of dental MCOs:

(A) You have the right to get accurate, easy-to-understand information to help you make good choices about you or your child's dentists and other providers.

(B) You have the right to know how your child's dentists are paid. You have a right to know about what those payments are and how they work.

(C) You have the right to know how your managed care organization (MCO) decides about whether a service is covered and/or medically necessary. You have the right to know about the people in the MCO's office who decide those things.

(D) You have the right to know the names of the dentists and other providers enrolled with your MCO and their addresses.

(E) You have the right to pick from a list of dentists that is large enough so that your child can get the right kind of care when your child needs it.

(F) You have the right to take part in all the choices about your child's dental care.

(G) You have the right to speak for your child in all treatment choices.

(H) You have the right to get a second opinion from another dentist enrolled in your MCO about what kind of treatment your child needs.

(I) You have the right to be treated fairly by your MCO, dentists and other providers.

(J) You have the right to talk to your child's dentists and other providers in private, and to have your child's dental records kept private. You have the right to look over and copy your child's dental records and to ask for changes to those records.

(K) You have a right to know that dentists, hospitals, and others who care for your child can advise you about your child's health status, medical care, and treatment. Your child's MCO cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

(L) You have a right to know that you are not responsible for paying for covered services for your child. Dentists, hospitals, and others cannot require you to pay any other amounts for covered services.

1 Tex. Admin. Code § 353.202

The provisions of this §353.202 adopted to be effective February 28, 1997, 22 TexReg 1799; Amended to be effective August 13, 2003, 28 TexReg 6265; Amended to be effective August 10, 2005, 30 TexReg 4466; Amended to be effective March 1, 2012, 37 TexReg 1283