Medical Services

Managed Care

State Plan Amendment - Title XIX of the Social Security Act

Supplement 4 - Enrollee Rights and Requirements

Enrollee Rights

PCCM beneficiaries have the following rights:

  • To receive information in accordance with CFR42 §438.10.
  • To be treated with respect and with due consideration for his or her dignity and privacy.
  • To receive information on available treatment options and alternatives presented in a manner appropriate to the enrollee's condition and ability to understand.
  • To participate in decisions regarding his or her health care, including the right to refuse treatment.
  • To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • To be informed of PCP enrollment requirements, be given adequate time to make the informed decision and to be provided with the information necessary to do so.
  • To receive a copy of his or her medical records, and to request that they be amended or corrected.
  • To be free to exercise his or her rights, and that the exercise of those rights does not adversely affect the way the PCP or the State treat the enrollee.

Beneficiary Requirements

PCP services:

  • Beneficiaries must access managed care covered services from their PCP or designated covering provider (DCP).

Non PCP services:

  • Beneficiaries must obtain PCP or DCP referrals prior to receiving managed care covered services from other providers.

Verify Medical Assistance Eligibility:

  • Beneficiaries must show their Medical Assistance Identification Card to all providers prior to receiving covered medical services.

Non covered services:

  • Beneficiaries are responsible for payment of services for non-covered medical care. This includes medical care identified as managed care services not received from the PCP or DCP and not prior referred.

Accept PCP enrollment:

  • Beneficiaries must select their PCP or accept OMS default assignment of PCP.