Rights and Responsibilities

1. Receive information about your rights and responsibilities as an IEHP DualChoice Member.
2. Be treated with respect and courtesy. IEHP DualChoice recognizes your dignity and right to privacy.
3. Receive services without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. 
4. Receive information about IEHP DualChoice, its programs and services, its doctors, providers, health care facilities, and your drug coverage and costs, which you can understand.
5. Have a primary care provider who is responsible for coordination of your care.
6. If your primary care provider changes, your IEHP DualChoice benefits and required co-payments will stay the same.
7. Your IEHP DualChoice doctor cannot charge you for covered health care services, except for required co-payments.
8. Request a second opinion about a medical condition.
9. Receive emergency care whenever and wherever you need it.
10. See plan providers, get covered services, and get your prescription filled timely.
11. Receive information about clinical programs, including staff qualifications, request a change of treatment choices, participate in decisions about your health care, and be informed of health care issues that require self-management.
12. If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period.
13. If you are under a doctor’s care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current doctor. To make this request, or if you have any concerns about your continuity of care, please call IEHP DualChoice member services at 1-877-273-IEHP (4347).
14. Receive member informing materials in alternative formats, including Braille, large print, and audio.
15. Information on procedures for obtaining prior authorization of services, quality assurance, disenrollment, and other procedures affecting IEHP DualChoice members.
16. IEHP DualChoice will honor authorizations for services already approved for you. If you have any authorizations pending approval, if you are in them idle of treatment, or if specialty care has been scheduled for you by your current doctor, contact IEHP to help you coordinate your care during this transition time. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8 a.m.-8 p.m. (PST), 7 days a week, including holidays. TTY users should call 1-800-718-IEHP (4347).
17. Review, request changes to, and receive a copy of your medical records in a timely fashion.
18. Receive interpreter services at no cost.
19. Notify IEHP if your language needs are not met.
20. Make recommendations about IEHP DualChoice members rights and responsibilities policies.
21. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws.
22. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury.
23. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation
24. Complain about IEHP DualChoice, its providers, or your care. IEHP DualChoice will help you with the process. You have the right to choose someone to represent you during your appeal or grievance process and for your grievances and appeals to be reviewed as quickly as possible and be told how long it will take.
    • Have grievances heard and resolved in accordance with Medicare guidelines;
    • Request quality of care grievances data from IEHP DualChoice.
25. Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment, or reduction of services. This includes denial of payment for a service after the service has been rendered (post-service) or denial of service prior to the service being rendered (pre-service).
    • Request fast reconsideration;
    • Request and receive appeal data from IEHP DualChoice;
    • Receive notice when an appeal is forwarded to the Independent Review Entity (IRE);
    • Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part;
    • Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more;
    • Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part;
    • Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more;
    • Make a quality of care complaint under the Quality Improvement Organization (QIO) process;
    • Request Quality Improvement Organization review of a determination of noncoverage of inpatient hospital care;
    • Request Quality Improvement Organization review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities;
    • Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information;
    • Challenge local and national Medicare coverage determination.

1. Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits
2. Inform your doctor about your medical condition, and concerns.
3. Follow the plan of treatment your doctor feels is necessary
4. Make necessary appointments for routine and sick care, and inform your doctor when you are unable to make a scheduled appointment.
5. Learn about your health needs and leading a healthy lifestyle.
6. Make every effort to participate in the health care programs IEHP DualChoice offers you.

For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook

Ending your membership in IEHP DualChoice (HMO D-SNP) may be voluntary (your own choice) or involuntary (not your own choice)

• You might leave our plan because you have decided that you want to leave.
• There are also limited situations where you do not choose to leave, but we are required to end your membership. Chapter 10 of your IEHP DualChoice Member Handbook tells you about situations when we must end your membership.

Most people with Medicare can end their membership during certain times of the year. Since you have Medi-Cal, you may be able to end your membership with our plan or switch to a different plan one time during each of the following Special Enrollment Periods:

• January to March
• April to June
• July to September

In addition to these three Special Enrollment periods, you may end your membership in our plan during the following periods each year:

• The Annual Enrollment Period, which lasts from October 15 to December 7. If you choose a new plan during this period, your membership in our plan ends on December 31 and your membership in the new plan starts on January 1.
• The Medicare Advantage Open Enrollment Period, which lasts from January 1 to March 31. If you choose a new plan during this period, your membership in the new plan starts the first day of the next month.

There may be other situations when you are eligible to make a change to your enrollment. For example, when:

• You moved out of our service area,
• Your eligibility for Medi-Cal or Extra Help changed, or
• If you recently moved into, currently are getting care in, or just moved out of a nursing home or a long-term care hospital.

Your membership ends on the last day of the month that we get your request to change your plan. For example, if we get your request on January 18, your coverage with our plan ends on January 31. Your new coverage begins the first day of the next month (February 1, in this example). If you leave our plan, you can get information about your:

• Medicare options in the table in Section C1, Your Medicare services.
• Medi-Cal services in Section C2, Your Medi-Cal services.

You can get more information about how you can end your membership by calling:

• Member Services at the numbers at the bottom of the page.
• Medicare at 800-MEDICARE (800-633-4227), 24 hours a day, 7 days a week. TTY users should call 877-486-2048.
• California Health Insurance Counseling and Advocacy Program (HICAP), at 800-434-0222, Monday through Friday from 8:00 a.m. to 5:00 p.m. For more information or to find a local HICAP office in your area, please visit www.aging.ca.gov/HICAP/.
• Health Care Options at 844-580-7272, Monday through Friday from 8:00 a.m. to 6:00 p.m. TTY users should call 800-430-7077.
• Medi-Cal Managed Care Ombudsman at 888-452-8609, Monday through Friday from 8:00 a.m. to 5:00 p.m. or e-mail MMCDOmbudsmanOffice@dhcs.ca.gov.

NOTE: If you’re in a drug management program, you may not be able to change plans. Refer to Chapter 5 of your Member Handbook for information about drug management programs.

1. If you decide to end your membership you can enroll in another Medicare plan or switch to Original Medicare. However, if you want to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan, you must ask to be disenrolled from our plan. There are three ways you can ask to be disenrolled:
   
2. You can make a request in writing to us. Contact IEHP DualChoice Member Services if you need more information on how to do this.
   
3. Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users (people who have difficulty with hearing or speaking) should call 1-877-486-2048. When you call 1-800-MEDICARE, you can also enroll in another Medicare health or drug plan.
   • Call Health Care Options at 844-580-7272, Monday through Friday from 8 a.m.-6 p.m. TTY users should call 1-800-430-7077.

For additional information, please see Chapter 10 of the IEHP DualChoice Member Handbook

If you leave IEHP DualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. (See Chapter 10 of the IEHP DualChoice Member Handbook for information on when your new coverage begins.) During this time, you must continue to get your medical care and prescription drugs through our plan.

• You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services.
• If you are hospitalized on the day that your membership ends, you will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).
• If you no longer qualify for Medi-Cal or your circumstances have changed that make you no longer eligible for Dual Special Needs Plan, you may continue to get your benefits from IEHP DualChoice for an additional three-month period. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information.
  • To stay a member of IEHP DualChoice, you must qualify again by the last day of the three-month period.
  • If you do not qualify by the end of the three-month period, you’ll de disenrolled by IEHP DualChoice.

IEHP DualChoice must end your membership in the plan if any of the following happen:

• If you do not stay continuously enrolled in Medicare Part A and Part B.
• If you move out of our service area for more than six months.       
• If you become incarcerated.
• If you lie about or withhold information about other insurance you have that provides prescription drug coverage.
• If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan.
• If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan.
• If you let someone else use your membership card to get medical care.
• Our plan is only for people who qualify for both Medicare and Medi-Cal. If you lose your Medi-Cal eligibility and you are within our plan’s 3-month period of deemed continued eligibility, we will continue to provide all Medicare Advantage plan-covered Medicare benefits. However, during this period, we will not continue to cover Medicaid benefits that are included under the applicable Medicaid State Plan. Medicare cost-sharing amounts for Medicare basic and supplemental benefits do not change during this period.
• The State or Medicare may disenroll you if you are determined no longer eligible to the program.

IEHP DualChoice (HMO D-SNP) is an HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal.

Information on this page is current as of October 15, 2024.
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