Everyone is concerned about quality care and service, especially our members. We are committed to seeing that our members receive the quality health care they deserve and expect. So we designed our Quality and Utilization Management Program to build our members' confidence that they are getting the care they need from people who care about them. This is how our Quality and Utilization Management Program ensures that we deliver safe, effective, quality health care and services.
Rights & Responsibilities
We honor our members' rights. All of our members are entitled to be treated in a manner that respects their rights. We recognize the specific needs of our members and maintain a mutually respectful relationship with them. This is our commitment to the rights of our members, and to those other than the member who are legally responsible for making health care decisions for the member.
As our member, you have the right to:
- Receive healthcare services regardless of your race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical conditions, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), genetic information, or source of payment.
- Receive information about us and our services, doctors, healthcare professionals and providers, members’ rights and responsibilities, as well as information about your health plan’s coverage for services you may need or are considering.
- Be treated with respect and recognition of your dignity and right to privacy.
- Be represented by parents, guardians, family members or other conservators if you are unable to fully participate in treatment decisions.
- Have information about our contracting physician and provider payments agreements, as well as explanations for any bills you receive for services not covered by us or your health plan.
- Receive healthcare services without requiring you to sign an authorization, release, consent or waiver that would permit us to disclose your medical information. We will treat information about you, including information about services and treatment we provide, as confidential according to all current privacy and confidentiality laws.
- Have round-the-clock access, seven days a week, to your PCP or an on-call physician when your PCP is unavailable.
- Know the name and qualifications of the doctor who is mainly responsible for coordinating your care,and the names, qualifications, and specialties of other doctors, and other providers who are involved in your care.
- Have a candid discussion of medically appropriate or necessary treatment options for your condition — regardless of the cost, the extent of your benefits or the lack of coverage. To the extent permitted by law, this includes the right to refuse any procedure or treatment.
- Actively participate in decisions regarding your healthcare and treatment plan and receive services at your own expense if we deny coverage. You and your treating doctor or healthcare provider decide whether you will receive a particular service or treatment.
- Receive complete information — before receiving care and in terms you can understand — about an illness, proposed course of treatment or procedure, and prospects for recovery, so that you may be well informed when consenting to refuse a course of treatment. This includes:
- being able to request and receive information about how medical treatment decisions are made by our review staff
- the criteria or guidelines applied when making such decisions
- an explanation of the cost of the care you will receive and what you will be expected to pay out of your own pocket
Except in emergencies, this information will include a description of the recommended procedure or treatment, the medically significant risks involved, any alternate course of treatment or non-treatment and the risks involved in each and the name of the person who will carry out the recommended procedure or treatment.
- Receive information about your medications - what they are, how to take them, and possible side effects.
- Reasonable continuity of care and to know the time and location of appointments, the name of the physician providing care and continuing healthcare requirements following discharge from inmember or outmember facilities.
- Be advised if a doctor proposes to engage in experimental or investigational procedures affecting your healthcare or treatment. Members have the right to refuse to participate in such research projects.
- Obtain upon request a copy or summary of the Utilization Management Program Description and the Quality Improvement Program Description that we publish annually.
- Voice complaints about us or appeal our care decisions.
- Be informed of rules about member conduct in any of the various settings where you receive healthcare services as our member.
- Complete an advance directive, living will or other instructions concerning your care in the event that in the future you become unable to make those decisions while receiving care through our physicians, healthcare professionals and providers.
- Make recommendations about these members’ rights and responsibilities policies.
Our Members Share Responsibility for Their Care
Just as we honor our members’ rights, we have expectations of our members. You have a responsibility to:
- Be familiar with the benefits, limitations and exclusions of your health plan coverage.
- Supply your healthcare provider with complete and accurate information which is necessary for your care (to the extent possible).
- Be familiar and comply with our rules for receiving routine, urgent, and emergency care.
- Contact your PCP (or covering doctor) for any non-urgent or emergency care that you may need after the doctor’s normal office hours, including on weekends and holidays.
- Be on time for all appointments and notify the physician’s or other provider’s office as far in advance as possible for appointment cancellation or rescheduling.
- Obtain an authorized referral form from your PCP before making an appointment with a specialist and/or receiving any specialty care.
- Understand your health problems,participate in developing mutually agreed upon treatment goals to the degree possible,and inform your doctors and healthcare providers if you do not understand the information they give you.
- Follow treatment plans and instructions for care you have agreed on with your doctors and healthcare providers, and report changes in your condition.
- Accept your share of financial responsibility for services received while under the care of a physician or while a member at a facility.
- Treat your doctors and healthcare providers and their office staff with respect.
- Contact our Member Services Department or your health plan’s member services if you have questions or need assistance.
- Respect the rights, property and environment of your physicians and healthcare providers, their staff and other members.
We Value Your Opinion
Our member surveys give us a better picture of how we are doing and whether we need to change anything. We regularly contact our members to find out how things are going for them. Do they think they get good care? Do they feel their doctor listens to them? Is it easy for them to get appointments? Are they treated with respect and dignity by our staff? Are we honoring their member rights? We also survey our practitioners to see what they think and to find out better ways to give their members the care they need.
We carefully observe all of the laws, regulations and professional ethics that govern member privacy and the confidentiality of member information. We do not give out any information that makes it possible to anyone or any organization to individually identify any of our members. View our HIPAA information or our Website Privacy information.
We gather general data about our members and the health care services we provide them, group the data together, and use the information to develop our quality programs and services. We share the grouped data with health care organizations, regulatory agencies and accreditation organizations. They in turn use the data to monitor the delivery of health care services to certain populations. Any member data that is exchanged electronically between our doctors, the medical group administrative staff, health plans or any other entity is protected as required by current state and federal laws.
When requested, we will tell our members how we use their personal health information. They may review their own personal health information and amend it. We have a process for receiving, analyzing, resolving, and complying with our members' requests to restrict the uses and disclosures of their protected health information.
Note: Valley Care IPA will not refuse to treat or otherwise discriminate against a member who has completed an Advance Health Care Directive or Durable Power of Attorney.
What is an Advance Health Care Directive?
California law allows you to choose another person to make healthcare decisions if for any reason you are unable to speak for yourself. You can also write down your healthcare wishes in the form (for example, a desire not to receive treatment that only prolongs the dying process if you are terminally ill). Your agent must follow these instructions and must honor any other wishes you have made known. A properly completed Advance Health Care Directive (AHCD) provides the best assurance that your wishes will be respected if you become seriously ill and cannot speak for yourself.
Who can I appoint as my health care agent?
You can appoint any adult to be your agent. You can choose a member of your family, such as your spouse or an adult child, a friend, or someone else you trust. (If you appoint your spouse and later get divorced, the AHCD is automatically invalidated.) You can also appoint one or more "alternate agents" in case the person you select as your health care agent is unavailable or unwilling to make a decision. It is important that you speak with the people you want to appoint to make sure they understand your wishes and agree to accept the responsibility.
The law prohibits you from appointing certain people to act as your agent. You may not choose your doctor or a person who operates a community care facility (sometimes called a "board and care" facility) or a residential care facility for the elderly. The law also prohibits you from appointing a person who works for your doctor, for the health facility in which you are being treated, for a community facility, or a residential care facility for the elderly, unless that person is related to you by blood, marriage or adoption. It is recommended by the California Medical Association that you only name one person as your health care agent.
How much authority will my health care agent have?
If you become incapacitated, your agent will have authority over any other person to speak for you in health care matters. Your agent will be able to accept or refuse medical treatment, to have access to your medical records, to make decisions about donating your organs, authorizing an autopsy and disposing of your remains when you die. However, if you do not want your agent to have power over all of these areas, you can write a statement on the form limiting your agent’s authority. In addition, the law says that your agent may not authorize convulsive treatment, psychosurgery, sterilization, abortion, or placement in a mental health treatment facility.
What should I do with the DPAHC form after I complete it?
Make sure the form has been properly signed, dated, and either notarized or witnessed by two qualified individuals (the form includes instructions about who can and cannot be a witness). Keep the original in a safe place and give photocopies of the completed form to the persons you have appointed as your agent and alternate agents, to your physician, family members or anyone else who is likely to be called if there is a medical emergency. Take a copy of the signed form with you if you are going to be admitted to the hospital, nursing home or other health care facility. Photocopies are accepted as though they are the original signed form.
The above information was obtained free off of the Internet at the following URL: Durable Power Info.
Valley Care IPA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age, sexual orientation, disability or method of payment. Valley Care IPA does not exclude people or treat them differently because of race, color, national origin, sex, age, sexual orientation, disability or method of payment.
Valley Care IPA provides appropriate auxiliary aids and services, free of charge and in a timely manner, to individuals with disabilities. For hearing impaired, please call TDD/TYY: 711.
Valley Care IPA provides language assistance services, free of charge and in a timely manner, to individuals with limited English proficiency. You can get an interpreter, documents read to you and some sent to you in your language. For help, please call the number listed on your ID card.
Valley Care IPA:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as: Qualified interpreters or Information written in other languages
If you need these services, contact our Compliance Officer. If you believe that Valley Care IPA has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Compliance Officer, 751 E. Daily Dr., Ste. 120, Camarillo, CA 93010, Phone: 805-256-7810, TDD/TYY: 711, Fax: 805-256-7840, Compliance@identitymso.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Compliance Officer is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at OCRPortal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at HHS.gov/ocr/office/file/index.html.