Members

Member Rights and Responsibilities

YOUR RIGHTS

It is the policy of Molina Healthcare to treat you with respect. We also care about keeping a high level of confidentiality with respect for your dignity and privacy. As a member you have certain rights. You have the right to:

  • Receive timely access to care and services in accordance with Molina contracts and federal and state regulations
  • Receive a prompt response to questions and requests
  • Know who is providing your medical services and care
  • Know what services are available to you. This includes if you need an interpreter because you don’t speak English
  • Participate with practitioners in making decisions about your health care, including the right to refuse treatment
  • Choose to receive long term services and supports in your home or community or in a nursing facility
  • Have confidentiality and privacy about your medical records and when you get treatment
  • Receive information on available treatment options and alternatives presented in a manner appropriate to your condition and ability to understand
  • Have a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit
  • Receive treatment for any emergency medical condition that will deteriorate from failure to provide treatment
  • Know if medical treatment is for the purpose of experimental research. If it is, the member can refuse or accept the services
  • Get information in a language you understand—you can get oral translation services free of charge
  • Receive reasonable accommodations to ensure you can effectively access and communicate with providers, including auxiliary aids, interpreters, flexible scheduling, and physically accessible buildings and services
  • Receive information necessary for you to give informed consent before the start of treatment
  • Be treated with respect and recognition for your dignity and right to privacy
  • Request and receive a copy of your medical records and request that they be amended or corrected, as specified in 45 CFR §§ 164.524 and 164.526
  • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, as specified in other federal regulations on the use of restraints and seclusion
  • Get care in a culturally competent manner without regard to disability, gender, race, health status, color, age, national origin, sexual orientation, marital status, religion, handicap or source of payment
  • Be informed of where, when and how to obtain the services you need from Molina, including how you can receive benefits from out-of-network providers if the services are not available in Molina's network
  • Receive full information and counseling on the availability of known financial resources for your care
  • Know whether a healthcare provider or facility accepts the Molina contract rates
  • Receive in writing from the provider, before receiving any non-covered services, notice:
    • of the non-covered service(s) to be rendered
    • that said services are not covered under the member benefits
    • that you will be liable for the cost of the service(s)
    • the cost of the service(s)


If requested, please provide a copy of such writing to Molina. If the member does not agree to pay for such non-covered services in writing, neither the member nor Molina is liable for the cost

  • Freely exercise your rights in a way that does not adversely affect the way the provider treats you
  • Voice complaints or file appeals to the State about Molina or the care it provides. You can call the Helpline at (800) 643-2273 to make a complaint about us
  • Appoint someone to speak for you about your care and treatment and to represent you in an Appeal
  • Make advance directives and plans about your care in the instance that you are not able to make your own health care decisions. See section 14 of your Member Handbook for information about Advance Directives
  • Change your health plan once a year for any reason during open enrollment or change your MCO after open enrollment for an approved reason. Reference section 2 of your Member Handbook or call the Managed Care Helpline at (800) 643-2273 (TTY (800) 817-6608) or visit the website at www.virginiamanagedcare.com for more information 
  • Appeal any adverse benefit determination (decision) by Molina that you disagree with that relates to coverage or payment of services. See Your Right to Appeal in section 12 of your Member Handbook
  • File a complaint about any concerns you have with our customer service, the services you have received, or the care and treatment you have received from one of our network providers. See Your Right to File a Complaint in section 12 of your Member Handbook 
  • Receive information about Molina, its services, its practitioners and providers and member rights and responsibilities
  • Make recommendations regarding our member rights and responsibility policy, for example by joining our Member Advisory Committee


Your right to be safe

Everyone has the right to live a safe life in the home or setting of their choice. Each year, many older adults and younger adults who are disabled are victims of mistreatment by family members, by caregivers and by others responsible for their well-being. If you, or someone you know, is being abused physically, is being neglected, or is being taken advantage of financially by a family member or someone else, you should call your local department of social services or the Virginia Department of Social Services 24-hour, toll-free hotline at (888) 832-3858. You can make this call anonymously; you do not have to provide your name. The call is free.

They can also provide a trained local worker who can assist you and help you get the types of services you need to assure that you are safe.

Your right to confidentiality

Molina will only release information if it is specifically permitted by state and federal law or if it is required for use by programs that review medical records to monitor quality of care or to combat fraud or abuse.

Molina staff will ask questions to confirm your identity before we discuss or provide any information regarding your health information.

Information about your medical conditions and services is kept very safe. All applicable confidentiality laws and regulations are followed by Molina, including those special rules related to substance use disorder and addiction, recovery and treatment services. We only share this information with others when you tell us it is okay to do so. If, for example, you would like for us to share this information with your family or other providers, we will ask you to sign a release form.

Your right to privacy

Molina believes in protecting the privacy of your health information. We may only use or disclose your Protected Health Information (PHI) for very specific reasons and will not release your health information to unauthorized individuals without your permission. PHI is any information related to a person’s health that identifies an individual. This information can be electronic or in any other format. Different types of uses and disclosures are listed and explained in further detail in our Notice of Privacy Practices, which can be found on our website. This notice also lists in detail your rights to privacy as a Molina member.

Molina follows all Commonwealth and federal laws and regulations relating to privacy. This includes the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We have rules that protect your health information in all forms—oral, written, and electronic. We protect the following information:

  • Member name
  • Member ID number
  • Member address
  • Member telephone number
  • Social security number
  • Date of birth
  • Health status
  • Names of your doctors


The Notice of Privacy Practices lists your rights under HIPAA. You have the right to see, correct and get copies of your PHI. Members can complete the authorization use and disclosure form to provide consent to share your PHI with authorized individuals. Molina will go over the authorization use and disclosure form with you if necessary. This form asks if you want to share your information with others involved in your care. This helps to coordinate your health care. This form can be found on the Molina website. Member Services can also provide you with the form. You can cancel your permission at any time.

If you need help, call Member Services toll-free at (800) 424-4518 (TTY 711).

How to join the Member Advisory Committee

Molina would like you to help us improve our health plan. We invite you to join our Member Advisory Committee. On the committee, you can let us know how we can better serve you. Going to these meetings will give you and your caregiver or family member the chance to help plan meetings and meet other members in the community. These educational meetings are held once every three months. If you would like to attend or would like more information, please contact Molina Member Services toll-free at (800) 424-4518 (TTY 711).

We follow non-discrimination policies

You cannot be treated differently because of your race, color, national origin, disability, age, religion, gender, marital status, pregnancy, childbirth, sexual orientation, or medical conditions.

If you think that you have not been treated fairly for any of these reasons, call the Department of Health and Human Services, Office for Civil Rights at (800) 368-1019. TTY users should call (800) 537-7697. You can also visit http://www.hhs.gov/ocr for more information. 

Molina complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

 

YOUR RESPONSIBILITIES

As a member, you also have some responsibilities. These include:

  • Present your Molina membership card whenever you seek medical care
  • Provide complete and accurate information to the best of your ability on your health and medical history to Molina and its practitioners and providers need to provide care
  • Report unexpected changes in your health status
  • Participate in your care team meetings (if applicable), develop an understanding of your health problems and provide input in developing mutually agreed upon treatment goals to the best of your ability
  • Keep your doctor appointments. If you must cancel, call as soon as you can
  • Follow your provider’s conduct rules and regulations
  • Follow plans and instructions for care that you have agreed to with your practitioners.
  • Receive all of your covered services from Molina's network
  • Obtain authorization from Molina prior to receiving services that require a service authorization review (see section 12 of your Member Handbook)
  • Call Molina whenever you have a question regarding your membership or if you need assistance toll-free at one of the numbers below
  • Tell Molina when you plan to be out of town so we can help you arrange your services
  • Use the emergency room only for real emergencies
  • Call your PCP when you need medical care, even if it is after hours
  • Follow plans and instructions for care you have agreed to with your providers    
  • Tell Molina when you believe there is a need to change your plan of care 
  • Tell us if you have problems with any health care staff. Call Member Services at one of the numbers below
  • Call Member Services at one of the phone numbers below about any of the following:
    • If you have any changes to your name, your address, or your phone number. Report these also to your case worker at your local Department of Social Services
    • If you have any changes in any other health insurance coverage, such as from your employer, your spouse’s employer, or workers’ compensation
    • If you have any liability claims, such as claims from an automobile accident
    • If you are admitted to a nursing facility or hospital
    • If you get care in an out-of-area or out-of-network hospital or emergency room
    • If your caregiver or anyone responsible for you changes
    • If you are part of a clinical research study

 

Advance directives

You have the right to say what you want to happen if you are unable to make health care decisions for yourself. There may be a time when you are unable to make health care decisions for yourself. Before that happens to you, you can:

  • Fill out a written form to give someone the right to make health care decisions for you if you become unable to make decisions for yourself
  • Give your doctors written instructions about how you want them to handle your health care if you become unable to make decisions for yourself


The legal document that you can use to give your directions is called an advance directive. An advance directive goes into effect only if you are unable to make health care decisions for yourself. Any person age 18 or over can complete an advance directive. There are different types of advance directives and different names for them. Examples are a living will, a durable power of attorney for health care, and advance care directive for health care decisions.

You do not have to use an advance directive, but you can if you want to. Here is what to do:

Where to get the advance directives form

You can get the Virginia Advance Directives form at: http://www.virginiaadvancedirectives.org/the-virginia-hospital—healthcares-association–vhha–form.html

You can also get the form from your doctor, a lawyer, a legal services agency, or a social worker. You can also contact Member Services to ask for the form.

Completing the advance directives form

Fill it out and sign the form. The form is a legal document. You may want to consider having a lawyer help you prepare it. There may be free legal resources available to assist you.

Share the information with people you want to know about it

Give copies to people who need to know about it. You should give a copy of the Living Will, Advance Care Directive, or Power of Attorney form to your doctor. You should also give a copy to the person you name as the one to make decisions for you. You may also want to give copies to close friends or family members. Be sure to keep a copy at home.

If you are going to be hospitalized and you have signed an advance directive, take a copy of it to the hospital. The hospital will ask you whether you have signed an advance directive form and whether you have it with you. If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.

We can help you get or understand advance directives documents

Your Care Manager can help you understand or get these documents. They do not change your right to quality health care benefits. The only purpose is to let others know what you want if you can’t speak for yourself.

Remember, it is your choice to fill out an advance directive or not. You can revoke or change your advance care directive or power of attorney if your wishes about your health care decisions or authorized representative change.

Other resources

You may also find information about advance directives in Virginia at: www.virginiaadvancedirectives.org.

You can store your advance directive at the Virginia Department of Health Advance Healthcare Directive Registry: www.connectvirginia.org.

If your advance directives are not followed

If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the following organizations.

For complaints about doctors and other providers, contact the Enforcement Division at the Virginia Department of Health Professions:

CALL
Virginia Department of Health Professions:
Toll-Free Phone: (800) 533-1560
Local Phone: (804) 367-4691

WRITE
Virginia Department of Health Professions
Enforcement Division
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233-1463

FAX (804) 527-4424

EMAIL  enfcomplaints@dhp.virginia.gov

WEBSITE  http://www.dhp.virginia.gov/Enforcement/complaints.htm

For complaints about nursing facilities, inpatient and outpatient hospitals, abortion facilities, home care organizations, hospice programs, dialysis facilities, clinical laboratories, and health plans (also known as managed care organizations), contact the Office of Licensure and Certification at the Virginia Department of Health:

CALL
Toll-Free Phone: (800) 955-1819
Local Phone: (804) 367-2106

WRITE  
Virginia Department of Health
Office of Licensure and Certification
9960 Mayland Drive, Suite 401
Henrico, Virginia 23233-1463

FAX (804) 527-4503

EMAIL  OLC-Complaints@vdh.virginia.gov

WEBSITE https://www.vdh.virginia.gov/licensure-and-certification/complaint-unit/