Member rights & responsibilities
For the most up to date Health Share member rights and responsibilities, check your member handbook.
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Health Share/Providence member rights
Health Share/Providence members shall have the following rights and are entitled to:
- Be treated with dignity and respect;
- Be treated by participating providers the same as other people seeking health care benefits to which they are entitled and to be encouraged to work with the member’s care team, including providers and community resources appropriate to the member’s needs;
- Choose a Primary Care Provider (PCP) or service site and to change their PCP
- Refer oneself directly to behavioral health or family planning services without getting a referral from a PCP or other participating provider;
- Have a friend, family member, member representative, or advocate present during appointments and other times as needed within clinical guidelines;
- Be actively involved in the development of their treatment plan;
- Be given information about their condition and covered and non-covered services to allow an informed decision about proposed treatments;
- Consent to treatment or refuse services and be told the consequences of that decision, except for court ordered services;
- Receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency;
- Have written materials explained in a manner that is understandable to the member and be educated about the coordinated care approach being used in the community and how to navigate the coordinated health care system;
- Receive culturally and linguistically appropriate services and supports in locations as geographically close to where members reside or seek services as possible and choice of providers within the delivery system network that are, if available, offered in non-traditional settings that are accessible to families, diverse communities, and underserved populations;
- Receive oversight, care coordination and transition and planning management from Health Share/Providence to ensure culturally and linguistically appropriate community-based care is provided in a way that serves them in as natural and integrated an environment as possible and that minimizes the use of institutional care;
- Receive necessary and reasonable services to diagnose the presenting condition;
- Receive integrated person-centered care and services designed to provide choice, independence and dignity and that meet generally accepted standards of practice and are medically appropriate;
- Have a consistent and stable relationship with a care team that is responsible for comprehensive care management;
- Receive assistance in navigating the health care delivery system and in accessing community and social support services and statewide resources including but not limited to the use of certified or qualified health care interpreters, certified traditional health workers including community health workers, peer wellness specialists, peer support specialists, doulas, and personal health navigators who are part of the member’s care team to provide cultural and linguistic assistance appropriate to the member’s need to access appropriate services and participate in processes affecting the member’s care and services;
- Obtain covered preventive services;
- Have access to urgent and emergency services 24 hours a day, seven days a week without prior authorization;
- Receive a referral to specialty providers for medically appropriate covered coordinated care;
- Have a clinical record maintained that documents conditions, services received, and referrals made;
- Have access to one's own clinical record, unless restricted by statute;
- Transfer of a copy of the clinical record to another provider;
- Execute a statement of wishes for treatment, including the right to accept or refuse medical, surgical, or behavioral health treatment and the right to execute directives and powers of attorney for health care established under ORS 127;
- Receive written notices before a denial of, or change in, a benefit or service level is made, unless a notice is not required by federal or state regulations;
- Be able to make a complaint or appeal with Health Share/Providence and receive a response;
- Request a contested case hearing;
- Receive certified or qualified health care interpreter services; and
- Receive a notice of an appointment cancellation in a timely manner;
- 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.
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Health Share/Providence member responsibilities
Health Share/Providence members shall have the following responsibilities:
- Choose or help with assignment to a PCP or service site;
- Treat Health Share/Providence staff, providers, and clinic staff members with respect;
- Be on time for appointments made with providers and to call in advance to cancel if unable to keep the appointment or if expected to be late;
- Seek periodic health exams and preventive services from the PCP or clinic;
- Use the PCP or clinic for diagnostic and other care except in an emergency;
- Obtain a referral to a specialist from the PCP or clinic before seeking care from a specialist unless self-referral to the specialist is allowed;
- Use urgent and emergency services appropriately and notify the member’s PCP or clinic within 72 hours of using emergency services;
- Give accurate information for inclusion in the clinical record;
- Help the provider or clinic obtain clinical records from other providers that may include signing an authorization for release of information;
- Ask questions about conditions, treatments, and other issues related to care that is not understood;
- Use information provided by Health Share/Providence providers or care teams to make informed decisions about treatment before it is given;
- Help in the creation of a treatment plan with the provider;
- Follow prescribed agreed upon treatment plans and actively engage in their health care;
- Tell their provider that their health care is covered under Health Share/Providence Oregon Health Plan (OHP) before services are received and, if requested, present their Health Share/Providence ID card;
- Contact the Oregon Health Authority (OHA) to provide a change of address or phone number;
- Contact the OHA if member becomes pregnant and notify the OHA when their child is born;
- Notify the OHA if any family members move in or out of the household;
- Notify Health Share/Providence or the OHA if member becomes eligible or has other health insurance;
- Pay for non-covered services under the provisions described in OAR 410-120-1200 and 410-120-1280;
- Assist Health Share/Providence in pursuing any third-party resources available and reimburse Health Share/Providence the amount of benefits it paid for an injury from any recovery received from that injury; and
- Bring issues, complaints or grievances to the attention of Health Share/Providence