Member Rights and Responsibilities
Trillium Oregon Health Plan
Member Rights and Responsibilities Statement
This statement explains your rights and responsibilities as a Trillium Community Health Plan (Trillium) member.
As a member you have certain rights. You also have the responsibility to be a part of your health care. As your health care partner, we make sure your rights are guarded while we provide your health benefits. This includes providing you access to ournetwork providers and providing information you need to make the best decisions for your health and welfare. We also honor your right to privacy and to receive care withrespect and dignity.
If you are a child or are unable to make choices about your medical care, your legal guardian or agent has responsibility for ensuring your member rights on your behalf.
Members have the right to request a copy of clinical practice guidelines. Clinical practice guidelines are statements that include health recommendations. These are to help improve the member’s quality of care . A paper copy can be mailed if requested. Members can also go to the Trillium website. Trilliumohp.com, under Member Resources. Member Rights and Responsibilities.
As an OHP member you have the right to:
- Be treated with respect and recognition of your dignity and your right to privacy;
- Be treated with respect with consideration for your dignity and privacy by participating providers, the same as others seeking health care benefits to which they are entitled;
- Be encouraged to work with your care team, including providers and community resources appropriate to your needs
- Pursue your Civil Rights under Title VI of the Civil Rights Act of 1964; and ORS 659A Unlawful Discrimination; the Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91; the Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972; Titles II and III of the Americans with Disabilities Act; and section 1557 of the Patient Protection and Affordable Act;
- Pursue your Civil Rights under Title VI of the Civil Rights Act and ORS 659A Unlawful Discrimination. You have a right to report a complaint of discrimination by contacting Trillium, OHA, the Bureau of Labor and Industries (BOLI) or the Office of Civil Rights (OCR);
- Receive written notice of Trillium’s nondiscrimination policy and process to report a complaint of discrimination on the basis of race, color, national origin, religion, sex, sexual orientation, marital status, age, or disability in accordance with all applicable laws including Title VI of the Civil Rights Act and ORS Chapter 659A;
- Choose a Primary Care Provider (PCP) or service site and to make changes to those choices as permitted by Trillium administrative policies;
- Receive equal access for both males and females who are under 18 years of age to appropriate facilities, services, and treatment;
- 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, or advocate present during appointments or other services as needed within clinical guidelines;
- Be actively involved in the development of your treatment plan, decision making about your health care, and to have family involved in such treatment planning;
- An open discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage;
- Be given information about your condition, covered and non-covered services, to allow you to make an informed decision about proposed treatments;
- Consent to treatment or refuse services and be told of the consequences of that decision, except for court ordered services;
- Have a consistent and stable relationship with the care team that is responsible for your comprehensive care management;
- Complete 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;
- Receive information about Trillium, its services, its practitioners and providers, member rights, and responsibilities.
- Receive written materials about benefits available, how to access services, and what to do in an emergency;
- Make recommendations regarding Trillium’s member rights and responsibilities policy;
- Have written materials explained in a manner that is easy to understand and be educated about the coordinated care approach being used in the community and how to navigate the coordinated health care system;
- If you also have Medicare coverage; to receive information about your coverage within 30 days of joining the Trillium plan and by request at least once a year;
- Receive culturally appropriate services in your preferred language, and supports in locations close to where you live or seek services you need. Choice of providers within the Trillium network that are, if available, offered in non- traditional settings that are easy to get to for families, diverse communities, and underserved people;
- Receive oversight, care coordination and transition, and planning management from Trillium to ensure culturally appropriate community-based care, in your preferred language, is provided in a way that serves you in a natural and integrated environment and that avoids 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, dignity and that meet generally accepted standards of practice and are medically appropriate;
- Receive help in navigating the health care delivery system and in getting access to community and social support services and statewide resources. This includes but is not limited to the use of certified or qualified health care interpreters, advocates, community health workers, peer wellness specialists, and personal health navigators who are part of your care team to provide cultural and linguistic help tailored to your need and to help you access needed services and take part in matters having an effect your care and services;
- Obtain covered preventive services;
- To have access to covered services, which have equal access available to others serviced by Trillium;
- 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 services as indicated in Trillium referral policies;
- Have any cost sharing comply with the Oregon Health Plan rules;
- To receive notification of your responsibility for paying co-payment for some services as specified by the Oregon Health Plan rules;
- Have a clinical record maintained that documents conditions, services received, and referrals made;
- Have access to your own clinical record, and receive a copy, unless restricted by statute, and to request that the record be amended or corrected;
- Transfer of a copy of your clinical record to another provider;
- Be able to make a complaint or appeal with Trillium about Trillium or the care it provides and receive a response;
- Receive written notices before a denial of, or change in, a benefit or service level is made, unless notice is not required by federal or state regulations;
- Request a contested case hearing;
- Have a right to exercise your member rights and the exercise of those rights not negatively affect the way Trillium, its staff, subcontractors, participating providers or OHA, treat you. Trillium will not discriminate in any way against you when you exercise your rights under the Oregon Health Plan; Receive certified or qualified health care interpreter services;
- 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;
- When available provide information to Trillium for electronic communications
- To have electronic information from Trillium by request, this does not include notice related to an Adverse Benefit Action or any portion of the Grievance, Appeal, Contested Case Hearing or any other Member rights or Member Protection process’s;
- To have materials provided in an electronic format with alternative language and formats available as requested;
- To have HIPAA requirements satisfied with respect to personal health information;
- To have Trillium maintain identical electronic information received in written format upon request;
- To report Fraud, Waste and Abuse anonymously and to be protected under applicable Whistleblower laws.
- To work with Trillium staff who fully understand all policies. These policies include Enrollment, Disenrollment, Fraud, Waste and Abuse, Grievance and Appeal, and advance directive. These policies also include Certified or Qualified Health Care Interpreter services and which Participating Provider’s offices have bilingual services.
As an OHP member, you agree to:
- Choose or help with assignment to a PCP or service site;
- Treat Trillium, 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 your 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 your PCP or clinic within 72 hours of using emergency services;
- Give accurate information to Trillium and your providers needed to provide care and include in your clinical record;
- Help your provider or clinic obtain your 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 your care that you do not know;
- Use information provided by Trillium providers or care teams to make informed decisions about treatment before it is given;
- Know your health problems and take part in developing mutually agreed-upon treatment goals and a treatment plan, to the degree you can;
- Follow treatment plans and instructions for care that you have agreed to with your practitioner;
- Tell the provider that your health care is covered under Trillium before services are received and, if requested, show the provider your Trillium Member ID card;
- Tell Oregon Health Plan of a change of address or phone number;
- Tell Oregon Health Plan if you become pregnant and notify Oregon Health Plan of the birth of your child;
- Tell Oregon Health Plan if any family members move in or out of the household;
- Tell Oregon Health Plan if there is any other insurance available;
- Help Trillium in pursuing any third-party resources available and reimburse Trillium 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 the Trillium.
For additional information or to request this information in another language or format, please call Member Services Toll Free: 1 (877) 600-5472 or TDD/TTY: 711
Trillium Member Services is available to answer your call directly 8 a.m. to 5 p.m., Monday through Friday (except on holidays).
Trillium Utilization Management (UM) staff is available to answer calls from 8 a.m. to 5 p.m., Monday through Friday (except holidays). UM staff makes decisions based on insurance coverage and medical need. UM staff can be reached by calling Member Services.
Our automated system is available anytime for self-service options, including after hours, weekends, and holidays. Voice messages are reviewed and responded to within one business day. Member Services also has free language interpreter service available for non-English speakers.
MCA_EK03V4 Effective 1/11/2019