Medicaid Member Rights and Responsibilities | Members

What Are My Rights?

Medicaid is a voluntary program. This means that you agree to be part of the Medicaid program and to follow the rules issued by Medicaid and Sentara Community Plan.

General Rights

As a Cardinal Care member, you have the right to:

Be free from discrimination based on race, color, ethnic or national origin, age, sex, sexual orientation, gender identity and expression, religion, political beliefs, marital status, pregnancy or childbirth, health status, or disability.
Be treated with respect and consideration for your privacy and dignity.
Get information (including through this handbook) about your health plan, provider, coverage, and benefits.
Get information in a way you can easily understand. Remember: interpretation, written translation, and auxiliary aids are available free of charge.
Access health care and services in a timely, coordinated, and culturally competent way.
Get information from your provider and health plan about treatment choices, regardless of cost or benefit coverage.
Participate in all decisions about your health care, including the right to say “no” to any treatment offered.
Ask your health plan for help if your provider does not offer a service because of moral or religious reasons.
Get a copy of your medical records and ask that they be changed or corrected in accordance with State and Federal Law.
Have your medical records and treatment be confidential and private. Sentara Health Plans will only release your information if it is allowed under federal or state law, or if it is required to monitor quality of care or protect against fraud, waste, and abuse.
Live safely in the setting of your choice. If you or someone you know is being abused, neglected, or financially taken advantage of, call your local DSS or Virginia DSS at 1-888-832-3858. This call is free.)
Receive information on your rights and responsibilities and exercise your rights without being treated poorly by your providers, Sentara Health Plans, or the Department.
Be free from any restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
File appeals and complaints and ask for a State Fair Hearing (see Section 8, Appeals and Complaints).
Voice a complaint or appeal about the organization or the care it provides.
Exercise any other rights guaranteed by federal or state laws (the Americans with Disabilities Act, for example).
Make recommendations regarding the organization’s member rights and responsibilities policy.
Ask about the Physician Incentive Plans

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 1-888 832-3858. 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

Sentara Health Plans 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.

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

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that Sentara Health Plans protect the confidentiality of your health information. We will not use or further release your health information except as necessary for treatment, payment, and health plan operations, as permitted or required by law, or as authorized by you.

Sentara Health Plans is required by law to maintain the confidentiality and security of your health information. We will only use or share your health information as needed to provide you with the care you need or as allowed by law unless you give us written permission to share it with others.

If you are receiving care or have a diagnosis for substance use disorder and/or addiction, recovery, and treatment services, you must provide us written permission to share your information unless the information is being shared with a company who is working for Sentara Health Plans in its efforts to provide you care and insurance benefits.

A complete description of your rights under HIPAA can be found in the Sentara Healthcare Notice of Privacy Practices. A copy of the notice is included in this handbook.

Your Right to Privacy

You have the legal right to see and receive a copy of your health information including your claims records. You have the right to correct your health information, request confidential communications, ask us to limit the information we share, and get a copy of the Sentara Healthcare Notice of Privacy Practices. You also have the right to request a list of who we have released your information to for certain circumstances. This is called an Accounting of Disclosures and may be obtained by calling Member Services.

You may file a complaint with Sentara Health Plans or with the Secretary of the U.S. Department of Health and Human Services, if you believe your privacy rights have been violated. Call Member Services to file a complaint with Sentara Health Plans.

General Responsibilities

As a Cardinal Care member, you have some responsibilities. This includes the responsibility to:

Follow this handbook, understand your rights, and ask questions when you do not understand or want to learn more.
Treat your providers, Sentara Health Plans staff, and other members with respect and dignity.
Choose your PCP and, if needed, change your PCP (see Section 3, Providers and Getting Care).
Be on time for appointments and call your provider’s office as soon as possible if you need to cancel or if you are going to be late.
Show your member ID card whenever you get care and services (see Section 2, Cardinal Care Managed Care Overview).
Provide (to the best of your ability) complete and accurate information about your medical history and your symptoms.
Understand your health problems and talk to your providers about treatment goals, when possible.
Work with your care manager and care team to create and follow a care plan that is best for you (see Section 4, Care Coordination and Care Management).
Invite people to your care team who will be helpful and supportive to be included in your treatment.
Tell Sentara Health Plans when you need to change your care plan.
Get covered services from the Sentara Health Plans network when possible (see Section 3, Providers and Getting Care).
Get approval from Sentara Health Plans for services that require a service authorization (see Section 7, Getting Approval for Your Services, Treatments, and Drugs).
Use the emergency room for emergencies only.
Pay for services you get that are not covered by Sentara Health Plans or the Department.

Call Sentara Health Plans Member Services at 1-800-881-2166 (TTY: 711) to let them know if:

Your name, address, phone number, or email have changed (see Section 1, Let’s Get Started).
Your health insurance changes in any way (from your employer or workers’ compensation, for example) or you have liability claims, like from a car accident.
Your member ID card is damaged, lost, or stolen.
You have problems with health care providers or staff.
You are admitted to a nursing facility or the hospital.
Your caregiver or anyone responsible for you changes.
You join a clinical trial or research study.

Reporting Fraud, Waste, and Abuse

As a Cardinal Care member, you are responsible for reporting suspected fraud, waste, and abuse concerns and making sure you do not participate in or create fraud, waste, and abuse. Fraud is an intentional deception or misrepresentation by a person who knows the action could result in an unauthorized benefit to themselves or someone else. Waste is overusing, underusing, or misusing Medicaid resources. Abuse is the practice of causing unnecessary cost to the Medicaid program or payment for services that are not medically necessary or that do not meet certain health care standards.

Examples of member fraud, waste, and abuse include:

Falsely reporting income and/or assets to qualify for Medicaid.
Permanently living in a state other than Virginia while receiving Cardinal Care benefits.
Using another person’s member ID card to get services.

Examples of provider fraud, waste, and abuse include:

Providing services that are not medically necessary.
Billing for services that were not provided.
Changing medical records to cover up illegal activity.

Information on how to report suspected fraud, waste, or abuse is included in the table below:

The Department’s Fraud and Abuse Hotline

Phone: 804-786-1066
Toll free: 1-866-486-1971
TTY: 711

Email: RecipientFraud@DMAS.virginia.gov

Mail: Department of Medical Assistance Services, Recipient Audit Unit
600 East Broad St Suite 1300
Richmond, VA 23219

Virginia Medicaid Fraud Control Unit (Office of the Attorney General

Phone: 804-371-0779
Toll free: 1-800-371-0824
TTY: 711
Fax: 804-786-3509

Email: MFCU_mail@oag.state.va.us

Mail: Office of the Attorney General, Medicaid Fraud Control Unit
202 North Ninth Street
Richmond, VA 23219