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Your Rights and Responsibilities

HSCSN and our team of health care professionals are proud partners in your health care. As a member, you have a right to certain services. It is our job to make sure we respect those rights. As partners, it is important that you help us, help you. By working together, we can deliver the best care possible and ensure that you get the most out of your benefits, at all times.

Here is a summary of your rights and responsibilities as a member.

HSCSN will provide written information to enrollees within five (5) business days of an enrollee’s request. All such information shall be prepared in advance and requires DHCF's prior approval.

  1. It is the enrollee’s and family’s right to:
    1. Be treated in a caring, respectful, culturally-sensitive, and professional manner by HSCSN staff and recognition of their dignity and right to privacy.
    2. Receive information about HSCSN, its services, cost sharing, if any; its care providers, and enrollee rights and responsibilities annually and at least 30 days prior to any change; and know the names and titles of all health care professionals involved in the enrollee’s care.
    3. Make recommendations regarding the organization’s enrollee rights and responsibilities.
    4. Be notified in writing annually and at least 30 days prior whenever circumstances occur that affect the following: membership or benefits; authorization requirements; referrals process for specialty care and other benefits not furnished by enrollee’s primary care provider; any provider changes; after hours and emergency care services; locations of any emergency settings at which providers and hospitals furnish emergency and post-stabilization services and the right of enrollees to choose which location for these services; and methods for notifying enrollees will be mailings, enrollee newsletter, website and loop tape messages.
    5. Choose and change the child’s or young adult’s PCP among network providers without restrictions and/or care manager to meet their needs.
    6. Understand the child or young adult’s health problems and consent to treatment before it is provided.
    7. Understand prior authorization procedures (i.e. authorization is not required for emergency services); know the use of 911 telephone system; and know what constitutes emergency medical conditions and post-stabilization services and rules.
    8. To have a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
    9. Be a part of the decision making process regarding the child or young adult’s health care, and the right to say yes or no to treatment before it is given to the enrollee. Enrollees have the right to seek a second opinion and/or to refuse proposed treatment.
    10. If an appropriately qualified provider is not available within the network, HSCSN shall arrange for a second opinion outside the network at no charge to the enrollee.
    11. Help develop and receive a current copy of your child or young adult’s plan of treatment.
    12. Be transported to all medically necessary appointments.
    13. Receive information about the child or young adult’s treatment and HSCSN’s policies in a language that allows you to understand and make decisions.
    14. Voice concerns, complaints, and grievances to HSCSN staff and receive a timely response.
    15. Contact the DC Department of Health Care Finance (DCHCF) ombudsman and/or receive a fair hearing about concerns, complaints, or grievances at any time without fear of retribution, even receiving assistance from HSCSN or DCHCF staff if needed.
    16. Designate advance directives about the child or young adult’s care in situations where there is danger of death, and create advance directives stating what you want done if you are unable to make your own medical decisions, if you are 18 years of age or older, chronologically and functionally; provide enrollees with information reflecting changes in state law no later than 90 days after the effective date of the change.
    17. Have the child or young adult’s medical records kept confidential and released generally only with written permission from a parent, legal guardian, or emancipated minor.
    18. Be able to request and receive a copy of his or her medical records, and request that they be amended or corrected as specified in 45 Code of Federal Regulations (C.F.R.) sec. 164.524 and 164.526.
    19. If required by law, be notified in writing within 10 days, when information concerning your child’s care has been released in response to an attorney request, subpoena, and/or court order.
    20. Have the child or young adult receive considerate health care with privacy during treatment, interviews, and any care planning meetings.
    21. Have access to HSCSN’s health care services for the child or young adult 24 hours a day, every day of the year.
    22. Enrollees and/or their authorized caregivers have the right not to be subjected to intimidation, coercion, discrimination, or retaliation for any reason.
    23. Every newly eligible or current enrollee with limited English proficiency or no English (LEP) will receive an oral interpreter, translation, and/or sign service free of charge when requested.
    24. Have all vital documents translated in other languages and formats for those visually limited or who have limited reading proficiency available to newly eligible and current enrollees approved by DCHCF.
    25. An enrollee with Limited English Proficiency (LEP) has the right to file a complaint or grievance if oral and translation services are not provided in a timely manner.
    26. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, and/or retaliation.
    27. Have knowledge of HSCSN’s financial condition, structure and operation; enrollees will not be held liable for any debts of HSCSN or payments for covered services in the event of HSCSN’s insolvency.
    28. Description of HSCSN’s prescription drug formulary, the Dispense as Written (DAW) policy, and the enrollee’s right to have a prescription filled, while a prescription is being disputed under a grievance or appeals process.
    29. A description of HSCSN’s Physician Incentive Plans (PIPs) in accordance with 42 Code of Federal Regulations (C.F.R.), Section 417.479(h)(3).
    30. Summaries of any enrollee satisfaction survey in accordance with the requirements found at 42 C.F.R. sec. 438.10(i)(3)(iv).
    31. Receive family planning services and supplies from any DCHCF provider in the District of Columbia.
    32. Receive a copy of this enrollee handbook and a provider directory.
  2. It is the enrollee’s and family’s responsibility to:
    1. Treat HSCSN staff and providers with the same courtesy and respect that you expect when receiving health care or care coordination services.
    2. Actively participate with the child or young adult’s providers and care managers in developing and following plans and instructions for care that they have agreed on with their providers.
    3. Understand the child’s or young adult’s health problems and participate in developing agreed upon treatment goals to the degree possible.
    4. Notify the child or young adult’s care manager and PCP if you would like to make a change in the plan of treatment.
    5. Have the child or young adult’s membership card and shot record available when receiving health care services.
    6. Keep all health care visits and notify the provider and HSCSN 24 hours in advance (or as soon as possible) when appointments are cancelled.
    7. Be ready when scheduled transportation arrives to pick up the child or young adult for a health care visit.
    8. Have a grown-up (adult) with enrollees under 18 years old when going to medical office visits. The grown-up has to stay with the enrollee during the ride to the medical appointment and while the enrollee is seeing the provider (doctor, dentist, etc.)
    9. Be ready to receive your child or youth when the transportation company returns from a scheduled health care visit or school activity.
    10. Ensure there is a responsible adult available to receive the child if you are not able to be there or are detained.
    11. Provide HSCSN with appropriate written releases of information (ROI) when requested.
    12. Notify HSCSN and Economic Security Administration (ESA) immediately about changes in name, address, telephone number, emergency contact person, when a enrollee is pregnant or has had a child while enrolled with HSCSN, death of a parent or legal guardian or enrollee, loss of SSI, placed in an institution, incarcerated, death or other information that affects our ability to contact you about the child or young adult’s health.
    13. Inform your child or young adult’s providers and care manager about your child’s medical history, answering questions to the best of your knowledge.
    14. Be an active advocate for your child or young adult’s best health by informing the HSCSN care manager, the network provider and/or DC Health Care Finance about your complaints and grievances.
    15. All clinical trials and experimental medications must be pre-authorized.
    16. Go to the Emergency Room only if you have a medical emergency.
    17. Help your doctor in getting medical records from providers who have treated you in the past.
    18. Report to Economic Security Administration (ESA) and HSCSN if you or a family member has other health insurance.
    19. Know the benefits and services available to the child or young adult with special health care needs under the HSCSN program.
    20. Do not engage in fraud or abuse in dealing with HSCSN, your primary care provider, or other providers.