Common use of Your Rights as a Participant Clause in Contracts

Your Rights as a Participant. When you enroll in the LIFE Program, you have certain rights and protections. Your LIFE Provider must fully explain your rights to you or someone acting on your behalf in a way you can understand at the time you join. At the LIFE Program, we are dedicated to providing you with quality health care services so that you may remain as independent as possible. This includes providing all Medicare-covered items and services and Medicaid services, and other services determined to be necessary by the interdisciplinary team across all care settings, 24 hours a day 7 days a week. Our staff and contractors seek to affirm the dignity and worth of each participant by assuring the following rights: You have the right to be treated with dignity and respect at all times, to have all of your care kept private and confidential, and to get compassionate, considerate care. You have the right: • To get all of your health care in a safe, clean environment and in an accessible manner. • To be free from harm. This includes excessive medication, physical or mental abuse, neglect, physical punishment, being placed by yourself against your will, and any physical or chemical restraint that is used on you for discipline or convenience of staff and that you do not need to treat your medical symptoms. • To be encouraged and helped to use your rights in your LIFE Program. • To get help, if you need it, to use the Medicare and Medical Assistance complaint and appeal processes, and your civil and other legal rights. • To be encouraged and helped in talking to LIFE staff about changes in policy and services you think should be made. • To use a telephone while at the LIFE Center. • To not have to do work or services for your LIFE Program. Discrimination is against the law. Every company or agency that works with Medicare and Medical Assistance must obey the law. They cannot discriminate against you because of your: • Race • Ethnicity • National Origin • Religion • Age • Sex • Mental or physical disability • Sexual Orientation • Source of payment for your health care (For example, Medicare or Medical Assistance). If you think you have been discriminated against for any of these reasons, contact a staff member at your LIFE Provider to help you resolve your problem. If you have any questions, you can call the Office for Civil Rights at 0-000-000-0000. TTY users should call 0-000-000-0000. • To get accurate, easy-to-understand information and to have someone help you make informed health care decisions. • To have someone help you if you have a language or communication barrier so you can understand all information given to you. • To have your LIFE Provider interpret the information into your preferred language in a culturally competent manner, if your first language is not English and you can’t speak English well enough to understand the information being given to you. • To get marketing materials and LIFE participant rights in English and in any other frequently used language in your community. You can also get these materials in Braille, if necessary. • To have the enrollment agreement fully explained to you in a manner understood by you. • To get a written copy of your rights. Your LIFE Provider must also post these rights in a public place in the LIFE center where it is easy to see them. • To be fully informed, in writing, of the services offered by your LIFE Provider. This includes telling you which services are provided by contractors instead of the LIFE staff. You must be given this information before you join, at the time you join, and when you need to make a choice about what services to receive. • To be provided, upon request, with a copy of individuals who provide care- related services that are not provided directly by your LIFE Provider. • To look at, or get help to look at, the results of the most recent review of your LIFE Provider. Federal and State agencies review all LIFE Programs. You also have a right to review how your LIFE Provider plans to correct any problems that are found at inspection. You have the right to choose your health care providers, including your primary care provider and specialists, from within your LIFE Provider’s network and to get quality health care. Women have the right to get services from a qualified women’s health care specialist for routine or preventive women’s health care services. You have the right to reasonable and timely access to specialists as indicated by your health condition and consistent with current clinical practice guidelines. You have the right to receive care in all care settings, up to and including placement in a long-term care facility when your LIFE Provider can no longer provide you the services necessary to keep you safely in the community. You have the right to get emergency services when and where you need them without your LIFE Provider’s approval. A medical emergency is when you think your health is in serious danger— when every second counts. You may have a bad injury, sudden illness or an illness quickly getting much worse. You can get emergency care anywhere in the United States. You have a right to participate in treatment decisions. If you cannot fully participate in your treatment decisions or you want someone you trust to help you, you have the right to choose that person to act on your behalf. You have the right: • To have all treatment options explained to you in a language you understand, to be fully informed of your health status and how well you are doing, and to make health care decisions. This includes the right not to get treatment or take medications. If you choose not to get treatment, you must be told how this will affect your health. • To have your LIFE Provider help you create an advance directive if you choose. An advance directive is a written document that says how you want medical decisions to be made in case you cannot speak for yourself. You should give it to the person who will carry out your instructions and make health care decisions for you. • To participate in making and carrying out your plan of care. You can ask for your plan of care to be reviewed at any time. • To be given advance notice, in writing, of any plan to move you to another treatment setting and the reason you are being moved. • You have the right to talk with health care providers in private and to have your personal health care information kept private and confidential, including health data that is collected and kept electronically, as protected under State and Federal laws. • You have the right to look at and receive copies of your medical records and request amendments. • You have the right to be assured that your written consent will be obtained for the release of information to persons not otherwise authorized under law to receive it. • You have the right to provide written consent that limits the degree of information and the persons to whom information may be given. There is a patient privacy rule that gives you more access to your own medical records and more control over how your personal health information is used. If you have any questions about this privacy rule, call the Office for Civil Rights at 0-000-000-0000. TTY users should call 0-000-000-0000. • You have a right to complain about the services you receive or that you need and don’t receive, the quality of your care, or any other concerns or problems you have with your LIFE Provider. You have the right to a fair and timely process for resolving concerns with your LIFE Provider. You have the right: o To a full explanation of the complaint process. o To be encouraged and helped to freely explain your complaints to LIFE staff and outside representatives of your choice. You must not be harmed in any way for telling someone your concerns. This includes being punished, threatened, or discriminated against. • To contact 1-800-Medicare for information and assistance, including to make a complaint related to the quality of care or the delivery of a service. • To request services from the LIFE Provider that you believe are necessary. o To a comprehensive and timely process for determining whether those services should be provided. o To appeal any denial of a service or treatment decision by your LIFE Provider, staff, or contractors. If, for any reason, you do not feel that your LIFE Provider is what you want, you have the right to leave the program at any time and have such disenrollment be effective the first day of the month following the date the LIFE Provider receives the participant’s notice of voluntary disenrollment. If you have complaints about your LIFE Provider, think your rights have been violated, or want to talk with someone outside your LIFE Provider about your concerns, call the Department’s Participant Hotline at 0-000-000-0000. You may also contact 0-000-XXXXXXXX for information and assistance or to make a complaint related to the quality of care or delivery of a service. Participants and caregivers have the following responsibilities: • Accept help from your LIFE Provider without regard to race, religion, color, age, sex, national origin, or disability of the care provider. • While enrolled, agree to receive Medicare and Medical Assistance benefits only from your LIFE Provider. • Keep appointments or tell your LIFE Provider if an appointment cannot be kept. • Give accurate and complete information to your LIFE Provider. • Authorize your LIFE Provider to obtain and use records and information from hospitals, residential health care facilities, home health agencies, physicians and any other healthcare providers who treat you. • Authorize your LIFE Provider to disclose and exchange personal information with the federal and state government and their agents during reviews. • Actively participate in developing and agreeing to your care plan. • Inform your LIFE Provider of all health insurance coverage and tell your LIFE Provider promptly of any changes in that coverage. • Cooperate with your LIFE Provider in billing for and collecting applicable fees from Medicare and other third-party payers. • Notify the CAO and your LIFE social worker within 10 days of any changes in your income and assets. Assets include bank accounts, cash in hand, certificates of deposit, stocks, life insurance policies and any other assets. The state operates a fraud control program under which local, state, and federal officials may verify the information you have given. • Ask questions and request further information regarding anything you do not understand. • Use your LIFE Provider’s designated providers for services included in the benefit package. • Assist in developing and maintaining a safe environment for you, your family, and your caregivers. • Notify your LIFE Provider promptly of any change in address or absence from the service area. • Comply with all policies of the program as noted in this Enrollment Agreement. • Cooperate in receiving the services as outlined in your care plan. • Take your prescribed medicines as directed. • If you get sick or injured and it is not an emergency, call your LIFE Provider at (000) 000-0000 for information on what to do. • In case of emergency, call 911. • If emergency services are required elsewhere or out of the service area, you must tell your LIFE Provider within forty-eight hours or as soon as reasonably possible. • Tell your LIFE Provider before you voluntarily disenroll. • Pay required monthly fees, if applicable. LIFE arranges a full array of health and social services 24 hours a day, 7 days a week, 365 days a year. A LIFE health team, also known as the Inter-disciplinary Team (IDT) composed of geriatric doctors, nurses, social workers, rehabilitation specialists and other health care professionals assesses your needs and desires. The LIFE health team works with you, your family and/or caregiver to plan and approve the services your will receive. The LIFE health team will also monitor you for changes and provide timely interventions to assist you to SAFELY remain in the community for as long as possible. Primary care and community services are provided through the LIFE center and through our in-home program according to your needs. Authorization of Care - You will get to know each of your LIFE health team members very well, as they will work closely with you to be as healthy and independent as you can be. The LIFE health team will talk with you and arrange for the services that will provide the care you need. Before you can start or stop receiving services through your LIFE Provider, your LIFE health team must approve it. They will reassess your needs on a regular basis, at least every six months, but more frequently if necessary. All care planning includes you, and if you wish, family members and caregivers. center, which will be arranged for you as needed. When necessary, services may also be provided in your own home, in a hospital, or in a nursing facility. Your LIFE physician is part of the LIFE health team and will manage your specialty and hospital care. Your LIFE Provider has agreements with physician specialists (cardiologists, urologists, orthopedists, etc.), laboratory and diagnostic testing services (X-rays, Imaging, etc.), and with hospitals, and nursing facilities. These services may be provided at locations other than the LIFE center. Your LIFE Provider’s drivers may also provide transportation to the hospital and other appointments the LIFE health team arranges for you. This program is designed and developed specifically to sustain independence for adults 55 and older that need a nursing facility level of care by offering coordinated and integrated services through a single organization. Advantages of the program include: • Dedicated, qualified geriatric health professionals who know you personally. • Complete long-term care coverage. • Coordinated 24-hour advice and care. • Support for family caregivers. • Care designed specifically for your individual needs. • A single provider to oversee your care whether at home, in a hospital, or in a nursing facility. • No co-insurance, deductibles, or payments due for services you receive. o In some cases, there may be a monthly premium required to participate in the program based on your income. o Also, a monthly patient pay, also known as cost of care, amount as calculated by the CAO may be required if nursing facility services are utilized. The CAO will send you a notice to tell you the amount you must pay to the LIFE Provider. • Prior approval is not required to obtain emergency medical services. More detail is provided on page 19. Your LIFE Provider benefits must include all Medicare and Medical Assistance covered items and services and any other services determined necessary by your LIFE Health Team to improve and maintain your health status. All services provided or arranged by your LIFE Provider are fully covered when approved by the LIFE health team. Your LIFE Provider will give you a copy of your care plan, which outlines the services you will receive. As your needs change, your care plan will be updated, and you will be given a copy. Services you may receive include the following: ♦ Adult day health services. ♦ Transportation to and from the center and LIFE coordinated services. ♦ Primary medical and specialist care, including consultation, routine care, preventive health care and physical examinations. ♦ Nursing care. ♦ Social services. ♦ Physical, occupational and speech therapies. ♦ Recreational Therapy. ♦ Nutritional counseling and education. ♦ Laboratory tests, x-rays, and other diagnostic procedures. ♦ Covered Medications and biologicals. ♦ Prosthetics, orthotics, medical supplies, medical appliances, and durable medical equipment (per Medicare and Medical Assistance guidelines). ♦ Podiatry, including routine foot care. ♦ Vision care, including examinations, treatment, and corrective devices such as eyeglasses. ♦ Dental care (see the dental section for more detail). ♦ Psychiatry, including evaluation, consultation, diagnostic and treatment. ♦ Audiology, including evaluation, hearing aids, repairs, and maintenance. ♦ Behavioral Health. ♦ Palliative Care *.

Your Rights as a Participant. When you enroll in the LIFE Program, you have certain rights and protections. Your LIFE Provider must fully explain your rights to you or someone acting on your behalf in a way you can understand at the time you join. At the LIFE Program, we are dedicated to providing you with quality health care services so that you may remain as independent as possible. This includes providing all Medicare-covered items and services and Medicaid services, and other services determined to be necessary by the interdisciplinary team across all care settings, 24 hours a day 7 days a week. Our staff and contractors seek to affirm the dignity and worth of each participant by assuring the following rights: You have the right to be treated with dignity and respect at all times, to have all of your care kept private and confidential, and to get compassionate, considerate care. You have the right: • To get all of your health care in a safe, clean environment and in an accessible manner. • To be free from harm. This includes excessive medication, physical or mental abuse, neglect, physical punishment, being placed by yourself against your will, and any physical or chemical restraint that is used on you for discipline or convenience of staff and that you do not need to treat your medical symptoms. • To be encouraged and helped to use your rights in your LIFE Program. • To get help, if you need it, to use the Medicare and Medical Assistance complaint and appeal processes, and your civil and other legal rights. • To be encouraged and helped in talking to LIFE staff about changes in policy and services you think should be made. • To use a telephone while at the LIFE Center. • To not have to do work or services for your LIFE Program. Discrimination is against the law. Every company or agency that works with Medicare and Medical Assistance must obey the law. They cannot discriminate against you because of your: • Race • Ethnicity • National Origin • Religion • Age • Sex • Mental or physical disability • Sexual Orientation • Gender Identity • Source of payment for your health care (For example, Medicare or Medical Assistance). If you think you have been discriminated against for any of these reasons, contact a staff member at your LIFE Provider to help you resolve your problem. If you have any questions, you can call the Office for Civil Rights at 0-000-000-0000. TTY users should call 0-000-000-0000. • To get accurate, easy-to-understand information and to have someone help you make informed health care decisions. • To have someone help you if you have a language or communication barrier so you can understand all information given to you. • To have your LIFE Provider interpret the information into your preferred language in a culturally competent manner, if your first language is not English and you can’t speak English well enough to understand the information being given to you. • To get marketing materials and LIFE participant rights in English and in any other frequently used language in your community. You can also get these materials in Braille, if necessary. • To have the enrollment agreement fully explained to you in a manner understood by you. • To get a written copy of your rights. Your LIFE Provider must also post these rights in a public place in the LIFE center where it is easy to see them. • To be fully informed, in writing, of the services offered by your LIFE Provider. This includes telling you which services are provided by contractors instead of the LIFE staff. You must be given this information before you join, at the time you join, and when you need to make a choice about what services to receive. • To be provided, upon request, with a copy of individuals who provide care- related services that are not provided directly by your LIFE Provider. • To look at, or get help to look at, the results of the most recent review of your LIFE Provider. Federal and State agencies review all LIFE Programs. You also have a right to review how your LIFE Provider plans to correct any problems that are found at inspection. You have the right to choose your health care providers, including your primary care provider and specialists, from within your LIFE Provider’s network and to get quality health care. Women have the right to get services from a qualified women’s health care specialist for routine or preventive women’s health care services. You have the right to reasonable and timely access to specialists as indicated by your health condition and consistent with current clinical practice guidelines. You have the right to receive care in all care settings, up to and including placement in a long-term care facility when your LIFE Provider can no longer provide you the services necessary to keep you safely in the community. You have the right to get emergency services when and where you need them without your LIFE Provider’s approval. A medical emergency is when you think your health is in serious danger— when every second counts. You may have a bad injury, sudden illness or an illness quickly getting much worse. You can get emergency care anywhere in the United States. You have a right to participate in treatment decisions. If you cannot fully participate in your treatment decisions or you want someone you trust to help you, you have the right to choose that person to act on your behalf. You have the right: • To have all treatment options explained to you in a language you understand, to be fully informed of your health status and how well you are doing, and to make health care decisions. This includes the right not to get treatment or take medications. If you choose not to get treatment, you must be told how this will affect your health. • To have your LIFE Provider help you create an advance directive if you choose. An advance directive is a written document that says how you want medical decisions to be made in case you cannot speak for yourself. You should give it to the person who will carry out your instructions and make health care decisions for you. • To participate in making and carrying out your plan of care. You can ask for your plan of care to be reviewed at any time. • To be given advance notice, in writing, of any plan to move you to another treatment setting and the reason you are being moved. • You have the right to talk with health care providers in private and to have your personal health care information kept private and confidential, including health data that is collected and kept electronically, as protected under State and Federal laws. • You have the right to look at and receive copies of your medical records and request amendments. • You have the right to be assured that your written consent will be obtained for the release of information to persons not otherwise authorized under law to receive it. • You have the right to provide written consent that limits the degree of information and the persons to whom information may be given. There is a patient privacy rule that gives you more access to your own medical records and more control over how your personal health information is used. If you have any questions about this privacy rule, call the Office for Civil Rights at 0-000-000-0000. TTY users should call 0-000-000-0000. • You have a right to complain about the services you receive or that you need and don’t receive, the quality of your care, or any other concerns or problems you have with your LIFE Provider. You have the right to a fair and timely process for resolving concerns with your LIFE Provider. You have the right: o To a full explanation of the complaint process. o To be encouraged and helped to freely explain your complaints to LIFE staff and outside representatives of your choice. You must not be harmed in any way for telling someone your concerns. This includes being punished, threatened, or discriminated against. • To contact 1-800-Medicare (0-000-000-0000 TTY 0-000-000-0000) for information and assistance, including to make a complaint related to the quality of care or the delivery of a service. • To request services from the LIFE Provider that you believe are necessary. o To a comprehensive and timely process for determining whether those services should be provided. o To appeal any denial of a service or treatment decision by your LIFE Provider, staff, or contractors. If, for any reason, you do not feel that your the LIFE Provider Program is what you want, you have the right to leave the program at any time and have such disenrollment be effective the first day of the month following the date the LIFE Provider receives the participant’s your notice of voluntary disenrollment. If you have complaints about your LIFE Provider, think your rights have been violated, or want to talk with someone outside your LIFE Provider about your concerns, call the Department’s Participant Hotline at 0-000-000-0000. You may also contact 0-000-XXXXXXXX (0-000-000-0000 TTY 0-000-000-0000) for information and assistance or to make a complaint related to the quality of care or delivery of a service. Participants and caregivers have the following responsibilities: • Accept help from your LIFE Provider without regard to race, religion, color, age, sex, sexual orientation, gender identity, pregnancy, national origin, or disability of the care provider. • While enrolled, agree to receive Medicare and Medical Assistance benefits only from your LIFE Provider. • Keep appointments or tell your LIFE Provider if an appointment cannot be kept. • Give accurate and complete information to your LIFE Provider. • Authorize your LIFE Provider to obtain and use records and information from hospitals, residential health care facilities, home health agencies, physicians and any other healthcare providers who treat you. • Authorize your LIFE Provider to disclose and exchange personal information with the federal and state government and their agents during reviews. • Actively participate in developing and agreeing to your care plan. • Inform your LIFE Provider of all health insurance coverage and tell your LIFE Provider promptly of any changes in that coverage. • Cooperate with your LIFE Provider in billing for and collecting applicable fees from Medicare and other third-party payers. • Notify the CAO and your LIFE social worker within 10 days of any changes in your income and assets. Assets include bank accounts, cash in hand, certificates of deposit, stocks, life insurance policies and any other assets. The state operates a fraud control program under which local, state, and federal officials may verify the information you have given. • Ask questions and request further information regarding anything you do not understand. • Use your LIFE Provider’s designated providers for services included in the benefit package. • Assist in developing and maintaining a safe environment for you, your family, and your caregivers. • Notify your LIFE Provider promptly of any change in address or absence from the service area. • Comply with all policies of the program as noted in this Enrollment Agreement. • Cooperate in receiving the services as outlined in your care plan. • Take your prescribed medicines as directed. • If you get sick or injured and it is not an emergency, call your LIFE Provider at (000) 000-0000 for information on what to do. • In case of emergency, call 911. • If emergency services are required elsewhere or out of the service area, you must tell your LIFE Provider within forty-eight hours or as soon as reasonably possible. • Tell your LIFE Provider before you voluntarily disenroll. • Pay required monthly fees, if applicable. LIFE arranges a full array of health and social services 24 hours a day, 7 days a week, 365 days a year. A LIFE health team, also known as the Inter-disciplinary Interdisciplinary Team (IDT) composed of geriatric doctors, nurses, social workers, rehabilitation specialists and other health care professionals assesses your needs and desires. The LIFE health team works with you, your family and/or caregiver (if applicable) to plan and approve the services your will receive. The LIFE health team will also monitor you for changes and provide timely interventions to assist you to SAFELY remain in the community for as long as possible. Primary care and community services are provided through the LIFE center and through our in-home program according to your needs. Authorization of Care - You will get to know each of your LIFE health team members very well, as they will work closely with you to be as healthy and independent as you can be. The LIFE health team will talk with you and arrange for the services that will provide the care you need. Before you can start or stop receiving services through your LIFE Provider, your LIFE health team must approve it. They will reassess your needs on a regular basis, at least every six months, but more frequently if necessary. All care planning includes you, and if you wish, family members and caregivers. center, which will be arranged for you as needed. When necessary, services may also be provided in your own home, in a hospital, or in a nursing facility. Your LIFE physician is part of the LIFE health team and will manage your specialty and hospital care. Your LIFE Provider has agreements with physician specialists (cardiologists, urologists, orthopedists, etc.), laboratory and diagnostic testing services (X-rays, Imaging, etc.), and with hospitals, and nursing facilities. These services may be provided at locations other than the LIFE center. Your LIFE Provider’s drivers may also provide transportation to the hospital and other appointments the LIFE health team arranges for you. This program is designed and developed specifically to sustain independence for adults 55 and older that need a nursing facility level of care by offering coordinated and integrated services through a single organization. Advantages of the program include: • Dedicated, qualified geriatric health professionals who know you personally. • Complete long-term care coverage. • Coordinated 24-hour advice and care. • Support for family caregivers. • Care designed specifically for your individual needs. • A single provider to oversee your care whether at home, in a hospital, or in a nursing facility. • No co-insurance, deductibles, or payments due for services you receive. o In some cases, there may be a monthly premium required to participate in the program based on your income. o Also, a monthly patient paypay amount, also known as cost of care, amount as calculated by the CAO may be required if nursing facility services are utilized. The CAO will send you a notice to tell you the amount you must pay to the LIFE Provider. • Prior approval is not required to obtain emergency medical services. More detail is provided on page 19. Your LIFE Provider benefits must include all Medicare and Medical Assistance covered items and services and any other services determined necessary by your LIFE Health Team to improve and maintain your health status. All services provided or arranged by your LIFE Provider are fully covered when approved by the LIFE health team. Your LIFE Provider will give you a copy of your care plan, which outlines the services you will receive. As your needs change, your care plan will be updated, and you will be given a copy. Services you may receive include the following: ♦ Adult day health services. ♦ Transportation to and from the center and LIFE coordinated services. ♦ Primary medical and specialist care, including consultation, routine care, preventive health care and physical examinations. ♦ Nursing care. ♦ Social services. ♦ Physical, occupational and speech therapies. ♦ Recreational Therapy. ♦ Nutritional counseling and education. ♦ Laboratory tests, x-rays, and other diagnostic procedures. ♦ Covered Medications and biologicals. ♦ Prosthetics, orthotics, medical supplies, medical appliances, and durable medical equipment (per Medicare and Medical Assistance guidelines). ♦ Podiatry, including routine foot care. ♦ Vision care, including examinations, treatment, and corrective devices such as eyeglasses. ♦ Dental care (see the dental section for more detail). ♦ Psychiatry, including evaluation, consultation, diagnostic and treatment. ♦ Audiology, including evaluation, hearing aids, repairs, and maintenance. ♦ Behavioral Health. ♦ Palliative Care *.