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Members Rights and Policies

We want to share with you some important information about CountyCare.

In this section, you will learn about:

  • Rights and Responsibilities
  • Grievances and Appeals
  • Fraud, Waste and Abuse

Rights and Responsibilities

CountyCare members have rights and responsibilities as summarized below. You are able to use your rights without any action taken against you. See the Member Handbook for a complete list of Member Rights and Responsibilities.

You have the right to:

  • Receive the facts about CountyCare Health Plan, our services, our practitioners and providers who contract with us to provide services
  • Receive the member handbook in a language you understand or in a way that meets your needs, such as audio CDs, large print or Braille.
  • Receive healthcare services in ways that comply with federal and state law. We must make covered services accessible to you. When medically needed, services must be available 24 hours a day, seven days a week.
  • Receive information about CountyCare and its services and providers. To get this information, visit www.countycare.com or call 312-864-8200 / 855-444-1661 (toll-free) / 711 (TDD/TTY).
  • Ask for an interpreter and have one there during any covered service.
  • Receive information about CountyCare Member Rights and Responsibilities policy. You also have the right to suggest changes in this policy.
  • Have a candid discussion with your provider about appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
  • Know about different treatment options and know your choices. This includes the right to ask for a second opinion, which is another provider’s view of your condition and what treatments you might need. Providers must explain your condition and your treatment options in ways you understand.
  • Make decisions about your healthcare. This includes the right to refuse treatment.
  • Be treated with respect and with care for your dignity and privacy.
  • Appeal a decision made by CountyCare on the phone or in writing.
  • Have an interpreter during any complaint or appeal process.
  • Be free from any form of restraint or seclusion used as way to force, control, ease of reprisal or retaliate.
  • Request and receive a copy of your medical records.
  • Request an amended or corrected version of your medical records.

You have the responsibility to:

  • Choose a PCP under this plan
  • Participate in your own healthcare, including making and keeping appointments
  • Provide the information necessary, to the extent possible, that CountyCare, our practitioners and providers need in order to care for you
  • Let your doctor know as soon as possible when you can’t make an appointment
  • Present your CountyCare ID card and state of Illinois Medicaid card when getting care or medicine
  • Know your health problems and take part in making mutually agreed upon treatment goals as much as possible
  • Follow the treatment plan agreed upon by you and your doctor
  • Keep your information up to date; tell your case worker about changes in income or address
  • Tell both your provider and your case worker if you have other insurance and follow the guidelines of your other insurance

Member Grievances and Appeals

CountyCare has a process for members to give us feedback. You can file a grievance when you have a complaint. You can file an appeal when a service is denied.

Member Grievances

A member grievance is a complaint about any matter other than a denied, reduced, or terminated service or item. CountyCare takes member grievances seriously. We want to know what is wrong so we can make our services better. Let us know right away if you have a grievance. To have someone else act on your behalf in an grievance, complete and return the Authorized Representative form. The person listed will be accepted as your authorized representative. We are unable to speak with this person on your behalf unless this form is completed, signed, and returned to us.

These are examples of when you might want to file a grievance:

  • Your provider did not respect your rights.
  • You did not get an appointment in a timely fashion.
  • You were unhappy with the quality of care you received.
  • A CountyCare staff member was rude.
  • Your provider or a CountyCare staff member was insensitive to your needs.

Filing a grievance will not affect your healthcare services or your benefits coverage. You can file your grievance by phone or in writing. Members can get help filing a grievance by calling Member Services. See the Member Handbook for more information on the grievance process.

Member Appeals

You can appeal any decision that CountyCare makes about your care. If a requested service or item cannot be approved, or if a service is reduced or stopped, you will get a Notice of Action (NOA) letter. You may appeal within 60 calendar days of the date on the NOA letter. To have someone else act on your behalf in an appeal, complete and return the Authorized Representative form. The person listed will be accepted as your authorized representative. We are unable to speak with this person on your behalf unless this form is completed, signed, and returned to us.

You may want to appeal if CountyCare:

  • Did not approve care your provider asked for.
  • Did not pay for care your provider asked for.
  • Stopped a service that was approved before.
  • Did not arrange for timely care.

You can get help filing an appeal by calling Member Services. Appeals can be filed by phone or in writing. Members filing an appeal by phone must follow-up in writing. For more information on Member Appeals, please see the Member Handbook.

Fraud and Abuse

Fraud is when a person gets benefits or payments to which he is not entitled. Please let us know if you think someone is committing fraud. This could be a provider or a member.

Some examples of fraud include:

  • Lying on a CountyCare or Medicaid form
  • Using someone else’s ID card
  • A provider billing for services not done

You can report any suspected fraud by calling Member Services. You can also use our Fraud and Abuse hotline at 844-509-4669. All information is private.

Abuse and Neglect

CountyCare knows that members often rely on others to help with healthcare needs. Sometimes someone who is supposed to help takes advantage of another person. This may be a provider or a family member. It is important to recognize the signs of abuse and neglect. We want CountyCare members to report abuse or neglect immediately.

What Is Neglect?

Neglect occurs when a caregiver withholds food, clothing, shelter, or medical care.

What Is Abuse?

Abuse means causing physical or mental harm. This can also be taking advantage of a person’s financially.

  • Physical abuse is contact that causes bodily harm. For example, being hit or stabbed.
  • Sexual abuse is any sexual behavior or contact that occurs without permission.
  • Mental abuse includes yelling, name calling or threats. Controlling behavior, embarrassment, or social isolation are also types of mental abuse.
  • Financial abuse is when someone uses someone else’s money without consent.

What Can I Do?

If you believe that you or someone else is being taken advantage of or hurt by someone, report it. All information is private.

There are many ways to report fraud and abuse:

CountyCare Member Services: 312-864-8200
855-444-1661 (toll-free)
711 (TDD/TTY)
CountyCare Fraud and Abuse hotline: 844-509-4669
DHS Office of the Inspector General: 800-368-1463
IL Department on Aging: 866-800-1409
888-206-1327 (TTY)
Senior Helpline: 800-252-8966
888-206-1327 (TTY)
IL Department of Public Health: 800-252-4343
Complete the Critical Incident Reporting Form and return:
  • Fax: (312) 548-9940
  • Mail:
    • CountyCare Administrative Offices
      1900 West Polk Street
      Suite 220C Chicago, IL 60612

See the Member Handbook for more information about Fraud, Abuse and Neglect.


  

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