CountyCare - Members Rights and Policies

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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.

Member Rights:

  • Be treated with respect and dignity at all times.
  • Have your personal health information and medical records kept private except where allowed by law.
  • Be protected from discrimination.
  • Be free from any form of restraint or seclusion used as a way to force, control, and ease of reprisal or retaliation.
  • Receive information, including the Member Handbook from CountyCare in other languages such as audio, large print or Braille.
  • Have use of an interpreter when needed.
  • Have a candid discussion with your provider about appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
  • Receive information on available treatment options and alternatives. This includes the right to ask for a second opinion. Providers must explain your treatment options in a way you understand.
  • Receive information necessary to be involved in making decisions about your healthcare treatment and choices.
  • Refuse treatment and be told what may happen to your health if you do.
  • Receive a copy of your medical records and in some cases request that they be amended or corrected.
  • Choose your own primary care provider (PCP) from CountyCare. You can change your PCP at any time.
  • File a complaint (sometimes called a grievance), or appeal about CountyCare or the care you received without fear of mistreatment or backlash of any kind.
  • Appeal a decision made by CountyCare on the phone or in writing.
  • Have an interpreter during any complaint or appeal process.
  • Request and receive in a reasonable amount of time, information about CountyCare Health Plan, and its providers, services and polices.
  • Receive information about CountyCare Member Rights and Responsibilities. You also have the right to suggest changes in this policy.
  • Receive healthcare services in ways that comply with federal and state law. CountyCare must make covered services accessible to you. Services must be available 24 hours a day, seven days a week.

Member Responsibilities:

  • Treat your doctor and the office staff with courtesy and respect.
  • Carry your CountyCare ID card with you when you go to your doctor appointments and to the pharmacy to pick up your prescriptions.
  • Keep your appointments and be on time for them.
  • If you cannot keep your appointments cancel them in advance.
  • Provide as much information as possible so that CountyCare and their providers can give you the best care possible.
  • Know your health problems and take part in making decisions about your treatment goals as much as possible.
  • Follow the instructions and treatment plan agreed upon by you and your doctor.
  • Tell CountyCare and your caseworker if your address or phone number changes.
  • Tell CountyCare and your case worker if you have other insurance and follow those guidelines.
  • Read your member handbook so you know what services are covered and if there are any special rules.

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: 312-637-8312
  • 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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