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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:

  • Be treated with respect and dignity.
  • Have your privacy protected.
  • Look at your medical records.
  • Have a copy of your medical record.
  • Request a change to your medical record.
  • Have your doctor explain your care in a way that you understand.
  • Talk to your doctor or nurse about your care.
  • Talk to your doctor about all care options.
  • Get a second opinion.
  • Have questions answered by your provider.
  • Make decisions about the care you get.
  • Say “NO” to care that you don’t want.
  • Get quick and easy access to care.
  • Have an interpreter provided.
  • Change your PCP.
  • Be told why health services were denied.
  • Be free from discrimination or retaliation.
  • Have an interpreter provided for any grievance or appeal.
  • Submit a grievance by phone or in writing.
  • Request a Fair Hearing if your appeal is denied.
  • Have access to reasonable accommodations.
  • Get a timely answer to your grievance.
  • Receive health care services as state and federal law provides.
  • Receive information about CountyCare.
  • Receive information in another language or format.

You have the responsibility to:

  • Choose a PCP.
  • Participate in your own healthcare.
  • Make and keep appointments.
  • Cancel appointments you cannot keep.
  • Present your CountyCare ID and Medicaid card when getting services.
  • Tell your doctor what he or she needs to know to treat you.
  • Follow the treatment plan agreed upon by you and your doctor.
  • Keep your information up to date.
  • Tell us if you have 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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