Member Rights & Policies

• Be treated with respect and dignity at all times.
• Have your personal health information and medical records kept private except where allowed by law.
• Receive information about CountyCare Member Rights and Responsibilities. You also have the right to suggest changes to this policy.
• Receive, in a reasonable amount of time, information about CountyCare Health Plan, and its services, providers, and polices.
• Participate with providers in making decisions about your health care treatment, including the right to refuse treatment.
• 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.
• Be protected from discrimination.
• Receive information, including the Member Handbook, in other languages such as audio, large print or Braille.
• Request an interpreter when needed.
• File a complaint (sometimes called a grievance), or appeal about CountyCare or the care you received without fear of punishment of any kind. You can request an interpreter during any complaint or appeal process.
• Appeal a decision made by CountyCare on the phone or in writing.
• Request and 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.
• Receive health care 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.
• Be free from any form of restraint or seclusion used for convenience or as a way to force, discipline, or retaliate.

• 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 its 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.

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. CountyCare has special procedures in place to help members who file grievances. We will do our best to answer your questions to resolve your concern. Filing a grievance will not affect your health care services or your benefits coverage.

To have someone else act on your behalf in a 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.

• 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.

You can file your grievance on the phone by calling Member Services at 312-864-8200/855-444-1661 (toll-free)/711 (TDD/TTY). You can also file your grievance in writing via mail or fax to:

CountyCare Health Plan
P.O. Box 21153
Eagan, MN 55121
Fax: 866-200-5031

We will try to resolve your grievance right away. If we cannot, we may contact you for more information.

If you have questions or would like more information on Member Grievances, please see the Member Handbook or call Member Services.

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 Adverse Benefit Determination letter. You may appeal within 60 calendar days of the date on the letter.

If you want your services to stay the same while you appeal, you must say so when you appeal. And, you must file your appeal no later than ten (10) calendar days from the date on the Adverse Benefit Determination 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.

• 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.

There are two ways to file an appeal:

1. Call Member Services at 312-864-8200 / 855-444-1661 (toll-free) / 711 (TDD/TTY). If you file an appeal over the phone, you must follow it with a written signed appeal request.
2. Mail or fax your written appeal request to:

CountyCare Health Plan
P.O. Box 21153
Eagan, MN 55121
Fax: 866-200-5031

You can get help filing an appeal by calling Member Services. For more information on Member Appeals, please see the Member Handbook (Spanish, Polish).

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

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.

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.

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

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

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, abuse or neglect:

• 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 fax it to 312-637-8312

See the Member Handbook (Spanish, Polish) for more information about Fraud, Abuse and Neglect.