Member Rights and Responsibilities

Rights ~ Respect & Dignity

You have the right to get covered services without concern about race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, the ability to pay or the ability to speak English.
You have the right to receive quality medical services that support your personal beliefs, medical condition, and background in a language you understand.
If you do not speak English, we have a service to help us help you get the medical services you need.

The name of your PCP and/or case manager
A copy of your medical records (as allowed by law)
Services, providers, and your rights & responsibilities
How Capstone pays providers, controls cost and uses services, general appeal results, summary of Member survey results and the health plan's financial status.
Treatment choices and health care benefits with pro's & con's of each choice.
Advance directives and information on how to have medical decisions made for you if you are not able to make them yourself.
If your services change or if your PCP stops participating with the health plan.

Choose a Health Plan PCP and change your PCP when needed.
Talk with your PCP, get information about your condition so you and/or your family understand and can help make decisions about your health care.
You can be informed about which procedures you will have and who will do them.
You can decide who you want to be there for treatments and exams.
You can have a female in the room for breast and pelvic exams.
You can say no to treatment, services or PCPs and be told what may happen if you do not have the treatment. Your eligibility or medical coverage does not depend on your agreement to follow a treatment plan.
We will let you know when health care services your PCP requests are suspended, reduced, terminated, or denied in writing. You must follow the instructions in your notification letter if you do not agree and want to appeal the decision.

You can get emergency health care services without the approval from your PCP or Capstone Health Plan when you have a true medical emergency.
You can see a specialist (with approved referrals).
You can refuse care from a doctor you were referred to and ask for a different doctor or for a second opinion.

Treat Capstone staff with respect and dignity.
Treat your PCP, doctors, dentist and their staff with respect and dignity.
Schedule appointments during office hours whenever possible instead of using urgent care facilities and/or emergency rooms.
Arrive to scheduled appointments on time.
Give 24-hour cancellation notice when possible.

Read your Member Handbook and all Capstone communication sent to you.
Know the name of your PCP.
Give information needed by professional staff giving services to you.
Bring your ID card to each appointment.
Bring shot records to every appointment for children 18 years of age and younger.
Sign a Medical Release Form when changing PCP's. Schedule a "get-to-know-you" appointment as soon as you can.

Read this handbook.
Follow the instructions you and your PCP have agreed to. Ask what can happen if you choose not to follow these instructions.