For Members: Member Online Services

Member Handbook - Member Rights and Responsibilities

As a Medicaid member, you have certain rights and responsibilities.

Member Rights

You have the right to:

  • Be treated with respect, dignity and regard for your privacy;
  • Be free from discrimination on the basis of race, religion, gender, age, disability, health status, or sexual orientation;
  • Get information on treatment options. You should get information in a way that is easy to understand; 
  • Take part in decisions made about your health care. This includes the right to refuse treatment, except as required by law;
  • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation;
  • Ask for and get a copy of your medical records. You can ask that they be changed or corrected;
  • Have an independent advocate;
  • Ask that we include a specific provider in our network;
  • Get a second opinion;
  • Receive culturally competent services;
  • Get interpreter services if you have disabilities or if you do not speak English;
  • Be told if your provider stops seeing members, or has changes in services;
  • Tell others your opinion about our services. You can tell regulatory agencies, the government, or the media without it affecting how we provide covered services;
  • Get medically necessary mental health care services according to federal law;
  • Be free to use all of your rights without it affecting how you are treated; and
  • Be free from sexual intimacy with a provider. If this happens, report it to the Colorado Department of Regulatory Agencies (DORA) at 303-894-7788. Or write to DORA at 1560 Broadway, Suite 1350, Denver 80202.

Member Responsibilities

You have the responsibility to:

  • Learn about your mental health benefits and how to use them;
  • Be a partner in your care. This means:
    • Following the plan you and your care coordinator have agreed on;
    • Participating in your treatment and working toward the goals in your service plan;
    • Taking medications as agreed upon between you and your prescriber.
  • Tell your therapist or doctor if you do not understand your service plan. You should tell him or her if you do not agree with your service plan, or want to change it.
  • Give your therapist or doctor the information he or she needs to give you good care. This includes signing releases of information so that your providers can coordinate your care.
  • Come to your appointments on time. You should call the office if you will be late, or if you can’t keep your appointment.
  • Cooperate with CHP when you choose a provider or are seen by your provider. If you have questions about choosing a provider, or how to make an appointment, call CHP at 1-800-804-5008
  • Let us know when you change your address or phone number.
  • Treat others with the same courtesy and respect that you expect to be treated.

Confidentiality

Information about your mental health services is considered “protected health information” (PHI). We will only use your PHI to make sure that you get good mental health care and for activities of payment. For example, we can only use PHI:

  • For treatment. We may share your health information with those who are involved in providing your healthcare.
  • For coordinating your care among providers, or between a provider and an insurance company.
  • To communicate with mental health professionals who have given you services so we can pay claims.
  • To look at how our members use services. This helps us to provide better care.
  • When required by law. We will share PHI when federal, state or local law requires it. We will share PHI if we get a court order or if your records are subpoenaed.
  • To collect information about disease or injury to report it to a public health authority.
  • In order to avoid a serious threat to health or safety. We may share PHI with law enforcement or other persons if we believe this is necessary to prevent or reduce the threat of harm

WHAT IF I HAVE PROBLEMS WITH SERVICES OR MY RIGHTS ARE NOT RESPECTED?

At Colorado Health Partnerships (CHP), we care about you and the quality of services that you get. We work hard to give you the best care. We are always trying to improve how we serve you. If you have problems with your services or if you disagree with a clinical decision, we need to hear from you.

Medicaid has a process for you to file a grievance (complaint) about your services. Medicaid also has a process for you to appeal a denial or reduction in service. Our Office of Member and Family Affairs staff can help you file a complaint or appeal. You can also contact our Engagement Center to start an appeal process.

Process for Grievances (Complaints) and Appeals

Terms (Definitions)

Action: An Action is when CHP:

  1. Denies or limits all or part of a requested treatment.
  2. Reduces, changes or ends treatment that was already approved.
  3. Denies payment in whole or in part for a service.
  4. Does not provide services in a timely manner.
  5. Fails to act within approved timeframes for grievances and appeals.
  6. Denies a request to obtain treatment outside the network in rural areas.

Appeal: An Appeal is when a member disagrees with an Action by CHP and asks for a review of the Action. 

Designated Client Representative (DCR): This is a person whom you name to file a grievance or appeal on your behalf. This person can be one of your service providers, including your doctor, a friend or a family member.

Grievance:  A Grievance is when a member complains about his or her mental health services, a provider or staff. Members can file a Grievance about any dissatisfaction with a service or staff person. 

Notice of Action:This is a letter which explains the Action CHP is taking and your Appeal rights.

State Fair Hearing Process:  This is a hearing before a state administrative law judge and is available for Appeals only.

How to File a Grievance:
If you are comfortable doing so, it is a good idea to talk directly with your provider or a supervisor so that problems can be fixed quickly. If you don’t want to do that, or if you have tried that and are still not satisfied, there are many ways you can file a grievance:

  • Contact the Client or Family Advocate at your mental health center: They are listed in Community Mental Health Centers
  • Contact the Office of Member and Family Affairs at 1-800-804-5040
  • Contact the Ombudsman for Medicaid Managed Care at 1-303-830-3560, 1-877-435-7123, TTY 1-888-876-8864. They will help you file a grievance with the BHO.

You may ask a family member, friend or provider to file a grievance for you. However, you must make that person your “Designated Client Representative.” This is a person whom you name to file a grievance or appeal on your behalf. This person can be one of your service providers. This means that you sign a form naming that person as your DCR and sign a Release of Information for CHP to share information with that person. 

You can file your grievance in person, on the phone, or by letter or grievance form. You must file your grievance within 30 calendar days from when the event happened.
You need to tell us your name and the best way to contact you. 

After we receive your grievance, we will send you a letter within two (2) working days telling you we received the grievance and asking you to tell us if we understood you correctly. 

We will look into your grievance and may call you for more information. If your grievance involves a clinical issue, we will talk to a clinical person who was not previously involved. This process is confidential. You or your family member will not lose your Medicaid benefits for filing a grievance.    

Within 15 working days after we get your grievance, we will mail you a letter with our decision. If you, or we, need more time to get information about your grievance that is in your best interest, we will extend the time for up to fourteen (14)more calendar days. We will send you a letter telling you why and how it is in your best interest to get the information. 

The decision letter will explain that if you do not agree with our decision, you can appeal to the Department of Health Care Policy and Financing (HCPF). To do so, contact:

Medicaid Customer Service at
303-866-3513 (Denver Metro area)
1-800 221-3943 (outside the Metro area)
TTY 303 866-7471

**The decision of HCPF will be final.

How to File an Appeal (Appeal an Action)

If you disagree with the decision in the notice of action, defined at the beginning of this section on grievances and appeals, you have the right to file an appeal. Staff of the BHO Office of Member and Family Affairs can help you in any way you need to file an appeal with the BHO or with the Office of Administrative Courts for a State Fair Hearing.

You must make your appeal to CHP within 30 calendar days from when we sent the Notice of Action. You can make your appeal in person or by phone, but must follow up in writing. You may ask a family member or friend or provider to appeal for you. However, you must make that person your Designated Client Representative (DCR). This means that you sign a form naming that person as your DCR and sign a Release of Information for CHP to share information with that person. An expedited (quick) appeal process is available if the standard time for resolving an appeal would cause harm.

What if my treatment was already approved, but the BHO now wants to stop my treatment?

This is a special situation.
When CHP sends you a Notice that it plans to stop or reduce a treatment that was already approved, you can appeal and ask that the service continue. For this to happen, there are several things you must do: 

  • You or your provider must file the appeal timely. Timely means that you must make your appeal within 10 calendar days from when CHP sent the Notice or 10 calendar days on or before the treatment was scheduled to stop or change—whichever is later. 
  • The services (treatment) must have been ordered by an authorized provider
  • The original period covered by the original authorization has not expired, and
  • You must ask that the benefits (services) continue. 

If the service is continued, it is for a limited time. The services will continue only until one of the following happens:

  • You withdraw your appeal;
  • Ten days pass after CHP mails the Resolution (decision) on your appeal;  Unless, within the 10-day period, you have asked for a State fair hearing and services to continue until the hearing decision is reached;
  • The decision of the State fair hearing is to stop your services;
  • The time period or service limits of the original authorization has been met.

Who can I file an appeal with?

There are many ways you can file an appeal.

  • Contact the CHP Care Management Department at 1 800-804-5008 or write them at:

Colorado Health Partnerships
Care Management Department
Grievance and Appeals Department
9925 Federal Drive, Suite 100
Colorado Springs, CO 80921

  • Contact the Client Advocate at your Community Mental Health Center
  • Contact the Ombudsman for Medicaid Managed Care at 1-303-830-3560, 1-877-435-7123, TTY 1-888-876-8864. They will help you file your appeal.
  • Contact the state Office of Administrative Courts directly. You do not have to file with CHP first, but you must let CHP know you have contacted the Office of Administrative Courts. Their contact information is:

Office of Administrative Courts
1525 Sherman Street, 4th Floor
Denver, CO 80203
303-866-2000
Fax 303-866-5909

If you appeal to CHP, we will send you a letter to let you know we got your appeal. We will do this within two working days. The letter will also tell you more about the appeal process including the fact that you can provide evidence of fact or law in person.

We will make a decision within ten calendar days. If we need more time, we will send you a letter telling you why and how it is in your best interest. The letter will also tell you when to expect a decision. When we make the decision, we will send you a letter. We will also try to call you on the telephone. If you need more time (for example, to collect more information about your appeal), you can also ask for more time.

If you think a delay could be harmful to your health, you can ask for an expedited (quicker) appeal. In that case, we will send you a decision letter within three calendar days of the date we got your expedited appeal. We will also try to call you on the phone.

If you need more time to get information to help your appeal, or if we need more time, we will extend the time of the decision letter for up to fourteen (14) more calendar days. We will send you a letter telling why more time is needed and why it is in your best interest for us to get the information. It will tell you when to expect the decision.

What if I disagree with CHP’s decision about my appeal?

If you are not satisfied with our decision on your appeal, you may ask for a State fair hearing. You do this by filing an appeal with the Office of Administrative Courts. You must do this within 60 calendar days from the date of the Notice of Action. You must appeal within ten (10) calendar days about a previously authorized service. We encourage you to file with the Office of Administrative Courts at the same time that you file your appeal with CHP. That way, you will not lose your right to a State fair hearing. If you prefer, you can file an appeal with the Office of Administrative Courts without appealing to CHP. You must do this within 60 calendar days of the date of the Notice of Action. You can provide evidence of fact or law and have someone represent you at the hearing.

If you ask for an appeal or a State fair hearing, the service you requested will continue if:

  • You or your provider files the appeal within the required timeframes;
  • You ask for your benefits to continue;
  • The services you are asking to continue were authorized by the BHO; and
  • The current service authorization has not expired.

During the time you are appealing, your requested services will continue for a limited time. The services will continue only until one of the following things happens:

  • You withdraw your appeal;
  • 10 days pass after we mail the notice of action, and you have not asked for a state fair hearing;
  • You have asked for a state fair hearing, and their decision is to stop your services; or
  • The original authorization for your service has expired.

Important note: if your appeal is denied at the State fair hearing level, you may have to pay for the cost of services you received while your appeal was being reviewed. 

Ombudsman for Medicaid Managed Care:

The Ombudsman is an advocacy organization independent of CHP. They can help you file a grievance or appeal, if you want. The Ombudsman for Medicaid Managed Care can also help you with other mental health quality issues. There is no cost to you to use the Ombudsman. Any Medicaid member who lives in Colorado can use them.

Their contact information is: 

Ombudsman for Medicaid Managed Care
1-877-435-7123 outside of Denver
303-830-3560 in the Denver Metro area
1-888-876-8864 (TTY) for hearing impaired

Advance Directives

You have the right to provide advance written instructions to health care workers about the type of health care you want or do not want if you become so ill or injured that you cannot speak for yourself. These decisions are called Advance Directives. Advance Directives are legal papers you prepare while you are healthy. In Colorado, they include:  

  • A Medical Durable Power of Attorney. This names a person you trust to make decisions for you if you cannot speak for yourself.
  • A Living Will. This tells your doctor what type of life sustaining procedures you want and do not want. 
  • A Cardiopulmonary Resuscitation (CPR) Directive. This is also known as a “Do Not Resuscitate” Order. It tells medical persons not to revive you if your heart and/or lungs stop working.

For more information about Advance Directives, talk with your Primary Care
Physician (PCP). Your PCP will have an Advance Directives form that you can fill out. Your BHO Office of Member and Family Affairs can also help you find out how to make an Advance Directive.

Your mental health provider will ask you if you have an Advance Directive and if you want a copy placed in your mental health record. But you do not need to have an advance directive to get mental health care. If you would like a copy of CHP’s policy on Advance Directives, please contact us at 1-800-804-5040.

If you think your providers are not following your Advance Directive, you can file a complaint with the Colorado Department of Public Health and Environment. They can be reached at:

Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, Colorado 80246-1530
1-303-692-2000

Should you make a mental health crisis plan?

Colorado does not have a law about mental health advance directives. However, it is a good idea to have a crisis plan. A crisis plan will help you have more control over decisions if you do have a mental health crisis. Talk with your mental health provider or Care Coordinator about writing a crisis plan. You can also write a Wellness Recovery Action Plan (WRAP, developed by Mary Ellen Copeland, M.A.) or other type of wellness plan. A wellness plan is a plan you can use to stay healthy. It also tells your family and providers what you want to happen in an emergency. Your provider can put a copy of your crisis plan or WRAP in your record.