Member Rights and Responsibilities
The Member receives the following information as it pertains to Member Rights and Responsibilities:
Medicaid Member Rights
1. You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:
2. You have the right to a reasonable opportunity to choose a dental plan and dentist. You have the right to change to another plan or dentist in a reasonably easy manner. That includes the right to:
- a. Be treated fairly and with respect.
- b. Know that your dental records and discussions with your dentists will be kept private and confidential.
3. You have the right to ask questions and get answers about anything that you do not understand. That includes the right to:
- a. Be told how to choose and change your dental plan and dentist.
- b. Choose any dental plan you want that is available in their area and choose your dentist from that plan.
- c. Change your dentist.
- d. Change your dental plan without penalty.
- e. Be told how to change your dental plan or your dentist.
4. You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to:
- a. Have your dentist explain your dental care needs to you and talk to the dentist about the different ways your dental care problems can be treated.
- b. Be told why care or services were denied and not given.
5. You have the right to use each available complaint and appeal process through DentaQuest and through Medicaid, and get a timely response to complaints, appeals and fair hearings. That includes the right to:
- a. Work as part of a team with your dentist in deciding what dental care is best for you.
- b. Say yes or no to the care recommended by your dentist.
6. You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to:
- a. Make a complaint to DentaQuest or to the state Medicaid program about your dental care, your dentist or your dental plan.
- b. Get a timely answer to your complaint.
- c. Use DentaQuest’s appeal process and be told how to use it.
- d. Ask for a fair hearing from the state Medicaid program and get information about how that process works.
7. You have the right to not be restrained or secluded when it is for someone else’s convenience, or is meant to force you to do something that you do not want to do, or is to punish you.
- a. Have telephone access to a dental professional 24 hours a day, 7 days a week to get any emergency or urgent care that you need.
- b. Get dental care in a timely manner.
- c. Be able to get in and out of a dental care provider’s office. This includes barrierfree access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act.
- d. Have interpreters, if needed, during appointments with your dentist and when talking to your dental plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information.
- e. Be given information you can understand about DentaQuest plan rules, including the dental care services that you can get and how to get them.
8. You have a right to know that dentists, hospitals, and others who care for you can advise you about your health status, dental care, and treatment. DentaQuest cannot prevent the dentists, hospitals, and others who care for you from giving you this information, even if the care or treatment is not a covered service.
9. You have a right to know that you are not responsible for paying for covered services. Dentists, hospitals, and others cannot require you to pay copayments or any other amounts for covered services.
Medicaid Member Responsibilities
1. You must learn and understand each right you have under the Medicaid program. That includes the responsibility to:
2. You must abide by DentaQuest’s and Medicaid’s policies and procedures. That includes the responsibility to:
- a. Learn and understand your rights under the Medicaid program.
- b. Ask questions if you do not understand your rights.
- c. Learn what choices of dental plans are available in your area.
3. You must share information about your health with your dentist and learn about service and treatment options. That includes the responsibility to:
- a. Learn and follow DentaQuest’s rules and Medicaid rules.
- b. Choose your dental plan and a dentist quickly.
- c. Make any changes in your dental plan and dentist in the ways established by Medicaid and by DentaQuest.
- d. Keep your scheduled appointments.
- e. Cancel appointments in advance when you cannot keep them.
- f. Always contact your dentist first for your non‐emergency dental needs.
- g. Be sure that you have approval from your dentist before going to a specialist.
- h. Understand when you should and should not go to the emergency room.
4. You must be involved in decisions relating to service and treatment options, make personal choices, and take action to maintain your health. That includes the responsibility to:
- a. Tell your dentist about your health.
- b. Talk to your dentist about your dental care needs and ask questions about the different ways your dental care problems can be treated.
- c. Help your dentist get your dental records.
- a. Work as a team with your provider in deciding what dental care is best for you.
- b. Understand how the things that you do can affect your dental health.
- c. Do the best that you can to stay healthy.
- d. Treat dentists and staff with respect.
CHIP Member Rights
1. You have a right to get accurate, easy‐to‐understand information to help you make good choices about your dentists and other providers.
2. You have a right to know how your dentists are paid. You have a right to know about what those payments are and how they work.
3. You have a right to know how DentaQuest decides whether a service is covered and/or medically necessary. You have the right to know about the people at DentaQuest who decide those things.
4. You have a right to know the names of the dentists and other providers enrolled with DentaQuest and their addresses.
5. You have a right to pick from a list of dentists that is large enough so that your child can get the right kind of care when your child needs it.
6. You have the right to take part in all the choices about your child's dental care.
7. You have the right to speak for your child in all treatment choices.
8. You have the right to get a second opinion from another dentist enrolled with DentaQuest about what kind of treatment your child needs.
9. You have the right to be treated fairly by DentaQuest, dentists, and other providers.
10. You have the right to talk to your child's dentist and other providers in private, and to have your child's dental records kept private. You have the right to look over and copy your child's dental records and to ask for changes to those records.
11. You have a right to know that dentists, hospitals, and others who care for your child can advise you about your child’s health status, medical care, and treatment. DentaQuest cannot prevent dentists, hospitals, and others who care for your child from giving you this information, even if the care or treatment is not a covered service.
12. You have a right to know that you are only responsible for paying allowable copayments for covered services, up to benefit maximum limits. Dentists, hospitals, and others cannot require you to pay any other amounts for covered services.
CHIP Member Responsibilities
The Member and DentaQuest both have an interest in seeing their child's dental health improve. The Member can help by assuming these responsibilities.
1. The Member must try to follow healthy habits. Encourage their child to stay away from tobacco, and to eat a healthy diet.
2. The Member must become involved in the dentist’s decisions about their child's treatments.
3. The Member must work together with DentaQuest’s dentists and other providers to pick treatments for their child that they have all agreed upon.
4. If the Member has a disagreement with DentaQuest, they must try first to resolve it using DentaQuest’s complaint process.
5. The Member must learn about what DentaQuest does and does not cover. The Member must read the Member Handbook to understand how the rules work.
6. If the Member makes an appointment for their child, they must try to get to the dentist's office on time. If they cannot keep the appointment, they must be sure to call and cancel it.
7. The Member must report misuse of CHIP by dental and health care providers, other CHIP Members, DentaQuest, or other CHIP plans.
If you think that you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll‐free at 1‐800‐368‐1019. The Member can also view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.