Member Rights & Responsibilities

Access Dental Plan Members shall have the following rights:

A. Be treated with dignity and respect;

B. Be treated by participating providers the same as other people seeking health care benefits to which they are entitled, and to be encouraged to work with the member’s care team, including providers and community resources appropriate to the member’s needs;

C. Choose a Primary Care Dentist or service site, and to change those choices as permitted in Access Dental Plan administrative policies;

D. Refer oneself directly to behavioral health or family planning services without getting a referral from a primary care provider or other participating provider;

E. Have a friend, family member, or advocate present during appointments and other times as needed within clinical guidelines;

F. Be actively involved in the development of their treatment plan;

G. Be given information about their condition and covered and non-covered services to allow an informed decision about proposed treatments;

H. Consent to treatment or refuse services, and be told the consequences of that decision, except for court ordered services;

I. Receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency;

J. Have written materials explained in a manner that is understandable to the member and be educated about the coordinated care and dental care coordination approach being used in the community and how to navigate the coordinated health care system;

K. Receive culturally and linguistically appropriate services and supports, in locations as geographically close to where members reside or seek services as possible, and choice of providers within the delivery system network that are, if available, offered in non-traditional settings that are accessible to families, diverse communities, and underserved populations.

L. Receive necessary and reasonable services to diagnose the presenting condition;

M. Receive integrated person centered care and services designed to provide choice, independence and dignity and that meet generally accepted standards of practice and are medically appropriate;

N. Have a consistent and stable relationship with a care team that is responsible for comprehensive care management;

O. Receive assistance in navigating the health care delivery system and in accessing community and social support services and statewide resources including but not limited to the use of certified or qualified health care interpreters, and advocates, community health workers, peer wellness specialists and personal health navigators who are part of the member’s care team to provide cultural and linguistic assistance appropriate to the member’s need to access appropriate services and participate in processes affecting the member’s care and services;

P. Obtain covered preventive services;

Q. Have access to urgent and emergency services 24 hours a day, 7 days a week without prior authorization;

R. Receive a referral to specialty providers for medically appropriate covered coordinated care services.

S. Have a clinical record maintained which documents conditions, services received, and referrals made;

T. Have access to one’s own clinical record, unless restricted by statute;

U. Transfer of a copy of the clinical record to another provider;

V. Execute a statement of wishes for treatment, including the right to accept or refuse medical, surgical, dental or behavioral health treatment and the right to execute directives and powers of attorney for health care established under ORS 127;

W. Receive written notices before a denial of, or change in, a benefit or service level is made, unless a notice is not required by federal or state regulations;

X. Be able to make a complaint or appeal with the CCO’s or Dental Care Organization and receive a response;

Y. Request a contested case hearing;

Z. Receive certified or qualified health care interpreter services; 

AA. Receive a notice of an appointment cancellation in a timely manner;

BB. The right to request a second opinion; and

CC. To ensure that members receive all benefits and services to which they are entitled without discrimination.

 

Access Dental Plan member shall have the following responsibilities:

A. Choose, or help with assignment to, a primary care dentist;

B. Treat plan staff, provider, and clinic staff members with respect;

C. Be on time for appointments made with providers and to call in advance to cancel if unable to keep the appointment or if he/she expects to be late;

D. Seek periodic health exams and preventive services from his/her primary care dentist;

E. Use his/her primary care provider or clinic for diagnostic and other care except in an emergency;

F. Obtain a referral to a specialist from the primary care dentist before seeking care from a specialist unless self-referral to the specialist is allowed;

G. Use urgent and emergency services appropriately, and notify the member’s primary care provider within 72 hours of using emergency service;

H. Give accurate information for inclusion in the clinical record;

I. Help the provider or clinic obtain clinical records from other providers which may include signing an authorization for release of information;

J. Ask questions about conditions, treatments, and other issues related to his/her care that is not understood;

K. Use information provided by providers or care teams to make informed decisions about treatment before it is given;

L. Help in the creation of a treatment plan with the provider;

M. Follow prescribed agreed upon treatment plans and actively engage in their care;

N. Tell the provider that his/her health care is covered under the OHP before services are received and, if requested, to show the provider the Division Medical Care Identification form;

O. Tell the Department or Authority worker of a change of address or phone number;

P. Tell the Department or Authority worker if the member becomes pregnant and to notify the worker of the birth of the member’s child;

Q. Tell the Department or Authority worker if any family members move in or out of the household;

R. Tell the Department or Authority worker if there is any other insurance available;

S. Pay for non-covered services under the provisions described in OAR 410-120-1200 and 410-120-1280;

T. Pay the monthly OHP premium on time if so required;

U. Assist the Risk Accepting Entity (RAE) in pursuing any third party resources available and reimburse the RAE the amount of benefits it paid for an injury from any recovery received from that injury; and

V. Bring issues, or complaints or grievances to the attention of the Access Dental Plan.

As a recipient of Federal financial assistance, Access Dental Plan does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, or national origin, religion, sex, sexual orientation, gender identity/expression, protected veteran’s status, genetic information, or on the basis of disability or age, participation in, or receipt of the services and benefits under any of the programs and activities, whether carried out by Access Dental Plan directly or through a contractor or any other entity with which Access Dental Plan arranges to carry out its programs and activities.