See our
index for
information
regarding:

The Colorado Patient Rights and Responsibilities in Managed Care Consortium is a group of voluntary health agencies, managed care organizations, employers, and concerned citizens working collaboratively to educate consumers about the specific benefits they receive when purchasing and using managed care products. The ultimate goal is to have responsible and knowledgeable health care consumers receiving quality of care while managing the costs of that care. The Minimum Community Standard is the basic philosophy of the Consortium and is the foundation for future development of educational tools.

As a minimum community standard for consumers considering purchasing or patients currently using the health care delivery under a managed care plan, we believe the patient has the right:

1. To know the benefits, limitations, and exclusions such as office visits, lab and x-rays, hospitalizations, therapy types and duration, home health coverage, skilled nursing and rehab coverage, and durable medical equipment of the particular health coverage in context with treatment, alternatives, and decisions to refuse care.

2. To be informed of the coverage (inclusions and exclusions) for mental health. The patient is entitled to receive at a minimum the state mandated benefits when appropriate.

3. To be informed of the coverage (inclusions and exclusions) for substance abuse treatment.

4. To know about treatment options prior to receiving care and is entitled to extended visits for asking questions about his/her health care. The patient has the right to discuss alternatives during treatment and to refuse treatment.

5. To know the managed care plan definition of "experimental and investigational treatment", as well as the limitations and exclusions for experimental and investigational treatment. Coverage for experimental and investigational procedures which also include studies, tests, drugs, and equipment which are not generally accepted as standard therapy may not be automatically covered.

6. To receive information regarding restrictions or limitations on specialist treatment including access to specialists both inside and outside of the network. The managed care plan has a formal, timely, and uncomplicated process for handling patient requests to see a specialist when the primary care physician does not refer.

7. To know the policies of the managed care plan regarding prescription drugs and biologics included in the health plan. The patient shall have access to guidelines addressing the managed care plan's policies regarding therapeutic substitutions, drug trials, and experimental medications. If the managed care plan uses a formulary, the patient has a right to request information about the availability of specific drugs included or not included in the treatment plan. Furthermore, the patient has the right to know if the managed care plan has a method whereby the primary physician or specialist can request use of non-formulary drugs.

8. To know the definition of "medically necessary treatment" at the time of enrollment for purposes of understanding benefits, limitations, and exclusions of the managed care plan.

9. To know the appeal process. The patient has a right to a patient advocate to assist with coordination of benefits, limitations, and exclusions. The managed care plan has the responsibility to respond to the patient making an appeal in a timely fashion and to inform the patient of the next steps, if the initial appeal is denied.

10. To know how providers are selected to participate in the managed care plan. This is sometimes called the credentialling process.

11. To have the most current information available about participating primary care physicians who are accepting new patients. The patient must be informed of physicians who have closed practices.

12. To know that all medical directives will be respected. This would include living wills, durable medical power of attorney, or other legal documents regarding care when the patient is incapacitated.

The patient has the responsibility:

1. To be knowledgeable about the health care coverage, and should read and become familiar with terms and coverage provisions. The patient also has the responsibility to ask questions about any terms or coverage which is not fully understood.

2. To keep all scheduled appointments, and come prepared with questions and concerns, so that the health care provider will be able to address these issues.

3. To follow the agreed upon treatment plan, and to take responsibility for the results if choosing to act against medical advice.

4. To provide complete and accurate information about his/her health status, medical history, and use of other treatments. The patient is also responsible for making sure all providers have copies of any advanced medical directives.

5. To use the appeal process in an appropriate and timely manner, and to respect the rights of health care providers and other professionals, and the confidentiality of others.

6. To pay the applicable co-payment at the time services are rendered.

Adopted by the Consortium, November, 1995

For more information: