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Individuals and Families / STAR & CHIP / CHIP / Rights & Responsibilities

CHIP Members Rights and Responsibilities

CHIP Member Rights

Members have the right to:

You have the right to get accurate, easy-to-understand information to help you make good choices about your child's health plan, doctors, hospitals and other providers.
Your health plan must tell you if they use a "limited provider network." This is a group of doctors and other providers who only refer patients to other doctors who are in the same group. “Limited provider network” means you cannot see all the doctors who are in your health plan. If your health plan uses "limited networks," you should check to see that your child's primary care provider and any specialist doctor you might like to see are part of the same "limited network."
You have a right to know how your doctors are paid. Some get a fixed payment no matter how often you visit. Others get paid based on the services they give to your child. You have a right to know about what those payments are and how they work.

You have a right to know how the health plan decides whether a service is covered and/or medically necessary. You have the right to know about the people in the health plan who decide those things.
You have a right to know the names of the hospitals and other providers in your health plan and their addresses.
You have a right to pick from a list of health care providers that is large enough so that your child can get the right kind of care when your child needs it.
If a doctor says your child has special health care needs or a disability, you may be able to use a specialist as your child's primary care provider. Ask your health plan about this.
Children who are diagnosed with special health care needs or a disability have the right to special care.
If your child has special medical problems and the doctor your child is seeing leaves your health plan, your child may be able to continue seeing that doctor for three months, and the health plan must continue paying for those services. Ask your plan about how this works.
Your daughter has the right to see a participating obstetrician/gynecologist (OB/GYN) without a referral from her primary care provider and without first checking with your health plan. Ask your plan how this works. Some plans may make you pick an OB/GYN before seeing that doctor without a referral.
Your child has the right to emergency services if you reasonably believe your child's life is in danger, or that your child would be seriously hurt without getting treated right away. Coverage of emergencies is available without first checking with your health plan. You may have to pay a copayment depending on your income. Copayments do not apply to the CHIP Perinatal Members.
You have the right and responsibility to take part in all the choices about your child's health care.
You have the right to speak for your child in all treatment choices.
You have the right to get a second opinion from another doctor in your health plan about what kind of treatment your child needs.
You have the right to be treated fairly by your health plan, doctors, hospitals and other providers.
You have the right to talk to your child's doctors and other providers in private, and to have your child's medical records kept private. You have the right to look over and copy your child's medical records and to ask for changes to those records.
You have the right to a fair and quick process for solving problems with your health plan and the plan's doctors, hospitals and others who provide services to your child. If your health plan says it will not pay for a covered service or benefit that your child's doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right.
You have a right to know that doctors, hospitals, and others who care for your child can advise you about your child’s health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

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CHIP Member Responsibilities

You and your health plan both have an interest in seeing your child's health improve. You can help by assuming these responsibilities.

You must try to follow healthy habits. Encourage your child to stay away from tobacco and to eat a healthy diet.
You must become involved in the doctor's decisions about your child's treatments.
You must work together with your health plan's doctors and other providers to pick treatments for your child that you have all agreed upon.

If you have a disagreement with your health plan, you must try first to resolve it using the health plan's complaint process.
You must learn about what your health plan does and does not cover. Read your Member Handbook to understand how the rules work.
If you make an appointment for your child, you must try to get to the doctor's office on time. If you cannot keep the appointment, be sure to call and cancel it.
If your child has CHIP, you are responsible for paying your doctor and other providers copayments that you owe them. If your child is getting CHIP Perinatal services, you will not have any copayments for that child.
You must report misuse of CHIP or CHIP Perinatal services by health care providers, other members, or health plans.
You must talk to your provider about your medications that are prescribed.

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If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

CHIP Perinatal Member Rights

CHIP Perinatal members have the right to:

You have a right to get accurate, easy-to-understand information to help you make good choices about your unborn child’s health plan, doctors, hospitals and other providers.
You have a right to know how the Perinatal providers are paid. Some may get a fixed payment no matter how often you visit. Others get paid based on the services they provide for your unborn child. You have a right to know about what those payments are and how they work.
You have a right to know how the health plan decides whether a Perinatal service is covered and/or medically necessary. You have the right to know about the people in the health plan who decide those things.

You have a right to know the names of the hospitals and other Perinatal providers in the health plan and their addresses.
You have a right to pick from a list of health care providers that is large enough so that your unborn child can get the right kind of care when it is needed.
You have a right to emergency Perinatal services if you reasonably believe your unborn child’s life is in danger, or that your unborn child would be seriously hurt without getting treated right away. Coverage of such emergencies is available without first checking with the health plan.
You have the right and responsibility to take part in all the choices about your unborn child’s health care.
You have the right to speak for your unborn child in all treatment choices.
You have the right to be treated fairly by the health plan, doctors, hospitals and other providers.
You have the right to talk to your Perinatal provider in private, and to have your medical records kept private. You have the right to look over and copy your medical records and to ask for changes to those records.
You have the right to a fair and quick process for solving problems with the health plan and the plan's doctors, hospitals and others who provide Perinatal services for your unborn child. If the health plan says it will not pay for a covered Perinatal service or benefit that your unborn child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right.
You have a right to know that doctors, hospitals, and other Perinatal providers can give you information about your or your unborn child’s health status, medical care, or treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

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CHIP Perinatal Member Responsibilities

You and your health plan both have an interest in having your baby born healthy. You can help by assuming these responsibilities.
You must try to follow healthy habits. Stay away from tobacco and eat a healthy diet.
You must become involved in the decisions about your unborn child’s care.

If you have a disagreement with the health plan, you must try first to resolve it using the health plan's complaint process.
You must learn about what your health plan does and does not cover. Read your CHIP Handbook to understand how the rules work.
You must try to get to the doctor's office on time. If you cannot keep the appointment, be sure to call and cancel it.
You must report misuse of CHIP Perinatal services by health care providers, other members, or health plans.
You must talk to your provider about your medications that are prescribed.

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If you think you have been treated unfairly or discriminated against, contact the U.S. Department of Health and Human Services (HHS)

Call toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr

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Call FirstCare CHIP Customer Service at 1-877-639-2447.

We're open Monday through Friday, from 8 a.m. to 5 p.m., excluding state approved holidays. If you call after hours, please leave us a message. We return all calls the next business day.

Our Customer Service Representatives speak both English and Spanish. If you speak another language, we can connect you with an interpreter. You can get information in larger print, audio (CD), braille, or in any other language format, if needed. For help, call FirstCare CHIP Customer Service at 1-877-639-2447.

Members with hearing loss can call the Relay Texas number 7-1-1. Relay Texas is a free telephone interpreting service to help people with hearing or speech disabilities.

Resources

CHIP Service Area CHIP Member News

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Need care advice? Should you see a doctor? FirstCare members can talk to a nurse by calling 1-855-828-1013. Get answers 24 hours a day, 7 days a week! Information is available in English and Spanish. Interpreter services available upon request. TTY users can call 7-1-1 or 1-800-955-8771. Voice communication is available at 1-800-955-8770.

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Helpful Links and Phone Numbers

CHIPInformation and Referral:
2-1-1 or 1-877-541-7905
Enrollment Helpline: 1-800-964-2777
TTY: 1-800-735-2989
MCNA Dental (CHIP)Medicaid & CHIP dental plan for Texas
1-855-691-6262
TTY: 1-800-955-8771
DentaQuest (CHIP)Medicaid & CHIP dental plan for Texas
1-800-508-6775
TTY: 1-800-855-2880
Navitus Health SolutionsFirstCare’s Pharmacy Benefit Manager
1-877-908-6023
TTY: 7-1-1
OCCC Financial Literacy Information1-800-538-1579

CHIP Members Rights and Responsibilities

CHIP Member Rights

CHIP Member Responsibilities

CHIP Perinatal Member Rights

CHIP Perinatal Member Responsibilities

If you think you have been treated unfairly or discriminated against, contact the U.S. Department of Health and Human Services (HHS)

Access a Doctor, 24/7/365

Need Help? Contact Us!

Resources

Talk to a Nurse—Nurse24™

Utilization Management

Helpful Links and Phone Numbers

Related Documents

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