[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.100]



[Page 221-222]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

                Subpart C_Enrollee Rights and Protections

 

Sec.  438.100  Enrollee rights.





    (a) General rule. The State must ensure that--

    (1) Each MCO and PIHP has written policies regarding the enrollee 

rights specified in this section; and

    (2) Each MCO, PIHP, PAHP, and PCCM complies with any applicable 

Federal and State laws that pertain to enrollee rights, and ensures that 

its staff and affiliated providers take those rights into account when 

furnishing services to enrollees.

    (b) Specific rights--(1) Basic requirement. The State must ensure 

that each managed care enrollee is guaranteed the rights as specified in 

paragraphs (b)(2) and (b)(3) of this section.

    (2) An enrollee of an MCO, PIHP, PAHP, or PCCM has the following 

rights: The right to--

    (i) Receive information in accordance with Sec.  438.10.



[[Page 222]]



    (ii) Be treated with respect and with due consideration for his or 

her dignity and privacy.

    (iii) Receive information on available treatment options and 

alternatives, presented in a manner appropriate to the enrollee's 

condition and ability to understand. (The information requirements for 

services that are not covered under the contract because of moral or 

religious objections are set forth in Sec.  438.10(f)(6)(xii).)

    (iv) Participate in decisions regarding his or her health care, 

including the right to refuse treatment.

    (v) Be free from any form of restraint or seclusion used as a means 

of coercion, discipline, convenience or retaliation, as specified in 

other Federal regulations on the use of restraints and seclusion.

    (vi) If the privacy rule, as set forth in 45 CFR parts 160 and 164 

subparts A and E, applies, request and receive a copy of his or her 

medical records, and request that they be amended or corrected, as 

specified in 45 CFR Sec.  164.524 and 164.526.

    (3) An enrollee of an MCO, PIHP, or PAHP (consistent with the scope 

of the PAHP's contracted services) has the right to be furnished health 

care services in accordance with Sec. Sec.  438.206 through 438.210.

    (c) Free exercise of rights. The State must ensure that each 

enrollee is free to exercise his or her rights, and that the exercise of 

those rights does not adversely affect the way the MCO, PIHP, PAHP, or 

PCCM and its providers or the State agency treat the enrollee.

    (d) Compliance with other Federal and State laws. The State must 

ensure that each MCO, PIHP, PAHP, and PCCM complies with any other 

applicable Federal and State laws (such as: title VI of the Civil Rights 

Act of 1964 as implemented by regulations at 45 CFR part 80; the Age 

Discrimination Act of 1975 as implemented by regulations at 45 CFR part 

91; the Rehabilitation Act of 1973; and titles II and III of the 

Americans with Disabilities Act; and other laws regarding privacy and 

confidentiality).



[67 FR 41095, June 14, 2002; 67 FR 65505, Oct. 25, 2002]