Your rights and responsibilities as a member of the MLTC plan

What are my rights as a member?

As a member you have the following rights:

Right #1: Treatment provided with consideration, dignity, respect and confidentiality. This treatment will be provided without discrimination. 

Members have the right to:

  • receive considerate, respectful and humane care from Fallon Health Weinberg-MLTC and its contractors at all times and in all circumstances.
  • not be discriminated against in the delivery of care and services based on race, ethnicity, national origin, color, religion, sex, age, sexual orientation, health status (mental or physical disability), marital status or source of payment.
  • receive care in a safe, clean and accessible environment.
  • be treated with dignity and respect with attention to privacy and confidentiality in all aspects of care.
  • not be required to perform services for Fallon Health Weinberg-MLTC
  • timely access to services.
  • freedom from harm including physical or mental abuse, neglect, corporeal punishment, involuntary seclusion, excessive medication, and any physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the member’s medical symptoms.
  • designate a representative to exercise any, or all, of the rights to which they are entitled. 
  • have all information provided in a culturally sensitive manner.
  • have information provided in a manner that is understood by the member and the member’s representative and receive information in the needed language and have oral translation free of charge.

Right #2: Have information disclosed before enrollment, at enrollment, and when there is a change in services. Disclosure must be in a manner that is accurate, easy to understand and supports informed decisions.

Members have the right to:

  • be fully informed, in writing, of the covered services provided by Fallon Health Weinberg-MLTC, including an explanation of those services provided through contract, and the procedures for obtaining needed care.
  • receive an enrollment agreement, and to have it explained in a manner that is understandable.
  • examine, or be assisted in examining, the results of the most recent review of Fallon Health Weinberg-MLTC by New York State Department of Health.
  • be informed of any changes in the organizational structure of Fallon Health Weinberg-MLTC.

Right #3: To choose a primary care physician

Right #4: Initiate disenrollment from the program at any time.

Right #5: Access emergency health services when and where the need arises without prior authorization from Fallon Health Weinberg-MLTC.

  • Members have the right to access emergency health care services without seeking prior approval.

Right #6: Fully participate in all decisions that relate to treatment and care.

  • Each member has the right to be fully informed of his or her functional status, medical condition, and treatment options, and his or her right to participate in treatment decisions, and the development of their Plan of Care.  
  • Members have the right to refuse medication, or any treatment. Fallon Health Weinberg–MLTC’s clinical staff must inform the member of the consequences of refusing medication, or treatment.             
  • Members have the right to receive an explanation of advance directives, and to establish them with the plan’s assistance if needed.
  • Members have the right and are encouraged to express their opinions and participate as a member of their Care Team in the development of their Plan of Care and in the request for reassessment.
  • Members have the right to expect reasonable advance written notice of any transfer to another treatment setting with a justification for the transfer.
  • Members have the right to be informed of the existence and purpose of the Consumer Advisory Committee in which he/she is encouraged to participate.
  • Members have the right to express opinions and recommend changes to policies and procedures.

Right #7: Communication with health care providers in confidence and to have information related to his or her care protected.

  • Members have the right to have access to records, upon written request and may request copies of or changes to these records.
  • Members have the right to have all records and information kept confidential.

Right #8: Fair and responsive process for resolving differences including a rigorous internal review of grievances and an independent external review.

  • Members have the right to present their concerns directly to the specific department involved, Care Team or staff member, whenever they feel a situation warrants such attention.
  • Members have the right to voice concerns to staff or outside representatives without fear of reprisal, restraint, interference, coercion or discrimination by the Fallon Health Weinberg-MLTC staff.
  • Exercise rights as a member, including using the grievance and appeals processes and to receive uninterrupted care during this process.
  • Members have the right to appeal any treatment decision of Fallon Health Weinberg-MLTC or its contractors.
  • Members have the right to information regarding the New York State Department of Health's complaint procedure, including contact information.
  • The right to be informed of the grievance and appeal processes. 

What are my responsibilities as a member?

As a member, you have the following responsibilities:

Responsibility #1: Active participation in care and care decisions

You have the responsibility to:

  • Communicate openly and honestly with your physician and Care Team about health and care. You are responsible to ask questions and to consider consequences of non-compliance.
  • Share in care decisions and continue to be in charge of your own health.
  • Complete self-care as planned, keeps appointments, and inform your Care Team of any need to change appointments.
  • Except for non-covered and Medicare covered services, use network providers for non-emergency situations.
  • Obtain prior approval from the plan before accessing services except for podiatry, dentistry, optometry, audiology, and nutrition.

Responsibility #2: Support Fallon Health Weinberg-MLTC

Members have the responsibility to:

  • Express their opinions, concerns and suggestions in a respectful manner.
  • Read the Member Handbook and follow procedures as outlined to receive services.
  • Help Fallon Health Weinberg-MLTC staff to maintain a safe home environment.
  • Notify Fallon Health Weinberg-MLTC of any change in address, personal information or financial responsibilities.

Responsibility #3: Fiscal responsibility

Members have the responsibility to:

  • Pay the Medicaid spend-down/surplus amount.

Information regarding the NY State Ombudsmen Service

You have the right to contact the New York State Ombudsman Service, called ICAN (Independent Consumer Advocacy Network). This is a free service for long-term care recipients. ICAN will answer your questions regarding Medicare, Medicaid, long-term care (for example, your home care or nursing home care) and your long-term managed care plan which is Fallon Health Weinberg-MLTC.

They can help you understand notices that you receive and other services including, but are not necessarily limited to:

  • providing pre-enrollment support, such as unbiased health plan choice counseling and general program-related information,
  • compiling member complaints and concerns about enrollment, access to services, and other related matters,
  • helping members understand the Fair Hearing, grievance and appeal rights and processes within the health plan and at the State level, and assisting them through the process if needed/requested, including making requests of plans and providers for records, and
  • informing plans and providers about community-based resources and supports that can be linked with covered plan benefits.
  • ICAN will assist anyone in a Medicaid managed care plan who needs long term care services (like home attendant, adult day care, or nursing home)
  • they can assist people who are applying for Medicaid and need help enrolling in a Managed Long Term Care (MLTC) or Medicaid Managed Care (MMC) plan.

You have the right to seek assistance from the Ombudsmen Program at any time and ICAN is able to talk with you, your friends, family members, and anyone else that is helping you with your medical decisions. You can reach ICAN by calling 1-844-614-8800 (TTY 711) or emailing ican@cssny.org

Take the next step

Contact us

1-716-250-3100
1-866-882-8185 (TTY 711)

8 a.m.–5 p.m., Monday–Friday

Member information

Member Handbook (pdf) ►

Overview of benefits and services ►

Contact us

1-866-882-8185 
8 a.m.–5 p.m., Monday–Friday