Your Rights

Member Rights and Responsibilities

As a member of CalOptima Health, you have certain rights and responsibilities.

Your rights

These are your rights as a member of CalOptima Health:

To be treated with respect and dignity, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information, such as medical history, mental and physical condition or treatment, and reproductive or sexual health
To be provided with information about the health plan and its services, including covered services, providers, practitioners, and member rights and responsibilities
To get fully translated written member information in your preferred language, including all grievance and appeals notices
To make recommendations about CalOptima Health’s member rights and responsibilities policy
To be able to choose a primary care provider within CalOptima Health’s network
To have timely access to network providers
To participate in decision-making with providers regarding your own health care, including the right to refuse treatment
To voice grievances, either verbally or in writing, about the organization or the care you got
To know the medical reason for CalOptima Health’s decision to deny, delay, terminate (end), or change a request for medical care
To get care coordination
To ask for an appeal of decisions to deny, defer or limit services or benefits
To get free interpreting and translation services for your language
To ask for free legal help at your local legal aid office or other groups
To formulate advance directives
To ask for a State Hearing if a service or benefit is denied and you have already filed an appeal with CalOptima Health and are still not happy with the decision, or if you did not get a decision on your appeal after 30 days, including information on the circumstances under which an expedited hearing is possible
To disenroll (drop) from CalOptima Health and change to another health plan in the county upon request
To access minor consent services
To get free written member information in other formats (such as braille, large-size print, audio, and accessible electronic formats) upon request and in a timely fashion appropriate for the format being requested and in accordance with Welfare and Institutions (W&I) Code section 14182 (b)(12)
To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation
To truthfully discuss information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand, regardless of cost or coverage
To have access to and get a copy of your medical records, and request that they be amended or corrected, as specified in 45 Code of Federal Regulations (CFR) sections 164.524 and 164.526
Freedom to exercise these rights without adversely affecting how you are treated by CalOptima Health, your providers, or the State
To have access to family planning services, Freestanding Birth Centers, Federally Qualified Health Centers, Indian Health Care Providers, midwifery services, Rural Health Centers, sexually transmitted infection services, and emergency services outside CalOptima Health’s network pursuant to federal law

Your responsibilities

CalOptima Health members have these responsibilities:

Knowing, understanding and following your member handbook
Understanding your medical needs and working with your health care providers to create your treatment plan
Following the treatment plan you agreed to with your health care providers
Telling CalOptima Health and your health care providers what we need to know about your medical condition so we can provide care
Making and keeping medical appointments and telling the office when you must cancel your appointment
Learning about your medical condition and what keeps you healthy
Taking part in health care programs that keep you healthy
Working with and being polite to the people who are partners in your health care.

You Can Report Fraud or Abuse

Compliance and Ethics Hotline 1-855-507-1805 (TTY 711)

Call Us

If you see any activity that you think is fraud or waste, we strongly encourage you to call our Compliance and Ethics Hotline at 1-855-507-1805 (TTY 711). You can also report the activity using CalOptima Health’s Compliance and Fraud, Waste and Abuse (FWA) Reporting form.

You do not have to give your name to report fraudulent activity.

Compliance and Fraud Waste, and Abuse Reporting Form

Reporting and Solving Problems

We want to hear your concerns about the health care services you get

There are two kinds of problems that you may have with your health network, CalOptima Health or a provider:

A complaint or grievance is when you have a problem with your health network, CalOptima Health or a provider, or with the health care or treatment you got from a provider.

An appeal is when you do not agree with your health network or CalOptima Health’s decision not to cover or change your services.

You should always contact CalOptima Health first to let us know about your problem. Below are some ways to let us know your concern:

Call CalOptima Health Customer Service toll-free at 1-888-587-8088 (TTY 711), Monday through Friday, from 8 a.m. to 5:30 p.m. We have staff who speak your language.
Fill out the member grievance or appeal form online and click the “submit” button
Visit our office at 505 City Parkway West, Orange, CA 92868
Fill out the member complaint form or write a letter to CalOptima Health and mail it to us at the address above

File a grievance or appeal online

Instructions for completing the form are here.

Download the printable member complaint form

Instructions for completing the form are here.

After CalOptima Health receives your complaint, we will send you a letter within 5 calendar days letting you know the status of your complaint and the name of our Resolution Specialist you can call if you have questions.

When the form is submitted online after business hours, the notice will be sent to you no later than 5 calendar days from the next business day. The letter explains a response to your complaint will be mailed to you within 30 calendar days of when we get it. For more details, please read the Medi-Cal member handbook.

Urgent or expedited matters: any complaint with serious health concerns will be reviewed by CalOptima Health within 72 hours of getting the complaint.

You may also call the CalOptima Health Fraud Hotline at 1-855-507-1805 to report any action you think may be fraud. You do not have to give your name to report fraud activity. Fraud is when a doctor or pharmacy asks you to pay more than proper for an office visit or medicines. Fraud is also when someone uses another person’s Medi-Cal card.

CalOptima Health will not discriminate against you or limit your benefits in any way if you express concerns, file a complaint or report fraud.

Notice of your right to a Medi-Cal State Hearing:

A Medi-Cal State Hearing is a meeting with people from the California Department of Social Services (DSS). A judge will help to resolve your problem. You can ask for a State Hearing only if you have already filed an appeal with CalOptima Health and you are still not happy with the decision. Or, if you have not received a decision on your appeal after 30 days. You must ask for a State Hearing within 120 days from the date on the notice telling you of the appeal decision. Call the DSS Public Response Unit toll-free at 1-800-952-5253. TDD/TTY users can call toll-free at 1-800-952-8349.

Or you may fill out the form we provided with your appeal resolution notice and mail it to:

California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 09-17-37
Sacramento, CA 94244-2430