Member Rights and Responsibilities
Gateway Health and its network of providers do not discriminate against members based on race, sex, religion, national origin, disability, age, sexual orientation, gender identity, or any other basis prohibited by law.
As a Gateway Health member, you have the following rights and responsibilities.
The following benefits are covered by Medicaid under federal law:
- Inpatient hospital services
- Outpatient hospital services
- EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
- Nursing facility services
- Home health services
- Physician services
- Rural health clinic services
- Federally qualified health center services
- Laboratory and X-ray services
- Family planning services
- Nurse midwife services
- Certified Pediatric and Family Nurse Practitioner services
- Freestanding Birth Center services (when licensed or otherwise recognized by the state)
- Transportation to medical care
- Tobacco cessation counseling for pregnant women
States may choose to cover the following services:
- Prescription drugs
- Clinic services
- Physical therapy
- Occupational therapy
- Speech, hearing and language disorder services
- Respiratory care services
- Other diagnostic, screening, preventive and rehabilitative services
- Podiatry services
- Optometry services
- Dental services
- Chiropractic services
- Private duty nursing services
- Personal care
- Case management
- Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
- State Plan Home and Community Based Services- 1915(i)
- Self-Directed Personal Assistance Services- 1915(j)
- Community First Choice Option- 1915(k)
- TB Related Services
- Inpatient psychiatric services for individuals under age 21
- Health Homes for Enrollees with Chronic Conditions – Section 1945
You have the right:
1. To be treated with respect, recognizing your dignity and need for privacy, by Gateway Health staff and network providers.
2. To get information in a way that you can easily understand and find help when you need it.
3. To get information that you can easily understand about Gateway Health, its services, and the doctors and other providers that treat you.
4. To pick the network health care providers that you want to treat you.
5. To get emergency services when you need them from any provider without Gateway Health approval.
6. To get information that you can easily understand and talk to your providers about your treatment options, without any interference from Gateway Health.
7. To make all decisions about your health care, including the right to refuse treatment. If you cannot make treatment decisions by yourself, you have the right to have someone else help you make decisions or make decisions for you.
8. To talk with providers in confidence and to have your health care information and records kept confidential.
9. To see and get a copy of your medical records and to ask for changes or corrections to your records.
10.To ask for a second opinion.
11.To file a grievance if you disagree with Gateway Health’s decision that a service is not medically necessary for you.
12.To file a complaint if you are unhappy about the care or treatment you have
13. To ask for a DHS Fair Hearing.
14. To be free from any form of restraint or seclusion used to force you to do something, to discipline you, to make it easier for the provider, or to punish you.
15. To get information about services that Gateway Health or a provider does not cover because of moral or religious objections and about how to get those services.
16. To exercise your rights without it negatively affecting the way DHS, Gateway Health, and network providers treat you.
17. To discuss all medically necessary treatment options regardless of cost or
Members need to work with their health care service providers. Gateway Health needs your help so that you get the services and supports you need.
These are the things you should do:
1. Provide, to the extent you can, information needed by your providers.
2. Follow instructions and guidelines given by your providers.
3. Be involved in decisions about your health care and treatment.
4. Work with your providers to create and carry out your treatment plans.
5. Tell your providers what you want and need.
6. Learn about Gateway Health coverage, including all covered and non-covered benefits and limits.
7. Use only network providers unless Gateway Health approves an out-of-network
8. Get a referral from your PCP to see a specialist.
9. Respect other patients, provider staff, and provider workers.
10. Make a good-faith effort to pay your co-payments.
11. Report fraud and abuse to the DHS Fraud and Abuse Reporting Hotline.
We welcome all Gateway Health members the opportunity to make recommendations about our Member Rights and Responsibilities policy.