Your Rights

Your Rights and Responsibilities

At CalOptima Health PACE, we are dedicated to providing you with quality health care services so you may remain as independent as possible. Our staff is committed to treating each and every participant with dignity and respect and ensuring that all participants are involved in planning for their care and treatment. 

As a CalOptima Health PACE participant, you have the following rights:

You have the right to be treated with respect

You have the right to be treated with dignity and respect at all times, have all of your care kept private, and receive compassionate, considerate care. You have the right to:

• Receive your health care in an accessible manner and in a safe, clean environment.
• Be free from harm. Harm includes physical or mental abuse, neglect, excessive medications, physical punishment or being placed by yourself against your will, as well as any physical or chemical restraint used on you for discipline or convenience of staff that you do not need to treat your medical symptoms or prevent injury.
• Be free from hazardous procedures.
• Receive treatment and rehabilitation services designed to promote your functional ability to the optimal level and to encourage your independence
• Receive care from professionally trained staff that has the education and experience to carry out the services for which they are responsible.
• Participate in a program of services and activities that promote positive attitudes on usefulness and capabilities and are designed to encourage learning, growth and awareness of constructive ways to develop your interests and talents.
• Self-determination within the day care setting, including the opportunity to: 1) Participate in developing a plan for services; 2) Decide whether or not to participate in any given activity; 3) Be involved to the extent possible in program planning and operation.
• To be cared about in an atmosphere of sincere interest and concern in which needed support and services are provided.
• Be ensured of auditory and visual privacy during all health care examinations and treatment visits.
• Receive assistance, if you need it, to use the Medicare and Medi-Cal complaint and appeal processes, and your civil and other legal rights.
• Be encouraged and helped in talking to CalOptima Health PACE staff about voicing your complaints and recommending changes in policies and services to CalOptima Health PACE staff and to outside representatives of your choice. There will be no restraint, interference, coercion, discrimination or reprisal by our staff if you do so.
• Use a telephone while at the CalOptima Health PACE Center, make and receive confidential calls and/or have such calls made, if necessary.
• Not have to do work or services for CalOptima Health PACE.

You have a right to protection against discrimination

Discrimination is against the law. Every company or agency that works with Medicare and Medi-Cal must obey the law. They cannot discriminate against you because of your:

• Race
• Ethnic origin
• National origin
• Religion
• Age
• Sex
• Sexual orientation
• Mental or physical disability
• Source of payment for your health care (for example, Medicare or Medi-Cal)

As a participant of CalOptima Health PACE, you have the right to receive competent, considerate, respectful care from staff and contractors without regard to race, national/ethnic origin, religion, age, sex, sexual orientation, mental or physical disability, or source of payment for your health care. 

If you think you have been discriminated against for any of these reasons, contact a staff member at CalOptima Health PACE to help you resolve your concerns. 

If you have any questions, you can call the Office for Civil Rights toll-free at 1-800-368-1019. TDD/TTY users should call 1-800-537-7697.

You have a right to information and assistance

You have the right to receive accurate, easy to understand information and to have someone help you make informed health care decisions. You have the right to:

• Have someone help you if you have a language or communication barrier in order that you can understand all information provided you.
• Have someone interpret all information given to you into your preferred language in a culturally competent manner, if your first language is not English and you cannot speak English well enough to understand the information being given to you.
• Have the Enrollment Agreement discussed fully and explained to you in a manner you understand.
• Receive marketing materials and CalOptima Health PACE Rights in English and any other frequently used language in your community. You can also receive these materials in Braille, if necessary.
• Receive a written copy of your rights from CalOptima Health PACE. CalOptima Health PACE will post these rights in a public place in the CalOptima Health PACE Center where it is easy to read them.
• Be fully informed, in writing, of the services offered by CalOptima Health PACE. This includes telling you which services are provided by contractors instead of the CalOptima Health PACE staff. You will be given this information before you join CalOptima Health PACE, at the time you join and when there is a change in services.
• Review, with assistance if needed, the results of the most recent review of CalOptima Health PACE. Federal and State agencies review all PACE programs. You also have a right to review how CalOptima Health PACE plans to correct any problems that are found at inspection.

You have a right to a choice of providers

• You have the right to choose a health care provider within the CalOptima Health PACE network and to receive quality health care.
• Women have the right to get services from a qualified women’s health care specialist for routine or preventive women’s health care services.
• You have the right to have reasonable and timely access to specialists as indicated by your health condition and consistent with current clinical practice guidelines.

You have a right to access emergency services

You have the right to receive emergency services when and where you need them without CalOptima Health PACE approval. A medical emergency is when you think your health is in serious danger – when every second counts. You may have a bad injury, sudden illness or an illness quickly getting much worse. You can get emergency care anywhere in the United States.

You have a right to participate in treatment decisions

• You have the right to fully participate in all decisions related to your health care. If you cannot fully participate in your treatment decisions or you want to have someone you trust help you, you have the right to choose that person to act on your behalf. You have the right to:
• Have all treatment options explained to you in a language you understand, be fully informed of your health and functional status and how well you are doing and make health care decisions.
• Be informed of all treatment prescribed by the interdisciplinary team prior to being treated, when and how services will be provided, and the names and functions of people providing your care.
• Refuse treatment or medications. If you choose not to receive treatment, you must be told how this will affect your health.
• Be assured that decisions regarding your care will be made in an ethical manner.
• Be assured that you and your family will be educated about an illness affecting you so that you can help yourself, and your family can understand your illness and help you.
• Receive information on advance directives and have CalOptima Health PACE help you create an advance directive. An advance directive is a written document that says how you want medical decisions to be made in case you cannot speak for yourself.
• Participate in making and carrying out your plan of care, which will be designed to promote your functional ability to the highest level and encourage your independence. You can ask for your plan of care to be reviewed at any time. You also can request a reassessment by the interdisciplinary team at any time.
• Appeal any treatment decision made by CalOptima Health PACE or our contractors through our appeals process and request a State hearing.
• Receive necessary care across all care settings, up to and including placement in a long-term care facility when the PACE organization can no longer maintain you safely in the community through the support of PACE services.
• Be given advance notice, in writing, of any plan to move you to another treatment setting, and the reason you are being moved.

You have a right to have your health information kept private

You have the right to:

• Talk with health care providers in private and have your personal health care information kept private as protected under state and federal laws.
• Review and receive copies of your medical records and request amendments to those records.
• Be assured that all information contained in your health record will be held in confidence, including information contained in any automated data bank. CalOptima Health PACE will require your written consent for the release of information to persons not otherwise authorized under law to receive it. You may provide written consent, which limits the degree of information and the persons to whom information may be given.
• Be assured of confidentiality when accessing Sensitive Services such as Sexually Transmitted Disease (STD) and HIV testing.
• There is a new participant privacy rule that gives you more access to your own medical records and more control over how your personal health information is used. If you have any questions about this privacy rule, you may call the Office for Civil Rights toll-free at 1-800-368-1019. TDD/TTY users should call 1-800-537-7697.

You have a right to file a complaint

You have a right to complain about the services you receive, or that you need and do not receive, about the quality of care, or any other concerns or problems you have with CalOptima Health PACE. You have the right to a fair and timely process for resolving concerns with CalOptima Health PACE. You have the right to:

• A full explanation of the complaint and appeals process.
• Assistance to exercise civil, legal and participant rights, including the CalOptima Health PACE grievance process, the Medi-Cal State hearing process and the Medicare and Medi-Cal appeals processes.
• You have a right to Contact 1-800-MEDICARE (1-800-633-4227) for information and assistance, including to make a complaint related to the quality of care or the delivery of a service.
• Be encouraged and helped to freely explain your complaints to CalOptima Health PACE staff and outside representatives of your choice. You must not be harmed in any way for telling someone your concerns. This includes being punished, threatened or discriminated against.
• Appeal any treatment decision by CalOptima Health PACE, staff or contractors.

You have a right to leave the program

If for any reason you do not feel that CalOptima Health PACE is what you want, you have the right to leave the program at any time. 

If you feel any of your rights have been violated, please report them immediately to your social worker or call our office Monday through Friday from 8 a.m. to 4:30 p.m.: 

1-714-468-1100 or Toll-Free 1-855-785-2584 

If you want to talk with someone outside of CalOptima Health PACE about your concerns, you may call: 

1-800-MEDICARE (1-800-633-4227), or 1-888-452-8609 (Department of Health Care Services Office of the Ombudsman). 

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 (The confidential form has instructions on how to fill it out and where to send it.) 

If you feel any of your rights have been violated, or you are dissatisfied and want to file a grievance or an appeal, please report this immediately to your social worker or call our office during regular business hours at:  

1-714-468-1100 or our toll-free line at 1-844-999-PACE (7223).  

If you would like to talk to someone outside of CalOptima Health PACE about your concerns, you may contact 1-800-MEDICARE (1-800-633-4227), or 1-888-804-3536 (Health Consumer Alliance- Medi-Cal Ombudsman Program).

We believe that you and any family member or caregiver involved in your care play crucial roles in the delivery of your care. To assure that you remain as healthy and independent as possible, please establish an open line of communication with those participating in your care and be accountable for the responsibilities listed below:  

You have the responsibility to:  

• Cooperate with the Interdisciplinary Team in implementing and following your care plan.  
• Discuss with your providers if you do not want to accept a treatment or medication your IDT decides you need, and to understand and accept the consequences to your health and well-being if you refuse any recommended treatment.  
• Provide the Interdisciplinary Team with a complete and accurate medical history.  
• Utilize only those services authorized by CalOptima Health PACE.  
• Take all prescribed medications as directed.  
• Call the CalOptima Health PACE physician for direction in an urgent situation.  
• Notify CalOptima Health PACE within 48 hours or as soon as reasonably possible if you require emergency services whether in or out of the service area.  
• Notify CalOptima Health PACE when you wish to initiate the disenrollment process.  
• Notify CalOptima Health PACE of a move or lengthy stay outside of the service area.  
• Pay required monthly fees as appropriate.  
• Treat our staff with respect and consideration, and without discrimination of any kind.  
• Not ask staff to perform tasks that they are prohibited from doing by CalOptima Health PACE or agency regulations.  
• Voice any concerns or dissatisfaction you may have with your care.  

CalOptima Health PACE will make every reasonable effort to provide a safe and secure environment at the center. However, we strongly advise participants and their families to leave valuables at home. CalOptima Health PACE is not responsible for safeguarding personal belongings. 

Information for Participants About the Grievance Process

The Grievance Process

All of us at CalOptima Health PACE share responsibility for your care and your satisfaction with the services you receive. Our grievance procedures are designed to enable you and/or your representative to express any concerns or dissatisfaction you have so that we can address them in a timely and efficient manner. You also have the right to appeal any decision about our failure to approve, furnish, arrange for or continue what you believe are covered services, or to pay for services that you believe we are required to pay.

This page describes our grievance and appeals processes. You will receive written information about the grievance and appeals processes when you enroll and annually after that. At any time, should you wish to file a grievance, we are available to assist you. If you do not speak English, a bilingual staff member or translation services will be available to assist you with the process.

You will not be discriminated against because a grievance or appeal has been filed. CalOptima Health PACE will continue to provide you with all the required services during the grievance or appeals process. We will maintain the confidentiality of your grievance or appeal throughout the process, and information pertaining to your grievance or appeal will only be released to authorized individuals.

Definition: A grievance is a complaint, either written or oral, expressing dissatisfaction with the services provided or the quality of care. A grievance may include, but is not limited to:

• The quality of services a PACE participant receives in the home, at the PACE Center or during an inpatient stay (hospital, rehabilitative facility, skilled nursing facility, intermediate care facility or residential care facility).
• Waiting times on the telephone, in the waiting room or exam room.
• Behavior of any of the care providers or program staff.
• Adequacy of center facilities.
• Quality of the food provided.
• Transportation services.
• A violation of a participant’s rights.

Filing of Grievances

The information below describes the grievance process for you or your representative to follow should you or your representative wish to file a grievance.

1. You can verbally discuss your grievance either in person or by telephone with PACE program staff of the center you attend. The staff person will make sure that you are provided with written information on the grievance process and that your grievance is documented on the Grievance Report form. You will need to provide complete information about your grievance so the appropriate staff person can help to resolve your grievance in a timely and efficient manner. If you wish to submit your grievance in writing, please send your written grievance to: 
   
   CalOptima Health PACE Quality Assurance Coordinator 
   13300 Garden Grove Blvd. 
   Garden Grove, CA 92843 
   Telephone: 1-714-468-1100 
   Fax: 1-714-468-1065 
   TTY: 1-714-468-1063 
   
   You may also contact our Quality Assurance department at 1-714-468-1100 to request a Grievance Report form and receive assistance in filing a grievance. TDD/TYY users can call 1-714-468-1063. Our Quality Assurance department will provide you written information on the grievance process. You may also access our website at www.caloptima.org to find information about the grievance process.
2. The staff member who receives your grievance will help you document your grievance (if your grievance is not already documented) and coordinate investigation and action. All information related to your grievance will be held in strict confidence.
3. You will be sent a written acknowledgement of receipt of your grievance within five (5) calendar days. Investigation of your grievance will begin immediately to find solutions and take appropriate action.
4. The CalOptima Health PACE staff will make every attempt to resolve your grievance within thirty (30) calendar days of receipt of your grievance, and you will receive a written letter with the resolution. If you are not satisfied with that resolution, you and/or your representative have the right to pursue further action.
5. In the event resolution is not reached within thirty (30) calendar days, you or your representative will be notified in writing of the status and estimated completion date of the grievance solution.

Expedited Review of Grievances

If you feel your grievance involves a serious or imminent threat to your health, including, but not limited to, potential loss of life, limb or major bodily function, severe pain, or violation of your participant rights, we will expedite the review process to a decision within 72 hours of receiving your written grievance and request for expedition. In this case, you will be immediately informed by telephone of:

• The receipt of your request for expedited review; and
• Your right to notify the Department of Social Services of your grievance through the State hearing process.

Resolution of Grievances

Upon CalOptima Health PACE completion of the investigation and reaching a final resolution of your grievance, you will receive written notification that will provide you with a report describing the reason for your grievance, a summary of actions taken to resolve your grievance, and options to pursue if you are not satisfied with the resolution of your grievance.

Grievance Review Options

If, after completing the grievance process, or participating in the process for at least thirty (30) calendar days, you or your representative are still dissatisfied, you or your representative may pursue the options described below. Note: If you feel that waiting thirty (30) calendar days represents a serious health threat, you and/or your representative need not complete the entire grievance process nor wait thirty (30) calendar days to pursue the options described below.

If you are covered by Medi-Cal only or by Medi-Cal and Medicare, you are entitled to pursue your grievance with the Department of Health Care Services, by contacting or writing to: 

Ombudsman Unit 
Medi-Cal Managed Care Division 
Department of Health Care Services 
P.O. Box 997413, Mail Station 4412 
Sacramento, CA 95899-7413 
Telephone:1-888-452-8609 
TDD/TTY: 1-800-735-2922 
 

State Hearing Process: At any time during the grievance process, per California State law, you may also request a State hearing from the California Department of Social Services by contacting or writing to: 

California Department of Social Services 
State Hearing Division 
P.O. Box 944243, Mail Station 19-37 
Sacramento, CA 94244-2430 
Telephone: 1-800-952-5253 
Fax: 1-916-229-4410 
TTY: 1-800-952-8349

If you want a State Hearing, you must ask for it within ninety (90) days from the date of receiving the letter for resolved grievance. You or your representative may speak at the State hearing or have someone else speak on your behalf, including a relative, friend or an attorney. You may also be able to get free legal help. You or your representative will be provided a list of Legal Services offices in Orange County at the time you file your grievance.