Member Rights

It is the policy of Virginia Premier to treat all members with respect. The organization remains dedicated in keeping members educated and informed of their rights and responsibilities while maintaining a high level of confidentiality with due consideration for dignity and privacy. 

As a member of Virginia Premier, you have the right to:

• All covered services described in the Member Handbook.
• Treatments with quality care, respect, dignity and the right to privacy.
• Have health care services twenty-four (24) hours a day, three hundred sixty-five (365) days a year, including urgent, emergency and post stabilization services.
• Choose your personal Virginia Premier doctor/Primary Care Physician (PCP).
• Change your personal Virginia Premier doctor and choose another one from Virginia Premier’s Provider Directory (You can find the Provider Directory online or call Member Services and ask for a copy to be mailed to you).
• Make your own doctor/PCP appointments to be seen in their private office at your convenience.
• Not be treated against your will.
• Ask your doctor/PCP questions. Do not be afraid.
• Call Member Services to file a complaint/grievance about Virginia Premier or file an appeal if you are not happy with the answer to your inquiry (question), complaint/grievance, or care given. Requests for a State Fair Hearing may be submitted to DMAS at the same time that an appeal is submitted to Virginia Premier; or, after exhausting the Virginia Premier appeal’s process; or, instead of appealing to Virginia Premier.
• Have your and/or your child’s medical records kept private unless you sign a permission form.
• Have timely access to you and/or your child’s medical records. (You may be required to sign a release form.)
• Participate with your doctor in making decisions about your health care.
• Have your and/or your child’s doctor tell you about any treatment choices you may have, no matter what the cost or benefit coverage as well as receive a second opinion from Virginia Premier’s network of providers.
• 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.
• Free exercise of rights and the exercise of those rights that does not adversely affect the way the Virginia Premier and its providers treat the enrollee.
• Receive information about Virginia Premier, its services, providers and member’s rights and responsibilities.
• Make suggestions regarding Virginia Premier’s member rights and responsibilities statements, which are found in this member handbook.

Supplemental Member Rights

Virginia Premier Health Plan members also have the right to:

• See an in network doctor in a timely manner based on the access standards listed in the Member Handbook document under the section called: Access to Health Care Standards.
• Get emergency care and family planning services in or out of network without prior authorization. Family planning services, preventive services, and basic prenatal care do not need preauthorization, but you should get care from an in network doctor/provider.
• Not have Virginia Premier stop or limit a doctor/provider acting within the lawful scope of practice, from telling or helping on behalf of a member who is his or her patient, related to the member’s health condition, medical care or treatment choices, including any other treatment that may be self-administered.
• Have the doctor write in his or her medical record whether or not the member has completed an advance directive.
• Not have the doctor/provider condition the delivery of care or discriminate against a member based on whether he/she has completed an advance directive form.
• Not be balanced billed by any provider for any reason for covered services.
• Contact Virginia Premier staff that has been trained on advance directives and asks questions, if needed.
• File any type of grievance, including those related to advance directives, with Virginia Premier by calling the toll free line at 1-800-727-7536 (TTY: 711).
• Give female members direct access (no referral needed) to a woman’s health doctor/provider in the network for covered routine and preventive care services. This is in addition to the member’s assigned primary care doctor/provider if that person is not a women’s health doctor/provider.
• Have his/her health care needs and information discussed and given to the doctors/providers they want. The member can call Member Services and ask that Virginia Premier have the information sent to their doctor.
• Confidentiality when managing care including medical records, member information and appointment records for the treatment of sexually transmitted diseases.
• Not be responsible for the bill or extra costs, if out of network services are given to a member for emergency care or care that has been preauthorized.
• See in network doctors/providers with office hours that are the same as those for other patients who may not have Medicaid like private commercial insurance members and or other types of Medicaid members (fee for service), if the doctor/provider sees only Medicaid members.
• See a doctor of his/her choice based on language and/or race and one who is sensitive to the member’s cultural needs, including those who cannot speak English well and those with different cultural and racial backgrounds.
• Get information in different formats (i.e., large print, braille, etc.), if needed and in an easy form that takes into consideration the special needs of those who may have problems seeing or reading.
• Have any service that has been stopped start again, if a member’s location is known.

Member Responsibilities

1. Choose your and/or your child’s Virginia Premier PCP from the list of our doctors. (See Provider Directory).
2. Get your and/or your child’s health care through our list of PCP’s and hospitals and other health care providers.
3. Keep doctor’s appointments or call to cancel them at least twenty-four (24) hours ahead of time.
4. Carry your and/or your child’s Virginia Premier and Medicaid ID member card with you at all times.
5. Tell the doctor that you and/or your child are/is a member of Virginia Premier Health Plan at the time that you speak with the doctor’s office.
6. Give your PCP and other providers honest and complete information about your and/or your child’s health to care for you.
7. Learn the difference between emergency and urgent care. Know:
   • What an emergency is
   • How to keep one from happening, and
   • What to do if one happens.
8. Follow plans and instructions for care given by your and/or your child’s doctor.
9. Understand your health problems and discuss and/or agree upon treatment plans with your and/or your child’s doctor. Get an okay from your and/or your child’s PCP or Virginia Premier before you and/or your child see another doctor.
10.  Let Virginia Premier know how we can work better for you