MEMBER SERVICES

• Member Rights
• Non-Discrimination
• Determining Eligibility
• Cultural Competence
• Member Problem Resolution Process
• Member Grievance Procedure

Members Rights

The SFMHP Consumer Services Guide reminds members that they have the following legal rights:

1. To privacy and confidentiality
2. To participate in their mental health care plan
3. To refuse any medical procedure
4. To be spoken to in words they understand
5. To read their medical record
6. To know the benefits, risk and costs of treatment before they consent to proceed
7. To be informed of their right to file a grievance or complaint

A provider shall not discriminate against a member on the basis of the fact or perception of the member's race, color, creed, religion, national origin, ancestry, age, sex, sexual orientation, gender identity, domestic partner status, marital status, disability, AIDS/HIV status, or medical or mental health condition unless such condition cannot be appropriately treated by provider.

San Francisco has opted to provide a single Mental Health Plan with comparable medically necessary (Appendix 1) services for Medi-Cal beneficiaries and indigent San Francisco residents. Eligibility for services is determined by the Access Team at (415) 255-3623 prior to referral using the following guidelines:

• All San Francisco Medi-Cal beneficiaries are eligible for membership in the San Francisco Mental Health Plan. A San Francisco Medi-Cal beneficiary is any person certified as eligible for services under the Medi- Cal Program according to Section 51001, Title 22, Code of California Regulations, whose beneficiary identification information includes San Francisco code number 38.
• Children in special education whose Individual Education Plan (IEP) recommends mental health services are eligible.
• In addition, SFMHP is a safety net for San Francisco residents who do not possess insurance coverage or the personal means adequate to cover the cost of medically necessary mental health care. Individuals whose incomes are below 100% of poverty ($700 per family of one as defined in the State Uniform Method of Determining Ability to Pay (UMDAP) guidelines) are eligible as members of Mental Health Plan without co-pay.
• Individuals who have no insurance will be charged under the State Uniform Method of Determining Ability to Pay (UMDAP) guidelines if their income is over poverty level. The amount of this obligation will be established by the Access Team prior to referral. Practitioner providers are expected to collect this amount from the member, and their payment will be adjusted to compensate for this.
• Individuals who are under-insured (their insurance does not provide the needed specialty mental health services)will be charged under the UMDAP guidelines if they receive medically necessary services through the SFMHP and their health payor will not pre-authorize the treatment. Policy #2.03-24 Eligibility for Planned Services for Individuals Enrolled in HMOs describes this protocol.

Organizational providers have a responsibility to complete Payor Financial Information (PFI) Forms to update eligibility information once a year in accordance with Policy #2.03-8.

Cultural competence is a fundamental value of the San Francisco Mental Health Plan. SFMHP is committed to developing and maintaining a system of care that is culturally competent and age appropriate, as well as consumer guided. In years past, efforts to improve our system's cultural competence has led to the adoption of a variety of principles which have guided the system in its development and delivery of services, and administration of policy and practices. SFMHP will further its cultural competency goals and objectives by integrating aspects of cultural competency in all operational areas of the SFMHP and through the development of standards by which outcomes can be measured.

The Mental Health Plan has established a problem resolution policy and procedure for its members which is summarized below and attached in Appendix 10 of this manual. It is essential that providers read the policy and understand their role in informing their clients about it. The primary goal is to assure members are provided with information and assistance in resolving any type of complaint or grievance in a timely manner and at the earliest possible point of intervention. There is also a provision for members to make suggestions to the SFMHP. Providers are expected to assure that their clients are informed about the complaint and grievance procedures, including posting information, as described in the policy. Members may be assisted by the Office of Consumer Affairs at (415) 255-3433 which will: 1) respond to questions and inquiries about the problem resolution processes for complaints and grievances and 2) assist members and their family members with their specific complaints or grievances. Other persons may serve as advocates, such as family members or friends, at the request of the consumer.

Informal complaints are to be handled promptly by the member's service provider or by the program director. In the event that a complaint involves a private practitioner provider, the complaint will be submitted to the Provider Systems Office. Every effort will be made by providers, and/or the Provider Systems Office to resolve problems or complaints from clients at an informal level as quickly and as simply as possible.

This complaint procedure is to be implemented consistent with the SFMHP operating principle for consumer guided services. Clients/parents may ask questions, ask for a new therapist or Care Manager, make requests or complain about the services they receive without reprisal.

The grievance procedure provides a formal avenue for the resolution of member concerns when the informal process is not sufficient to resolve the problem. A complaint becomes a grievance when it is put in written form and submitted to the Quality Improvement Office at 1380 Howard Street, 2nd floor. The person filing a grievance may obtain assistance from the Office of Consumer Relations, Patient's Rights Advocate Services (PRAS), or any one else at the member's request. While the use of the complaint process to resolve issues promptly and informally is to be encouraged, a grievance may be filed without a complaint and without reprisal at any stage of the process. Grievance forms and self-addressed envelopes shall be available for beneficiaries to pick up at all SFMHP sites.

All Grievances will be submitted to the the Quality Improvement Office, 1380 Howard Street, 2nd floor. The Grievance Procedure involves two basic steps:

• Step 1: Grievance, reviewed by Quality Improvement and referred to the appropriate SFMHP Administrative section for disposition.
• Step 2: Final Appeal, reviewed by Quality Improvement and referred to the Director of Mental Health or his/her designee for disposition. The Director may assign an independent third party or parties for review of grievances at his/her discretion.

Medi-Cal Beneficiaries May Receive Notice of Action

Members who are Medi-Cal beneficiaries, and who receive a Notice of Action indicating their services have been denied, reduced, or terminated may request a State Fair Hearing. (This does not prevent them from using the SFMHP complaint and grievance procedures.) If the hearing is requested within 10 days of receipt of notice, under certain circumstances the level of services will be maintained pending the outcome of the hearing.