<today_date_mmmm_ddyyyy>
Important Plan Information
<Member Name>
<Address 1>
<Address 2>
<City>, <State<ZIP>
Your Care Plan
Dear <Member Name>,
When we spoke recently, I promised to send you a Care Plan. The plan enclosed is a summary
of our discussion. It includes the steps we agreed would help you meet your health goals. In
addition, I can help you with:
Provide-A-RideSM
This program is available to members who need a ride to medical and dental visits. To schedule
a ride, call 952-992-2580 or 1-888-347-3630 (toll free). TTY: 711. You may call 8 a.m. to 8 p.m. seven days a week. Access to a representative may be limited at times.
Health Care Directive
This form helps you outline your health care wishes. You can request a form from me and I will answer any questions you have before you discuss it with your doctor.
Annual Physical
Take a key step on your path to good health and set up an annual physical at your clinic.
<Free text for member specific information/content>.
Questions?
Call me at <CC phone number> <Monday - Friday> between <CC hours of operation>.
TTY: 711.Aswediscussed,I plan to be in touch with you again on <specify timeframe and communications method>.
Sincerely,
<Care Coordinator Name>, <Credentials>
<County/Care System/Agency name>
<CC phone number>
cc: member records
For accessibleformats ofthis publication or assistance with additional equalaccess to our services, writeto medica.com/ContactMedicaid, call
1-888-347-3630(toll free) oruseyourpreferred relayservice.
© 2018 Medica. Medica®is a registeredservicemark of Medica Health Plans. “Medica” refers to thefamilyof health plan businessesthat includesMedica Health Plans, MedicaHealthPlans ofWisconsin, MedicaInsurance Company, MedicaSelf-Insured,and MedicaHealth Management,LLCandMMSI,Inc.
HMGSPP15492-1-00718 (B)
CB5MCOs3-18
CivilRightsNotice
Discriminationisagainstthelaw.Medicadoesnotdiscriminateonthebasisofanyofthe following:
- race
- color
- nationalorigin
- creed
- religion
- sexualorientation
- publicassistancestatus
- age
- disability(including physicalormentalimpairment)
- sex(includingsexstereotypesandgenderidentity)
- maritalstatus
- politicalbeliefs
- medicalcondition
- healthstatus
- receiptofhealthcareservices
- claimsexperience
- medicalhistory
- geneticinformation
AuxiliaryAidsandServices:Medicaprovidesauxiliaryaidsandservices,likequalifiedinterpretersorinformationinaccessibleformats,freeofchargeandinatimelymannertoensureanequalopportunitytoparticipateinourhealthcareprograms.
ContactMedicaat1-888-347-3630(tollfree);TTY:711oratmedica.com/contactmedicaid.
LanguageAssistanceServices:Medicaprovidestranslateddocumentsandspokenlanguageinterpreting,freeofchargeandinatimelymanner,whenlanguageassistanceservicesarenecessarytoensurelimitedEnglishspeakershavemeaningfulaccesstoourinformationandservices.ContactMedicaat1-888-347-3630(tollfree);TTY:711oratmedica.com/contactmedicaid.
CivilRightsComplaints
You havetherighttofileadiscriminationcomplaintifyoubelieveyouweretreatedinadiscriminatorywaybyMedica.Youmaycontactanyofthefollowing fouragenciesdirectlytofileadiscriminationcomplaint.
U.S.DepartmentofHealthandHumanServices’OfficeforCivilRights(OCR)
You havetherighttofileacomplaintwiththeOCR,afederal agency,ifyoubelieveyouhavebeendiscriminatedagainstbecauseofanyofthe following:
- race
- color
- nationalorigin
- age
- disability
- sex
ContacttheOCRdirectlytofileacomplaint:Director
U.S.DepartmentofHealthandHumanServices’ Officefor Civil Rights200IndependenceAvenueSW
Room509FHHHBuilding
Washington,DC20201800-368-1019(voice)
800-537-7697(TDD)
ComplaintPortal:
MinnesotaDepartmentofHumanRights(MDHR)
InMinnesota, youhavetherighttofileacomplaintwiththeMDHRifyoubelieveyouhavebeendiscriminatedagainstbecauseofanyofthefollowing:
- race
- color
- nationalorigin
- religion
- creed
- sex
- sexualorientation
- maritalstatus
- publicassistancestatus
- disability
ContacttheMDHRdirectlytofileacomplaint:MinnesotaDepartmentofHumanRightsFreemanBuilding,625NorthRobertStreetSt.Paul,MN55155
651-539-1100(voice)
800-657-3704(tollfree)
711or800-627-3529(MNRelay)
651-296-9042(fax)
(email)
MinnesotaDepartmentofHumanServices(DHS)
You havetherighttofileacomplaintwithDHSifyoubelieveyouhavebeendiscriminatedagainstinourhealthcareprogramsbecauseofanyofthefollowing:
- race
- color
- nationalorigin
- creed
- religion
- sexualorientation
- publicassistancestatus
- age
- disability(including physicalormentalimpairment)
- sex(includingsexstereotypesandgenderidentity)
- maritalstatus
- politicalbeliefs
- medicalcondition
- healthstatus
- receiptofhealthcareservices
- claimsexperience
- medicalhistory
- geneticinformation
Complaintsmustbeinwritingandfiledwithin180 daysofthedateyoudiscoveredtheallegeddiscrimination.Thecomplaintmustcontainyournameandaddressanddescribethediscriminationyouarecomplainingabout.Afterwegetyourcomplaint, wewill reviewitandnotifyyouinwritingaboutwhetherwehaveauthoritytoinvestigate.Ifwedo, wewillinvestigatethecomplaint.
DHSwill notifyyouinwriting oftheinvestigation’soutcome.Youhavetherighttoappealtheoutcomeifyoudisagreewiththedecision.Toappeal,youmustsendawrittenrequesttohaveDHSreviewtheinvestigationoutcome.Bebriefandstatewhyyoudisagreewiththedecision.Includeadditionalinformationyouthinkisimportant.
Ifyoufileacomplaintinthisway, thepeoplewho workfortheagencynamedinthecomplaintcannot retaliateagainstyou. Thismeans they cannot punishyouinanywayforfilingacomplaint. Filingacomplaintinthiswaydoes notstopyoufromseeking outother legaloradministrativeactions.
ContactDHSdirectlytofileadiscriminationcomplaint:CivilRightsCoordinator
MinnesotaDepartmentofHumanServicesEqual OpportunityandAccessDivision
P.O.Box64997
St.Paul,MN55164-0997
651-431-3040(voice)oruseyourpreferredrelayservice
MedicaComplaintNotice
YouhavetherighttofileacomplaintwithMedicaifyoubelieveyouhavebeendiscriminatedagainstbecauseofany ofthefollowing:
- medicalcondition
- healthstatus
- receiptofhealthcareservices
- claimsexperience
- medicalhistory
- geneticinformation
- disability(includingmental orphysicalimpairment)
- maritalstatus
- age
- sex(includingsexstereotypesandgenderidentity)
- sexualorientation
- national origin
- race
- color
- religion
- creed
- publicassistancestatus
- politicalbeliefs
Youcanfile acomplaintandaskforhelpinfilingacomplaintinpersonorbymail,phone,fax,oremailat:
MedicaCivilRightsCoordinatorMedicaHealthPlans
POBox9310,MailRouteCP250Minneapolis,MN55443-9310
952-992-3422(voice andfax)TTY:711Email: