Member Rights and Responsibilities
The Plan strongly endorses the rights of members as supported by State and Federal laws. As well, the Plan expects members to be responsible for certain aspects of the care and treatment they are offered and receive. All member rights and responsibilities are to be acknowledged and honored by the Plan’s staff and all contract providers. Contract providers are provided with a declaration of the Plan’s member rights and responsibilities in their Provider Manual and on the Plan’s website. In addition, providers are given a handout of these rights and responsibilities and urged to post them in their respective offices. Members are afforded a listing of their rights and responsibilities as a member of the Plan in their Evidence of Coverage.
As a member of the Plan, you have the right to:
- Be treated with courtesy and respect, with appreciation of your dignity, and protection of your need for privacy.
- A prompt and reasonable response to questions and requests.
- Know who is providing medical services and who is responsible for your care.
- Know what patient support services you can get, and if an interpreter is available if you do not speak English.
- Know what rules and laws apply to the conduct of the staff of the Plan and contracted providers.
- Be provided by the Plan’s providers, information about diagnosis, planned course of treatment, alternatives, risks, and prognosis.
- Accept or refuse any treatment, except as provided by law, and complete an advance directive.
- File a complaint with the state survey and certification agency for any dissatisfaction with the Plan’s process for handling advance directives.
- If eligible for Medicare, know upon request and in advance of treatment, if the health care provider or health care facility accepts the Medicare assignment rate.
- Receive, before treatment, a reasonable estimate of charges for medical care.
- Receive a copy of a reasonable, clear, and understandable detailed bill and, upon request, to have the charges explained.
- Access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or source of payment.
- Treatment for any emergency medical condition that will get worse from failure to provide treatment.
- Know if medical treatment is for experimental research and to grant consent or refusal to take part in such experimental research.
- Private handling of medical records and, except when required by law, be given the chance to approve or refuse their release.
- Voice complaints or appeals about the organization or the care it provides.
- Express grievances about any violation of your rights, through the Plan’s grievance and appeals system, and to appeal to a state grievance and appeal oversight entity; and for Medicare members, through the CMS established appeal process.
- Participate with practitioners in making decisions about your health care, and provide input into your proposed treatment plan.
- Receive information about the Plan, its services, practitioners and providers, and members’ rights and responsibilities.
- Have a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
- Make recommendations regarding the Plan’s member rights and responsibilities policies.
- Review, copy, and amend incorrect data in your medical records. You may be denied access to your medical records if a provider believes it could engager your or someone else’s physical safety, for some psychotherapy notes, for information compiled for a lawsuit, or for certain other limited circumstances. If you are denied your medical records, you may appeal this decision.
- Receive an accounting of all disclosures of your personal information to third parties.
- Receive a written summary or explanation of your health condition.
As a member of the Plan, your provider expects you to:
- Provide your health care provider, to the best of your knowledge, correct and complete information about present complaints, past illnesses, hospital stays, medicines and other health matters.
- Report unexpected changes in your condition to your health care provider.
- Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
- Discuss with your health care provider if you do not comprehend a course of treatment or what is expected of you.
- Follow the treatment plan suggested by your health care provider and agreed upon by you.
- Keep appointments, and when you are unable to do so for any reason, notify your health care provider or health care facility.
- Answer for your actions if you refuse treatment or do not follow the health care provider's instructions.
- Assure that the financial obligations of your health care are fulfilled as promptly as possible.
- Follow health care facility rules and laws that affect patient care and conduct.
Last updated 10/01/2019