Skip to Main Content

Member Rights and Responsibilities

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Providers must comply with the rights of members as set forth below.

  1. To participate with providers in making decisions about their health care. This includes working on any treatment plans and making care decisions. The member should know any possible risks, problems related to recovery and the likelihood of success. The member shall not have any treatment without consent freely given by the member or the member's legally authorized surrogate decision-maker. The member must be informed of their care options.
  2. To know who is approving and who is performing the procedures or treatment. All likely treatments and the nature of the problem should be explained clearly.
  3. To receive the benefits for which the member has coverage.
  4. To be treated with respect and dignity.
  5. To privacy of their personal health information, consistent with state and federal laws, and health plan policies.
  6. To receive information or make recommendations, including changes, about health plan's organization and services, the health plan network of providers, and member rights and responsibilities.
  7. To candidly discuss with their providers appropriate and medically necessary care for their condition, including new uses of technology, regardless of cost or benefit coverage. This includes information from the member's primary care physician (PCP) about what might be wrong (to the level known), treatment and any known likely results. The provider must tell the member about treatments that may or may not be covered by the plan, regardless of the cost. The member has a right to know about any costs they will need to pay. This should be told to the member in a way that the member can understand. When it is not appropriate to give the member information for medical reasons, the information can be given to a legally authorized person. The provider will ask for the member's approval for treatment unless there is an emergency and the member's life and health are in serious danger.
  8. To make recommendations regarding the health plan member's rights, responsibilities and policies.
  9. To voice complaints or appeals about the health plan, any benefit or coverage decisions the plan makes, health plan coverage, or the care provided.
  10. To refuse treatment for any condition, illness or disease without jeopardizing future treatment, and be informed by the provider(s) of the medical consequences.
  11. To see their medical records.
  12. To be kept informed of covered and non-covered services, program changes, how to access services, PCP assignment, providers, advance directive information, referrals and authorizations, benefit denials, member rights and responsibilities, and other health plan rules and guidelines. Health plan will notify members at least [insert timeframe] before the effective date of the modifications. Such notices shall include the following:
    • Any changes in clinical review criteria.
    • A statement of the effect of such changes on the personal liability of the member for the cost of any such changes.
  13. To have access to a current list of network providers. Additionally, a member may access information on network providers' education, training and practice.
  14. To select a health plan or switch health plans, within the guidelines, without any threats or harassment
  15. To adequate access to qualified medical practitioners and treatment or services regardless of age, race, creed, sex, sexual preference, national origin, or religion.
  16. To access medically necessary urgent and emergency services 24 hours a day and seven days a week.
  17. To receive information in a different format in compliance with the Americans with Disabilities Act, if the member has a disability.
  18. To refuse treatment to the extent the law allows. The member is responsible for their actions if treatment is refused or if the provider's instructions are not followed. The member should discuss all concerns about treatment with their PCP or other provider. The PCP or other provider must discuss different treatment plans with the member. The member must make the final decision.
  19. To select a PCP within the network. The member has the right to change their PCP or request information on network providers close to their home or work.
  20. To know the name and job title of people providing care to the member. The member also has the right to know which physician is their PCP.
  21. To have access to an interpreter when the member does not speak or understand the language of the area.
  22. To a second opinion by a network physician, at no cost to the member, if the member believes that the network provider is not authorizing the requested care, or if the member wants more information about their treatment.

Member Responsibilities

  1. To read their health plan contract in its entirety.
  2. To treat all health care professionals and staff with courtesy and respect.
  3. To give accurate and complete information about present conditions, past illnesses, hospitalizations, medications, and other matters about their health. The member should make it known whether they clearly understand their care and what is expected of them. The member needs to ask questions of their provider so they understand the care they are receiving.
  4. To review and understand the information they receive about the health plan. The member needs to know the proper use of covered services.
  5. To show their identification (ID) card and keep scheduled appointments with their provider, and call the provider's office during office hours whenever possible if the member has a delay or cancellation.
  6. To know the name of their assigned PCP. The member should establish a relationship with their PCP. The member may change their PCP verbally or in writing by contacting the Member Services Department.
  7. To read and understand to the best of their ability all materials concerning their health benefits or to ask for assistance if they need it.
  8. To understand their health problems and participate, along with their health care providers in developing mutually agreed upon treatment goals to the degree possible.
  9. To supply, to the extent possible, information that health plan and/or their providers need in order to provide care.
  10. To follow the treatment plans and instructions for care that they have agreed on with their health care providers.
  11. To understand their health problems and tell their health care providers if they do not understand their treatment plan or what is expected of them. The member should work with their PCP to develop mutually agreed upon treatment goals. If the member does not follow the treatment plan, the member has the right to be advised of the likely results of their decision.
  12. To follow all health benefit plan guidelines, provisions, policies and procedures.
  13. To use any emergency room only when they think they have a medical emergency. For all other care, the member should call their PCP.
  14. To give all information about any other medical coverage they have at the time of enrollment. If, at any time, the member gains other medical coverage besides health plan coverage, the member must provide this information to the health plan.
  15. To pay their monthly premium, all deductible amounts, copayment amounts, or cost-sharing percentages at the time of service. 
Last Updated: 10/30/2019