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.
Members must have the following rights:
- You have the right to be treated with respect and dignity.
- We must provide information in a way that works for you and consistent with your cultural sensitivities (in languages other than English, in audio, in braille, in large print, or other alternate formats, etc.).
- You have the right to choose a primary care provider (PCP) in the Plan’s network to provide and arrange for your covered services. You also have the right to go to a women’s health specialist (such as a gynecologist) without a referral.
- You have the right to get appointments and covered services from the Plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.
- We must ensure that you get timely access to your covered services and drugs.
- We must protect the privacy of your personal health information.
- You have the right to look at your medical records held by the Plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made.
- You have the right to know how your health information has been shared with others for any purposes that are not routine.
- We must give you information about the Plan, its network of providers, your rights and responsibilities, and your covered services.
- We must support your right to make decisions about your care.
- You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:
- To know about all of your choices. You have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our Plan. It also includes being told about programs our Plan offers to help members manage their medications and use drugs safely.
- To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.
- The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result.
- You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself.
- You have the right to make complaints and to ask us to reconsider decisions we have made.
- You have the right to make recommendations about our member rights and responsibilities policy.
Members have the following responsibilities:
- Get familiar with your covered services and the rules you must follow to get these covered services. To read their health plan contract in its entirety.
- If you have any other health insurance coverage or prescription drug coverage in addition to our Plan, you are required to tell us.
- Tell your doctor and other health care providers that you are enrolled in our Plan. Show your Plan membership card whenever you get your medical care or Part D prescription drugs.
- Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.
- To help get the best care, tell your doctors and other health providers about your health problems. Follow the treatment plans and instructions that you and your doctors agree upon.
- Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.
- If you have any questions, be sure to ask and get an answer you can understand. You have the responsibility to understand your health problems and help set treatment goals that you and your doctor agree upon.
- Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices.
- Pay what you owe. As a Plan member, you are responsible for these payments:
- You must continue to pay a premium for your Medicare Part B to remain a member of the Plan.
- For most of your medical services or drugs covered by the Plan, you must pay your share of the cost when you get the service or drug.
- If you are required to pay the extra amount for Part D because of your yearly income, you must continue to pay the extra amount directly to the government to remain a member of the Plan.
- If you move within our Plan service area, we need to know so we can keep your membership record up to date and know how to contact you.
- If you move outside of our Plan service area, you cannot remain a member of our Plan. If you move, it is also important to tell Social Security (or the Railroad Retirement Board).