Member Rights and Responsibilities
- Participating Physician Groups (PPG)
Providers must comply with the rights of members as set forth below.
- To be treated with respect and dignity.
- To receive information in a way that works for members and is consistent with their cultural sensitivities, including information in other languages and alternate formats.
- Timely access to covered services and drugs.
- To privacy of their personal health information, consistent with state and federal laws, and health plan policies. To see their medical records and understand how it is shared.
- To receive information about the health plan, it’s (covered and noncovered) services, its network of providers, and member rights and responsibilities.
- To participate with providers in making decisions about their health care. To give instructions about what is to be done if members are not able to make medical decisions for themselves.
- To voice complaints or appeals about the health plan, any benefit or coverage decisions the plan makes, health plan coverage, or the care provided.
- To make recommendations to the Plan’s member rights and responsibilities policy.
- To candidly discuss with their providers appropriate and medically necessary care for their conditions, including new uses of technology, regardless of cost or benefit coverage.
- To adequate access to qualified medical practitioners and treatment or services regardless of age, race, creed, sex, sexual preference, national origin, or religion.
- To read their health plan contract in its entirety.
- 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.
- To follow all health benefit plan guidelines, provisions, policies and procedures.
- 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.
- To provider their membership card whenever they get medical care or prescription drugs.
- To give accurate and complete information that the health plan and its providers need in order to provide care.
- To understand their health problems and participate, along with their health care providers in developing mutually agreed upon treatment goals to the degree possible.
- To follow the treatment plans and instructions for care that they have agreed on with their health care providers.
- To treat all health care professionals and staff with courtesy and respect.
- To pay their monthly premium, all deductible amounts, copayment amounts, or cost-sharing percentages at the time of service.