Rights & Responsibilities

Member Rights & Responsibilities

Since you have Medicare, you have certain rights. In your Evidence of Coverage we explain your Medicare rights and protections as a member of our plan, and we explain what you can do if you think you are being treated unfairly or your rights are not being respected.

Your right to be treated with dignity, respect and fairness at all times

We must obey laws that protect you from discrimination or unfair treatment. We don't discriminate based on a person's race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age, or national origin. If you need help with communication, such as help from a language interpreter, please call Customer Service. Customer Service can also help if you need to file a complaint about access (such as wheelchair access).

Your right to see plan providers, get covered services and to get your prescriptions filled within a reasonable period of time

You have the right to timely access to your providers and to see specialists when care from a specialist is needed. Timely Access means that you can get appointments and services within a reasonable amount of time.

Your right to privacy of your medical records and personal health information

There are federal and state laws that protect the privacy of your medical records and personal health information. We protect your personal health information under these laws. Any personal information that you give us when you enroll in this plan is protected. We will make sure that unauthorized people don't see or change your records. Generally, we must get written permission from you (or from someone you have given legal power to make your decisions for you) before we can give your health information to anyone who isn't providing care for you or paying for your care. There are exceptions allowed or required by law, such a release of health information to government agencies that are checking on quality of care.

Your right to know your treatment options and participate in decisions about your healthcare

You have the right to get full information from your providers when you go for medical care, and the right to participate fully in decisions about your healthcare. Your providers must explain things in a way you can understand. Your rights include knowing 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. This includes the right to know about the different Medication Therapy Management programs we offer, and in which you may participate. You 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, and be given the choice of refusing experimental treatment.

Your right to use advance directives (such as living will or power of attorney)

You have the right to ask someone such as a family member or friend to help you with decisions about your healthcare. Sometimes, people become unable to make healthcare decisions for themselves due to accidents or serious illness. If you want to, you can use a special form to give someone the legal authority to make decisions for you if you ever become unable to make decisions for yourself. You also have the right to give your doctors written instructions on how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you use to give your directions in advance in these situations are called advance directives. Call Customer Service for the forms or more information.

Your right to make complaints

You have the right to make a complaint if you have concerns or problems related to your coverage or care. A complaint can be called a grievance, an organization determination, or a coverage determination depending on the situation.

Your right to get information about our Plan, plan providers, drugs, network pharmacies, healthcare coverage, and costs

You have the right to get information from us about our plan. This includes information about your financial condition, about our providers and their qualifications, about information on our network pharmacies, and how our plan compares to other health plans. You have the right to find out from us how we pay our doctors. To get any of this information call Customer Service. You have the right under law to have a written binding advance coverage determination made for the service, even if you obtain this service from a provider not affiliated with our organization.

The Evidence of Coverage tells you about the medical services that are covered and what you have to pay. If you need further information, again call Customer Service.

Your responsibilities include the following:

Getting familiar with your coverage and the rules you must follow to get care as a member. You can use the Evidence of Coverage to learn about your coverage, what you have to pay and the rules you need to follow. We also hold Orientation Meetings to help you become familiar with your benefits. Please call Customer Service if you have any questions, we are open seven days a week.

  • Letting us know if you have additional health insurance coverage.
  • Notifying providers when seeking care (unless it is an emergency) that you are enrolled in our plan and you must present your plan enrollment card to the provider.
  • Giving your doctor and other providers the information they need to care for you, and following the treatment plan and instructions that you and your doctors agree upon. Be sure to ask your doctors and other providers if you have any questions and have them explain your treatment in a way you can understand.
  • Acting in a way that supports the care given to other patients and helps the smooth running of your doctor's office, hospitals, and other office.
  • Paying your plan premiums and your copayment/coinsurance for your covered services. You must pay for services that aren't covered.
  • Letting us know if you have any questions, concerns, problems or suggestions. If you do, please call Customer Service.
last update 10/1/2019