Member Rights and Responsibilities

What are Member Rights?

Note: This information is shared with every member at time of enrollment.

A Member has the right to:

1. Members have the right to receive information about their health plan, its practitioners and providers, and members’ rights and responsibilities.
2. Members have the right to courteous treatment. We respect your right to:
   • Be treated with respect and recognition of your dignity. We will not discriminate in the care offered to you based on race, religion, national origin, sex, age, sexual preference, type of illness, or financial status.
   • Be addressed in a manner that is comfortable to you.
   • Know your health care providers. You have the right to ask all personnel involved in your care to introduce themselves, state their position, and explain what they are going to do for you.
3. Members have the right to available and accessible services, including emergency services. Responsibility for payment for such services will be determined by Your coverage.
4. Members have the right to privacy.
5. Members have the right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
6. Members have the right to be informed about their health care and to receive information about proposed treatments and alternatives. Members have the right to an explanation from health care providers of:
   • Diagnosis
   • Recommended treatment and alternatives to treatment
   • Potential outcomes and/or prognosis
   • Significant benefits and risks of each alternative
7. Members have the right to participate with providers in making decisions about their care. These rights generally include:
   • Giving informed consent, i.e. agreeing to treatment based on a full explanation of your disease and the risks and benefits or proposed treatment, as well as alternative treatments.
   • Refusing diagnostic procedures or treatment. It is your right to decide whether you wish to be treated, and if so, by which method of treatment.
8. Members have the right to appropriate confidentiality of all medical and financial records in accordance with state and federal law. Generally, your medical records will not be released to persons outside your health plan unless you grant permission in writing, or we are required or permitted, under applicable law, to use or release this information. Certain examples of permitted releases of information are:
   • If required by a court order
   • To medical personnel in a medical emergency
   • As necessary to facilitate complaint investigations or inspections by federal or state entities
   • To qualified personnel for research, audit or program evaluation, as long as individuals cannot be identified
9. Members have a right to voice complaints or appeals about their health plan or the care provided.
10. Members have the right to make recommendations regarding the plan’s member rights and responsibilities.

A Member has the responsibility to:

1. Members have the responsibility to understand their health problems and to participate in developing mutually agreed upon treatment goals to the greatest degree possible. Once members and their health care provider(s) have agreed upon a treatment plan, it is the member’s responsibility to follow the prescribed plan and instructions for care. Advise the health care provider treating you if you are unable to follow a treatment plan.
2. Members have the responsibility to make informed decisions. Because you are responsible for the decisions you make about your care, we encourage you to gather as much information as you need to make your decisions.
3. Members have the responsibility to be honest and to provide, to the extent possible, information that the health plan needs to administer plan benefits and its providers need to provide care. Provide an accurate and complete medical history.
4. Members have the responsibility to report changes in their health. Tell your doctor about any changes in your health.
5. Members have the responsibility to know their providers. Try to know the names and the positions of everyone who cares for you (doctors, dentists, nurses, etc.).

If members need help understanding any of this information, call us at 800-299-6080.