Member rights & responsibilities

Commercial member rights and responsibilities statement

Commercial member rights

The members have a right to receive information about the health plan, its benefits, services included or excluded from coverage policies, participating practitioners/providers and members’ rights and responsibilities. Written and Web-based information that is provided to the member will be readable and easily understood.

The members have a right to be treated with respect and recognition of their dignity and right to privacy.

The members have a right to participate in decision making regarding his/her health care. This right includes candid discussions of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage.

The members have a right to voice complaints or appeals about the health plan or care provided, and to receive a timely response. The members have a right to be notified of the disposition of appeals/complaints and the right to further appeal, as appropriate.

The members have a right to make recommendations regarding the organization’s member rights and responsibilities policies by contacting Customer Service in writing.

The members have a right to confidential treatment of personally identifiable health/medical information. The members also have the right to have access to their medical record in accordance with applicable federal and state laws.

The members have a right to reasonable access to medical services.

The members have a right to receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, genetic information, color, religion, gender, gender identity, sexual orientation, national origin, or source of payment.

The members have a right to formulate advance directives. The Plan will provide information concerning advance directives to members and practitioners/providers and will support members through its medical record keeping policies.

The members have a right to obtain a current directory of participating practitioners/providers in the Plan’s network, upon request. The directory includes addresses, telephone numbers, and a listing of practitioners/providers who speak languages other than English.

The members have a right to file a complaint or appeal about the health plan or care provided with the applicable regulatory agency and to receive an answer to those complaints within a reasonable period of time and to be notified of the disposition of an appeal or complaint and further appeal, as appropriate.

The members have a right to appeal a decision to deny or limit coverage, first within the Plan and then through an independent organization for a filing fee as applicable. The members also have the right to know that their doctor cannot be penalized for filing a complaint or appeal on the member’s behalf.

The members have a right to choose a primary care provider within the limits of covered benefits and availability within the Plan network. The members also have the right to refuse care from specific practitioners/providers.

For members with chronic disabilities, they have the right to obtain assistance and referrals to practitioners/providers who are experienced in treating their disabilities.

The members have a right to candid discussions of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage, in terms that members understand including an explanation of their medical condition, recommended treatment, risks of treatment, expected results and reasonable medical alternatives. If the members are unable to easily understand this information, they have the right to have an explanation provided to their next of kin or guardian and documented in their medical record. The Plan does not direct practitioners/providers to restrict information regarding treatment options.

The members have a right to have available and accessible services, when medically necessary, including availability of care 24 hours a day, seven days a week for urgent and emergency conditions.

The members have a right to call 911 in a potentially life-threatening situation without prior approval from the Plan; the right to have the Plan pay per contract for a medical screening evaluation in the emergency room to determine whether an emergency medical condition exists.

The members have a right to continue receiving services from a practitioner/provider who has been terminated from the Plans’ network (without cause) in the timeframes as defined by the applicable state requirements. This continuation of care does not apply if the provider is terminated for reasons which would endanger the member, public health or safety, breach of contract or fraud.

The rights afforded to members by law or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language they understand.

The right to be free from balance billing by practitioners/providers for medically necessary services that are authorized or covered by the Plan except as permitted for copayments, coinsurance and deductibles, by contract.

The right to prompt notification of terminations or changes in benefits, services or practitioner/provider network.

Commercial member responsibilities

Members have the responsibility to communicate, to the extent possible, information the Plan, participating practitioners and practitioners/providers need in order to care for the member.

Members have the responsibility to follow the plans and instructions for care that they have agreed on with their practitioners/providers. This responsibility includes consideration of the possible consequences of failure to comply with recommended treatment.

Members have the responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.

Members have the responsibility to review all benefit and membership materials carefully and to follow the rules pertaining to the health plan.

Members have the responsibility to ask questions to assure understanding of the explanations and instructions given.

Members have the responsibility to treat others with the same respect and courtesy expected for oneself.

Members have the responsibility to keep scheduled appointments or to give adequate notice of delay or cancellation.

The responsibility to pay deductibles, coinsurance, or copayments, as appropriate, according to the member’s contract.

The responsibility to pay for charges incurred that are not covered under or authorized under the member’s benefit policy or contract.

The responsibility to pay for charges that exceed what the plan determines are customary and reasonable (usual and customary, or usual, customary and reasonable, as appropriate) for services that are covered under the out-of-network component of the member’s benefit contract with respect to point of service contracts.