Quality Management
Member Rights & Responsibilities
Member Rights
A member has the right to:
- Request information about the health plan and 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 written in plain English and able to be easily understood.
- Voice complaints (concerns, Medicare “grievances”) and file appeals about the health plan or a provider and receive a timely response.
- Choose providers subject to the limits of the plan’s network and refuse care from specific providers. Certain benefits plans may require use of network providers, including designated network providers (for designated covered services such as physical therapy).
- Be treated with respect and recognition of his or her dignity and right to privacy.
- Participate in decision–making about his or her health care. This right includes candid discussions of medically necessary treatment and other appropriate treatment options for the condition, regardless of cost or benefit coverage available under the member’s plan.
- Receive confidential treatment of medical information. The member also has the right to have access to his or her medical record in accordance with applicable federal and state laws.
- Receive reasonable access to medical services.
- Receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, genetic information, color, religion, gender, sexual orientation, national origin, or source of payment.
- Formulate advance directives. We will provide information concerning advance directives to members and providers. Our policy requires providers to record either the existence of an advance directive or the discussion of an advance directive.
Member Responsibilities
A member has the responsibility to:
- Review all benefits and membership materials carefully and follow the requirements, policies, and procedures of the health plan.
- Communicate, to the extent possible, information that the health plan and participating providers need in order to provide care for the member.
- Follow instructions for care that the member agrees to with his or her provider. This responsibility includes consideration of the possible consequences of failure to comply with recommended treatment.
- Ask questions to ensure understanding of provider explanations and instructions given.
- Treat others with the same respect and courtesy a member expects for himself or herself.
- Keep scheduled appointments or give adequate notice of delay or cancellation.
