Member Rights and Responsibilities

• We must provide information in a way that works for you (in languages other than English, in Braille, large print, or other alternate formats, etc.).
• We must treat you with fairness, respect, and dignity at all times.
• We must ensure that you get timely access to your covered services and drugs.
• We must protect the privacy of your personal health information.
• We must give you information about the plan, its network of providers, your covered services, and your rights and responsibilities.
• You have the right to participate with practitioners in making decisions about your care.
• You have the right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
• You have the right to make complaints about our organization or the care we provide and to appeal (ask us to reconsider) decisions we have made.
• You have the right to know the number of and what happened to appeals, grievances, and exceptions filed by our Members, which you may find out by asking us to send you this information.
• You have the right to make recommendations as well as get more information about your rights and responsibilities.

• Get familiar with your covered services and the rules you must follow to get these covered services.
• If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us.
• Tell your doctor and other health care providers that you are enrolled in our plan.
• Help your plan, doctors and other providers help you by giving them information (to the extent possible) we might need to provide you with care.
• Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree you are able.
• Follow through on the care that you have agreed to with your practitioners.
• Be considerate.
• Pay what you owe.
• Tell us if you move.
• Call Member Services for help if you have questions or concerns.

• Until your membership ends, you must keep getting your medical services and drugs through our plan.
• Until your membership ends, you are still a member of our plan.
• You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends.
• If you are hospitalized on the day that your membership ends, you will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).
• We cannot ask you to leave our plan for any reason related to your health.
• You have the right to make a complaint if we end your membership in our plan.

• If you do not stay continuously enrolled in Medicare Part A and Part B.
• If you move out of the service area.
• If you are away from our service area for more than six months
  • If you move or take a long trip, you need to call Member Services to find out if the place you are moving or traveling to is in our plan's area.
• If you become incarcerated (go to prison).
• If you lie or withhold information about other insurance you have that provides prescription drug coverage.
• If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
• If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
• If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.
• If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose your prescription drug coverage.

• A right to receive information about the organization, its services, its practitioners and providers and member rights and responsibilities.
• A right to be treated with respect and recognition of their dignity and their right to privacy.
• A right to participate with practitioners in making decisions about their health care.
• A right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
• A right to voice complaints or appeals about the organization or the care it provides.
• A right to make recommendations regarding the organization’s member rights and responsibilities policy.
• A responsibility to supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.
• A responsibility to follow plans and instructions for care that they have agreed to with their practitioners.
• A responsibility to understand their health problems and participate in developing mutually agreed- upon treatment goals, to the degree possible.

For more information on Member Rights and Responsibilities including disenrollment procedures and situations, please review Ultimate Health Plans Evidence of Coverage, Chapter 8. Your Rights and Responsibilities.

For a printable version of the information above, please download this file: