Member Rights & Responsibilities
Your Rights & Responsibilities
As a Senior Whole Health member, you have certain rights and responsibilities. Senior Whole Health has listed them below. They help you to know what to expect from your health care. They can also help you to get the most out of your health care.
Your right to be treated with dignity, respect and fairness
You have the right to be treated with dignity, respect, and fairness always. Our Plan 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 Member Services. Member Services can also help if you need to file a complaint about access (such as wheelchair access). You may also call the Office for Civil Rights at (800) 368-1019 or TTY/TDD
(800) 537-7697, or your local Office for Civil Rights.
Your right to the 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 decisions for you) before we can give your health information to anyone who isn’t providing your care or paying for your care. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care. The Plan will release your information, including your prescription drug event data, to Medicare, which may release it for research and other purposes that follow all applicable Federal statutes and regulations.
The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We are required to provide you with a notice that tells about these rights and explains how we protect the privacy of your health information. You have the right to look at medical records held at the Plan, and to get a copy of your records (there may be a fee charged for making copies). You also have the right to ask us to make additions or corrections to your medical records (if you ask us to do this, we will review your request and figure out whether the changes are appropriate). You have the right to know how your health information has been given out and used for non-routine purposes. If you have questions or concerns about privacy of your personal information and medical records, please call Member Services.
Your right to see network providers, get covered services, and get your prescriptions filled within a reasonable period of time
As explained in this booklet, you will get most or all your care from network providers, that is, from doctors and other health providers who are part of our Plan. You have the right to choose a network provider (we will tell you which doctors are accepting new patients). You have the right to go to a women’s health specialist in our Plan (such as a gynecologist) without a referral 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
You have the right to timely access to your prescriptions at any network pharmacy, your right to know your treatment options and participate in decisions about your health care.
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 health care. Your providers must explain things in a way that you can understand. Your rights include knowing about all 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 have 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 treatments.
You have the right to receive a detailed explanation from us if you believe that a provider has denied care that you believe you were entitled to receive or care you believe you should continue to receive. In these cases, you must request an initial decision called an organization determination or a coverage determination. Organization determinations and coverage determinations are discussed in Section 5.
You have the right to refuse treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. This includes the right to stop taking your medication. If you refuse treatment, you accept responsibility for what happens because of your refusing treatment.
Your right to get information about our Plan
You have the right to get information from us about our Plan. This includes information about our financial condition, and how our Plan compares to other health plans. To get any of this information, please call Member Services.
Your right to get information in other formats
You have the right to get your questions answered. Our plan must have individuals and translation services available to answer questions from non-English speaking beneficiaries and must provide information about our benefits that is accessible and appropriate for persons eligible for Medicare because of disability. If you have difficulty obtaining information from your plan based on language or a disability, call (800) MEDICARE (633-4227). TTY users should call (877) 486-2048, 24 hours a day, 7 days a week.
Your right to get information about our network pharmacies and providers
You have the right to get information from us about our network pharmacies, providers and their qualifications and how we pay our doctors. To get this information, please call Member Services.
Your right to get information about your prescription drugs, Part C medical care or services, and costs
You have the right to an explanation from us about any prescription drugs or Part C medical care or service not covered by our Plan. We must tell you in writing why we will not pay for or approve a prescription drug or Part C medical care or service, and how you can file an appeal to ask us to change this decision. See Section 5 for more information about filing an appeal. You also have the right to this explanation even if you obtain the prescription drug, or Part C medical care or service from a pharmacy and/or provider not affiliated with our organization. You also have the right to receive an explanation from us about any utilization-management requirements, such as step therapy or prior authorization, which may apply to your plan. Please review our formulary website or please call Member Services for 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. See Section 4 and Section 5 for more information about complaints. If you make a complaint, we must treat you fairly (i.e., not retaliate against you) because you made a complaint. You have the right to get a summary of information about the appeals and grievances that members have filed against our Plan in the past. To get this information, call Member Services.
How to get more information about your rights
If you have questions or concerns about your rights and protections, you can
- Please call Member Services
- Get free help and information from your State Health Insurance Assistance Program (SHIP) at (800) 434-0222.
- Visit www.medicare.gov to view or download the publication "Your Medicare Rights & Protections."
- Call (800) MEDICARE (633-4227). TTY users should call (877) 486-2048, 24 hours a day, 7 days a week
What can you do if you think you have been treated unfairly or your rights are not being respected?
If you think you have been treated unfairly or your rights have not been respected, you may call Member Services or:
- If you think you have been treated unfairly due to your race, color, national origin, disability, age, or religion, you can call the Office for Civil Rights at (800) 368-1019 or TTY/TDD (800) 537-7697 or call your local Office for Civil Rights.
- If you have any other kind of concern or problem related to your Medicare rights and protections described in this section, you can also get help from your SHIP.
You have the right to make a complaint if we end your membership in our plan
If we disenroll you from our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can file a grievance or make a complaint about our decision to end your membership. For more information about how to make a complaint please visit How to File a Grievance.
Your responsibilities as a member of our Plan include:
- Getting familiar with your coverage and the rules you must follow to get care as a member. You can use this booklet to learn about your coverage, what you must pay, and the rules you need to follow. Please call Member Services if you have questions.
- Using all your insurance coverage. If you have additional health insurance coverage or prescription drug coverage besides our Plan, it is important that you use your other coverage in combination with your coverage as a member of our Plan to pay your health care or prescription drug expenses. This is called “coordination of benefits” because it involves coordinating all the health or drug benefits that are available to you.
- You are required to tell our Plan if you have additional health insurance or drug coverage. Please call Member Services.
- Notifying providers when seeking care (unless it is an emergency) that you are enrolled in our Plan and you must present your plan membership card to the provider.
- Giving your doctor and other providers the information they need to care for you, and following the treatment plans 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 offices.
- Paying your coinsurance or co-payment for your covered services. You must pay for services that aren’t covered.
- Notifying us if you move. If you move within our service area, we need to keep your membership record up to date. If you move outside of our plan service area, you cannot remain a member of our plan, but we can let you know if we have a plan in that area.
- Letting us know if you have any questions, concerns, problems, or suggestions. If you do, please call Member Services.