Beneficiary Rights

What are my rights?

You have the right to:

• Receive all the benefits to which you are entitled under your contract;
• Receive quality health care through your providers in a timely manner and medically appropriate setting;
• Considerate, courteous and respectful care;
• Be treated with respect and recognition of your dignity and right to privacy.
• Information about services, staff, hours of operation and your benefits, including access to routine services as well as after-hours and emergency services and members' rights and responsibilities;
• Participate in decision-making with your physician about your health care;
• Obtain complete, current information concerning a diagnosis, treatment and prognosis from a provider in terms that you can reasonably be expected to understand;
• Refuse treatment as allowed by law, and be informed by your physician of the medical consequences;
• Refuse to participate in research;
• Confidentiality of medical records and information, with the authority to approve or refuse the redisclosure by us of such information, to the extent protected by law;
• Receive all information needed to give informed consent for any procedure or treatment;
• Access to your medical records as permitted by New York State law;
• Express concerns and complaints about the care and services provided by physicians and other providers, and have us investigate and respond to these concerns and complaints;
• Candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage;
• Care and treatment without regard to age, race, color, sex or sexual orientation, religion, marital status, national origin, economic status or source of payment;
• Voice complaints and recommend changes in benefits and services to staff, administration and/or the New York State Insurance Department or Department of Health, without fear of reprisal;
• Formulate advance directives regarding your care. To obtain a Health Care Proxy form, contact us;
• Contact one of our service departments to obtain the names, qualifications and titles of providers who are responsible for your care;
• All information about your health plan, its services and its providers and procedures.
• To make recommendations regarding the organization's members' rights and responsibilities.

What are my responsibilities?

You have the responsibility to:

• Be an active partner in the effort to promote and restore health by:
  • openly sharing information about your symptoms and health history with your physician;
  • listening;
  • asking questions;
  • becoming informed about your diagnosis, recommended treatment and anticipated or possible outcomes;
  • following the plans of care you have agreed to (such as taking medicine and making and keeping appointments);
  • returning for further care, if any problem fails to improve; and
  • accepting responsibility for the outcomes of your decisions.
• Participate in understanding their health problems ad developing mutually agreed upon treatment goals.
• Have all care provided, arranged or authorized by your primary care physician (PCP);
• Inform your PCP if there are changes in your health status;
• Obtain services authorized by your PCP;
• Share with your PCP any concerns about the medical care or services that your receive;
• Permit us to review your medical records in order to comply with federal, state and local government regulations regarding quality assurance, and to verify the nature of services provided;
• Respect time set aside for your appointments with providers and give as much notice as possible when an appointment must be rescheduled or cancelled;
• Understand that emergencies arise for your providers and that your appointments may be unavoidably delayed as a result;
• Respect staff and providers;
• Follow the instructions and guidelines given by your providers;
• Show your ID card and pay your visit fees to the provider at the time the service is rendered;
• Become informed about our policies and procedures, as well as the office policies and procedures of your providers, so that you can make the best use of the services that are available under your contract;
• Abide by the conditions set forth in your contract.

Beneficiary Rights

Medicare Prescription Drug Coverage & Your Rights (CMS form 10147)

You have the right to request a coverage determination and get a written explanation from your Medicare drug plan if:

• Your prescriber or pharmacist tells you that your Medicare drug plan will not cover a prescription drug in the amount or form prescribed; or
• You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.

You also have the right to ask your Medicare drug plan for an exception (a special type of coverage determination) and get a written explanation from your Medicare drug plan if:

• You believe you need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary;”
• You believe a coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons; or
• You believe you should get a drug you need at a lower cost-sharing amount.

What you need to do:

• Contact your Medicare drug plan to ask for a coverage determination, including an exception request.
• Refer to the benefits booklet you received from your Medicare drug plan or call 1-800-MEDICARE to find out how to contact your drug plan.
• When you contact your Medicare drug plan, be ready to tell them:
  1. The prescription drug(s) that you believe you need. Include the dose and strength, if known.
  2. The name of the pharmacy or prescriber who told you that the prescription drug(s) is not covered.
  3. The date you were told that the prescription drug(s) is not covered.

The Medicare drug plan’s written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan’s decision.

No. CMS-10147 (11/30/2011) Approved OMB #0938-0975