Member Rights & Responsibilities

Member Rights

Information Disclosure

• You have the right to receive accurate, easy-to-understand information about your health plan, providers, covered services, financial liability, health promotion, illness prevention, advance directives (e.g., Living Will, Healthcare Power of Attorney), and rights and responsibilities.
• You have the right to receive information about us. As applicable to your plan, you have the right to receive information about services provided on behalf of your employer or plan sponsor as well as our staff, and staff qualifications and any contractual relationships.
• You may choose to ask another person to help you or act on your behalf if you are unable to act alone at any step in the healthcare process.
• If English is not your primary language or if you have a disability or do not understand your health plan or healthcare, we can provide help so you can make informed healthcare decisions.

Choice of Providers

• You have the right to choose providers, hospitals, pharmacies and other facilities within our network.
• You have the right to choose a primary care provider in our network who is accepting new patients.
• You have the right to see a specialist in our network without a referral from your primary care provider.

Coverage

• If you are a member of a group health plan or non-grandfathered individual policy, with plan years beginning on or after January 1, 2014, you have the right to receive covered services without the consideration of pre-existing conditions.
• You have the right to not have your policy rescinded after it was active except in situations of fraud or intentional misrepresentation, according to federal and state laws and the terms of your policy.
• You may have the right to receive certain essential health benefits covered by your health plan without annual dollar limits.
• You have the right to get covered services and prescriptions filled within a reasonable timeframe.
• You have the right to receive coverage for an ongoing course of treatment pending the outcome of an appeal of a coverage decision that reduces or terminates benefits for that course of treatment.
• For the services provided to you within the terms of your plan, your rights include prompt and accurate payment of your claim.
• You have the right to have your coverage decisions made by individuals who have expertise in the area of medicine in which your claim falls and by individuals who are impartial.

Access to Emergency Services

• If you have severe pain, an injury or sudden illness that leads you to believe that your health is in serious jeopardy, you have the right to be screened and stabilized for an emergency medical condition in a facility that provides emergency care.
• When you are injured or experiencing severe pain or sudden illness that leads you to believe your health is in serious jeopardy, you do not need our prior approval before seeking emergency care.
• When using emergency room services for emergency care, you are not required to see a network provider, and you will not be charged an out-of-network penalty for receiving services for emergency care from an out-of-network provider.

Participation in Your Health Plan and in Treatment Decisions

• You have the right to talk in confidence with your healthcare provider and to participate 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 decline medical treatment or participation in a program we offer and to disenroll from services we offer.
• You have the right to make recommendations about this Member Rights and Responsibilities policy statement.
• You have the right to restrict the information that your healthcare provider shares with your health plan if you self-pay for services in full and notify the provider of your restriction.

Respect and Nondiscrimination

• You have the right to fair, considerate, courteous, respectful and nondiscriminatory care from your healthcare providers, our employees and plan representatives. You have the right to be treated with respect and recognition of your dignity and your right to privacy.
• You have the right to ask for help if you think you are treated unfairly or your rights are not respected.
• You are not required to waive rights to get benefits from your health plan.

Privacy and Confidentiality

• You have the right to exercise all federal and state privileges that protect your personal and medical information and records. You can also exercise your privacy rights under the Health Information Portability and Accountability Act (HIPAA) without fear of retaliation or condition of payment.
• You have the right to privacy and confidentiality in the usage of your personal and medical information and records.

Request to Place Restrictions on Use/Disclosure of Protected Health Information

• You have the right to request that your information receive special treatment, meaning that you can request additional restrictions on your information when used for treatment, payment or other day-to-day operations. Please Note: Medical Mutual of Ohio is not required to agree to the restrictions.
• You have the right to access or receive a copy of your protected health information maintained by us in a designated record set. For access to your entire medical record, you must contact the doctor or facility that provided the service.
• You have the right to request an amendment to your personal and medical information. We cannot amend information we did not create. We will refer you to the service provider if you request an amendment to your diagnosis or treatment information.
• You have a right to an accounting of certain disclosures of your information made by us and our business associates over the last six years.
• You have the right to complain if you believe your rights have been violated, including the right to complain to the Secretary of the U.S. Department of Health and Human Services.
• You have the right to receive a Notice of Privacy Practices describing our legal duties and privacy practices with respect to your protected health information.
• You have the right to request that we communicate with you in confidence about your information at a location different from the address associated with your policy.

Complaints and Appeals

• You have the right to voice complaints or appeals about us, the care provided or any quality issue.
• You have a right to communicate complaints to us and receive instructions on how to use the complaint process that includes our standards of timeliness for responding to and resolving complaints and quality issues.
• You have the right to request and receive, at no charge, copies of the information and documentation we considered or relied on to make a coverage decision.
• You have the right to file an appeal of a denial or reduction of a benefit or a claim because you were told it was not medically necessary, was experimental or investigational, was not a benefit of your health plan or involved a pre-existing condition.
• You have the right to file an appeal if you were denied coverage because of ineligibility or your policy was rescinded after you became an active member.
• You have the right to get a fair, objective and timely review and resolution of an appeal; to be told how the appeal will be handled according to federal and state laws; and to be told any important time limits related to filing your appeal.
• If you are covered by a fully insured plan, you have the right to request a review of a denied service or benefit by your state’s department of insurance (DOI). A review by your state’s DOI may be available if we deny, reduce or discontinue coverage for a service you were told is not covered, not medically necessary or is experimental or investigational.
• Once you have exhausted your internal appeals, you may have the right to an external review by an Independent Review Organization (IRO). This right may exist if we deny, reduce or discontinue coverage for a service on the basis of medical necessity, appropriateness of care, healthcare setting, level of care, effectiveness of a covered benefit, or an experimental or investigational determination. This right depends on the type of health plan you have. Review your Certificate or Benefit Book, or contact us or your health plan administrator to find out if this right and the process for pursuing this right applies to your health plan.

Member Responsibilities

• When speaking with us or your provider, supply all the information needed to provide care.
• When speaking with us or your provider, understand your health problems and participate in developing a mutually agreed-upon treatment plan and goals that work for you and your doctor or health provider, to the degree possible.
• When speaking with us or your provider, follow the agreed-upon plan and instructions for care.
• Choose a primary care provider who is accepting new patients and can coordinate medical services if required or advised by your plan.
• Take responsibility for improving or maintaining your healthy lifestyle habits including exercising, not smoking, controlling stress, eating a healthy diet, drinking alcohol only in moderation and following safety guidelines.
• Learn how to voice a complaint and file an appeal.
• Learn about your coverage options, limitations and exclusions by reviewing the resources available to you.
• Know the rules regarding use of network providers, coverage and prior approval according to your plan.
• Know how to get information from your health plan’s website, customer service and/or your health plan administrator.
• Meet your financial obligations to the providers who treat you.
• Report to us suspected wrongdoing and fraud.
• Be a responsible consumer of healthcare resources available to you.