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  • Member Policies and Rights > Rights and Responsibilities of EmblemHealth Plan Members

    The rights and responsibilities listed below indicate what members can expect of EmblemHealth and what responsibilities our members have to EmblemHealth.

    EmblemHealth plan members have the right to:

    • Be treated without discrimination, including discrimination based on race, color, religion, gender, national origin, disability, sexual orientation or source of payment.
    • Participate with physicians in making decisions about their health care.
    • A non-smoking environment.
    • Be treated with fairness and respect at all times, and in a clean and safe environment.
    • Receive, upon request, a list of the physicians and other health care providers in our participating provider network.
    • Change their physician.
    • Information about our plans and networks and their covered services.
    • Be assured that our participating health care providers have the qualifications stated in our Professional Standards, established by the EmblemHealth Credentialing Committee, which are available upon request.
    • Know the names, positions and functions of any participating provider’s staff and to refuse their treatment, examination or observation.
    • Timely access to covered services and drugs.
    • Obtain from their physician, during practice hours, comprehensive information about their diagnosis, treatment and prognosis, regardless of cost or benefit coverage, in language they can understand. When it is not medically advisable to give them such information, or when the member is a minor or is incompetent, the information will be made available to a person who has been designated to act on that person’s behalf.
    • Receive from their physician the information necessary to allow them to give informed consent prior to the start of any procedure or treatment and to refuse to participate in, or be a patient for, medical research. In deciding whether to participate, they have the right to a full explanation.
    • Know any risks involved in their care.
    • Refuse treatment, to the extent permitted by law, and to be informed of the medical consequences of refusing it.
    • Have all lab reports, X-rays, specialists’ reports and other medical records completed and placed in their chart so they may be available to their physician at the time of consultation.
    • Be informed about all medication given to them, as well as the reasons for prescribing the medication and its expected effects.
    • Receive, from their provider, all information they need to give informed consent for an order not to resuscitate. They also have the right to designate an individual to give this consent if they are too ill to do so.
    • Request a second opinion from a participating physician.
    • Privacy concerning their medical care. This means, among other things, that no person who is not directly involved in their care may be present without their permission during any portion of their discussion, consultation, examination or treatment. We will give them a written notice, called a “Notice of Privacy Practice,” that describes their rights.
    • Expect that all communications, records and other information about their care or personal condition will be kept confidential, except if disclosure of that information is required by law or permitted by them.
    • Request that copies of their complete medical records be forwarded to a physician or hospital of their choice at their expense. However, information may be withheld from them if, in the physician’s judgment, release of the information could harm them or another person. Additionally, a parent or guardian may be denied access to medical records or information relating to a minor’s pregnancy, abortion, birth control or sexually transmitted diseases if the minor’s consent is not obtained.
    • Have a person of their choice accompany them in any meeting or discussion with medical or administrative personnel.
    • Give someone legal authority to make medical decisions for them.
    • Consult by appointment, during business hours, with our responsible administrative officials and their participating physician’s office to make specific recommendations for the improvement of the delivery of health services.
    • Make a complaint or file an appeal related to the organization or a determination about seeking care or about care and services they have received. See information on filing member appeals.
    • Receive an explanation from us if a provider has denied care that they believe they should receive. To receive this explanation, they will need to ask us for a copy of the written decision.
    • Receive from us information in a way that works for them, in languages other than English or other alternate formats, in accordance with company policy and regulatory rules.
      IMPORTANT: State and federal laws give adults in New York State the right to accept or refuse medical treatment, including life-sustaining treatment, in the event of catastrophic illness or injury. EmblemHealth makes available materials on advance directives with written instructions, such as a living will or health care proxy containing the members’ wishes relating to health care should they become incapacitated. If members live in another state, they should check with their local state insurance department, if available, for information on additional rights they may have.
    • Receive information about our organization, our services and our provider networks and about member rights and responsibilities.
    • Make recommendations regarding our member rights and responsibilities policies.

    EmblemHealth plan members have the responsibility to:

    • Provide us and our participating physicians and other providers with accurate and relevant information about their medical history and health so that appropriate treatment and care can be rendered. They should tell their doctors they are enrolled in our plan and show them their membership card.
    • Keep scheduled appointments or cancel them, giving as much notice as possible in accordance with the provider's guidelines for cancelation notification.
    • Update their record with accurate personal data, including changes in name, address, phone number, additional health insurance carriers and an increase or decrease in dependents within 30 days of the change.
    • Treat with consideration and courtesy all of our personnel and the personnel of any hospital or health facility to which they are referred.
    • Be actively involved in their own health care by seeking and obtaining information, by discussing treatment options with their physician and by making informed decisions about their health care.
    • Participate in understanding the member’s health issues and to follow through with treatment plans agreed upon by all parties in the member’s health care: the member, EmblemHealth and participating physicians.
    • Follow plans and instructions for care that they have agreed to with their practitioner.
    • Understand their health problems and participate in developing mutually agreed upon treatment goals, to the degree possible.
    • Understand our benefits, policies and procedures as outlined in their Contract or Certificate of Coverage and handbook, including policies related to prior approval for all services that require such approval.
    • Pay premiums on time and to pay copayments, if applicable, at the time services are rendered.
    • Abide by the policies and procedures of their participating physician's office.
    • Notify us if they have any other health insurance or prescription drug coverage in addition to our plan.
    • Be considerate. We expect them to respect the rights of other patients and act in a way that helps the smooth running of their doctors’ office, hospitals and other offices. 
       

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    Glossary terms found on this page:

    Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    An insurance company that either administers insurance or self-insures.

    Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:

    • A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
    • Treatment experienced through the plan, its providers or contractors
    • Any concern with the plan, its benefits, employees or providers.

    Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

    An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.

    A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    A set of providers contracted with a health plan to provide services to the enrollees.

    The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.

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