Child Health Plus (CHPlus) Member Rights and Responsibilities

 

 

Understanding your rights and responsibilities as a plan member can help you and us make the most of your membership.

Below, we have listed your rights, or what you can expect of us, as well as your responsibilities, or what we expect from you.

Your Rights

This section explains your rights as a member. If you do not understand these rights or you have questions, we will work with our participating health care professionals to help you.

 

As a member, you have:

 

  • The freedom to exercise your rights without unfair treatment from other health plans, providers, or outside organizations.
  • The right to be free from any unfair treatments used with the intent to intimidate or punish for any reason.
  • The right to get covered services without discrimination, including discrimination based on: race, color, religion, gender, national origin, disability, sexual orientation, or source of payment.
  • The right to work with health care professionals to make decisions about your health care.
  • The right to a non-smoking environment.
  • The right to be treated with fairness and respect at all times, and to receive care in a clean and safe environment.
  • The right to get, upon request, a list of the health care professionals in our network. A network is a group of health care professionals or facilities that contract with EmblemHealth. They provide covered products and services to members. You’ll usually pay less when you use this network.
  • The right to change your health care professional.
  • The right to information about our plans, networks, and your covered services.
  • The right to know that participating health care professionals have the qualifications outlined in our professional standards established by our credentialing committee. These standards are available upon request.
  • The right to know the names, positions, and functions of any participating health care professional’s staff and to refuse their treatment, examination, or observation.
  • The right to timely access to your covered services and drugs.
  • The right to get from your health care professional, during practice hours, comprehensive information about your diagnosis, treatment, and prognosis, regardless of cost or benefit coverage, in language you can understand. Coverage is the benefits and services available to you from your health insurance plan. When it is not medically advisable to give such information to you, 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.
  • The right to receive from your health care professional the information necessary to allow you 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. While you decide whether or not to participate, you have the right to a full explanation.
  • The right to know any risks involved in your care.
  • The right to refuse treatment, as permitted by law, and to be informed of the medical consequences of refusing it.
  • The right to have all lab reports, x-rays, specialists’ reports, and other medical records completed and placed in your chart, so they may be available to your health care professional at the time of consultation.
  • The right to be informed about all medication given to you, the reasons for prescribing the medication, and its expected effects.
  • The right to get, from your health care professional, all information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent if you are too ill to do so.
  • The right to ask for a second opinion from a participating health care professional.
  • The right to privacy concerning your medical care. This means, among other things, that no person who is not directly involved in your care may be present without your permission during any portion of your discussion, consultation, examination, or treatment. We will give you a written notice, called “Notice of Privacy Practice,” that describes your rights.
  • The right to expect that all communications, records, and other information about your care or personal condition will be kept confidential, except if disclosure of that information is required by law or permitted by you.
  • The right to ask that copies of your complete medical records be sent to a health care professional or hospital of your choice at your own cost. Information may be withheld from you if, in the health care professional’s judgment, release of the information could harm you 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 disease if the minor’s consent is not obtained.
  • The right to have a person of your choice go with you to any meeting or discussion with medical or administrative staff.
  • The right to give someone legal authority to make medical decisions for you.
  • The right to consult by appointment, during business hours, with responsible administrative officials at your participating health care professional’s office to make specific recommendations for the improvement of the delivery of health services.
  • The right to make a complaint or file an appeal related to the organization or a determination about the care and services you received. This means that if you are not happy with a decision we have made, you or your doctor can ask us to review your request again. For additional information on filing an appeal, see If You Disagree With a Coverage Decision or Service in your Contract and/or call Customer Service at 855-283-2146 (TTY: 711).
  • 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.
  • The right to get information about our organization, services, health care professional network, and your member rights and responsibilities.
  • The right to make recommendations regarding member rights and responsibilities policies.

Your Responsibilities

This section explains your responsibilities as a member. Please make yourself familiar with this section so that we can give you the best health care possible.

 

As a member, you have:

 

  • The responsibility to provide us and our participating health care professionals with accurate and relevant information about your medical history and health so that you can receive the right treatment.
  • The responsibility to keep scheduled appointments or cancel them, giving as much notice as possible. Please follow your health care professional’s guidelines for canceling appointments.
  • The responsibility to update your records with accurate personal information within 30 days of a change, including changes in name, address, phone number, additional health insurance carriers, and/or an increase or decrease in dependents.
  • The responsibility to treat with consideration and courtesy all staff, including the staff of any hospital or health facility you are referred to.
  • The responsibility to be actively involved in your own health care by seeking and obtaining information, by discussing treatment options with your health care professional, and by making informed decisions about your health care.
  • The responsibility to follow plans and instructions for care that you have agreed to with your health care professional.
  • The responsibility to understand your health problems and participate as much as possible in developing mutually agreed-upon treatment options and goals.
  • The responsibility to understand our benefits, policies, and procedures as outlined in your contract, including policies for services that require prior approval.
  • The responsibility to pay copayments, if applicable, at the time services are provided. A copay is the set dollar amount you pay for health services each time you use them.
  • The responsibility to follow the policies and procedures of your participating health care professional’s office.
  • The responsibility to let us know if you have any other health insurance or prescription drug coverage in addition to our plan.

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