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Member Rights and Responsibilities | EmblemHealth

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Member Rights and Responsibilities

Our members have a right to appropriate treatment in a proper setting.

It is also important that practitioners have the same information about member rights and responsibilities in order to ensure that our members, their patients, get the care and services which your benefit plan entitles you to.

Understanding your rights and responsibilities as a plan member can help you and us make the most of your membership. Below, we have listed what you can expect of us, as well as what we expect from you.

Your Rights

This section explains your rights as a plan member. If, for any reason, you do not understand these rights or how to interpret them, we and our participating physicians will provide you with assistance.

The right to be treated and to access covered services without discrimination, including discrimination based on race, color, religion, gender, national origin, disability, sexual orientation, or source of payment.
The right to participate with physicians and other practitioners in making decisions about your health care.
The right to a non-smoking environment.
The right to be treated and to access covered services without discrimination, including discrimination based on race, color, religion, gender, national origin, disability, sexual orientation, or source of payment.
The right to participate with physicians and other practitioners in making decisions about your health care.
The right to a non-smoking environment.
The right to be treated with fairness and respect, and the right to recognition of their dignity and privacy at all times, and in a clean and safe environment.
The right to receive, upon request, a list of the physicians and other health care providers in our participating provider network.
The right to change your physician.
The right to information about our plans and networks, and your covered services.
The right to 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.
The right to know the names, positions, and functions of any participating provider’s staff and to refuse their treatment, examination, or observation.
The right to timely access to your covered services and drugs.
The right to obtain from your physician, during practice hours, comprehensive information about your diagnosis, treatment, and prognosis, regardless of cost or benefit coverage, in language you can understand. 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 a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
The right to receive from your physician 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. In deciding whether 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, to the extent 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 physician at the time of consultation.
The right to be informed about all medication given to you, as well as the reasons for prescribing the medication and its expected effects.
The right to receive, from your provider, 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 request a second opinion from a participating physician.
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 a “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 request that copies of your complete medical records be forwarded to a physician or hospital of your choice at your expense. However, information may be withheld from you if, in the physician’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 accompany you in any meeting or discussion with medical or administrative personnel.
The right to give someone legal authority to make medical decisions for you.
The right to consult by appointment, during business hours, with our responsible administrative officials and your participating physician’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 the care it provides or a determination about seeking care or about care and services you have received. See information on filing an appeal.
You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a copy of the written decision.
We must provide information in a way that works for you, in languages other than English or other alternate formats, in accordance with company policy and regulatory rules.
The right to ask practitioners the verbal and written language services including languages spoken by the practitioner and office staff.
The right to know how information about race, language, ethnicity, gender orientation, and sexual identity, gender, pronouns are collected and used, and the right to not provide this information.
The right to ask practitioners the verbal and written language services including languages spoken by the practitioner and office staff.

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 your wishes relating to health care should you become incapacitated. If you live in another state, check with your local state insurance department, if available, for information on additional rights you may have.
The right to receive information about our organization, our services, practitioners and provider and our practitioner/provider network, and about member rights and responsibilities.
The right to make recommendations regarding our member rights and responsibilities policies.

Your Responsibilities

Now we come to the section about your responsibilities. It is important to us that you also become familiar with this section because doing so will make it easier to provide you with access to the best health care possible.

The responsibility to provide us and our participating physicians and other providers with accurate and relevant information to the extent possible about your medical history and health so that appropriate treatment and care can be rendered. Tell your doctors you are enrolled in our plan and show them your membership card.
The responsibility to keep scheduled appointments or cancel them, giving as much notice as possible in accordance with the provider’s guidelines for cancellation notification.
The responsibility to update your record with accurate personal data, including changes in name, address, phone number, and additional health insurance carriers, as an increase or decrease in dependents within 30 days of the change.
The responsibility to treat with consideration and courtesy all of our personnel and the personnel of any hospital or health facility to which you are referred.
The responsibility to be actively involved in your own health care by seeking and obtaining information, by discussing treatment options with your physician and by making informed decisions about your health care.
The responsibility to participate in understanding your health issues and to follow through with treatment plans agreed upon by all parties in the your health care: the member, EmblemHealth, and participating physicians.
The responsibility to follow plans and instructions for care that you have agreed to with your practitioner.
The responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
The responsibility to understand our benefits, policies, and procedures as outlined in your Contract or Certificate of Coverage and handbook, including policies related to preapproval for all services that require such approval.
The responsibility to pay premiums on time and to pay copayments, if applicable, at the time services are rendered.
The responsibility to abide by the policies and procedures of your participating physician’s office.
The responsibility to notify us if you have any other health insurance or prescription drug coverage in addition to our plan.
The responsibility to be considerate. We expect you to respect the rights of other patients and act in a way that helps the smooth running of your doctor’s office, hospitals and other offices.
As appropriate for care, the responsibility to ask practitioners their race and ethnicity.

If you would like to receive a paper copy of any material on our website, please contact Customer Service using the number on the back of your ID card.

Demographic Information

Members have the right to know how information is collected and used, and to not provide information about race, language, ethnicity, sexual orientation, gender identity, gender, and pronouns.

This information is collected through enrollment information, self-disclosure, and the member portal. They are used to assess health care disparities, design intervention programs, and design and direct outreach materials, and they inform health care practitioners and providers about individuals’ needs. This information is not used in contracting or credentialing decisions or for any discriminatory purpose. Member race, language, ethnicity, sexual orientation, and gender identity cannot be used to perform underwriting, rate setting, and benefit determinations (specifically denial of coverage and benefits) and cannot be disclosed to unauthorized users. EmblemHealth limits and terminates access to information by employees who are not or no longer authorized to have access. Information is protected as outlined in EmblemHealth’s policies. Network providers and practitioners are also contractually obligated to protect the confidentiality of members’ information.

In addition, information is protected by information systems security, and authentication and authorization procedures, such as but not limited to password-protected files; storage, data disposal, and reuse of media and devices; and transmission and physical security requirements using company-protected equipment including access to devices and media that contain individual-level data. Devices can include but not be limited to diskettes, CDs, tapes, mobile applications, portable drives, desktops, laptops, secure portals, and hardware. Information is protected as stated in EmblemHealth’s policies.