Provider Manual

Chapter 5: Member Policies and Rights

 

 

In the chapter, you will find information on our member copay policy and procedures, along with members' rights and responsibilities, including privacy right.

 

 

Some plan members have required copayment (copay) charges. Copays should be collected from members by the provider's office at the time of service. The copay, in conjunction with an office visit, is part of the provider's remuneration and its collection is the provider's responsibility.

In the event that the copay is not collected from the member, the provider may not seek reimbursement of the copay from EmblemHealth. If the contracted fee under the participating provider agreement with the EmblemHealth companies is less than the copay amount, the participating provider is not permitted to collect the difference between the contracted fee and the copay and must refund such difference to the member if it was collected.

Members with a Select Care Network-based benefit plan may have a deductible for in-network services. When collecting a copay at an office visit, please note that this amount may actually be a payment towards the member's deductible and that a true copay will not apply until after the deductible is met. Please see the remittance statement for the member's actual out-of-pocket responsibility.

Patient-specific copay information is listed on the member's ID card. It can also be obtained from our secure website at emblemhealth.com in the member's Summary of Benefits or from our Customer Service departments as listed in the Directory chapter.

Important things to note:

  • Copays may not be collected from Medicare members for the preventive care services as defined by CMS and listed in Appendix C.
  • Members enrolled in Dual Eligible PPO SNP, Dual Eligible HMO SNP and GuildNet Gold plans may not be charged cost-sharing greater than what would have been charged if the member was enrolled in NYS Medicaid.
  • Medicaid members do not have copays for the following services:
    • Emergency room visits for needed emergency care
    • Family planning services, drugs and supplies
    • Mental health visits
    • Chemical dependency visits
    • Drugs to treat mental illness
    • Drugs to treat tuberculosis
    • Prescription drugs for residents of adult care facilities
  • The following Medicaid members do not have copays for any services:
    • Children under age 21
    • Pregnant women (through 60 days postpartum)
    • Permanent residents of nursing homes
    • Residents of community-based residential facilities licensed by the Office of Mental Health or the Office of Mental Retardation and Developmental Disability
    • Those who are financially unable to make copays at any time and who tell the provider they are unable to pay
    • Medicaid members in a Comprehensive Medicaid Case Management (CMCM) or service coordination program
    • Medicaid members in an OMH or OPWDD Home and Community-Based Services (HCBS) waiver program
    • Medicaid members in a DOH HCBS waiver program for persons with traumatic brain injury (TBI)
    • Medicaid members cannot be denied health care services based on their inability to pay the copay at the time of service. However, providers may bill these members or take other action to collect the owed copay amount.
    • Members with Medicaid have only pharmacy copays and an annual $200 maximum copay obligation.
  • There are no plan copay requirements for CHPlus members.
  • Copays may not exceed the amount payable under the participating provider agreement.

Preventive Services Covered Under the Affordable Health Care Act


The Affordable Health Care Act dictates that any person who has a new insurance plan or policy as of September 23, 2010 must have certain preventive services covered without having to pay a copay or coinsurance or meet a deductible. Our Preventive Health Guidelines booklet helps members learn more about the screenings, tests and immunizations that they and their family need every year.

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. 

The protection and security of our members' personal information is a major objective of EmblemHealth. Our Notice of Privacy Practices describes how medical information about our members may be used and disclosed and how our members can get access to this information. Our member handbook tells members how to give consent to the collection, use and release of personal health information, how to obtain access to their medical records and what we do to protect access to their personal information. We are also committed to serving our members in a culturally competent and nondiscriminatory manner.

Confidentiality of Personal Information

As members consider joining an EmblemHealth plan, we want them to know that we make the protection of personal information a high priority. Our members entrust us with information that is personal, sensitive and highly confidential. Our employees and other authorized individuals working for us are accountable for exercising a high degree of care in safeguarding the confidentiality of that information.

Indeed, our employees and other authorized individuals are prohibited from:

  • Accessing or trying to access personal information, except on a "need to know" basis and only when authorized to do so.
  • Disclosing personal information to any person or organization within or outside the Plan, unless that person or organization has a "need to know" and is authorized by us to receive that information.

Confidentiality of Health Information for Minors Enrolled in Medicaid Managed Care Plans

Effective September 1, 2016, EmblemHealth will suppress all Explanation of Benefits (EOBs) for Medicaid minors 0 – under 18 years of age, with the exception of dental-related services and situations where the member may be financially responsible. New York State Department of Health (DOH) requires Medicaid Managed Care Plans, including EmblemHealth, to establish an effective, uniform and systemic mechanism to comply with confidentiality protections for health care services provided to minors who are enabled by statute to consent to their own heath care.

Member Consent

Providers should be aware of who may and may not consent for care. Public Health Law section 2504 specifically states the following:

  • Any person who is 18 years of age or older, or is the parent of a child or has married, may give effective consent for medical, dental, health and hospital services for himself or herself, and the consent of no other person is necessary.
  • Any person who has been married or who has borne a child may give effective consent for medical, dental, health and hospital services for his or her child. Any person who has been designated by law as a person in parental relation to a child may consent to any medical, dental, health and hospital services for such child for which consent is otherwise required. The above excludes (a) major medical treatment as defined in the mental hygiene law; (b) electroconvulsive therapy; and (c) the withdrawal or discontinuance of medical treatment that is sustaining life functions.
  • Any person who is pregnant may give effective consent for medical, dental, health and hospital services relating to prenatal care.
  • Medical, dental, health and hospital services may be rendered to persons of any age without the consent of a parent or legal guardian when, in the physician's judgment an emergency exists and the person is in immediate need of medical attention and an attempt to secure consent would result in a delay of treatment that would increase the risk to the person's life or health.
  • Where not otherwise already authorized by law to do so, any person in a parental relation to a child as defined by law as well as (i) a grandparent, an adult brother or sister, or an adult aunt or uncle, any of whom has assumed care of the child and (ii) an adult who has care of the child and has written authorization to consent from a person in a parental relation to a child as defined by law may give effective consent for the immunization of a child. However, a person other than one in a parental relation to the child cannot give consent under this subdivision if he or she has reason to believe that a person in parental relation to the child (as defined by law) objects to the immunization.
  • Anyone who acts in good faith based on the representation by a person that he or she is eligible to consent pursuant to the terms of this section shall be deemed to have received effective consent.

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA requires providers to take reasonable and appropriate measures to protect member/patient information. Examples of measures considered reasonable and appropriate to safeguard the patient chart include limiting access to certain areas, ensuring that the area is supervised, escorting non-employees in the area, and placing the patient chart in the box with the front cover facing the wall so that protected health information is not visible to anyone who walks by. An office sign-in sheet may not display medical information that is unnecessary for the purpose of signing in (e.g., information about symptoms or treatment). In addition, while providers may leave messages for members on home answering machines, they should consider leaving only the member's name on the machine along with information necessary to confirm an appointment, or simply asking the individual to call back.

Confidentiality of HIV-related Information

The provider must develop policies and procedures to assure confidentiality of HIV-related information. These policies and procedures must include:

  • Initial and annual in-service education of staff and contractors
  • Identification of staff allowed access and limits of access
  • Procedures to limit access to trained staff (including contractors)
  • Protocols for secure storage (including electronic storage)
  • Procedures for handling requests for HIV-related information
  • Protocols to protect persons with or suspected of having HIV infection from discrimination

 

Confidentiality of Behavioral Health and Substance Use Information

Each provider must develop policies and procedures to assure confidentiality of mental health and substance related information. These policies and procedures must include:

  • Initial and annual in-service education of staff and contractors
  • Identification of staff allowed access and limits of access
  • Procedures to limit access to trained staff (including contractors)
  • Protocols for secure storage (including electronic storage)
  • Procedures for handling requests for BH/SU information protocols to protect persons with behavioral health and/or substance use disorder from discrimination

 

Routine Consent

Before releasing personal information, consent must first be obtained from the member or a qualified person, unless release of that information is required by law. In many cases, when new members enroll in an EmblemHealth plan, routine consent for release of information is obtained on the enrollment application. The consent authorizes the use of personal information for general treatment, coordination of care, quality assessment, utilization review and fraud detection. The consent also authorizes the use of personal information for oversight reviews, such as those performed by the state or for accreditation purposes. In addition, it covers future routine use of such information. HIPAA permits the disclosure of information for payment, treatment and health care operations.

Authorization to Release Information

Authorization must be obtained from the member or qualified person before any personal health information can be released to an outside organization or agency, unless release of that information is legally required or permitted.

Special restrictions apply to the release of information relating to alcohol and drug abuse, abortion, sexually transmitted disease, adoption, psychiatric treatment, psychotherapy notes and HIV/AIDS.

Access to Medical Records

Our providers maintain medical records for the benefit of our members. A member has the right to review, copy and request amendments to his or her medical record. Any member or qualified person who desires a copy of the medical record may obtain one by submitting a written request to his or her network or facility.

A member or qualified person may challenge the accuracy of the information in the medical record. In addition, he or she may require that a statement describing the challenge be added to the record.

Access by a member or qualified person to information in the medical record may be denied, but only if the network provider or facility determines that:

  • Access can reasonably be expected to cause substantial harm to the member or to others
  • Access would have a detrimental effect on the network practitioner's or facility's professional relationship with the member, or on their ability to provide treatment

Nondiscrimination

The network provider represents and warrants to EmblemHealth that he or she will not discriminate against members with respect to the availability or provision of health services based on a member’s race, ethnicity, creed, sex, age, national origin, religion, place of residence, HIV status, source of payment, plan membership, color, sexual orientation, marital status, veteran status, or any factor related to a member’s health status, including, but not limited to, a member’s mental or physical disability or medical condition or handicap or other disability, claims experience, receipt of health care, medical history, genetic information or type of illness or condition, evidence of insurability (including conditions arising out of acts of domestic violence), disability or on any other basis otherwise prohibited by state or federal law.

Further, the provider shall comply with Title VI of the Civil Rights Act of 1964, as implemented by regulations at 45 C.F.R. part 84; the Americans with Disabilities Act; the Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. part 91; other laws applicable to recipients of federal funds; and all other applicable laws and rules, as required by applicable laws or regulations. The provider shall not discriminate against a member based on whether or not the member has executed an advance directive. The provider acknowledges that EmblemHealth is receiving federal funds and that payments to the provider for covered services are in whole or in part from federal funds.

Cultural Competency

The US Department of Health & Human Services defines cultural and linguistic competence as a set of congruent behaviors, attitudes and policies that come together in a system or agency or among professionals and enable effective work in cross-cultural situations. Delivering quality, sensitive care to a diverse cross-cultural population promotes respectful and responsive health care without cultural communication differences hindering the relationship.

For additional information regarding cultural and linguistic competence, as well as educational materials and online courses, the following resources are available:

• US Department of Health & Human Services: The Office of Minority Health
• AHRQ: Setting the Agenda for Research on Cultural Competence in Health Care
• America’s Health Insurance Plans: Tools to Address Disparities in Health
• EmblemHealth Learn Online: Cultural Competency

In addition, EmblemHealth encourages its providers (medical, physical, behavioral, long term services and support [LTSS] and pharmacy) to consider how people’s religious beliefs and practices intersect with medical science. We recognize that cultural competence is particularly important to the diverse cultural and religious identities of our members and the communities we serve.

That is why we sponsored Tanenbaum Center for Interreligious Understanding to write The Medical Manual for Religio-Cultural Competency. It is user-friendly and filled with information for the busy health care practitioner who wants to be religio-culturally competent. Its wide-ranging chapters not only include practical information on the various religions, but also spiritual assessment forms and tools and tips for working effectively with people of diverse religious backgrounds and points of view. As a leader in providing coverage of innovative and evidence-based approaches to health care, EmblemHealth is pleased to offer this first-of-its-kind publication to our network practitioners. Log on to emblemhealth.com to access The Medical Manual.

Notice of Privacy Practices

See the following page for our Notice of Privacy Practices.