Member Rights and Responsibilities

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 health care professionals will provide you with assistance. You have the right to:

• Be treated and access covered services without discrimination, including discrimination based on race, color, gender, national origin, disability, sexual orientation, or source of payment.
• Participate with doctors and other health care professionals in making decisions about your health care.
• A nonsmoking environment.
• Be treated with fairness and respect, and the right to recognition of your dignity and right privacy at all times, in a clean and safe environment.
• Receive, upon request, a list of in-network doctors and health care professionals.
• Change your doctor.
• Information about our plans and networks, and your covered services.
• Be assured that our in-network health care professionals 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 in-network doctor's staff and refuse their treatment, examination, or observation.
• Timely access to your covered services and drugs.
• Obtain from your doctor, during business hours, complete information about your diagnosis, treatment, and prognosis, regardless of cost or benefit coverage, in a 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.
• A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
• Receive the information necessary from your doctor 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.
• Know any risks involved in your 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 your chart so they may be available to your doctor at the time of consultation.
• Be informed about all medicine given to you, as well as the reasons for prescribing the medicine and its expected effects.
• Receive from your doctor, all information you need to give informed consent for an order not to resuscitate. You also have the right to designate another person to give this consent if you are too ill to do so.
• Request a second opinion from an in-network doctor.
• 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 Practices,” that describes your rights.
• 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.
• Request that copies of your complete medical records be forwarded to a  doctor or hospital of your choice at your expense. However, information may be withheld from you if, in the doctor’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 infections if the minor’s consent is not obtained.
• Have a person of your choice accompany you in any meeting or discussion with medical or administrative personnel.
• Give someone legal authority to make medical decisions for you.
• Consult with EmblemHealth’s administration officials and your doctor (by appointment, during business hours) 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 the care it provides or a determination about seeking care or about care and services you have received.  See information on filing an appeal.
• Receive an explanation from us, if a health care professional  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.
• Receive 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.
• Ask doctors about verbal and written language services including languages spoken by the doctor and office staff.
• Know how information about race, language, ethnicity, gender orientation, sexual identity, gender, pronouns are collected and used, and the right to not provide this information.*

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 for information on additional rights you may have, if available.

• Receive information about our organization, our services, health care professionals, networks, and member rights and responsibilities.
• The right to make recommendations regarding our member rights and responsibilities policies.