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MA PAP 401

Medicare Advantage Rights and Responsibilities


Provider Administrative Policy

Section
Member Rights and Responsibilities
Policy Date
August 2005
Status/Date
Revised/November 2013
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Medicare Advantage Rights and Responsibilities

Member Rights

As a Medicare Advantage member, your patient has the right to:

  • Be treated with dignity, respect and fairness at all times.
  • Receive these rights and services in a culturally competent manner regardless of the member's race, physical or mental ability, ethnicity, gender, sexual orientation, creed, age, religion or their national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for their care as defined in Civil Rights Act, Title Four, American Disability Act, Age Discrimination Act and Rehabilitation Act.
  • Receive information in alternative formats, large print, Braille, languages other than English or other alternate formats.
  • Receive free language interpreter services in any language.
  • Patients eligible for Medicare because of a disability will be provided information about the plan's benefits that is accessible and appropriate for the patient.
  • See plan providers, get covered services and get prescriptions filled within a reasonable period of time.
  • Privacy of medical records and personal health information.
  • Request a copy of your company’s privacy practices.
  • Confidential treatment of all communications and records pertaining to their care. They have the right to access their medical records. Blue Cross of Idaho and service providers must provide timely access to their records and any information that pertains to them. Except as authorized by state law, Blue Cross of Idaho and service providers must get written permission from the member, or their authorized representative, before medical records can be made available to any person not directly concerned with their care or responsible for making payments for the cost of such care.
  • Extend their rights to any person who may have legal responsibility to make decisions on their behalf regarding their medical care.
  • Receive Medicare Advantage general coverage and plan comparison information.
  • Receive information about utilization control procedures such as, obtaining information about their coverage and rules that must be followed when using coverage.
  • Have access to statistical data on grievances and appeals.
  • Have access to information about the financial condition of Blue Cross of Idaho.
  • Obtain information about network pharmacies, providers, prescription drugs, medical care, covered services and costs.
  • Receive information about their medications - what they are, how to take them and possible side effects.
  • Obtain information about why something is not covered and what to do about it.
  • Examine and receive an explanation of any bills for non-covered services, regardless of payment source.
  • Know the names and qualifications of physicians and health care professionals involved in their medical treatment. Receive information about how medical treatment decisions are made by the contracting medical group or Medicare Advantage plan, including payment structure.
  • Know treatment options and participate in decisions about healthcare.
  • Receive information about any proposed treatment or procedure they may need in order to give an informed consent or refuse a course of treatment. Except in cases of emergency services, this information shall include a description of the procedure or treatment descriptions, the medically significant risks involved, any alternate course of treatment or non-treatment and the risks involved in each and the name of the person who will perform the procedure or treatment.
  • Receive information about an illness, the course of treatment and prospects for recovery in terms they can understand.
  • Refuse treatment or leave a medical facility, even against the advice of physicians (providing the member accepts responsibility and consequences of the decision).
  • Be involved in decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment.
  • Complete an advance directive, living will, or other directive to the contracting medical providers.
  • Receive reasonable continuity of care and know in advance the time and location of an appointment, as well as the doctor providing care.
  • Be advised if a doctor proposes to engage in experimentation affecting their care or treatment and have the right to refuse to participate in such research projects.
  • Be informed of continuing healthcare requirements following discharge from inpatient or outpatient facilities.
  • Obtain information about Blue Cross of Idaho plans, including information about financial conditions and how Blue Cross of Idaho plans compare to other health plans.
  • Have access to a summary of provider compensation agreements.
  • Have access to a summary of Blue Cross of Idaho’s quality improvement plan.
  • Expect these rights to be upheld by both Blue Cross of Idaho and contracting provides.

Medicare Advantage Member Responsibilities

As a Medicare Advantage member, your patient has the following responsibilities to:

  • Provide doctors and other healthcare givers the information needed in order to care for them.
  • Tell their providers that they are enrolled in our plan and provide any other health insurance coverage information. 
  • Treat all plan providers and personnel courteously and behave in a manner that supports the care given to other patients and the general functioning of the facility.
  • Communicate openly with their provider and develop patient/provider relationships based on mutual trust and cooperation.
  • Accept the financial responsibility for any copayment or coinsurance associated with covered services received while under the care of a doctor or while a patient in a facility.
  • Accept the financial responsibility for any premiums associated with membership in their evidence of coverage.
  • Be familiar with covered services and the rules that must be followed to get these covered services.
  • Use plan providers when applicable (obtain referrals) and present their member identification card when accessing medical services.
  • Ask questions of their physician regarding their medical treatment or Blue Cross of Idaho Medicare Advantage regarding suggestions, concerns or payment issues.
  • Tell Blue Cross of Idaho if they have moved.
  • Call Customer Service for help if they have questions or concerns.

Policy History

Date Action Reason
November 2013 Revised Language added regarding alternative language and disability communication formats.
September 2012 Revised Language added regarding interpreter services and alternative language rights.
March 2009 Revised Combined with MA PAP402 and MA PAP404

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