Member Rights and Responsibilities

Your Rights

• Learn about your rights and responsibilities.
• Get the help you need to understand your Member Handbook.
• Learn about us, our services, doctors, and other health care providers.
• See your medical records as allowed by law.
• Have your medical records kept private unless you tell us in writing that it is OK for us to share them, or it is allowed by law.
• All facts from your doctor of any information about your medical condition, treatment plan, or ability to look at and offer corrections to your own medical records.
• Be part of honest talks about your health care needs and treatment options no matter the cost and whether your benefits cover them. Be part of choices that are made by your doctors and other providers about your health care needs.
• Be told about other treatment choices or plans for care in a way that fits your condition.
• Get news about how doctors are paid.
• Find out how we decide if new technology or treatment should be part of a benefit.
• Be treated with respect, dignity, and the right to privacy all the time.
• Know that we, your doctors, and your other health care providers cannot treat you in a different way because of your age, sex, race, national origin, language needs, or degree of illness or health condition.
• Talk to your doctor about private things.
• Have problems taken care of fast, including things you think are wrong, as well as issues about your coverage, getting an approval from us, or payment of service.
• Be treated the same as others.
• Get care that should be done for medical reasons.
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
• Choose your PCP from the PCPs in our Provider Directory that are taking new patients.
• Use doctors who are in our network.
• Get medical care in a timely manner.
• Get services from doctors outside our network in an emergency.
• Refuse care from your PCP or other caregivers.
• Be able to make choices about your health care.
• Make an Advance Directive (also called a living will).
• Tell us your worries about Highmark Health Options and the health care services you get.
• Question a choice we make about coverage for care you got from your doctor.
• File a complaint or an appeal about Highmark Health Options, any care you get, or if your language needs are not met.
• Ask how many grievances and appeals have been filed and why.
• Tell us what you think about your rights and responsibilities and suggest changes.
• Ask us about our Quality Improvement program and tell us how you would like to see changes made. Ask us about our utilization review process and give us ideas on how to change it.
• Know that we only cover health care services that are part of your plan.
• Know that we can make changes to your health plan benefits as long as we tell you about those changes in writing.
• Ask for this Member Handbook and other member books and brochures in other formats such as other languages, large print, audio CD, or Braille at no charge to you.
• Ask for an oral interpreter and translation services at no cost to you.
• Use interpreters who are not your family members or friends.
• Know you are not responsible if your health plan becomes bankrupt (broke).
• Know your provider can object to the denial of service if you agree.
• Know that you can request a copy of the Member Handbook at any time. You will be told every year of your right to request a Member Handbook.
• You can get a list of network providers that includes the following details about the doctors: name, specialty, hospitals the doctor can visit, education, language spoken, gender, and office location.

Your Responsibilities

• Tell us, your doctors, and other health care providers what they need to know to treat you.
• You can ask us to correct your health and claims records if you feel they are incorrect or incomplete. We may say “no” to your request, but we will tell you why in writing within 60 calendar days. If we cannot change your records, you may have a statement of your disagreement added to your personal medical information. If you would like to make a request, call Member Services at 1-844-325-6251.
• Learn as much as you can about your health issue and work with your doctor to set up treatment goals you agree on with your doctor.
• Ask questions about any medical issue and make sure you know what your doctor tells you.
• Follow the care plan and orders that you have agreed on with your doctors or other health care professionals.
• Do the things that keep you from getting sick. Make and keep medical appointments and tell your doctor at least 24 hours in advance when you cannot make it.
• Always show your member Highmark Health Options ID card and Delaware Medicaid card when you get health care services.
• Use the emergency room only in cases of an emergency or as your doctor tells you.
• If you owe a copay to your pharmacies, pay at the time the services are received.
• Tell us right away if you get a bill that you should not have gotten or if you have a complaint.
• Treat all Highmark Health Options staff and doctors with respect and courtesy.
• Know and follow the rules of your health plan.
• Know that laws guide your health plan and the services you get.
• Know that we do not take the place of workers’ compensation insurance.
• Tell the DHSS Change Report Center and us when you change your address, family status, or other health care coverage.
• If a minor becomes emancipated, or legally freed from control by his or her parents (age 16 or older), or marries, he or she shall be responsible for following all Highmark Health Options member guidelines set forth above.