Member Rights and Responsibilities

Your Rights

• Learn about your rights and responsibilities
• Get the help you need to understand this 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
  
• Complete facts from your doctor of any information relating to your medical condition, treatment plan or ability to inspect 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 decisions 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 providers who are in our network
• Get medical care in a timely manner
• Get services from providers 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 concerns about Highmark Health Options and the health care services you get
• Question a decision 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 the date we use when you joined our health plan decide your benefits
• 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 materials 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 liable if your health plan becomes bankrupt (insolvent)
• Know your provider can challenge the denial of service with your approval
• Know that you can request a copy of the member handbook at any time. You will be notified annually of your right to request a member handbook
• Know how you can get a list of providers in the network, including the names and education level of all Network providers, and the how you may choose providers within Highmark Health Options

TO RECEIVE THE BEST CARE YOU MUST DO YOUR PART

• Tell us, your doctors, and other health care providers what they need to know to treat you
• 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 understand what your doctor tells you
• Follow the care plan and instructions 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 co pay to your hospital, PCPs, or 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 your DHSS caseworker 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 (over the age of sixteen), or marries, he or she shall be responsible for following all Highmark Health Options member guidelines set forth above.