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Your Member Rights

As a CMS Health Plan member, you have certain rights. You have the right to:

  • Be treated with courtesy and respect
  • Have your dignity and privacy respected at all times
  • Receive a quick and useful response to your questions and requests
  • Know who is providing medical services and who is responsible for your care
  • Know what member services are available, including whether an interpreter is available if you do not speak English
  • Know what rules and laws apply to your conduct
  • Be given information about your diagnosis, the treatment you need, choices of treatments, risks, and how these treatments will help you
  • Say no to any treatment, except as otherwise provided by law
  • Be given full information about other ways to help pay for your health care
  • Know if the provider or facility accepts the Medicare assignment rate
  • To be told prior to getting a service how much it may cost you
  • Get a copy of a bill and have the charges explained to you
  • Get medical treatment or special help for people with disabilities, regardless of race, national origin, religion, handicap, or source of payment
  • Receive treatment for any health emergency that will get worse if you do not get treatment
  • Know if medical treatment is for experimental research and to say yes or no to participating in such research
  • Make a complaint when your rights are not respected
  • Ask for another doctor when you do not agree with your doctor (second medical opinion)
  • Get a copy of your medical record and ask to have information added or corrected in your record, if needed
  • Have your medical records kept private and shared only when required by law or with your approval
  • Decide how you want medical decisions made if you can’t make them yourself (advance directive)
  • To file a grievance about any matter other than a Plan’s decision about your services.
  • To appeal a Plan’s decision about your services
  • Receive services from a provider that is not part of our Plan (out-of-network) if we cannot find a provider for you that is part of our Plan
  • Receive information about the Plan, its services, its practitioners an providers and member rights and responsibilities
  • Make recommendations regarding the Plan’s member rights and responsibilities policy

Your Member Responsibilities

As a CMS Health Plan member, you also have the responsibility to:

  • Give accurate information about your health to your Plan and providers
  • Tell your provider about unexpected changes in your health condition
  • Talk to your provider to make sure you understand a course of action and what is expected of you
  • Listen to your provider, follow instructions and ask questions
  • Keep your appointments or notify your provider if you will not be able to keep an appointment
  • Be responsible for your actions if treatment is refused or if you do not follow the health care provider's instructions
  • Make sure payment is made for non-covered services you receive
  • Follow health care facility conduct rules and regulations
  • Treat health care staff with respect
  • Tell us if you have problems with any health care staff
  • Use the emergency room only for real emergencies
  • Notify your care manager if you have a change in information (address, phone number, etc.)
  • Have a plan for emergencies and access this plan if necessary for your safety
  • Report fraud, abuse and overpayment
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Last Updated On: 5/20/2019
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