Your rights and responsibilities
Member rights
As a member of this health plan, you have the right to:
- Observe and protect your member rights and responsibilities.
- Get the help you need to understand the member handbook (Evidence of Coverage).
- Be treated with respect and consideration for your dignity and privacy.
- Participate in decisions regarding your health care, including the right to refuse treatment.
- Be free from any form of restraint or seclusion used as a means coercion, discipline, convenience or retaliation as specified in the federal regulations on the use of restraints and seclusion.
- Be able to request and get a copy of your records and request that they be amended or corrected.
- Be notified in writing of the termination of a contracted provider you are getting primary care from, or seeing on a regular basis, within 30 calendar days prior to the effective date of the termination or 15 calendar days after receipt or issuance of the provider termination notice.
- Get health care services that are accessible; are comparable in amount, duration, and scope to those provided under Medicaid Fee-for-Service (FFS); and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished.
- Get services that are appropriate and are not denied or reduced solely because of:
- Diagnosis.
- Type of illness.
- Medical condition.
- Get health care services similar to those given under Healthy Connections in:
- Length of time given.
- Scope.
- Get the correct care services for your health issue. This means your services are enough in:
- Amount.
- Length of time given.
- Scope.
- Get information about the basic features of managed care so you can choose the right health plan for you. This information includes:
- Enrollment notices.
- Informational materials.
- Available treatment options.
- Alternatives in a matter and format that may be easily understood.
- The health plan’s duties for coordinating care in a timely manner.
- Know that Healthy Blue, your doctors and your other health care providers cannot treat you differently because of your:
- Age.
- Race.
- National origin.
- Gender.
- Gender identity.
- Sexual preference.
- Language needs.
- Degree of illness or health issue.
- Speak freely or talk honestly to the doctor about treatments regardless of cost or coverage.
- Get medically necessary care.
- Get help from the South Carolina Department of Health and Human Services (SCDHHS) and Healthy Blue in knowing what is required and covered.
- Get interpretation services free of charge for all non-English languages, not just those identified as prevalent, or if you have hearing, vision or speech loss.
- Get health plan documents in formats such as braille, large-size print or audio at no cost to you.
- Get all information and notices in a format that is easy to understand.
- Get information about our benefits, doctors and other health care providers with whom we have contracts.
- Get information from your health plan about services. This includes but is not limited to:
- Benefits covered.
- Procedures for obtaining benefits, including any authorization requirements.
- Cost-sharing requirements.
- Service area. Healthy Blue’s service area is in every county statewide in South Carolina.
- • Names, locations, and phone numbers of current network providers, including primary care providers (PCPs), specialists, and hospital staff, who speak a language other than English.
- Any limits on your freedom of choice among network providers.
- Providers who are not taking new patients.
- Benefits not offered by your health plan. Plus, how you may get them and get a ride to and from these services.
- Member rights and responsibilities
- Get a complete description of disenrollment rights at least annually.
- Get notice of any significant changes in the Benefits Package at least 30 days before the intended effective date of the change.
- Get details on emergency and after-hours coverage, including but not limited to:
- What an emergency medical condition is, emergency services, and post-stabilization services.
- Emergency services do not require prior authorization.
- The process and procedures for getting emergency services.
- The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under the contract.
- The fact that you have the right to use any hospital or other setting for emergency care.
- Post-stabilization care services rules as noted in 42 CFR 422.113(c).
- Exercise these rights without adversely affecting the way Healthy Blue providers or SCDHHS treat you.
- Be notified of how to access our services.
- Be told about other treatment choices or plans for care in a way that fits your health needs.
- Know we only cover health care services that are part of your plan.
- Refuse care from your PCP or other health care providers.
- Find out how we decide if new technology or treatment should be part of a benefit.
- Get 24/7 access to medical advice from your PCP, either in person or by phone.
- Get news about and make an advance directive. This includes:
- A description of state laws that apply to living wills (Chapter 66, Section 44).
- Changes in the state law as soon as they can be given to you, but no later than 90 days after the change goes into effect.
- The ability to change or revoke your advance directive at any time.
- Choose a provider who is part of your network. If you get services from a provider who is not in your network or not approved by us, those services will not be covered.
- Get family planning services and supplies from a provider not in your network.
- Have problems taken care of fast. This includes things you think are wrong and issues about getting an approval from us, your coverage, or payment of services.
- Know the date you join Healthy Blue is the date your benefits begin. We won’t cover services you got before this date.
- Question a decision we make about coverage for care you got from your doctor. You will not be treated differently if you make a complaint.
- Make recommendations regarding our rights and responsibilities policy.
- Tell us what you would like to change about our health plan.
- Have news about your health insurance and medical records kept private by us, your doctors and all of your other health care providers.
- Get written documents about your plan that include information about how the plan is set up and operates.
- Get information on the grievance, appeal and State Fair Hearing processes.
- Get our rules on referrals for specialty care and other benefits not given by your PCP.
- Have your privacy guarded as noted in 45 CFR parts 160 and 164, subparts A and E (as this rule applies).
- Use your rights without being treated differently by us, the providers who contract with us, or staff from SCDHHS.
- Know you will not be held liable if your health plan becomes insolvent.
Member responsibilities
As a member of this health plan, you have these responsibilities:
- Tell us and your social worker if:
- You move.
- You change your phone number.
- The number of people in your household changes.
- You have other insurance.
- You become pregnant.
- Your ID card is lost or stolen.
- Understand your health problems and help your doctor set treatment goals.
- Show your ID cards each time you get medical care.
- Know the plan’s procedures.
- Call us if you have questions or want to learn more.
- Make every reasonable effort to keep any agreed-upon appointments and follow-up appointments and to access preventive care services.
- Use the emergency room (ER) only for emergency services, not for routine services.
- Pay for services that are not covered by us.
- Supply information, to the extent possible, that Healthy Blue and its practitioners and providers need in order to provide care.
- Treat your PCP and other health care providers with respect.
- Follow the treatment or care that you have agreed to with your provider, or let the provider know the reasons the treatment cannot be followed, as soon as possible.
- Understand diagnosed health problems and participate in developing mutually agreed-upon treatment goals.