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Your rights and responsibilities

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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 Explanation of Benefits.
  • Always be treated with respect and consideration for your dignity and privacy.
  • To participate in decisions regarding your health care, including the right to refuse treatment.
  • To be free from any form of restraint or seclusion used as a mean coercion, discipline, convenience or retaliation as specified in the federal regulations on the use of restraints and seclusion.
  • To be able to request and receive a copy of your records and request that they be amended or corrected.
  • To receive health care services that are accessible; are comparable in amount, duration and scope to those provided under Medicaid 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.
  • Receive 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 easilty 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.
    • Sex.
    • 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.
  • Receive 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 (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.
  • Receive a complete description of disenrollment rights at least annually.
  • Receive 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 is an emergency medical condition, 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 prescribed treatment or care recommended by the 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.