Member rights and responsibilities

Below are the rights and responsibilities of our members.

Member rights

Privacy

Members have the right to:

• Be treated with respect and due regard for their dignity and privacy.
• Have news about their health insurance and medical records kept private by us, their doctors and all of their other health care providers.
• Have their privacy guarded as noted in 45 Code of Federal Regulations (CFR) parts 160 and 164, subparts A and E (as this rule applies).
• Have access to their medical records and ask that they be changed or corrected as federal and state laws allow.
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or action to get back at you as stated in federal regulations on the use of restraints and seclusion.

Take part in decisions regarding their health care

Members have the right to:

• Use their rights without being treated differently by us, the providers who contract with us or staff from South Carolina Department of Health and Human Services (SCDHHS).
• Get help from SCDHHS and Healthy Blue in knowing what is required and covered.
• Be told about other treatment choices or plans for care in a way that fits their health issue.
• Have honest talks with their doctors about the right treatment for their condition, in spite of the cost or their benefit coverage. Get care that is medically necessary.
• Get services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness or medical condition.
• Refuse care from their PCP or other health care providers.
• Get news about and make an advance directive. This includes a description of state laws that apply to living wills (Chapter 66, Section 44). This also includes changes in the state law as soon as they can be given to the member, but no later than 90 days after the change goes into effect.
• Change or revoke their advance directive at any time.
• Question a decision we make about coverage for care they got from their doctor. (The member will not be treated differently if they make a complaint.)

Grievances, appeals and fair hearings

Get information on the grievance, appeal and state fair hearing procedures.

Healthy Blue information

Members have the right to:

• Get all information and notices in a format that is easy to understand.
• Get interpreter services free of charge if they speak a language other than English or if they have hearing, vision or speech loss.
• Be notified of how to access those services.
• Get health plan documents in formats such as Braille, large-size print or audio at no cost to the member.
• Get the help you need to understand your Evidence of Coverage (EOC).
• Get written documents about this plan that includes information about how the plan is set up and how it operates.
• Get news about our benefits, doctors and other health care providers with whom we have contracts.
• Make an informed health plan choice (before they join a plan) by getting information about the basic features of managed care, including:
  • Which groups of people may or may not enroll in the program.
  • The health plan’s duties for coordinating care in a timely manner.
• Get information from their health plan about services. This includes but is not limited to:
  • Benefits covered.
  • How to get benefits, as well as an approval from Healthy Blue or their doctor.
  • Cost-sharing rules.
  • Service area.
  • Names, locations and phone numbers of current network providers (PCPs, specialists and hospital staff) who speak a language other than English.
  • Any limits on their freedom of choice among network providers.
  • Providers who are not taking new patients.
  • Benefits not offered by their health plan. Plus, how the member may get them and get a ride to and from these services.
• Get a complete outline of their disenrollment rights at least once per year.
• Know that we may make changes to your health plan benefits package as long as we tell you about those changes in writing 30 days before they take effect.
• Tell us what they do not like about our rights and responsibilities policy.
• Tell us what they would like to change about our health plan.
• Know they will not be held liable if their health plan becomes insolvent.

Medical Care

Members have the right to:

• Choose a provider who is part of their network. (If the member receives services from a provider who is not in their network or not approved by us, those services will not be covered.)
• Get our rules on referrals for specialty care and other benefits not given by their PCP.
• Receive health care services that they can access.
• Receive health care services that are similar to those given under Healthy Connections in:
  • Length of time given.
  • Scope.
• Get health care services that are enough in amount, length of time given and scope to do what they should be able to do for the member’s health issue.
• Get family planning services from a provider not in their network.
• Get 24-hour-a-day, 7-day-a-week access to medical advice from their PCP, either in person or by phone.
• Get details on emergency and after-hours coverage, including but not limited to:
  • What emergency medical conditions, emergency services and post-stabilization services are.
  • The fact that emergency services do not need an approval from Healthy Blue.
  • The process and procedures for getting emergency services.
  • The fact that they 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).​
• Know that Healthy Blue, the member’s doctors and other health care providers cannot treat them differently because of their age, sex, race, color, national origin, gender, sexual preference, language needs, degree of illness or health issue.
• Know that we only cover health care services that are part of their plan.
• Find out how we decide if new technology or treatment should be part of a benefit.
• Have problems taken care of fast. This includes things the member thinks are wrong, as well as issues about getting an approval from us, their coverage or payment of services and so on.
• Know the date they join Healthy Blue is used as the date when your benefits begin. (We won’t cover services the member received before this date.)

Member responsibilities

Respect their health care providers

Members have the responsibility to:

• Treat their PCP and other health care providers with respect.
• Not be disruptive in the doctor’s office.
• Make it to their PCP visits and follow-up visits on time. If the member cannot make it, they should change the visit as far in advance as they can.
• Respect the rights and property of all providers.

Cooperate with the people providing health care

Members have the responsibility to:

• Tell us, their doctors and their other health care providers what they need to know to treat them.
• Understand their health problems and help their doctor set treatment goals.
• Follow the treatment plans the member, their doctors and other health care providers agree on. If the member could not follow the treatment plans, they should tell us why.
• Use the ER only for emergency services. Members should not use the ER for routine services. (To learn more about this, members should review Part 8 Emergency and urgent care in their EOC.)

Follow Healthy Blue policies outlined in the member handbook

Members have the responsibility to:

• Know the plan’s procedures.
• Show their ID cards each time they receive medical care.
• Tell us and their social worker if:
  • They move.
  • They change their phone number.
  • The number of people in their household changes.
  • They have other insurance.
  • They become pregnant.
  • Their ID card is lost or stolen.
  • They pay for services that are not covered by us.

Members can call us if they have questions or want to learn more.