Chapter 8: Member Rights and Responsibilities

HIPAA privacy regulations offer full federal protection to protect member health care information. These regulations control the internal and external uses and disclosures of such data. They also assert member rights.

Access to Protected Health Information

Members may access their medical records or billing information either held at your office or through us. If their information is electronic, they may ask that you or us send a copy in an electronic format. They may also ask that a copy of their information be provided to a third party.

Amendment of PHI

Our members have the right to ask that information be changed if they believe it is inaccurate or incomplete. Any request must be in writing and explain why they want the change. This request must be acted on within 60 days. The timing may be extended 30 days with written notice to the member. If the request is denied, members may have a disagreement statement added to their health information.

Accounting of Disclosures

Our members have the right to request an accounting of certain disclosures of their PHI, made by you or us, during six years prior to the request. This accounting must include disclosures by business associates. It will not include disclosures made:

• For treatment, payment and health care operations purposes
• To members or pursuant to member’s authorization
• To correctional institutions or law enforcement officials
• For which federal law does not need us to give an accounting

Right to Request Restrictions

Members have the right to ask you or us to restrict the use and disclosures of their PHI for treatment, payment and health care operations. This request may be denied. If it is granted, the covered entity is bound by any restriction to which is agreed. Document these restrictions. We must agree to restrict disclosure. Members may request to restrict disclosures to family members or to others who are involved in their care or its payment.

Right to Request Confidential Communications

Members have the right to request communications from you or us be sent to a separate location or other means. Accommodate reasonable requests, especially if the member states disclosure could endanger them. Requests for confidential communication do not require a member explanation. Keep a written copy of the request.

The following information is in the Member Handbook at the following member website: uhccommunityplan.com.

Member Rights

Members may:

• Request information on advance directives.
• Give and be treated with respect, dignity and privacy.
• Receive courtesy and prompt treatment.
  
• Receive cultural assistance, including having an interpreter during appointments and procedures.
• Receive information about us, rights and responsibilities, their benefit plan and which services are not covered.
• Know the qualifications of their health care provider.
• Give their consent for treatment unless unable to do so because life or health is in immediate danger.
• Discuss any and all treatment options with you.
• Refuse treatment directly or through an advance directive.
• Be free from any restraint used as discipline, retaliation, convenience or force them to do something they do not want to do.
• Receive medically necessary services covered by their benefit plan.
• Receive information about in-network care providers and practitioners, and choose a care provider from our network.
• Change care providers at any time for any reason.
• Tell us if they are not satisfied with their treatment or with us; they can expect a prompt response.
• Tell us their opinions and concerns about services and care received.
• Register grievances or complaints concerning the health plan or the care provided.
• Appeal any payment or benefit decision we make.
• Review the medical records you keep and request changes and/or additions to any area they feel is needed.
• Receive information about their condition, understand treatment options, regardless of cost or whether such services are covered, and talk with you when making decisions about their care.
• Get a second opinion with an in-network care provider.
• Expect health care professionals are not kept from advising them about health status, medical care or treatment, regardless of benefit coverage.
• Make suggestions about our member rights and responsibilities policies.
• Get more information upon request, such as on how our health plan works and a care provider’s incentive plan, if they apply.

Member Responsibilities

Members should:

• Understand their benefits so they can get the most value from them.
• Show you their Medicaid member ID card.
• Prevent others from using their ID card.
• Understand their health problems and give you true and complete information.
• Ask questions about treatment.
• Work with you to set treatment goals.
• Follow the agreed-upon treatment plan.
• Get to know you before they are sick.
• Keep appointments or tell you when they cannot keep them.
• Treat your staff and our staff with respect and courtesy.
• Get any approvals needed before receiving treatment.
• Use the emergency room only during a serious threat to life or health.
• Notify us of any change in address or family status.
• Make sure you are in-network.
• Follow your advice and understand what may happen if they do not follow it.
• Give you and us information that could help improve their health.

Our member rights and responsibilities help uphold the quality of care and services they receive from you. The three primary member responsibilities as required by the National Committee of Quality Assurance (NCQA) are to:

• Supply information (to the extent possible) to UnitedHealthcare Community Plan and to you that is needed for you to provide care.
• Follow care to which they have agreed.
• Understand their condition and take part in developing mutually agreed-upon treatment goals, to the degree possible.