MEMBER RIGHTS AND RESPONSIBILITIES
Introduction about your rights and protections
Since you have Medicare, you have certain rights to help protect you.
In this Section, we explain your Medicare rights and protections as a member of
Mercy Care Advantage, and we explain what you can do if you think you are being
treated unfairly or your rights are not being respected. If you want to receive
Medicare publications on your rights, you may call and request them at 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.
Your right to be treated with fairness and respect
You have the right to be treated with dignity, respect, and fairness at all times.
Mercy Care Advantage must obey laws that protect you from discrimination or unfair treatment.
These laws do not allow us to discriminate against you (treat you unfairly) because of your
race or color, age, religion, national origin, or any mental or physical disability.
If you need help with communication, such as help from a language interpreter,
please call Member Services at the number listed in Section 1. Member Services can also
help if you need to file a complaint about access (such as wheel chair access).
You can also call the Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800-537-7697,
or, call the Arizona Attorney General's Office, Civil Rights Division at (602) 542-5263
in Phoenix or (877) 491-5740 or TTY (877) 881-7552 in Tucson.
Your right to the privacy of your medical records and personal health information
There are federal and state laws that protect the privacy of your medical records and personal health
information. We protect your personal health information under these laws. Any personal information that
you give us when you enroll in this plan is protected. We will make sure that unauthorized people do
not see or change your records. Generally, we must get written permission from you (or from someone
you have given legal power to make decisions for you) before we can give your health information to
anyone who is not providing your care or paying for your care. There are exceptions allowed or required
by law, such as release of health information to government agencies that are checking on quality of care.
The laws that protect your privacy give you rights related to getting information and controlling how your
health information is used. We are required to provide you with a notice that tells about these rights
and explains how we protect the privacy of your health information. For example, you have the right
to look at your medical records, and to get a copy of the records (there may be a fee charged for making copies). You also have the right to ask us to make additions or corrections to your medical records (if you ask us to do this, we will review your request and figure out whether the changes are appropriate). You have the right to know how your health information has been given out and used for non-routine purposes. If you have questions or concerns about privacy of your personal information and medical records, please call Member Services at the phone number in Section 1.
Your right to see plan providers, get covered services, and get your prescriptions
filled within a reasonable period of time
As explained in this booklet, you will get most or all of your care from plan providers, that is,
from doctors and other health providers who are part of Mercy Care Advantage. You have the right
to choose a plan provider (we will tell you which doctors are accepting new patients).
You have the right to go to a women's health specialist (such as a gynecologist) without
a referral. You have the right to timely access to your providers and to see specialists when
care from a specialist is needed. You also have the right to timely access to your prescriptions
at any network pharmacy. "Timely access" means that you can get appointments and services within a
reasonable amount of time. Section 2 explains how to use plan providers to get the care and services
you need. Section 3 explains your rights to get care for a medical emergency and urgently needed care.
Your right to know your treatment choices and participate in decisions about your health care
You have the right to get full information from your providers when you go for medical care, and the right to participate fully in decisions about your health care. Your providers must explain things in a way that you can understand. Your rights include knowing about all of the treatment choices that are recommended for your condition, no matter what they cost or whether they are covered by Mercy Care Advantage. This includes the right to know about the different Medication Management Treatment Programs we offer and which you may participate. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment, and be given the choice of refusing experimental treatments.
You have the right to receive a detailed explanation from us if you believe that a plan provider has denied care that you believe you are entitled to receive or care you believe you should continue to receive. In these cases, you must request an initial decision. "Initial decisions" are discussed in Sections 10 and 11.
You have the right to refuse treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. This includes the right to stop taking your medication. If you refuse treatment, you accept responsibility for what happens as a result of refusing treatment.
Your right to use advance directives (such as a living will or a power of attorney)
You have the right to ask someone such as a family member or friend to help you with decisions about
your health care. Sometimes, people become unable to make health care decisions for themselves due to
accidents or serious illness. If you want to, you can use a special form to give someone you trust
the legal authority to make decisions for you if you ever become unable to make decisions for yourself.
You also have the right to give your doctors written instructions about how you want them to
handle your medical care if you become unable to make decisions for yourself. The legal
documents that you can use to give your directions in advance in these situations are called "advance
directives." There are different types of advance directives and different names for them. Documents called
"living will" and
"power of attorney for health care" are examples of advance directives.
If you decide that you want to have an advance directive, there are several ways to get this type of legal form. You can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare, such as the Arizona State Health Insurance Assistance Program. Section 1 of this booklet tells how to contact the Arizona State Health Insurance Assistance Program. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it. It is important to sign this form and keep a copy at home. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can't.
You may want to give copies to close friends or family members as well.
If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you. If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.
Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. If you have signed an advance directive, and you believe that a doctor or hospital has not followed the instructions in it, you may file a complaint with the Arizona Attorney General's Office, Civil Rights Division at (602) 542-5263 in Phoenix or (877) 491-5740 or TTY (877) 881-7552 in Tucson.
Your right to make complaints
You have the right to make a complaint if you have concerns or problems related to your coverage or care. "Appeals" and "grievances" are the two different types of complaints you can make. The complaint is called an appeal or grievance depending on the situation. Appeals and grievances that involve your Medicare health benefits under Mercy Care Advantage are discussed in Sections 10 and 11. Appeals and grievances that involve the Mercy Care Advantage drug benefit are discussed in Sections 10 and 12.
If you make a complaint, we must treat you fairly (i.e., not retaliate against you) because you made a complaint. You have the right to get a summary of information about the appeals and grievances that members have filed against Mercy Care Advantage in the past. To get this information, call Member Services at the phone number listed in Section 1.
Your right to get information about your health care coverage and costs
This booklet tells you what medical services are covered for you as a plan member and what you have to pay. If you need more information, please call Member Services at the number listed in Section 1. You have the right to an explanation from us about any bills you may get for services not covered by Mercy Care Advantage. We must tell you in writing why we will not pay for or allow you to get a service, and how you can file an appeal to ask us to change this decision. See Sections 10 and 11 for more information about filing an appeal.
Your right to get information about Southwest Catholic Health Network Corporation, Mercy Care Advantage, plan providers, your drug coverage, and costs
You have the right to get information from us about Southwest Catholic Health Network Corporation and Mercy Care Advantage. This includes information about our financial condition,
about our health care providers and their qualifications, and about how Mercy Care Advantage compares to other health plans. This includes information about our financial condition and about our network pharmacies. You have the right to find out from us how we pay our doctors. To get any of this information, call Member Services at the phone number listed in Section 1.
How to get more information about your rights
If you have questions or concerns about your rights and protections,
please call Member Services at the number listed in Section 1. You
can also get free help and information from as the Arizona State Health
Insurance Assistance Program.
(Section 1 tells how to contact the Arizona State Health Insurance Assistance Program).
In addition, the Medicare program has written a booklet called Your Medicare Rights and Protections.
To get a free copy, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
You can call 24 hours a day, 7 days a week. Or, you can visit
www.medicare.gov on
the web to order this booklet or print it directly from your computer.
What can you do if you think you have been treated unfairly or your rights are not being respected?
If you think you have been treated unfairly or your rights have not been respected, what you should do depends on your situation.
- If you think you have been treated unfairly due to your race, color, national origin, disability, age, or religion, please let us know. Or, you can call the Office for Civil Rights in your area at the Arizona Attorney General's Office, Civil Rights Division at (602) 542-5263 in Phoenix or (877) 491-5740 or TTY (877) 881-7552 in Tucson.
- For any other kind of concern or problem related to your Medicare rights and protections described in this section, you can call Member Services at the number listed in Section 1 You can also get help from as the Arizona State Health Insurance Assistance Program. (Section 1 tells how to contact as the Arizona State Health Insurance Assistance Program.)
What are your responsibilities as a member of Mercy Care Advantage?
Along with the rights you have as a member of Mercy Care Advantage, you also have
some responsibilities. Your responsibilities include the following:
- To get familiar with your coverage and the rules you must follow to get care as a member.
You can use this booklet and other information we give you to learn about your coverage,
what you have to pay, and the rules you need to follow. Please call Member Services
at the phone number listed in Section 1 if you have any questions.
- To give your doctor and other providers the information they need to care for you,
and to follow the treatment plans and instructions that you and your doctors agree upon.
Be sure to ask your doctors and other providers if you have any questions and to explain
your treatment in a way you understand.
- To act in a way that supports the care given to other patients and helps the
smooth running of your doctor's office, hospitals, and other offices.
- To pay your plan premiums and any co-payments you owe for the covered services you get.
You must also meet your other financial responsibilities that are described in Section 8 of this booklet.
- To let us know if you have any questions, concerns, problems, or suggestions.
If you do, please call Member Services at the phone number listed in Section 1.