QUEST Integration – Members’ Rights and Responsibilities

Original Effective Date:

07/01/1997

Current Effective Date:

01/01/2015

HMSA is committed to treating members in a manner that respects their rights and has policies addressing the member’s responsibilities for cooperating with those providing health care services.

The following is in the member handbook given to all members. It is included in the Provider Handbook so you know what a member is expected to provide and receive in return as an HMSA QUEST Integration member.

HMSA complies with any applicable Federal and State laws on member enrollment rights and ensures that HMSA’s staff and participating providers take these rights into account when furnishing services to enrolled members.

Your Rights

• You have a right to receive information about your health plan that is easily understood, in larger print, in audio format, translated into Chinese, Korean, Ilocano or Vietnamese, or orally translated, at no charge to you. Once you tell us that you want us to send you information in one of the alternate languages, we will send it to you within 7 days of the request or next business day.
• You have a right to oral interpretation at no cost to you. You have a right to sign language services and TTY/TDD services at no cost to you.
• You have rights under state law, as stated in the Hawaii Revised Statutes 432E, Patient's Bill of Rights and Responsibilities.
• You have rights under this plan. You may make suggestions to us about your rights and responsibilities. If you have a grievance, follow the process described in Grievances & Appeals starting on page 53.
• Exercising your rights will not affect in a negative way how we or network providers treat you. This is true regardless of race, color, ancestry, sex (including gender identity or expression), sexual orientation, physical or mental disability, creed, age, religion, national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or the source of the payment for your care.

Respect

You have the right to be treated with dignity and respect. This includes the right to treatment that:

• Is fair, without prejudice, and given with regard to your culture.
• Does not restrain or keep you away from others unless it is medically necessary or for safety.
• Treatment shall not be used to control, punish, or retaliate. Nor shall it be for convenience only.

Privacy and Information

You have a right to information and the privacy of that information. This includes the right to:

• Information about HMSA and its services.
• Information about member rights and responsibilities.
• Information about HMSA providers.
• Keep your medical records and conversations with your doctors private.
• Request and get copies of your medical records. Only you, your authorized representative, or your doctor may get copies of your records without your written approval. This is true unless otherwise allowed by law.
• Request that your medical records be amended or corrected.
• Know what medical services you can get and how to get them.
• Names and skills of the doctors involved in your treatment.

Your PCP

You have the right to choose or change your PCP. This includes knowing how to do so. PCP means primary care provider. This is the doctor or health care provider you will see most of the time and who will coordinate or arrange your care.

Your Plan

You have the right to:

• Know how we make treatment decisions. This includes payment structure.
• Review any bills for services that are not covered. This right is without regard to the payment source.
• Know the reason why a service is not covered.
• Voice grievances or appeals about HMSA or the care we provide.

Your Medical Condition

You have a right to information about:

• Your medical condition. It should be given to you in a way that you can understand.
• Except for emergency services, the information should include:
  • A description of the procedure or treatment.
  • Significant risks involved with a procedure or treatment.
  • Any alternate course of treatment or non-treatment.
  • Any risks involved with an alternate course of treatment or non-treatment.
  • The name of the person who will carry out the services.
  • Any medications you take or may need to take. For example, the name of the drug and how you need to take it.
  • Any care you need after you check out of a hospital.

Right to Consent or Refuse

You have the right to consent to or refuse treatment. You have the right to take part in treatment decisions. This includes the right to:

• Work as part of a team with a provider in deciding what health care is best for you.
• Say yes or no to the treatment your doctor recommends.

Care

You have a right to:

• Advance notice, including:
  • The time and location of an appointment.
  • The doctor providing care.
• Access to timely care, including:
  • Medical care within 24 hours for immediate care and without prior approval for emergency medical services.
  • Medical care within 24 hours for urgent care and for PCP pediatric sick visits.
  • Medical care within 72 hours for PCP adult sick visits.
  • Behavioral health care within 21 days for adult and child routine visits.
  • Medical care within 21 days for PCP routine visits.
  • Medical care within four weeks for visits with a specialist or for non-emergency hospital admissions.
  • Provider office hours of operation for HMSA QUEST Integration members to be the same as the provider office hours for all other patients.
• Access to care that is without barrier in accordance with the Americans with Disabilities Act. This includes:
  • Being able to get in and out of a doctor’s office if you have a disability or other condition that limits mobility.
  • The right to an interpreter who can:
    • Speak your native language.
    • Assist with a disability.
    • Help you understand information.

Providers

You have the right to:

• Go to a specialist with a referral from your PCP.
• Go to a doctor who is not in the network if:
  • A network doctor is not available.
  • A network doctor does not have the skills to treat your condition.
  • You have a medical emergency and cannot reach a network provider.
  • In these cases, you will not pay more than if you had received the services from a provider in the network.
• A second opinion at no cost to you.
• Go to an emergency room if you have:
  • A medical emergency.
  • Unusual or extenuating circumstances that prevent you from getting care from your PCP.

Consistency

You have the right to coverage that is consistent. This right shall be without regard to diagnosis, type of illness, or condition. Services shall not be arbitrarily denied or reduced (in amount, duration, or scope).

Treatment Decisions

You have the right to:

• Discuss treatment options with your doctor. It should be given to you in a way that you can understand in your condition. This right is without regard to cost or coverage.
• Refuse treatment or leave a hospital. Any negative outcome of such decision is your responsibility if it is against the advice of your doctor.
• Know if a doctor wants to engage in an experiment that could impact your care or treatment. You have the right to refuse to take part in such research projects.
• Complete an advance directive, living will, or other directive to give to your doctors. See Advance Directives on page 58.
• Transfer your rights to a person who has legal authority to make medical decisions on your behalf.

Right to Financial Protection

You are not responsible for:

• HMSA debts in the event HMSA goes out of business.
• Services that we choose to cover even though the DHS does not pay HMSA.
• Covered services you get that the DHS or HMSA does not pay the provider for.
• Charges for covered services that are more costly than covered services provided by a network provider due to the fact that the provider:
  • Is under a contract.
  • Was referred to you.
  • Other arrangement.

Your Responsibilities

You have the responsibility to learn and understand each right you have under the QUEST Integration program. You should:

• Ask questions if you do not understand your rights.
• Learn what choices of health plans are available in your area.
• Read your member handbook.
• Comply with all terms of your membership.
• Give your health care providers the information they need to care for you to the extent possible.
• Report changes that may affect your membership.

Self-Management

• To the degree possible, you must:
• Participate in decisions relating to service and treatment options, make personal choices, take action to maintain your health.
• Understand your health problems.
• Work as a team with your provider in deciding what health care is best for you.
• Follow plans and instructions for care you and your provider have agreed upon.
• Understand how the things you do can affect your health.
• Do the best you can to stay healthy.
• Treat providers and staff with respect.
• Report any wrongdoing or fraud.

Revision History