Members

Introduction about rights and protections for Medicare recipients

Medicare recipients have certain rights that help protect them. This includes receiving information on members’ rights and responsibilities contained in the Evidence of Coverage brochure for 65C Plus members.

In this document, we explain Medicare rights and protections for 65C Plus members and what members can do when they think they are being treated unfairly or their rights are not being respected.

To receive Medicare publications on a Medicare recipient’s rights, call and request them at 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048).

Notice of privacy policies and practices for personal financial information required by law*

HMSA and our affiliated organizations throughout the state of Hawaii have established the following policies and practices:

• Maintain physical, electronic and procedural safeguards to protect the privacy, confidentiality and integrity of personal information.
• Ensure that those in HMSA’s workforce who have access to members’ personal information, need that information to perform their jobs and have been trained to properly handle personal information. Our employees are fully accountable to management for following our policies and practices.
• Require that third parties who access members’ personal information on our behalf comply with applicable laws and agree to HMSA’s strict standards of confidentiality and security.

HMSA is required by state law to provide an annual notice of our privacy policies and practices for personal financial information to members who are enrolled in our health plans. This section contains information regarding how we collect and disclose personal financial information about our members to our affiliates and to nonaffiliated third parties. This applies to former as well as current HMSA members.

*Privacy of Consumer Financial Information, H.R.S. Chapter 431, Article 3A, effective July 1, 2002.

Members’ right to be treated with fairness and respect

A member of 65C Plus has the right to be treated with dignity, respect and fairness at all times. HMSA must obey laws against discrimination that protect a member from unfair treatment. These laws say that we cannot discriminate against a member (treat a member unfairly) because of a member’s race or color, age, religion, national origin, or any mental or physical disability a member may have.

Members’ right to privacy of medical records and personal health information

There are federal and state laws that protect the privacy of a member’s medical records and personal health information. We keep a member’s personal health information private as protected under these laws. Any personal information that a member gives us when enrolling in 65C Plus is protected. We will make sure that unauthorized people do not see or change a member’s records. Generally, we must get written permission from a member (or from someone a member has given legal power to make decisions for him or her) before we can give a member’s health information to anyone who is not providing the member’s care or paying for the member’s 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 member privacy gives a member rights related to getting information and controlling how a member’s health information is used. We are required to provide a member with a notice that tells about these rights and explains how we protect the privacy of a member’s health information. For example, a member has the right to look at his or her medical records and get a copy of the records (there may be a fee charged for making copies). A member also has the right to ask his or her 65C Plus contracting provider to make additions or corrections to a member’s medical records (if a member asks his or her provider to do this, the provider will review the member’s request and figure out whether the changes are appropriate). Members have the right to know how their health information has been given out and used for non-routine purposes.

Members’ right to see 65C Plus contracting providers and receive covered services within a reasonable period of time

A member will receive most or all of his or her care from 65C Plus contracting providers, that is, from doctors and other health providers who are part of 65C Plus. A member has the right to choose a 65C Plus provider (we will tell a member which doctors are accepting new patients). A member has the right to timely access to his or her provider and to see specialists when care from a specialist is needed. Timely access means that members can get appointments and services within a reasonable amount of time.

Members’ right to know their treatment choices and participate in decisions about members’ healthcare

A member has the right to get full information from his or her provider when going for medical care and the right to participate fully in decisions about his or her health care. Providers must explain things in a way that members can understand. Members’ rights include knowing about all of the treatment choices that are recommended for their condition, no matter what they cost or whether they are covered by 65C Plus. Members have the right to be told about any risks involved in their care. Members 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. Members have the right to refuse treatment. This includes the right to leave a hospital or other medical facility, even if their doctor advises them not to leave. If Members refuse treatment, Members accept responsibility for what happens as a result of refusing treatment.

Members’ right to use advance directives, such as a living will or power of attorney

A member has the right to ask someone, such as a family member or friend, to help with decisions about his or her healthcare. Sometimes, people become unable to make healthcare decisions for themselves due to accidents or serious illness. If a member chooses, he or she may want to use a special form to give someone he or she trusts the legal authority to make decisions if the member ever becomes unable to make decisions for him- or herself. A member also has the right to give his or her doctors written instructions about how he or she wants the doctors to handle his or her medical care if the member becomes unable to make decisions for him- or herself. The legal documents that a member can use to give a member’s 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 a member wants to have an advance directive, there are several ways to get this type of legal form. Members can get a form from a lawyer, from a social worker, or from some office supply stores. Members can sometimes get advance directive forms from organizations that give people information about Medicare, such as the state of Hawaii, Executive Office on Aging, SAGE Plus program. Regardless of where a member gets this form, keep in mind that it is a legal document. A member should consider having a lawyer help him or her prepare it. It is important that members sign their advance directive and keep a copy at home. A member should give a copy of the form to the member’s:

• Doctor
• Person named on the form as one to make decisions for the member when he or she is unable to
• Close family members

If a member knows ahead of time that he or she is going to be hospitalized and has signed an advance directive, he or she should take a copy with him or her to the hospital. When a member is admitted to the hospital, the member will be asked whether he or she has signed an advance directive and whether he or she has it with him or her. If a member has not signed an advance directive, the hospital has forms available and will ask if the member wants to sign one.

Remember, it is the member’s choice whether he or she wants to fill out an advance directive (including whether a member wants to sign one if he or she is in the hospital). According to law, no one can deny care to a member or discriminate against a member based on whether or not a member has signed an advance directive. If a member has signed an advance directive and he or she believes that a doctor or hospital has not followed the instructions in it, a member may file a complaint with the state of Hawaii, Regulated Industries Complaint Office.

Members’ right to make complaints

A member has the right to make a complaint if a member has concerns or problems related to a member’s coverage or care. Appeals and grievances are the two different types of complaints members can make. Which one a member makes depends on the situation.

Members’ right to get information about members’ healthcare coverage and costs

Evidence of Coverage brochure for 65C Plus members explains what medical services are covered for a plan member and what a member has to pay. If a member needs more information, please call our Customer Service department. A member has the right to an explanation from us about any bills he or she may get for services not covered by 65C Plus. HMSA must tell a member in writing why we will not pay for or allow a member to get a service and how a member can file an appeal to ask us to change this decision.

Collection of personal financial information

HMSA collects personal financial information about members that is necessary to administer the 65C Plus health plan. We may collect personal financial information about members from sources such as applications and other forms that members complete and members’ transactions with us, our affiliates or others.

Sharing of personal financial information

HMSA may share with our affiliates and with nonaffiliated third parties any of the personal financial information that is necessary to administer the 65C Plus health plan, as permitted by law. Nonaffiliated third parties are those entities that are not part of HMSA and its affiliates. We do not otherwise share a member’s personal financial information with anyone without a member’s permission.

How to get more information about members’ rights and make recommendations

If a member has questions or concerns about his or her rights and protections, please call our Customer Service department. Members have the right to make recommendations regarding the 65C Plus members’ rights and responsibilities policies. Members can also get free help and information from the state of Hawaii, Executive Office on Aging, SAGE Plus program. In addition, the Medicare program has written a booklet called Your Medicare Rights and Protections. To get a free copy of this booklet, call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Or visit the Medicare Web site at www.medicare.gov to order this booklet or print it directly from a computer.

What members can do if they think they have been treated unfairly or their rights are not being respected

If a member thinks he or she has been treated unfairly or his or her rights have not been respected, what a member should do depends on the situation.

• If a member thinks he or she has been treated unfairly due to his or her race, color, national origin, disability, age or religion, please let us know. Or, a member can call the Hawaii Civil Rights Commission on Oahu.
• For any other kind of concern or problem related to a member’s Medicare rights and protections described in this section, a member can call our Customer Service department. A member can also get help from the state of Hawaii, Executive Office on Aging, SAGE Plus program.

What are members’ responsibility as a member of 65C Plus?

Along with the rights members of 65C Plus have, there are also some member responsibilities. A member’s responsibilities include the following:

• To become familiar with member coverage and rules a member must follow to receive healthcare as a member. Information given to members to learn about their coverage, what a member pays and the rules a member needs to follow are available in the Evidence of Coverage brochure for 65C Plus members. Please call our Customer Service with any questions.
• To provide HMSA’s 65C Plus plan, his or her doctor and other providers the information needed to care for a member and for a member to follow the treatment plans and instructions that the member and his or her doctors agree upon. A member should be sure to discuss any questions he or she may have for the doctors and other providers.
• To understand his or her health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
• To act in a way that supports the care given to other patients and helps the smooth running of his or her doctor’s office, hospitals and other offices.
• To pay the premiums and any copayments a member may owe for the covered services received.
• To let us know if a member has any questions, concerns, problems or suggestions. If you do, please call our Customer Service department.

Revision History