Presbyterian Health Plan Member Rights & Responsibilities
Each Presbyterian member (or their legal guardian) shall have the right:
To receive information about Presbyterian Health Plan, needed to make informed decisions including but not limited to its healthcare services and benefits, how to access those services, its network of providers, its appeals and grievance process, its policies and procedures, and members' rights and responsibilities.
To be treated equitably, with courtesy, consideration, and respect, and with recognition of their dignity and need for privacy.
To choose a primary care provider (PCP) within the limits of the plan, and participate with healthcare providers in making decisions about all aspects of their health care, including the course of treatment development, acceptable treatments, and the right to refuse treatment, as well as the following:
Know the names and professional status of individuals participating in the member’s treatment; have timely access to the provider primarily responsible for care; and obtain referrals to specialists when medically necessary.
Obtain information about diagnoses, treatments, and expected outcomes to make informed decisions, unless the provider determines that the information could be detrimental to the member. (In this case, the information will be given to a person designated by the member or a person legally authorized to receive such information.) In emergency cases, this information shall include a description of the procedure or treatment description, the medically significant risks involved, any alternate course of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment.
To informed consent based on sufficient information to permit a reasonably prudent person to make an informed decision about the proposed treatment, the inherent and potential hazards of the proposed treatment and hereby result if the condition remains untreated.
To seek a second opinion from a qualified health care professional within Presbyterian Health Plan’s network of providers, or Presbyterian Health Plan shall arrange for the member to obtain a second opinion outside the network, if there is not another qualified provider in the network, at no additional cost to the member.
To all the rights afforded by law, rule, or regulation as a patient in a licensed health care facility, including the right to refuse medications and treatment after possible consequences of this decision have been explained in a language the member understands.
Reasonable continuity of care and to know in advance the time and location of an appointment as well as the provider providing care.
Be advised if a provider proposes to engage in experimentation affecting care or treatment and have the right to refuse to participate in such research projects.
Be advised of continuing health care requirements following discharge from inpatient or outpatient facilities.
Obtain prompt notification of termination, decreases or changes in benefit(s), services, or the provider network that directly impacts the member’s care.
Be advised of their financial responsibility when seeking care from a non-participating provider or in the event services are obtained without required benefit certifications that may be required under their plan.
To a candid discussion and explanation of appropriate or medically necessary treatment options or healthcare decisions for their conditions, regardless of cost or benefit coverage and including payment structure or billing explanation for non-covered services. This includes the right to have the explanation provided to next of kin, guardian, agent or surrogate if available, when the member is unable to understand and have all explanations recorded in the member’s medical record, including where appropriate, a signed medical release authorizing release of medical information by the member.
To a complete explanation of why care is denied, including the opportunity to voice complaints, or appeals with Presbyterian Health Plan or its regulatory bodies about Presbyterian Health Plan, or the care it provides. The member also has the right to receive an answer to such within a reasonable time and without fear of retaliation. Medicare Advantage members have the right to an automatic reconsideration determination made by an independent, outside entity contracted by the Centers for Medicare and Medicaid Services (CMS) if Presbyterian Health Plan affirms, in whole or in part, its original adverse decision.
If the amount in controversy meets requirements for requesting an Administrative Law Judge (ALJ) hearing, Medicare Advantage members have the right to an ALJ hearing, a Medicare Administrative Contractor (MAC) review of the ALJ hearing determination, and the right to judicial review of the hearing decision.
For Inpatient Hospital care, Medicare Advantage members may also file an appeal to the Quality Improvement Organization (QIO) to request immediate QIO review if Presbyterian Health Plan determines that inpatient hospital care is no longer necessary, and the member disagrees. Medicare Advantage members may also file quality of care grievances with the QIO.
To make recommendations regarding Presbyterian Health Plan's members' rights and responsibilities policy.
To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in federal or state of New Mexico regulations.
To receive health care services in a non-discriminatory fashion. No member may be denied the benefits of, or participation in, covered services on the basis of gender, age, race, color, sexual orientation, physical or mental disability, cultural or educational background, religion or national origin, ancestry, marital status, economic or health status, genetic information, history of the frequency of the use of health care services, source of payment for care, or if a Member has filed a grievance or appeal.
Members who have a disability shall have the right to receive information in an alternative format in compliance with the Americans with Disabilities Act.
To be free from harassment by Presbyterian Health Plan or its network providers in regard to contractual disputes between Presbyterian Health Plan and its providers.
To choose from the available providers within the limits of the Presbyterian Health Plan network for their plan and its referral and benefit certification requirements and have adequate access to qualified health professionals for the treatment of covered benefits near where they live or work within the Service Area. (Members whose plan contains out-of-network benefits are not required to be treated by network providers for those services.)
A female member has the right to self-refer to a women’s health specialist within the network for covered care necessary to provide women’s routine and preventive health care services. This is in addition to the member’s designated source of primary care if that source is not a women’s health specialist.
To make healthcare wishes known through advance directives regarding health care decisions consistent with federal and state laws and regulations, living will or other directive, including the right to withhold resuscitative service or to forgo or withdraw life-sustaining treatment, and/or to choose a surrogate decision-maker to be involved as appropriate, to assist with care decisions.
To available and accessible services when medically necessary, 24 hours per day, seven days per week for urgent or emergency care services when the member believes, and/or their authorized representative believes, they (the member) have a medical condition that could seriously jeopardize health, cause serious impairment to bodily functions, or create a serious dysfunction of any bodily organ or part.
To have access to translation services for members who do not use English as their first language, and translation services for hearing-impaired members for communication with Presbyterian Health Plan.
To refuse care, treatment, or medications after the provider has explained the care, treatment or provided other advice in a language that they understand.
To receive information from their provider in language and terms that they understand, an explanation of their complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives appropriate to the member’s condition, irrespective of Presbyterian Health Plan’s position on treatment options. If the member is not capable of understanding the information, the explanation shall be provided to their next of kin, guardian, agent or surrogate, if available, and documented in the covered person’s medical record.
To continue an ongoing course of treatment for a period of at least 30 days if the member’s provider leaves the Presbyterian Health Plan provider network or if a new member’s provider is not in the Presbyterian Health Plan provider.
To know upon request of any financial arrangements or provisions between the health care insurer and its providers which may restrict referral or treatment options or limit the services offered to members.
To affordable health care, with limits on out-of-pockets expenses, including the right to seek care from a nonparticipating provider and an explanation of a member’s financial responsibility when services are provided by a non-participating provider or provided without required benefit certification.
To receive detailed information about coverage, maximum benefits, and exclusions of specific conditions, ailments or disorders, including restricted prescription benefits, and all requirements that a member must follow for prior authorization and utilization review.
To obtain prescription drug coverage within a reasonable period of time and information about their drug coverage and costs.
To receive a Certificate of Creditable coverage when a member’s enrollment in Presbyterian Health Plan terminates.
For plans with Out-of-Network coverage, members have the right to an approved example of the financial responsibility incurred by a covered person when going out-of-network..
Member’s Rights with Respect to Protected Health Information (PHI):
Members have the right to privacy of medical and financial records maintained by Presbyterian Health Plan and Presbyterian Health Plan’s network of providers, in accordance with existing law.
To access their medical and financial records according to applicable federal and state laws and regulations. Members are entitled to confidentiality of medical and financial records. Records will be released only with the written consent of the member or legal guardian or as otherwise allowed by law.
Members have the right to request restrictions on certain Uses and Disclosures of PHI, including a statement that Presbyterian Health Plan is not required to agree to a requested restriction.
Members have the right to receive confidential communications of PHI from Presbyterian Health Plan.
Members have the right to inspect and receive a copy of PHI.
Members have the right to amend incorrect or incomplete PHI.
Members have the right to receive an accounting of certain Disclosures of PHI.
Members have the right to obtain a paper copy of the Notice from Presbyterian Health Plan upon request (even if the Member previously agreed to receive the Notice(s) electronically).
Members have the right to file a complaint if the member believes Presbyterian Health Plan is not complying with the HIPAA Standards for Privacy of Individually Identifiable Health Information.
Member Responsibilities
Presbyterian Health Plan expects members to cooperate responsibly in matters regarding their health care, including the following:
A responsibility to supply information (to the extent possible) that the organization and its providers need in order to provide care.
A responsibility to follow plans and instructions for care that they have agreed to with their providers.
A responsibility to understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
To notify Presbyterian Health Plan of any changes in names, address, phone number, marital status, newborns that affect eligibility.
To advise treating providers of coverage with Presbyterian Health Plan at the time of service. Members may be required to pay for services if they do not inform their treating Provider of their Presbyterian Health Plan coverage.
To behave in a manner that supports the care provided to other patients—and the general functioning of the facility.
To safeguard the confidentiality of their own care and that of other patients.
To accept the financial responsibility, as applicable, associated with services received while under the care of a provider. Be responsible for the payment of all services obtained prior to the effective date of the Agreement and subsequent to its termination or cancellation.
To review information regarding covered services, policies and procedures as stated in their Evidence of Coverage (EOC), and to contact the Presbyterian Customer Service Center for clarification of benefits, benefit limitations, and exclusions outlined in these documents. Medicare Advantage members will also receive and be required to review their Annual Notice of Change (ANOC).
To request and obtain information about any financial arrangements between Presbyterian Health Plan and its providers which might restrict referral or treatment options, or limit services offered to members.
To change a primary care provider (PCP) by following the rules described in their EOC.