Member rights and responsibilities

Introduction about your rights and protections

Since you have Medicare, you have certain rights to help protect you. This page explains your Medicare rights and protections as a Blue Medicare HMO or Blue Medicare PPO member. We will tell you what you can do if you think you are being treated unfairly or your rights are not being respected. If you want Medicare publications about your rights, you may call and request them at 1-800-MEDICARE (1-800-633-4227). For the hearing and speech impaired, 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. We must obey laws against discrimination that protect you from unfair treatment. These laws say that we cannot discriminate against you (treat you unfairly) because of your race or color, age, religion, national origin or any mental or physical disability you may have.

If you think you have been treated unfairly due to your race, color, national origin, disability, age or religion, please let us know. You can also reach the Office for Civil Rights at 1-800-368-1019 (For the hearing and speech impaired: 1-800-537-7697), or you can contact the regional Office for Civil Rights in your area.

Regional Office for Civil Rights

• State in region
• North Carolina
• Alabama
• Florida
• Georgia
• Kentucky
• Mississippi
• South Carolina
• Tennessee

Phone number
(404) 562-7886

For the hearing and speech impaired:
(404) 331-2867 (TTY/TTD)

Address
Office for Civil Rights
U.S. Department of Health and Human Services
Human Services
Atlanta Federal Center
Suite 3B
7061 Forsyth Street, S.W.
Atlanta, GA 30303-8909

If you need help with communication, such as help from a language interpreter, please call Blue Medicare HMO at 1-888-310-4110, or Blue Medicare PPO at 1-877-494-7647.

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 keep your personal health information private as protected under these laws. Any personal health 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. Blue Medicare HMO and Blue Medicare PPO are required to provide you with a notice that tells about these rights and explains how they 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 for additions or corrections to your medical records (if you ask Blue Medicare HMO and Blue Medicare PPO to do this, they will review your request and determine 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 the privacy of your personal information and medical records, please call Blue Medicare HMO at 1-888-310-4110, or Blue Medicare PPO at 1-877-494-7647.

Your right to get your prescriptions filled within a reasonable period of time

You should get all of your prescriptions filled from a network pharmacy, that is, from pharmacies that contract with Blue Medicare HMO or Blue Medicare PPO. You have the right to go to any network pharmacy in order to get your prescriptions filled at the benefit level. You have the right to timely access to your prescriptions. "Timely access" means that you can get your prescriptions filled within a reasonable amount of time.

Your right to know your treatment choices and participate in decisions about your health care

You have the right to know about the different Medication Therapy Management Programs offered and in which you may participate. You have the right to be told about any risks involved in your care. You have the right to refuse treatment. 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.

You have the right to get a detailed explanation from Blue Medicare HMO and Blue Medicare PPO if you believe that a network pharmacy has denied coverage for a drug that you believe you are entitled to get or care you believe you should continue to get.

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. Which one you make depends on your situation.

If you make a complaint, we must treat you fairly (i.e., not discriminate against you). You have the right to get a summary of information about the appeals and grievances that members have filed against these plans in the past. To get this information, call Blue Medicare HMO at 1-888-310-4110, or Blue Medicare PPO at 1-877-494-7647.

Your right to get information about your drug coverage and costs

This Web site tells you what you have to pay for prescription drugs as a member of Blue Medicare HMO or Blue Medicare PPO. If you need more information, please call Blue Medicare HMO at 1-888-310-4110, or Blue Medicare PPO at 1-877-494-7647. You have the right to an explanation from us about any bills you may get for drugs not covered by your plan. We must tell you in writing why we will not pay for a drug, and how you can file an appeal to ask us to change this decision. Learn more about filing an appeal.

Your right to get information about our Plan and our network pharmacies

You have the right to get information from us about Blue Medicare HMO or PPO and our Medicare Advantage prescription drug Plans. This includes information about our financial condition and about our network pharmacies. To get any of this information, call Blue Medicare HMO at 1-888-310-4110, or Blue Medicare PPO at 1-877-494-7647.

Your right to disenroll from your plan

You have the right to disenroll from Blue Medicare HMO and Blue Medicare PPO plans with Medicare prescription drug benefits during certain periods by giving written notice to the plan of your intent to do so. Coverage will end on the last day of the month following the date when Blue Medicare HMO or Blue Medicare PPO receives your written request. To end your coverage, you may send written notice to Blue Medicare HMO or Blue Medicare PPO, P.O. Box 17468, Winston-Salem, NC 27116. You will receive an acknowledgement of your disenrollment from Blue Medicare HMO or Blue Medicare PPO.

How to get more information about your rights

If you have questions or concerns about your rights and protections, please call Blue Medicare HMO at 1-888-310-4110, or Blue Medicare PPO at 1-877-494-7647. You can also get free help and information from Seniors' Health Insurance Information Program (SHIIP). You can reach SHIIP at 1-800-443-9354. 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). For the hearing and speech impaired, call 1-877-486-2048 (TTY/TDD). You can call 24 hours a day, 7 days a week. Or, you can visit medicare.gov 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?

For concerns or problems related to your Medicare rights and protections described in this section, you can call Blue Medicare HMO at 1-888-310-4110, or Blue Medicare PPO at 1-877-494-7647. You can also get help from SHIIP by calling 1-800-443-9354.

What are your responsibilities as a member of Blue Medicare HMO or Blue Medicare PPO?

Along with the rights you have as a Blue Medicare HMO or Blue Medicare PPO member, you also have some responsibilities. Your responsibilities include the following:

• Become familiar with your coverage and the rules you must follow to get care as a member. Use the information available on this Web site as well as other information available about your coverage, what you have to pay, and the rules you need to follow. Please call Blue Medicare HMO at 1-888-310-4110, or Blue Medicare PPO at 1-877-494-7647 if you have any questions.
• Give your health care provider(s) the information they need to care for you, and follow the treatment plans and instructions given to you. Be sure to ask your health care provider(s) if you have any questions.
• Pay your plan premiums and any copayments you may owe for the covered drugs you get.
• Let Blue Medicare HMO or Blue Medicare PPO know if you have any questions, concerns, problems, or suggestions. If you do, please call Blue Medicare HMO at 1-888-310-4110, or Blue Medicare PPO at 1-877-494-7647.