STATEMENT OF MEMBER RIGHTS AND RESPONSIBILITIES

MEMBER RIGHTS

1. You have the right to be treated with respect, dignity and consideration for your privacy by health care providers and by Blue Cross and Blue Shield of North Carolina (BCBSNC) staff.
2. You have the right to receive information about the Plan, its services, its health care providers and your rights and responsibilities as a member of the Plan. (For example: When you are hospitalized, you should receive a document called Important Message from Medicare, which explains your rights as a hospital patient. These include the right to be told why you are being released from the hospital and what to do if you disagree.
3. You have the right to private, confidential treatment of your records by Plan staff and providers, and you have the right to access your medical records by contacting the provider of service.
4. You have the right to accessible services from the Plan and from providers of health care, regardless of your English proficiency, reading skill, cultural or ethnic background, and/or physical or mental disabilities.
5. You have the right to receive medically necessary services as described in your BCBSNC Blue Medicare HMO or Medicare PPO Evidence of Coverage Agreement.
6. You have the right to coverage for emergency and urgently needed care without prior authorization using prudent layperson standards outlined in your Certificate of Coverage. (Refer to the Certificate of Coverage for details.)
7. You have the right to a second opinion if you question a contracting provider's decision about the need for surgery. A list of contracting providers can be found in the provider directory. With authorization from either your Primary Care Physician or the plan a second opinion from the provider you select is Covered.
8. You have the right to prompt resolution of any problems or complaints regarding BCBSNC Blue Medicare HMO or Medicare PPO or contracting providers via the Plan's grievance process. You have a right to prompt resolution of any request for reconsideration of pre-service or claim denials via the Medicare appeals process. Questions about benefits, claims payment, contracting providers, plan services, or the appeals and grievance procedures referenced above should be directed to a PARTNERS Medicare Choice Customer Service Representative by calling 1-888-310-4110 or 1-888-451-9957 (TDD/TTY).
9. You have the right to disenroll from BCBSNC Blue Medicare HMO or Medicare PPO 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 the Plan receives your written request. To end your Coverage, you may either: Send written notice to BCBSNC, PO Box 17509, Winston-Salem, NC 27116-7509; or Disenroll at any Social Security Administration Office or Railroad Retirement Board Office
10. You have the right to continue coverage with BCBSNC, except in the following situations: non–payment of plan premiums, fraud, abuse of the organization's membership card, permanent moves outside the BCBSNC Blue Medicare HMO and Medicare PPO service area, loss of Medicare entitlement, or "for cause" subject to CMS approval.
11. You have the right to participate with providers in making decisions about your health care and to receive information on available treatment options (including no treatment) or alternative courses of care. In addition, you have the right to designate someone to make your health care decisions for you in the event you are unable to make these decisions yourself. (These are known as Advance Directives. For more information, ask your Primary Care Physician.)
12. You have the right to receive the services of the BCBSNC Blue Medicare HMO or Medicare PPO (primary care physician) of your choice. Your choice of PCP must be reported to and recorded by the Plan. Your PCP is required to provide or arrange care 24 hours a day, 7 days a week.

MEMBER RESPONSIBILITIES

1. It is your responsibility to select a Primary Care Physician and have all your medical care provided by or arranged by your PCP except for emergency or urgently needed care. Blue Medicare HMO or Blue Medicare PPO does not cover services which you arrange on your own except for emergencies and urgently needed care or as specified in your Evidence of Coverage.
2. In the event of an emergency, go to the nearest emergency room or call 911 for assistance. We ask that your notify your PCP within 48 hours or as soon as possible if you seek emergency care so that he or she can arrange for appropriate follow up care. If you are out of the service area and require urgently needed care, we request that you, if possible, first telephone your PCP and then seek care from an appropriate local medical facility, according to your PCP's instructions. (Refer to the Evidence of Coverage for details.)
3. It is your responsibility to make monthly Plan premium payments for your coverage on or before the first day of the month of coverage, unless your employer/retiree group makes these payments on your behalf. If the premium is not paid on time, we will send you notice of late payment, indicating that your Blue Medicare HMO and PPO coverage may be ended according to our Blue Medicare HMO and PPO Payment Guidelines. For more Plan payment information, call Customer Service at 1-888-310-4110 for Blue Medicare HMO and 1-xxx-xxx-xxxx for Blue Medicare PPO or for the hearing impaired, 1-888-451-9957 (TDD/TTY).
4. It is your responsibility to inform us of changes in name, address and telephone number, PCP selection, etc.
5. It is your responsibility to pay any required copayments when they are requested of you, such as copayments for office visits.
6. It is your responsibility to pay for any service that is not Covered under the plan. This includes services which are excluded from coverage, services obtained from a specialist without referral from your PCP (except in instances where direct access is available), and services obtained from non-Plan providers without prior approval.
7. It is your responsibility to notify the Plan if you move out of the Blue Medicare HMO or Blue Medicare PPO service area. According to Medicare regulations, persons who live outside of the Blue Medicare HMO or Blue Medicare PPO service area are not eligible to continue enrollment in Blue Medicare HMO or Blue Medicare PPO.
8. It is your responsibility to keep appointments or follow procedures to avoid missed appointment charges.
9. It is your responsibility to understand how the plan works and follow plan procedures. This includes understanding the referral process to avoid unauthorized, non-covered services.
10. It is your responsibility to supply health care providers information needed to provide adequate care, and to follow treatment advice given by those providing health care services.
11. It is your responsibility to consult with your Primary Care Physician in all matters regarding your health care. This includes contacting your Primary Care Physician for instructions on care after regular office hours, except for emergency or urgently needed care.

Inquiries regarding Member Rights and Responsibilities should be directed to the Customer Service Department at 1-888-310-4110 for Blue Medicare HMO and 1-xxx-xxx-xxxx for Blue Medicare PPO or for the hearing and speech impaired: 1-888-451-9957 (TDD/TTY), Monday-Friday from 8:00 a.m. to 8:00 p.m. You may also write to: Blue Medicare HMO or Medicare PPO, BCBSNC, PO Box 17509, Winston-Salem, NC 27116-7509