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Member rights and responsibilities

We must honor your rights as a member of the WellSense Medicare Advantage plan.

We must provide information in a way that works for you (e.g., in languages other than English, in Braille, in large print or other alternate formats).

  • To get information from us in a way that works for you, please call Member Services. At no cost to our members, we offer language interpreter services for non-English-speaking members, sign language interpreters for when our nurses and others visit you, information in Braille, large print and other alternate formats.
  • If you have Medicare and you have any trouble getting information from our plan because of problems related to language or a disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week, and tell them that you want to file a complaint. TTY users can call 1-877-486-2048.

We must treat you with fairness and respect at all times.

We do not discriminate based on a person’s race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area.

  • If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights.
  • If you have a disability and need help with access to care or a complaint, such as a problem with wheelchair access, please call us our Member Services Department.

We must ensure that you get timely access to your covered services and prescription drugs.

  • You have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services.
  • You have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.
  • If you do not have Medicare and develop End-Stage Renal Disease (ESRD) while you are a member of our plan, you will not be terminated. Our plan will coordinate access to the care and services that you need.

Mental Health Parity

Federal and state laws require that all managed care organizations, including WellSense, provide behavioral health services to members in the same way they provide physical health services. This is what is referred to as parity.

  • We must provide the same level of benefits for any mental health and substance abuse problems you may have as for other physical problems you may have;
  • We must have similar prior authorization requirements and treatment limitations for mental health and substance abuse services as it does for physical health services;
  • We must provide you or your provider with the medical necessity criteria used by us for prior authorization upon your or your provider’s request; and
  • We must also provide you within a reasonable time frame the reason for any denial of authorization for mental or substance abuse services.

If you think that we are not providing parity as explained above, you have the right to file a Grievance with us. You may also file a grievance with Medicare. Find out how to file a grievance.

We must protect the privacy of your personal health information.

  • We protect the privacy of your medical records and personal health information.
  • You have rights related to getting information and controlling how your health information is used. We give you a Notice of Privacy Practice that tells about these rights and explains how we protect the privacy of your health information.

How we protect the privacy of your health information:

  • We make sure that unauthorized people don’t see or change your records.
  • In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you or your authorized representative first. There are certain exceptions that do not require us to get your written permission first. For example, if we are required to release health information to government agencies that are checking on quality of care.
  • If you receive Medicare benefits, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations.
  • You have the right to know how your health information is shared with others for any purposes that are not routine. You can see the information in your records and know how it is shared with others

You have the right to know your treatment options and participate in decisions about your healthcare.

You have the right to get full information from your doctors and other healthcare providers when you go for medical care. Your rights include the following:

  • To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely.
  • To know about the risks involved in your care.
  • The right to say "no" to a recommended treatment.
  • To receive an explanation if you are denied coverage for care.
  • Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself. Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. These legal documents are called "advance directives," which include a "living will" and "power of attorney for health care.
  • To end your membership in our plan at any time. This change takes effect on the first day of the following month. You have the right to make complaints and to ask us to reconsider decisions we have made.
  • You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do, we are required to treat you fairly.
  • You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. We must give you information about the plan, its network of providers, and your covered services
  • You have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats.)
  • If you want any of the following kinds of information, please call Member Services:
    • Information about our plan.
    • Information about our network providers including our network pharmacies.
    • Information about your coverage and the rules you must follow when using your coverage.
    • Information about why something is not covered and what you can do about it.

You have the right to make recommendations to us about our organization’s rights and responsibilities.

We must support your right to make decisions about your care

  • If it is about discrimination, call the Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.
  • If you believe you have been treated unfairly or your rights have not been respected, you can call Member Services.

How to get more information about your rights

There are several places where you can get more information about your rights:

You have some responsibilities as a member of the plan

Things you need to do as a member of the plan are listed below. If you have any questions, please call Member Services. We’re here to help.

  • Be familiar with your covered services and the rules you must follow to get these covered services. Use your Evidence of Coverage booklet to learn what is covered for you and the rules you need to follow to get your covered services.
  • If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Please call Member Services to let us know.
  • Tell your doctor and other health care providers that you are enrolled in our plan.
  • Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.
  • Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices.
  • Pay what you owe.
  • Tell us if you move. If you are going to move, it’s important to tell us right away. Please call Member Services to let them know.
  • If you move outside of our plan service area, you cannot remain a member of our plan. We’re here to help. Please call Member Services for help if you have questions, concerns, or feedback.