Attention Members:

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Blue Choice

South Carolina Healthy Connections

Member Rights and Responsibilities

Rights

    As a member of this health plan, you have the right to:
    • Always be treated with respect and due regard for your dignity and privacy.
    • Get the help you need to understand your
      Evidence of Coverage (EOC).
    • Get interpreter services free of charge if you speak a language other than English or if you have hearing, vision or speech loss.
    • Be notified of how to access those services.
    • Get health plan documents in formats such as Braille, large-size print or audio at no cost
      to you.
    • Get all information and notices in a format that is easy to understand.
    • Get news about our benefits, doctors and other health care providers with whom we have contracts.
    • Take part in decisions about your health care. (This includes the right to refuse treatment.)
    • Be told about your member rights and responsibilities.
    • Be told about other treatment choices or plans for care in a way that fits your health issue.
    • Get help from the South Carolina Department of Health and Human Services (SCDHHS) and BlueChoice HealthPlan Medicaid in knowing what is required and covered.
    • Know that we only cover health care services that are part of your plan.
    • Know that we may make changes to your health plan benefits as long as we tell you about those changes in writing 30 days before they take effect.
    • Refuse care from your primary care provider (PCP) or other health care providers.
    • Find out how we decide if new technology or treatment should be part of a benefit.
    • Get 24-hour-a-day, 7-day-a-week access to medical advice from your PCP, either in person or by phone.
    • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or action to get back at you as stated in the federal regulations on the use of restraints and seclusion.
    • Get care that is medically necessary.
    • Get news about and make an advance directive. This includes a description of state laws that apply to living wills (Chapter 66, Section 44). This also includes changes in the state law as soon as they can be given to you, but no later than 90 days after the change goes into effect.
    • Change or revoke your advance directive at any time.
    • Choose a provider who is part of your network. (If you get services from a provider who is not in your network or not approved by us, those services will not be covered.)
    • Get family planning services from a provider not in your network.
    • Know that BlueChoice HealthPlan Medicaid, your doctors and your other health care providers cannot treat you differently because of your:
      • Age.
      • Sex.
      • Race.
      • National origin.
      • Gender.
      • Sexual preference.
      • Language needs.
      • Degree of illness or health issue.
    • Have problems taken care of fast. (This includes things you think are wrong, as well as issues about getting an approval from us, your coverage or payment of services.)
    • Know the date you join BlueChoice HealthPlan Medicaid is used as the date when your benefits begin. (We won’t cover services you got before this date.)
    • Question a decision we make about coverage for care you got from your doctor. (You will not be treated differently if you make a complaint.)
    • Tell us what you do not like about our rights and responsibilities policy.
    • Tell us what you would like to change about our health plan.
    • Have access to your medical records and ask that they be changed or corrected as federal and state laws allow.
    • Have news about your health insurance and medical records kept private by us, your doctors and all of your other health care providers.
    • Receive health care services that you can access.
    • Receive health care services that are similar to those given under Healthy Connections in:
      • Length of time given.
      • Scope.
    • Get health care services that are enough in amount, length of time given and scope to do what they should be able to do for your health issue.
    • Make an informed health plan choice (before you join a plan) by getting information about the basic features of managed care, including:
    • Which groups of people may or may not enroll in the program.
    • The health plan’s duties for coordinating care in a timely manner.
    • Get information from your health plan about services. This includes but is not limited to:
      • Benefits covered.
      • How to get benefits, as well as an approval from BlueChoice HealthPlan Medicaid or your doctor.
      • Cost-sharing rules.
      • Service area.
      • Names, locations and phone numbers of current network providers (PCPs, specialists and hospital staff) who speak a language other than English.
      • Any limits on your freedom of choice among network providers.
      • Providers who are not taking new patients.
      • Benefits not offered by your health plan. Plus, how you may get them and get a ride to and from these services.
    • Get a complete outline of your disenrollment rights at least once per year.
    • Get written documents about this plan that includes information about how the plan is set up and how it operates.
    • Get information on the grievance, appeal and state fair hearing procedures.
    • Get details on emergency and after-hours coverage, including but not limited to:
      • What are emergency medical conditions, emergency services and post-stabilization services.
      • The fact that emergency services do not need an approval from BlueChoice HealthPlan Medicaid.
      • The process and procedures for getting emergency services.
      • The fact that you have the right to use any hospital or other setting for emergency care.
      • Post-stabilization care services rules as noted in 42 Code of Federal Regulations (CFR) 422.113(c).
    • Get our rules on referrals for specialty care and other benefits not given by your PCP.
    • Have your privacy guarded as noted in 45 CFR parts 160 and 164, subparts A and E (as this rule applies).
    • Use your rights without being treated differently by us, the providers who contract with us or staff from SCDHHS.
    • Know you will not be held liable if your health plan becomes insolvent.
    • Get services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness, or medical condition.
    • Have honest talks with your doctors about the right treatment for your condition, in spite of the cost or your benefit coverage.

    Responsibilities

      As a member of this health plan, you have these responsibilities:
      • Tell us and your social worker if:
        • You move.
        • You change your phone number.
        • The number of people in your household changes.
        • You have other insurance.
        • You become pregnant.
        • Your ID card is lost or stolen.
      • Understand your health problems and help your doctor set treatment goals.
      • Show your ID cards each time you get medical care.
      • Know the plan’s procedures.
      • Call us if you have questions or want to learn more.
      • Make it to your PCP visits and follow-up visits on time. If you cannot make it, change the visit as far in advance as you can.
      • Use the ER only for emergency services. Do not use the ER for routine services. (To learn more about this, see Part 8 Emergency and urgent care in your EOC.)
      • Pay for services that are not covered by us.
      • Treat your PCP and other health care providers with respect.
      • Tell us, your doctors and your other health care providers what they need to know to treat you.
      • Follow the treatment plans you, your doctors and your other health care providers agree on. If you could not follow them, tell us why.