会员权利及责任

• 您有权获得有关您的计划的详细信息. 这可能包括本计划涵盖或不包括的福利和服务, and all requirements that must be followed for Prior approval and Utilization Review.
• You have a right to always have available and accessible services for Medically Necessary and covered services; including 24 hours per day, 每周7天提供紧急护理服务, and for other healthcare services as defined by the Evidence of Coverage or the Summary of Benefits and Coverage.
• 你有权了解你的自付费用限制, 并说明你对所提供服务的经济责任.
• 你有权受到尊重你的隐私和尊严的对待.
• You have a right to participate with your 供应商 in making decisions about your healthcare.
• You have a right to receive an explanation of your medical Condition; recommended treatment; risks of the treatment; expected results; and reasonable medical alternatives from your Provider in a language that you understand, 不计成本或你的计划的好处.
• You have a right to be informed about your treatment from your Participating Provider; to request your consent (agreement) to the treatment; to refuse treatment, including medication; and to be told of the possible consequences of refusing such treatment. This right exists even if treatment is not a covered benefit or Medically Necessary according to the Plan. The right to consent or agree to treatment may not be possible in a medical emergency where your life and health are in serious danger.
• 你有表达不满的权利, 不满 or 上诉 with the Plan or its regulatory bodies about the Plan and/or the care that we provide.
• You have a right to make recommendations regarding the Plan’s 会员权利及责任 policies.
• 你有权得到及时、礼貌和负责任的帮助.
• You have a right to the confidential handling of all communication and information maintained by the Plan. Your written permission will always be required for the release of medical and financial information, 除了:
  • 当医疗保健提供者需要临床数据进行护理时;
  • 当计划受法律约束必须发布信息时;
  • When the Plan prepares and releases data but without identifying 成员; and
  • 必要时支持计划的项目或运作, 包括付款和评估质量和服务.
• 您有权立即被告知终止或福利的变化, 服务或参与供应商.
• 你有权知道, 要求, of any financial arrangements or provisions between the Plan and its Participating 供应商, which may restrict referrals or treatment options or limit the services offered to you.
• You have a right to receive an explanation of why a benefit is denied; the opportunity to appeal the denial decision; the right to a second level of appeal with the Plan; and the right to request help from the New Mexico Superintendent of Insurance.
• You have a right to adequate access to healthcare providers near your home or work within the Plan’s service area.
• You have a right to receive detailed information about requirements that you must follow for prior approval of certain services.
• You have a right to have access to a current list of Participating 供应商 in the Plan’s network.
• You have the right to an example of the financial responsibility incurred by a Covered Person for services received from an Out-of-Network or Non-Participating Provider.

你有责任了解你的计划是如何运作的. You should carefully read and refer to your Evidence of Coverage (also called a Member Handbook) and your Summary of Benefits and Coverage. 如果您对您的计划有疑问或疑虑，请联系客户服务中心.