Ascension_Personalized_Care_ACA_health_plan_Member_Rights_Responsibilities

Members rights and responsibilities

You have the right as a healthcare Plan member to:

Be treated with respect, dignity and privacy;

Have access to medically necessary and appropriate covered healthcare services, including emergency services, 24 hours a day, seven (7) days a week;

Be informed of your health problems and to receive information regarding treatment alternatives and their risk in order to make an informed choice about your care regardless of whether the health Plan pays for treatment;

Participate with your healthcare provider in decisions about your treatment;

Give your healthcare provider a healthcare directive or a living will (a list of instructions about health treatments to be carried out in the event of incapacity or the inability to make your own health decisions);

Refuse treatment;

Privacy of medical and financial records maintained by the healthcare Plan, the claims administrator and its healthcare providers in accordance with existing law;

Receive information about the healthcare Plan, its services, its providers, and your rights and responsibilities;

Make recommendations regarding these rights and responsibilities policies;

Have a resource at the healthcare Plan, the claims administrator or at the clinic that you can contact with any concerns about services;

File an appeal with the claims administrator and receive a prompt and fair review;

and Initiate a legal proceeding when experiencing a problem with the healthcare Plan or its providers.

You have the responsibility as a healthcare Plan member to:

Know your healthcare Plan benefits and requirements;

Provide, as much as you can, information that the healthcare Plan, the claims administrator and its providers need in order to care for you;

Understand your health and work with your provider to set mutually agreed upon treatment goals;

Follow the treatment plan that your healthcare provider recommends or to discuss with your provider why you are unable to follow the treatment plan;

Provide proof of health insurance coverage when you receive services and to update the clinic with any personal changes;

Pay copayments at the time of service and to promptly pay deductibles, coinsurance and, if applicable, charges for services that are not covered.

No Surprises Act 

When you get emergency care or get treated by an out-of-network doctor at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.  

What is “balance billing” (sometimes called “surprise billing”)? 
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a doctor or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes doctors and facilities that haven’t signed a contract with your health plan. Out-of-network doctors may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “
balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network doctor. 

You are protected from balance billing for:

Emergency services 
If you have an emergency medical condition and get emergency services from an out-of-network doctor or facility, the most the doctor or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center 
When you get services from an in-network hospital or ambulatory surgical center, certain doctors there may be out-of-network. In these cases, the most those doctors may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These doctors can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network doctors can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a doctor or facility in your plan’s network. 

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network doctors and facilities directly. 

• Your health plan generally must:  
          • Cover emergency services without requiring you to get approval for services in advance (prior authorization). 
          • Cover emergency services by out-of-network doctors.
          • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network doctor or facility and show that 
               amount in your explanation of benefits. 
          • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit. 

If you believe you’ve been wrongly billed, you may contact the Customer Service department at the number listed on the back of your ID card. 

Visit https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills for more information about your rights under federal law.