Member’s Rights and Responsibilities

HMSA is committed to treating members in a manner that respects their rights and has adopted policies addressing members’ responsibility for cooperating with their healthcare providers.

Members’ Rights

HMSA recognizes the following rights of members:

• Members have the right to make recommendations regarding their health plan’s member rights and responsibilities policies.

Information disclosure

• Members have a right to information about HMSA, covered services, the names and qualifications of practitioners and providers involved in their medical treatment, and members’ rights and responsibilities.
• Members have a right to information about how medical treatment decisions are made by participating practitioners and providers and HMSA, including information about how payment is determined and made.
• Members have a right to information about their medications – what the medications are, how to take them and any possible side effects.
• Members have a right to receive as much information about a proposed treatment or procedure as they may need to give informed consent or to refuse a course of treatment. Except in cases of emergency services, this information shall include:
  • a description of the procedure or treatment,
  • any medically significant risks involved,
  • any alternate course of treatment or nontreatment and the risks involved in each, and
  • the name of the person who will carry out the procedure or treatment.
• Members have a right to be informed of continuing healthcare needs following discharge from inpatient or outpatient facilities.
• Members have a right to examine and receive an explanation of any bills for noncovered services, regardless of payment source.

Accessibility of services and providers

• Members have a right to receive emergency services when they, as prudent laypersons acting reasonably, believe that an emergency medical condition exists. Payment will not be withheld in such circumstances.
• Members have a right to receive urgently needed services when traveling within or outside of the service area or in the service area when unusual or extenuating circumstances prevent them from obtaining care from their personal physician.

• Members have a right to a choice of healthcare providers that are sufficient to ensure access to appropriate high-quality care and services.

  Note: Selection choice may be limited by the practitioner’s and provider’s patient caseload.

• Members have a right to a reasonable choice of qualified practitioners and providers of women’s health services.
• Members have a right to reasonable continuity of care and to know in advance the time and location of an appointment, as well as the name of the practitioner or provider providing care.
• Members have the right to timely access to their personal physician and referrals to specialists when medically appropriate.

Participation in treatment decisions

• Members have a right to a candid discussion of appropriate or medically appropriate treatment options for their conditions, regardless of cost or benefit coverage.
• Members have a right to participate in all decisions regarding their healthcare.
• Members have a right to refuse treatment or leave a medical facility, even against the advice of physicians (providing they accept the responsibility and consequences of the decision).
• Members have a right to be advised if a practitioner or provider proposes to engage in experimental or investigative treatment. Members have the right to refuse to participate in such research projects.
• Members have a right to complete an advance directive, living will or other directive and to place that directive in their medical records.
• Members have a right to assign their rights to any person who may have legal responsibility to make decisions on their behalf regarding their medical care.

Respect and nondiscrimination

• Members have a right to be treated with respect and recognition of their right to privacy.
• Members have a right to exercise these rights regardless of their race, physical or mental disability, ethnicity, gender, sexual orientation, creed, age, religion or national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for their care. These rights will be upheld by both HMSA and contracting practitioners and providers.

Confidentiality of health information

• HMSA has always safeguarded and handled members’ information on a confidential basis. HMSA members have the right to request access to records that HMSA holds about them.
• Members also have the right to request that their records be amended, that the use of their records be restricted, that their communications be sent to an alternative address in order to avoid putting their life in danger, and that they receive an accounting of disclosures made about them by HMSA.
• HMSA also requires verbal or written permission from members or the members’ personal representative before their information may be released to persons other than the member or for purposes that are not required by law or permitted by our policies.

(See also Privacy)

Complaints

• Members have a right to voice complaints and appeal decisions about their health plan or care provided.
• Members have a right to expect problems to be fairly examined and appropriately addressed.
• Members have a right to a response from HMSA or from contracted practitioners and providers to reasonable requests made for services.

Members’ Responsibilities

HMSA members have the following responsibilities:

Plan information and benefits

• Members are responsible to review information regarding covered services, policies and procedures as stated in their Guide to Benefits or Evidence of Coverage and Disclosure Information and other member materials.
• Members are responsible for complying with all terms of their membership in HMSA.
• Members are responsible to accept the financial responsibility associated with services received while under the care of a physician or while a patient at a facility.
• Members are responsible to ask questions of their practitioners, providers and HMSA.
• Members are responsible for providing their health plan, practitioners and providers, to the extent possible, information needed to provide care.

Self-management

• Members are responsible to understand their health problems and participate in developing mutually agreed-upon treatment plans to the degree possible.
• Members are responsible to follow treatment plans and instructions for care that they have agreed on with their practitioners and providers.
• Members are responsible to behave in a manner that supports the care provided to other patients and the general functioning of the facility where they are receiving care.

Reporting fraud

• Members are responsible for reporting wrongdoing and fraud to the appropriate resources or legal authorities.

Revision History