Member Rights and Responsibilities

We must honor your rights as a member of the plan

We must provide information in a way that works for you (in languages other than English, in Braille, in large print, or other alternate formats, etc.). We will print and send to you within 5 days of the request.

To get information from us in a way that works for you, please call Member Services. We offer free of charge: language interpreter services for non-English speaking members; sign language interpreters for when our nurses and others visit you; information in Braille, large print, or 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, 7 days a week, and tell them that you want to file a complaint. TTY users can call 1-877-486-2048.

Tenemos la obligación de brindar información de una manera que sea conveniente para usted (en otros idiomas que no sean el idioma inglés, en Braille, en letra grande u otros formatos alternativos, etc.) Si desea que le proporcionemos información de una manera que sea conveniente para usted,por favor, llame a Servicios al Miembro (los números de teléfono se encuentran en la contratapa de este cuadernillo).

Nuestro plan cuenta con personal y servicios de interpretación gratuitos que están disponiblespara responder las preguntas de los miembrosd que no hablan inglés. Además, podemosbrindarle información en Braille, en letra grande u otros formatos alternativos si lo necesita. Siusted cumple con los requisitos de Medicare debido a una discapacidad, tenemos la obligación de darle información sobre los beneficios del plan de una manera que sea accesible y adecuada para usted.

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 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 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 Senior Care Options (SCO), provide behavioral health services to MassHealth members in the same way they provide physical health services. This is what is referred to as “parity”. In general, this means that:

• 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. Learn how to file a Grievance. You may also file a grievance with MassHealth. You can do this by calling the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497- 4648) Monday—Friday 8:00 a.m. to 5:00 p.m.

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 written notice, called a “Notice of Privacy Practice,” that tells about these rights and explains how we protect the privacy of your health information.

How do 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 has been shared with others for any purposes that are not routine. You can see the information in your records and know how it has been shared with others

You have the right to know your treatment options and participate in decisions about your health care

You have the right to get full information from your doctors and other health care 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 1st of the following month.

What if your instructions are not followed?

If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with Massachusetts Department of Public Health, Division of Health Care Quality’s Complaint Unit by calling 1-800-462-5540. To file a complaint against an individual doctor, please call the Board of Registration in Medicine at 781-876-8200. You may also file a grievance with Massachusetts Executive Office of Elder Affairs at 1-800-243-4636 or 1-617-727-7750. TTY/TDD users please call 1-800-872-0166.

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 – ask for a coverage decision, make an appeal, or make a complaint – 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.

What can you do if you believe you are being treated unfairly or your rights are not being respected?

• Get 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. If you are a WellSense Senior Care Options (HMO D-SNP) Plan member, you are responsible for certain payments owed. Please refer to your Evidence of Coverage
• Tell us if you move. If you are going to move, it’s important to tell us right away. Please call Member Services<<link to: /contact-us>> to let them know. If you move outside of our plan service area, you cannot remain a member of our plan.
• You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies.
• You have the right to ask us to make additions or corrections to your medical records.

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.
• If you are a member of our HMO SNP plan, you can call the State Health Insurance Assistance Program at 1-800-243-4636 (option #3) or visit www.massresources.org/health-care.html. Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

How to get more information about your rights

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

• You can call Member Services.
• You can call the State Health Insurance Assistance Program.
• You can contact Medicare.
  • You can visit the Medicare website to read or download the publication “Your Medicare Rights & Protections.” (The publication is available at: http://www.medicare.gov/Pubs/pdf/11534.pdf.)
  • Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

You have some responsibilities as a member of the plan

What are your responsibilities?

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.

• Get 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. If you are a WellSense Senior Care Options (HMO D-SNP) Plan member, you are responsible for certain payments owed. Please refer to your Evidence of Coverage.
• 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.

For more detailed information, please refer to your Evidence of Coverage.