Rights and Responsibilities

As a member of the plan, you have the right to:

• Available and accessible services for Medically Necessary and Covered Services, including 24 hours per day, 7 days per week for Urgent or Emergency Services, and for other Health Care Services as defined by your Policy or Summary of Benefits and Coverage.
• Be treated in a prompt, courteous and responsible manner that respects your dignity and privacy.
• Affordable health care including information regarding your out-of-pocket expenses; limitations; the right to seek care from a non-participating provider; and an explanation of your financial responsibility when services are provided by a non-participating provider or without Prior Authorization.
• Choose a Primary Care Provider within the limits of the Covered Services, the Plan’s network and, as provided by the Policy, including the right to refuse care of specific health care professionals.
• Be promptly notified of termination or changes in benefits, services or the Provider Network.
• Confidential handling of all communications, including medical and financial information, maintained by the Plan. CHRISTUS Health Plan and our providers will maintain privacy of your medical and financial records in accordance with existing law.
• A complete explanation of why a benefit is denied, the opportunity to appeal the denial decision to our internal review and the right to request help from the Superintendent.
• Know, upon request, of any financial arrangements or provisions between the Plan and our participating providers, which may restrict referrals or treatment options or limit the services offered to you.
• Qualified health care professionals for treatment and services that are Covered Benefits near where you live or work within the Plan’s service area.

For a full list of Member Rights, please refer to your plan’s Evidence of Coverage.

As a Member of the Plan, you have the responsibility to:

• Provide honest and complete information to those providing care.
• Review and fully understand the information you receive about your Plan.
• Know the proper use of the services covered by the Plan.
• Present your Plan ID card before you receive care.
• Consult your Physician before receiving medical care unless your condition is life threatening.
• Promptly notify your Provider if you will be delayed or unable to keep an appointment.
• Pay all charges or Copay/Coinsurance amounts, including those for missed appointments. This also applies to Deductibles and any charges for Non-Covered Benefits and Services.
• Express your opinions, complaints or concerns in a constructive way to CHRISTUS Health Plan Member Services or to your Provider.
• Inform the Plan of any changes in family size, address, phone number or membership status within 30 calendar days of the change.
• Make Premium payments on time.
• Notify the Plan of other insurance coverage.
• Follow our Grievance and Appeal process when displeased with the Plan or a Provider’s actions or decisions.
• Understand your health problems and participate in developing treatment goals that you agree to with your Providers.
• Follow plans and instructions for care that you have agreed to with your Provider.

All Members are responsible for understanding how the Plan works. Please refer to the Forms & Documents section for more information on your plan.

CHRISTUS Health Plan Generations members have the right to:

• Choose a qualified provider and hospital. Selection choice may be limited by the provider's patient caseload and their willingness to accept payment from CHRISTUS Health Plan.
• Open discussion of appropriate or medically necessary treatment options, regardless of cost or benefit coverage.
• Timely access to a primary care provider or specialist when medically necessary.
• Receive emergency services when, as a prudent layperson, acting reasonably would have believed that an emergency medical condition existed and payment will not be withheld in cases where members seek emergency services.
• Actively participate in decisions regarding health and treatment options.
• Receive urgently needed services when traveling outside the Plan's service area or in the Plan's service area when unusual or extenuating circumstances prevent a member from obtaining care from his/her primary care provider.
• Be treated with dignity and respect and have the right to privacy recognized.
• Exercise these rights regardless of 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, mental condition or source of payment for health care. And to expect that both the Plan and contracting medical providers will uphold these rights.
• Confidential treatment of all communications and records pertaining to care. Members have the right to access medical records. The Plan must provide timely access to records and any information that pertains to them. Written permission from a member or a member's authorized representative shall be obtained before medical records can be made available to any person not directly concerned with the member's care or responsible for making payments for the cost of such care.
• Extend rights to any person who may have legal responsibility to make decision on a member's behalf regarding medical care.
• Refuse treatment or leave a medical facility, even against the advice of providers (given the member accepts responsibility and the consequences of the decision).
• Complete an advance directive, living will or other directive and provide copies to appropriate people and medical providers.
• Receive information about CHRISTUS Health Plan Generations and covered services.
• Know the names and qualifications of providers and health care professionals involved in medical treatment.
• Receive information about an illness, the course of treatment and prospects for recovery in understandable terms.
• Receive information regarding how medical treatment decisions are made by contracting medical providers, including payment structure.
• Receive information about medications including what they are, how to take them and possible side effects.
• Receive as much information about any proposed treatment or procedure as needed in order 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 description, the medically significant risks involved, any alternate course of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment.
• Reasonable continuity of care.
• To know in advance the time and location of an appointment, as well as the person providing the care.
• Be advised if a provider proposes to engage in experimentation affecting care or treatment. Members have the right to refuse to participate in such research projects.
• Be informed of continuing health care requirements following discharge from inpatient or outpatient facilities.
• Examine and receive an explanation of any bills for non-covered services, regardless of payment source.
• Make complaints and appeals without discrimination and expect problems to be fairly examined and appropriately addressed.
• Responsiveness to reasonable requests made for services.

CHRISTUS Health Plan Generations members have the responsibility to:

• Give your PCP or other health care providers the information needed in order to provide proper care.
• Do their part to improve health conditions by following treatment plans, instructions and care agreed to with providers.
• Behave in a manner that supports the care provided to other patients and the general functioning of the facility.
• Accept the financial responsibility associated with services received while under the care of a physician or while a patient in a facility.
• Review information regarding covered services, policies and procedures as stated in the Member Agreement and Disclosure Information.
• Ask questions of personal care physician or health plan staff

As a member of the US Family Health Plan, you have the right to:

• Receive information about the organization, its services, its practitioners and providers and member rights and responsibilities.
• Be treated with respect and recognition of dignity and the right to privacy.
• Participate with providers in making decisions about your health care.
• A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
• Voice complaints or appeals about the organization or the care it provides.
• Change your PCP once every 30 days.
• Attend all member meetings and to make recommendations regarding the organization’s member rights and responsibilities policy.
• Use all additional programs offered by the plan.
• Submit a letter if a problem concerning your health care was not solved where it occurred.
• Talk with a patient advocate or member services representative.
• Call and speak with a nurse 24 hours a day by calling 1-800-455-WELL(1-800-455-9355).
• Have one complete eye exam and one annual physical each year.
• Get current information about the providers and hospitals that participate in the plan.
• Have the information you need to make appointments and get health care from your PCP during and after office hours.
• Have the information you need to contact your PCP or on-call support 24 hours a day, every day.

As a member of the US Family Health Plan, you have a responsibility to:

• Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.
• Follow plans and instructions for care that you have agreed to with you providers.
• Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
• Pay your enrollment fees on time.
• Pay copayments required by the Plan.
• Not use Medicare Part A or B and Medicaid for services covered by the Plan.
• Keep your military ID updated.
• Keep your Defense Enrollment Eligibility Reporting System (DEERS) record information and status correct and current.
• Notify member services at 800-67-USFHP (800-678-7347) if there is a change in address and/or phone number or in eligibility for you or a family member.
• Disenroll from the Plan if you move outside of the service area.
• Provide the Plan with information if you are a member of other health insurance plans.
• Bring your member card with you when visiting your provider, pharmacy or you are seeking medical treatment.
• Give the correct spelling of your first and last name, date of birth and sponsor’s Social Security number to the provider any time a claim is filed.
• Provide a complete medical history to your provider, including a list of all your prescription and over-the-counter medicines.
• Use your Plan PCP, Plan network specialist, Plan network hospital/facility and the network pharmacy for routine care.
• Not use a military hospital or clinic, TRICARE or NMOP (National Mail-Order Pharmacy) for routine care.
• Notify your PCP, if possible, before seeking emergency medical treatment or seeking care outside of the service area (except when outside of the United States).
• Notify the Plan at 800-67-USFHP (800-678-7347) as soon as possible within the first 24 hours of an emergency medical treatment or an accident requiring medical attention (motor vehicle accident, workers’ compensation, etc.).
• Transfer your medical record(s) when necessary.