Members Rights and Responsibilities

The Member Bill of Rights and Responsibilities assures that all members are treated in a manner consistent with the Plan’s mission, goals and objectives and assures that members are aware of their obligations and responsibilities upon joining the Plan and throughout their membership with the Plan.

Member Notice:

As a member of the Plan, you are entitled to all covered benefits; however, you must learn how the Plan works, follow the proper procedures, and use the proper network – doctors, hospitals, mental health providers and other health care specialists – participating with the Plan.

Member Rights:

Be treated in a manner reflecting respect for your privacy and dignity as a person.
Be informed regarding your diagnosis, treatment and prognosis in terms you can
reasonably be expected to understand.
Receive sufficient information to enable you to give informed consent prior to the initiation of any procedure and/or treatment.
Participate with practitioners in decision-making about your health care and refuse treatment to the extent permitted by law, and be made aware of the potential medical consequences of such action.
A candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
Expect that all communications and records pertaining to your health care will be treated as confidential. Any data shared with employers is not implicitly or explicitly member identifiable unless specific consent has been obtained. No records will be released without your written authorization to protect access to your medical information. In the case of a minor, release of information is allowed only by authorization of a legal guardian or court order.
Select a Primary Care Physician (PCP) and expect the physician to provide, arrange for, and coordinate, all the care you require.
Express complaints or appeals to the Plan about the managed care organization or care provided, and expect a response to that complaint or appeal within a reasonable period of time.
Reasonable access to necessary medical services.
Be informed of the Plan’s policies and procedures regarding services, benefits, practitioners and providers, and member rights and responsibilities, and be notified of any significant changes in those policies and procedures.
Discuss your medical record with your physician and receive, upon request, a summary of that record (at a nominal charge) as required under State law. The Plan’s staff can only release records with your physician’s approval and signed consent.
Obtain from the Plan a certificate of creditable coverage which shows prior, continuous coverage. With the certificate, you may be able to receive coverage under your next health plan with either no waiting period for pre-existing conditions or a reduced waiting period.
Make recommendations regarding member rights and responsibilities.

Member Responsibilities

You also have responsibilities to:

Work with your Primary Care Physician (PCP) to help establish the proper patient/physician relationship.
Schedule appointments and arrive on time for those appointments or notify the primary care physician’s office if you must cancel or come late for a scheduled appointment. Charges for missed appointments are not covered by the Plan.
Meet the financial obligations regarding member premiums and copays when services are rendered.
Ask any questions and understand the answers about your illness and/or treatment.
Obtain prior authorization from your Primary Care Physician (PCP) before seeking consultation or other medical services, except in potentially life-threatening situations.
Get and carefully consider all information necessary to give informed consent for a procedure or treatment.
Weigh the potential consequences of any refusal to comply with physician instructions or recommendations.
Follow the plans and instructions for care that you have agreed on with your
practitioners.
Be courteous, considerate and cooperative in dealing with your Primary Care physician (PCP), his/her office staff, and employees of the Plan, and to respect the rights of fellow Plan members.
Express opinions, concerns or complaints in a constructive manner to avoid similar problems in the future.
Read and be aware of all material distributed by the Plan explaining policies and procedures regarding services and benefits, and to follow those policies and procedures when receiving care.
Provide the Plan and providers with complete and accurate information necessary to care for you, for your medical record and for Plan membership records. This includes notifying the Plan of any changes in status such as phone number, address, and number of dependents (i.e., birth, marriage, divorce, etc.), and information regarding other health insurance coverage for coordination of benefits purposes.
Assist the Plan in compiling a complete medical record by providing, or by authorizing the Plan to obtain, necessary medical information. Ultimately, it is your responsibility to furnish the Plan with any medical records needed to process a complaint, grievance or appeal of a denied claim when the Plan has been unable to obtain this information.

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Optima Family Care Member Rights and Responsibilities

What Are My Rights?

As a member of Optima Family Care, you are entitled to all the benefits outlined in your Evidence of Coverage. With your plan, you have the right to:

Be treated in a manner reflecting respect for your privacy and dignity as a person. While receiving health care services there will be no discrimination based on race, ethnicity, national origin, religion, sex, age and mental or physical disability.
Be informed regarding your diagnosis, treatment and prognosis in terms you can reasonably be expected to understand.
Receive enough information to enable you to give informed consent prior to the beginning of any procedure and/or treatment.
Participate with practitioners in decision-making about your health care and refuse treatment to the extent permitted by law, and be made aware of the potential medical consequences of such action.
A candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
Expect that all communications and records about your health care will be treated as confidential. Any data shared is not member specific. No records will be released without your written authorization. In the case of a minor, release of information is allowed only by the authorization of the legal guardian.
Express complaints or appeals to the Plan about Family Care or care provided and expect a response. The Plan will respond to all complaints within 30 days. To file an appeal for denied services, see Section 9 (Complaints and Appeals Procedure) of the Evidence of Coverage for details.
Reasonable access to necessary medical services.
Be informed of the Plan’s policies and procedures regarding services, benefits, practitioners and providers, and your rights and responsibilities, and be notified of any significant changes in those policies and procedures. Upon request, receive a copy of the Plan’s Practice Guidelines.
Discuss your medical record with your doctor and receive, upon request, a copy of that record as required under State law and request that the record be amended or corrected. The Plan’s staff can only release records with your doctor’s approval and your signed consent.
Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
Obtain from the Plan information on how providers are paid.
The MCO and its employees are prohibited from providing incentives for denials, limiting or discontinuing medical services.
Make recommendations regarding member rights and responsibilities.
Freedom to exercise your member rights and expect that you will not be negatively affected by the Plan and its providers by exercising those rights.

What Are My Responsibilities?

As a member of Optima Family Care, you also have responsibilities to:

Work with your doctor to help establish the proper patient/doctor relationship.
Schedule appointments and arrive on time for those appointments or notify the doctor’s office if you must cancel or come late for a scheduled appointment.
Ask any questions and understand the answers about your illness and treatment.
Get and carefully consider all information necessary to give informed consent for a procedure or treatment.
Follow the plans and instructions for care that you have agreed on with your doctors.
Weigh the possible consequences of your refusal to follow doctor’s instructions or recommendations.
Be courteous, considerate and cooperative in dealing with your doctor, his/her office staff, and employees of Family Care, and to respect the rights of fellow plan members.
Express opinions, concerns or complaints in a constructive manner to avoid similar problems in the future.
Read and be aware of all material distributed by the Plan explaining policies and procedures regarding services and benefits, and follow those policies and procedures when receiving care.
Provide Family Care and your doctor with complete and accurate information. This includes notifying the Plan of any changes in status such as phone number, address and number of dependents (example: birth, marriage, divorce, etc), and information regarding other health insurance coverage you may have. You must also contact your Medicaid/FAMIS Plus caseworker at your local Department of Social Services with this information.
Help the Plan to gather your complete medical record by providing, or by authorizing your Plan to obtain necessary medical information. Ultimately, it is your responsibility to furnish your Plan with any medical records needed to process a complaint, grievance or appeal of a denied claim if your Plan has been unable to obtain this information.
Obtain prior authorization from your PCP before seeking consultation or other medical services except in potentially life-threatening situations.

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Optima Medicare (PPO) Member Rights and Responsibilities

Your right to be treated with dignity, respect and fairness

You have the right to be treated with dignity, respect, and fairness at all times. Our Plan must obey laws that protect you from discrimination or unfair treatment. We don’t discriminate based on a person’s race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age, or national origin. If you need help with communication, such as help from a language interpreter, please call Member Services. Member Services can also help if you need to file a complaint about access (such as wheel chair access). You may also call the Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800-537-7697, or your local Office for Civil Rights.

Your right to the privacy of your medical records and personal health information

There are federal and state laws that protect the privacy of your medical records and personal health information. We protect your personal health information under these laws. Any personal information that you give us when you enroll in this plan is protected. We will make sure that unauthorized people don’t see or change your records. Generally, we must get written permission from you (or from someone you have given legal power to make decisions for you) before we can give your health information to anyone who isn’t providing your care or paying for your care. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care.

The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We are required to provide you with a notice that tells about these rights and explains how we protect the privacy of your health information. You have the right to look at medical records held at Optima, and to get a copy of your records (there may be a fee charged for making copies). You also have the right to ask us to make additions or corrections to your medical records (if you ask us to do this, we will review your request and figure out whether the changes are appropriate). You have the right to know how your health information has been given out and used for non-routine purposes. If you have questions or concerns about privacy of your personal information and medical records, please call Member Services.

Your right to see network providers, get covered services within a reasonable period of time

You can get your care from network doctors and other health providers who are part of our Plan. You can also get care from non-network doctors and other health providers who are not part of the Optima Medicare network. You have the right to choose a network provider (we will tell you which doctors are accepting new patients). You have the right to go to a women’s health specialist (such as a gynecologist) without a referral and still pay in-plan cost-sharing. You have the right to timely access to your providers and to see specialists when care from a specialist is needed. “Timely access” means that you can get appointments and services within a reasonable amount of time.

Your right to know your treatment options and participate in decisions about your health care

You have the right to get full information from your providers when you go for medical care, and the right to participate fully in decisions about your health care. Your providers must explain things in a way that you can understand. Your rights include knowing about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by Optima. This includes the right to know about the different Medication Therapy Management Programs we offer and in which you may participate. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment, and be given the choice of refusing experimental treatments.

You have the right to receive a detailed explanation from us if you believe that a provider has denied care that you believe you were entitled to receive or care you believe you should continue to receive. In these cases, you must request an initial decision called an organization determination.

You have the right to refuse treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. This includes the right to stop taking your medication. If you refuse treatment, you accept responsibility for what happens as a result of your refusing treatment.

Your right to use advance directives (such as a living will or a power of attorney)

You have the right to ask someone such as a family member or friend to help you with decisions about your health care. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. If you want to, you can use a special form to give someone the legal authority to make decisions for you if you ever become unable to make decisions for yourself. You also have the right to give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives.

If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare.. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it. It is important to sign this form and keep a copy at home. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well.

If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you. If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. If you have signed an advance directive, and you believe that a doctor or hospital hasn’t followed the instructions in it, you may file a complaint with the Virginia Insurance Counseling and Assistance Program (VICAP).

Your right to get information about our Plan

You have the right to get information about Optima Medicare. This includes information about our financial condition, and how our Plan compares to other health plans. To get any of this information, call Member Services.

Your right to get information in other formats

You have the right to get your questions answered. Our plan must have individuals and translation services available to answer questions from non-English speaking beneficiaries, and must provide information about our benefits that is accessible and appropriate for persons eligible for Medicare because of disability. If you have difficulty obtaining information from your plan based on language or a disability, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Your right to get information about our network providers

You have the right to get information about our network providers and their qualifications and how we pay our doctors. To get this information, call Member Services.

Your right to get information about your prescription drugs, Part C medical care or services, and costs

You have the right to an explanation from us about any prescription drugs or Part C medical care or service not covered by our Plan. We must tell you in writing why we will not pay for or approve a prescription drug or Part C medical care or service, and how you can file an appeal to ask us to change this decision. You also have the right to this explanation even if you obtain the prescription drug, or Part C medical care or service from a pharmacy and/or provider not affiliated with our organization. You also have the right to receive an explanation from us about any utilization-management requirements, such as step therapy or prior authorization, which may apply to your plan.

Your right to make complaints

You have the right to make a complaint if you have concerns or problems related to your coverage or care. If you make a complaint, we must treat you fairly (i.e., not retaliate against you) because you made a complaint. You have the right to get a summary of information about the appeals and grievances that members have filed against our Plan in the past. To get this information, call Member Services.

How to get more information about your rights

If you have questions or concerns about your rights and protections, you can

Call Member Services at 1-866-783-5191. TTY users should call 1-800-225-7784
Get free help and information from your State Health Insurance Assistance Program (SHIP). Visit www.medicare.gov to view or download the publication “Your Medicare Rights & Protections.”
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

What can you do if you think you have been treated unfairly or your rights are not being respected?

If you think you have been treated unfairly or your rights have not been respected, you may call Member Services or:

If you think you have been treated unfairly due to your race, color, national origin, disability, age, or religion, you can call the Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800-537-7697, or call your local Office for Civil Rights.
If you have any other kind of concern or problem related to your Medicare rights and protections described in this section, you can also get help from your SHIP.

Your responsibilities as a member of Optima Medicare include:

Getting familiar with your coverage and the rules you must follow to get care as a member. Call Member Services if you have questions.
Using all of your insurance coverage. If you have additional health insurance coverage besides our Plan, it is important that you use your other coverage in combination with your coverage as a member of our Plan to pay your health care expenses. This is called “coordination of benefits” because it involves coordinating all of the health benefits that are available to you.
You are required to tell Optima if you have additional health insurance. Call Member Services.
Notifying providers when seeking care (unless it is an emergency) that you are enrolled in our Plan and you must present your plan membership card to the provider.
Giving your doctor and other providers the information they need to care for you, and following the treatment plans and instructions that you and your doctors agree upon. Be sure to ask your doctors and other providers if you have any questions and have them explain your treatment in a way you can understand.
Acting in a way that supports the care given to other patients and helps the smooth running of your doctor’s office, hospitals, and other offices.
Paying your plan premiums and coinsurance or co-payment for your covered services. You must pay for services that aren’t covered.
Notifying us if you move. If you move within our service area, we need to keep your membership record up-to-date. If you move outside of our plan service area, you cannot remain a member of our plan, but we can let you know if we have a plan in that area.
Letting us know if you have any questions, concerns, problems, or suggestions. If you do, please call Member Services.

Ending your Membership

Ending your membership in our Plan may be voluntary (your own choice) or involuntary (not your own choice):

You might leave our Plan because you have decided that you want to leave.
There are also limited situations where we are required to end your membership. For example, if you move permanently out of our geographic service area.

Voluntarily ending your membership

There are only certain times during the year when you may voluntarily end your membership in our Plan. The key time to make changes is the Medicare fall open enrollment period (also known as the “Annual Election Period”), which occurs every year from November 15 through December 31. This is the time to review your health care and drug coverage for the following year and make changes to your Medicare health or prescription drug coverage. Any changes you make during this time will be effective January 1. Certain individuals, such as those with Medicaid, those who get extra help, or who move, can make changes at other times. For more information on when you can make changes see the enrollment period table later in this section.

If you want to end your membership in our plan during this time, this is what you need to do:

If you are planning on enrolling in a new Medicare Advantage plan: Simply join the new plan. You will be disenrolled from our plan when your new plan’s coverage begins on January 1.
If you are planning on switching to the Original Medicare Plan and joining a Medicare Prescription drug plan: Simply join the new Medicare Prescription drug plan. You will be disenrolled automatically from our plan when your new coverage begins on January 1.
If you are planning on switching to the Original Medicare Plan without a Medicare Prescription drug plan: Contact Member Services for information on how to request disenrollment. You may also call 1-800-MEDICARE (1-800-633-4227) to request disenrollment from our plan. TTY users should call 1-877-486-2048. Your enrollment in Original Medicare will be effective January 1.

For more information about the options available to you during these enrollment periods, contact Medicare at 1-800-MEDICARE (1-800-633-4227.) TTY users should call 1-877-486-2048. Additional information can also be found in the “Medicare & You” handbook. This handbook is mailed to everyone with Medicare each fall. You may view or download a copy from www.medicare.gov - under “Search Tools,” select “Find a Medicare Publication.”

Until your membership ends, you must keep getting your Medicare services and/or prescription drug coverage through our Plan

If you leave our Plan, it may take some time for your membership to end and your new way of getting Medicare to take effect (we discuss when the change takes effect earlier in this section). While you are waiting for your membership to end, you are still a member and must continue to get your care and prescription drugs as usual through our Plan. If you happen to be hospitalized on the day your membership ends, generally you will be covered by our Plan until you are discharged. Call Member Services for more information and to help us coordinate with your new plan.

Until your prescription drug coverage with our Plan ends, use our network pharmacies to fill your prescriptions. While you are waiting for your membership to end, you are still a member and must continue to get your prescription drugs as usual through our Plan’s network pharmacies. In most cases, your prescriptions are covered only if they are filled at a network pharmacy including our mail-order-pharmacy service, are listed on our formulary, and you follow other coverage rules.

We cannot ask you to leave the Plan because of your health

We cannot ask you to leave your health plan for any health-related reasons. If you ever feel that you are being encouraged or asked to leave our Plan because of your health, you should call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY users should call 1-877-486-2048. You may call 24 hours a day, 7 days a week.

Involuntarily ending your membership

If any of the following situations occur, we will end your membership in our Plan.

If you do not stay continuously enrolled in Medicare A and B
If you move out of the service area or are away from the service area for more than 6 months, you cannot remain a member of our Plan. And we must end your membership (“disenroll” you)”. If you plan to move or take a long trip, please call Member Services to find out if the place you are moving to or traveling to is in our Plan’s service area.
If you knowingly falsify or withhold information about other parties that provide reimbursement for your prescription drug coverage.
If you intentionally give us incorrect information on your enrollment request that would affect your eligibility to enroll in our Plan.
If you behave in a way that is disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you or for others who are members of our Plan. We cannot make you leave our Plan for this reason unless we get permission first from Medicare.
If you let someone else use your plan membership card to get medical care. If you are disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation.
If you do not pay the Plan premiums, we will tell you in writing that you have a 90- day grace period during which you may pay the Plan premiums before your membership ends.

You have the right to make a complaint if we end your membership in our Plan

If we end your membership in our Plan we will tell you our reasons in writing and explain how you may file a complaint against us if you want to.

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Members Rights and Responsibilities

Policy Statement

Optima Family Care Member Rights and Responsibilities

Optima Medicare (PPO) Member Rights and Responsibilities