Member Rights and Responsibilities

At Blue Cross and Blue Shield of Texas, we want to make sure our members get the health care they need. We also want to make sure our members’ rights are respected.

Member Rights

1. You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:
   a. Be treated fairly and with respect.
   b. Know that your medical records and discussions with your providers will be kept private and confidential.
2. You have the right to a reasonable opportunity to choose a health care plan and primary care provider. This is the doctor or health care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to:
   a. Be told how to choose and change your health plan and your primary care provider.
   b. Choose any health plan you want that is available in your area and choose your primary care provider from that plan.
   c. Change your primary care provider.
   d. Change your health plan without penalty.
   e. Be told how to change your health plan or your primary care provider.
3. You have the right to ask questions and get answers about anything you do not understand. That includes the right to:
   a. Have your provider explain your health care needs to you and talk to you about the different ways your health care problems can be treated.
   b. Be told why care or services were denied and not given.
   c. Be given information about your health, plan, services and providers.
   d. Be told about your rights and responsibilities.
4. You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to:
   a. Work as part of a team with your provider in deciding what health care is best for you.
   b. Say yes or no to the care recommended by your provider.
5. If your MCO offers In-Lieu-Of Services and Settings, you have the right to:
   a. Be given information about the In-Lieu-Of Services and Settings you can get and how to request them.
   b. Be told why any In-Lieu-Of Services and Settings were reduced or denied.
   c. Choose to refuse to receive In-Lieu-Of Services and Settings instead of other Covered Services.
6. You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid and get a timely response to complaints, appeals and fair hearings. That includes the right to:
   a. Make a complaint to your health plan or to the state Medicaid program about your health care, your provider or your health plan.
   b. Get a timely answer to your complaint.
   c. Use the plan’s appeal process and be told how to use it.
   d. Ask for an External Medical Review and State Fair Hearing from the state Medicaid program and get information about how that process works.
   e. Ask for a State Fair Hearing without an External Medical Review from the state Medicaid program and receive information about how that process works.
7. You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to:
   a. Have telephone access to a medical professional 24 hours a day, seven days a week to get any emergency or urgent care you need.
   b. Get medical care in a timely manner.
   c. Be able to get in and out of a health care provider’s office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act.
   d. Have interpreters, if needed, during appointments with your providers and when talking to your health plan. Interpreters include people who can speak in your native language, help someone with a disability or help you understand the information.
   e. Be given information you can understand about your health plan rules, including the health care services you can get and how to get them.
8. You have the right to not be restrained or secluded when it is for someone else’s convenience or is meant to force you to do something you do not want to do or is to punish you.
9. You have a right to know that doctors, hospitals and others who care for you can advise you about your health status, medical care and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.
10. You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals and others cannot require you to pay copayments or any other amounts for covered services.
11. You have the right to make recommendations regarding the health plan's member rights and responsibilities policy.
12. A right to receive information about the organization, its services, its practitioners and providers and member rights and responsibilities.
13. A right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
14. You have a right to be treated with respect and recognition of your dignity and your right to privacy.
15. You have a right to participate with practitioners in making decisions about your health care.
16. You have a right to voice complaints or appeals about the organization or the care it provides.
17. You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.

Member Responsibilities

1. You must learn and understand each right you have under the Medicaid program. That includes the responsibility to:
   a. Learn and understand your rights under the Medicaid program.
   b. Ask questions if you do not understand your rights.
   c. Learn what choices of health plans are available in your area.
2. You must abide by the health plan’s and Medicaid’s policies and procedures. That includes the responsibility to:
   a. Learn and follow your health plan’s rules and Medicaid rules.
   b. Choose your health plan and a primary care provider quickly.
   c. Make any changes in your health plan and primary care provider in the ways established by Medicaid and by the health plan.
   d. Keep your scheduled appointments.
   e. Cancel appointments in advance when you cannot keep them.
   f. Always contact your primary care provider first for your non-emergency medical needs.
   g. Be sure you have approval from your primary care provider before going to a specialist.
   * This means to make sure your PCP is aware of the specialty care your child is receiving. No referral is required. h. Understand when you should and should not go to the emergency room.
3. You must share information about your health with your primary care provider and learn about service and treatment options. That includes the responsibility to:
   a. Tell your primary care provider about your health.
   b. Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated.
   c. Help your providers get your medical records.
4. You must be involved in decisions relating to service and treatment options, make personal choices and take action to keep yourself healthy. That includes the responsibility to:
   a. Work as a team with your provider in deciding what health care is best for you.
   b. Understand how the things you do can affect your health.
   c. Do the best you can to stay healthy.
   d. Treat providers and staff with respect.
   e. Talk to your provider about all of your medications.
5. A responsibility to supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.
6. A responsibility to follow plans and instructions for care that they have agreed to with their providers.
7. A responsibility to understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.

Additional Responsibilities While Using Non-Emergency Medical Transportation (NEMT) Services

1. When requesting NEMT Services, you must provide the information requested by the person arranging or verifying your transportation.
2. You must follow all rules and regulations affecting your NEMT services.
3. You must return unused advanced funds. You must provide proof that you kept your medical appointment prior to receiving future advanced funds.
4. You must not verbally, sexually or physically abuse or harass anyone while requesting or receiving NEMT services.
5. You must not lose bus tickets or tokens and must return any bus tickets or tokens that you do not use. You must use the bus tickets or tokens only to go to your medical appointment.
6. You must only use NEMT services to travel to and from your medical appointments.
7. If you have arranged for an NEMT Service but something changes and you no longer need the service, you must contact the person who helped you arrange your transportation as soon as possible.

If you think your child has been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can find information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

To learn more about your right to appeal, check Your Rights for Appeal of an Adverse Determination. To file an appeal, you can use the Appeal Request Form.