As a member of KelseyCare Advantage, you have certain rights and responsibilities. These are discussed in the information below.Your rights as a member of the plan:
We must provide information in a way that works for you.
We must treat you with fairness and respect at all times.
We must ensure that you get timely access to your covered services and drugs.
We must protect the privacy of your personal health information.
We must give you information about the plan, its network of providers, and your covered services.
We must support your right to make decision about your care.
You have the right to make complaints and to ask us to reconsider decisions we have made.
What you do if you think you are being treated unfairly or your rights are not being respected.
How to get more information about your rights.
We must provide information in a way that works for you.
To get information from us in a way that works for you, please call Member Services..
Our plan has people and free language interpreter services available to answer questions from non-English speaking members. We can also give you information in Braille, in large print, or other alternate formats if you need it. If you are eligible for Medicare because of disability, we are required to give you information about the plan's benefits that are accessible and appropriate for you.
If 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 call 1-877-486-2048.
Our plan must obey laws that protect you from discrimination or unfair treatment. 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 at 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, please call Member Services. If you have a complaint, such as a problem with wheelchair access, Member Services can help.
As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan's network to provide and arrange for your covered services. Call Member Services to learn which doctors are accepting new patients. You also have the right to go to a women's health specialist (such as a gynecologist) without a referral.
As a plan member, you have the right to get appointments and covered services from the plan's network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.
If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter 9, Section 10 of your Evidence of Coverage tells what you can do. (If we have denied coverage for your medical care or drugs and you don't agree with our decision, Chapter 9, Section 4 of the Evidence of Coverage tells what you can do.)
You can see the information in your records and know how it has been shared with others.
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 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 work with your healthcare provider to decide whether the changes should be made.
You have the right to know how your health information has been shared with others for any purposes that are not routine.
If you have questions or concerns about the privacy of your personal health information, please call Member Services.
As a member of KelseyCare Advantage, you have the right to get several kinds of information from us. If you want any of the following kinds of information, please call Member Services at please call Member Services at 713-442-CARE (2273) or 1-866-535-8343, 8 a.m. to 8 p.m., seven days a week. TTY/TDD users should call 1-866-302-9336.
We must support your right to make decisions about your care.
You have the right to know your treatment options and participate in decisions about your healthcare.
You have the right to get full information from your doctors and other healthcare providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand.
You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself.
Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:
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 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.
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 a 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.
What if your instructions are not followed?
If you 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 TMF Health Quality Institute or the State of Texas QIO.
If you have any problems or concerns about your covered services or care, Chapter 9 of the Evidence of Coverage tells what you can do. It gives the details about how to deal with all types of problems and complaints.
As explained in Chapter 9 of the Evidence of Coverage, what you need to do to follow up on a problem or concern depends on the situation. 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. To get this information, please call Member Services.
What can you do if you think you are being treated unfairly or your rights are not being respected?
If it is about discrimination, call the Office for Civil Rights.
If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you believe you have been treated unfairly or your rights have not been respected, and it's not about discrimination, you can get help dealing with the problem you are having:
There are several places where you can get more information about your rights:
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What are your responsibilities?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.
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