PPO II - EmblemHealth

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2013 Evidence of Coverage for <strong>PPO</strong> <strong>II</strong> Chapter 8: Your Rights and Responsibilities • To know about the risks. 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. You always have the choice to refuse any experimental treatments. • Th e right to say “no.” You have the right to refuse any recommended treatment. Th is includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result. • To receive an explanation if you are denied coverage for care. You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. Chapter 9 of this booklet tells how to ask the plan for a coverage decision. 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. Th is means that, if you want to, you can: • 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. Th e legal documents that you can use to give your directions in advance in these situations are called “advance directives.” Th ere are diff erent types of advance directives and diff erent names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives. If you want to use an “advance directive” to give your instructions, here is what to do: • Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some offi ce supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also contact Customer Service to ask for the forms (phone numbers are printed on the back cover of this booklet). • Fill it out and sign it. 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. • Give copies to appropriate people. 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. Be sure to keep a copy at home. 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. 135
136 2011 Evidence of Coverage for HMO Medicare Supplement (Cost) Chapter 8: Your Rights and Responsibilities Remember, it is your choice whether you want to fi ll 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. 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 fi le a complaint with the New York State Department of Health. If you wish to fi le a complaint about a hospital, you should call 1-800-804-5447. If you wish to fi le a complaint about a doctor, you should call 1-800-663-6114. Section 1.7 You have the right to make complaints and to ask us to reconsider decisions we have made If you have any problems or concerns about your covered services or care, Chapter 9 of this booklet 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, 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 fi led against our plan in the past. To get this information, please call Customer Service (phone numbers are printed on the back cover of this booklet). Section 1.8 What can you do if you believe you are being treated unfairly or your rights are not being respected? If it is about discrimination, call the Offi ce 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’ Offi ce for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Offi ce 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: • You can call Customer Service (phone numbers are printed on the back cover of this booklet). • You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3. • 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.
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