Appears in 4 contracts

Samples: Group Subscriber Agreement, Group Subscriber Agreement, Group Subscriber Agreement

Additional Member Rights and Responsibilities. In addition to the rights and responsibilities afforded you by the state, we provide our Members with the following additional rights to: • Receive information about our organization, our services and benefits, how to access ~~Healthcare~~ Health Care Services, our Practitioners and Providers, and your rights and responsibilities; • Have a clear, private and candid discussion about appropriate or Medically Necessary treatment options for your medical condition regardless of cost or benefit Coverage; • Participate with your Practitioner/Provider in making decisions about your ~~healthcare~~health care; • Refuse care, treatment, medication or a specific Practitioner/Provider, after the consequences of your decision have been explained in a language that you understand; • Seek a second opinion for surgery from another In-network Practitioner/Provider when you need additional information regarding recommended treatment or requested care; • Receive ~~Healthcare~~ Health Care Services in a non-discriminatory fashion. This means that you may not be denied Covered Services on the basis of race, color, sex, sexual preference, age, handicap, cultural or educational background, religion or national origin, economic or health status or source of payment for care. If you have a disability you have the right to receive any information in an alternative format in compliance with the Americans with Disabilities Act; • Make recommendations regarding our Members’ rights and responsibilities policies; • Make your wishes known through an Advance Directive regarding ~~healthcare~~ health care decisions, such as living xxxxx or right-to-die directives, consistent with federal and state laws and regulations; • Choose a surrogate decision maker to assist with care decisions. If you are unable to understand your medical care, to have the ~~healthcare~~ health care explanation provided to the next of kin, guardian, agent or surrogate if available, and recorded in your medical record including, where appropriate, a medical release that you signed authorizing release of medical information; You and or your legal guardian/representative have the responsibility to: • Provide, whenever possible, the information that we and your Practitioners/Providers need in order to provide services or care and to oversee the quality of those services or care; • Follow the plans and instructions for care that you have agreed upon with your treating Practitioner/Provider. You may, for personal reasons, refuse to accept treatment recommended by Practitioners/Providers. Practitioners/Providers may regard such refusal as incompatible with continuing the Practitioner/Provider-patient relationship and as obstructing the provision of proper medical care; • Understand your health problems and to participate in developing mutually agreed upon treatment plans and goals; • Review your Group Subscriber Agreement (GSA) and if you have questions, contact our Presbyterian Customer Service ~~Center~~ Center, Monday through ~~Friday~~ Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 01-~~000~~800-~~000-0000~~356- 2219. Hearing impaired users may call TTY 711. You may visit our website at xxx.xxx.xxx for clarification of Benefits, Limitations, and Exclusions outlined in this Subscriber Agreement. Translation/Interpretation services to understand your benefits are available, please call our Customer Service Center at the phone numbers listed above; • Notify us within 31 days of any changes of name, address, telephone number, marital status, eligible Dependents or newborns; • Immediately notify us or any loss or theft of your ~~PIC~~ PHP Identification Card; • Refuse to allow any other person to use your ~~PIC~~ PHP Identification Card; • Advise a Practitioner/Provider of your Coverage with us at the time of service. You may be required to pay for services if you do not inform your Practitioner/Provider of our Coverage; • Pay all required, pre-determined Cost Sharing (Deductible, ~~Coinsurance,~~ Coinsurance and/or Copayments) at the time services are rendered when amounts due are made clear at that time; • Pay for all services obtained prior to the effective date of this Agreement and subsequent to its termination or ~~cancellation;~~ cancellation • Insure that all information you give to us in Applications for enrollment, questionnaires, forms or correspondence is true and complete; • Be informed of the potential consequences of providing us with incorrect or incomplete information as described in this Agreement; • Obtain Prior Authorization as described in the Prior Authorization Section; • Pay any charges over Medicare Allowable. We have established a Consumer Advisory Board and we want your participation. This Board meets quarterly and provides Members’ perspectives, as ~~healthcare~~ health care consumers, on the products and services that we offer. In addition, we share information with the Consumer Advisory Board on how well the health plan is performing. The information we receive is very valuable and helps us improve the health of individuals, families and communities. If you are interested in serving on our Consumer Advisory Board, please call our Presbyterian Customer Service Center, Monday through ~~Friday~~ Friday, 7 a.m. to 6 p.m., at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. You may also visit our website at xxx.xxx.xxx. This plan is an “HMO” (Health Maintenance Organization). People who receive Health Care Benefits through an HMO are sometimes called “Enrollees” or “Subscribers. We strive to work closely with Subscribers, their Covered Dependents, and their health care Practitioners/Providers to prevent illness and provide quality, cost-effective health care. Because of this close working relationship, we consider our Enrollees and Subscribers to be Members of our health plan. This plan is a fully qualified High Deductible Health Plan (HDHP) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PHP. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Preventive benefits, as defined by the Affordable Care Act (ACA) are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical benefits available to you. HSAs are not administered by PHP and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxxx://xxxx.xxxxxxxx.xxx/. PHP accepts premium and cost-sharing payments from the following third-party entities from plan enrollees (in the case of a downstream entity, to the extent the entity routinely collects premiums or cost-sharing): a Xxxx Xxxxx HIV/AIDS Program under title XXVI of the Public Health Service Act, an Indian tribe, tribal organization, or urban Indian organization, and a local, State, of Federal government program, including a grantee directed by a government program to make payments on its behalf. We require that: • You must physically live or work (commuting daily) in the State of New Mexico (our Service Area) unless you are a Dependent and meet all of the terms and conditions for such Coverage as outlined in the Eligibility, Enrollment and Effective Dates, Termination and Continuation of Coverage Section. • All of your Health Care Services are provided by provided by In-Network Contract Practitioner/Providers in our Service Area, except for Urgent and Emergency Health Care Services situations. Please refer to the Benefits Section Accidental Injury / Urgent Care • You select a Primary Care Physician (PCP) from the Provider Directory to coordinate all of your care. • You pay your pre-determined Cost Sharing (Deductible, Coinsurance and/or Copayments) at the time you receive Covered Services. We will reimburse the Practitioner/Provider the balance for Covered Services based upon Total Allowable Charges (some services may not require a Cost Sharing Deductible, Coinsurance and/or Copayment). Refer to your Summary of Benefits and Coverage to find Covered Services subject to Cost Sharing amounts. • Under the Market Stabilization rule finalized on April 13, 2017, to the extent permitted by State law, Presbyterian Health Plan may attribute to any past-due premium amounts owed to it the initial premium payment made in accordance with the terms of the health insurance policy to effectuate coverage, for coverage in the 12-month period preceding the effective date. This is done in an effort to prohibit abuse of the grace period. Be aware that failure to pay premiums in a preceding 12-month period may result in the group or individual’s inability to effectuate new coverage until past-due premium payments and initial premium payments are satisfied. To receive care under our plan, you must select an In-network Primary Care Physician to manage your health care needs. Your Primary Care Physician will be able to meet most of these needs. A list of Practitioners/Providers who serve as In-network Primary Care Physicians may be found in the Provider Directory. Primary Care Physicians include, but are not limited to, General Practitioners, Family Practice Physicians, Internists, Pediatricians, and Obstetricians/Gynecologists (if applicable). As a Member of the health plan, you may choose as your Primary Care Physician any doctor or Nurse Practitioner on that list. If you do not designate a Primary Care Physician on your enrollment form, we will suggest one for you. You will find our Primary Care Physicians close to where you live and work across the State. The Provider Directory is available on our website at xxxxx://xxx.xxx.xxx/Pages/find-a-doctor.aspx. If you need additional information about a provider, you may call our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 1-800- 356-2219. Hearing impaired users may call TTY 711. The Provider Directory is subject to change and you should always verify the Practitioner/Provider’s network status by visiting our website at xxxxx://xxx.xxx.xxx/Pages/find-a-doctor.aspx. Updates are made to the provider directory on To receive care under this plan, you and all Covered Members of your family must select an In- network Primary Care Physician (PCP) to manage your health care needs. Primary Care Physicians include, but are not limited to, General Practitioners, Family Practice Physicians, Internists, Pediatricians and Obstetricians/Gynecologists (if applicable).

Appears in 2 contracts

Samples: Group Subscriber Agreement, Group Subscriber Agreement

Additional Member Rights and Responsibilities. In addition to the rights and responsibilities afforded you by the state, we provide our Members with the following additional rights to: • Receive information about our organization, our services and benefits, how to access ~~Healthcare~~ Health Care Services, our Practitioners and Providers, and your rights and responsibilities; • Have a clear, private and candid discussion about appropriate or Medically Necessary treatment options for your medical condition regardless of cost or benefit Coverage; • Participate with your Practitioner/Provider in making decisions about your healthcare; • Refuse care, treatment, medication or a specific Practitioner/Provider, after the consequences of your decision have been explained in a language that you understand; • Seek a second opinion for surgery from another In-network Practitioner/Provider when you need additional information regarding recommended treatment or requested care; • Receive ~~Healthcare~~ Health Care Services in a non-discriminatory fashion. This means that you may not be denied Covered Services on the basis of race, color, sex, sexual preference, age, handicap, cultural or educational background, religion or national origin, economic or health status or source of payment for care. If you have a disability you have the right to receive any information in an alternative format in compliance with the Americans with Disabilities Act; • Make recommendations regarding our Members’ rights and responsibilities policies; • Make your wishes known through an Advance Directive regarding healthcare decisions, such as living xxxxx or right-to-die directives, consistent with federal and state laws and regulations; • Choose a surrogate decision maker to assist with care decisions. If you are unable to understand your medical care, to have the healthcare explanation provided to the next of kin, guardian, agent or surrogate if available, and recorded in your medical record including, where appropriate, a medical release that you signed authorizing release of medical information; You and or your legal guardian/representative have the responsibility to: • Provide, whenever possible, the information that we and your Practitioners/Providers need in order to provide services or care and to oversee the quality of those services or care; • Follow the plans and instructions for care that you have agreed upon with your treating Practitioner/Provider. You may, for personal reasons, refuse to accept treatment recommended by Practitioners/Providers. Practitioners/Providers may regard such refusal as incompatible with continuing the Practitioner/Provider-patient relationship and as obstructing the provision of proper medical care; • Understand your health problems and to participate in developing mutually agreed upon treatment plans and goals; • Review your Group Subscriber Agreement (GSA) and if you have questions, contact our Presbyterian Customer Service Center Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. You may visit our website at xxx.xxx.xxx for clarification of Benefits, Limitations, and Exclusions outlined in this Subscriber Agreement. Translation/Interpretation services to understand your benefits are available, please call our Customer Service Center at the phone numbers listed above; • Notify us within 31 days of any changes of name, address, telephone number, marital status, eligible Dependents or newborns; • Immediately notify us or any loss or theft of your PIC Identification Card; • Refuse to allow any other person to use your PIC Identification Card; • Advise a Practitioner/Provider of your Coverage with us at the time of service. You may be required to pay for services if you do not inform your Practitioner/Provider of our Coverage; • Pay all required, pre-determined Cost Sharing (Deductible, Coinsurance, Copayments) at the time services are rendered when amounts due are made clear at that time; • Pay for all services obtained prior to the effective date of this Agreement and subsequent to its termination or cancellation; • Insure that all information you give to us in Applications for enrollment, questionnaires, forms or correspondence is true and complete; • Be informed of the potential consequences of providing us with incorrect or incomplete information as described in this Agreement; • Obtain Prior Authorization as described in the Prior Authorization Section; • Pay any charges over Medicare Allowable. We have established a Consumer Advisory Board and we want your participation. This Board meets quarterly and provides Members’ perspectives, as healthcare consumers, on the products and services that we offer. In addition, we share information with the Consumer Advisory Board on how well the health plan is performing. The information we receive is very valuable and helps us improve the health of individuals, families and communities. If you are interested in serving on our Consumer Advisory Board, please call our Presbyterian Customer Service Center, Monday through Friday 7 a.m. to 6 p.m., at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. You may also visit our website at xxx.xxx.xxx.. This plan is a Preferred Provider Organization (PPO) Health Care Plan. Each time you need Health Care Services, you can choose your Practitioners and Providers and the level of Covered Benefits that will apply to their charges. You will receive the highest level of Covered Benefits and the lowest cost to you when you obtain services from our In-network Practitioners/Providers. You still have the flexibility provided by the Out-of-network benefits to see any Practitioner/Provider you choose for many of your Health Care Services. This plan is a fully qualified High Deductible Health Plan (HDHP) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PIC. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Preventive benefits, as defined by the Affordable Care Act (ACA) are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical benefits available to you. HSAs are not administered by PIC and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxxx://xxxx.xxxxxxxx.xxx/. Under the Market Stabilization rule finalized on April 13, 2017, to the extent permitted by State law, Presbyterian Insurance Company Inc. may attribute to any past-due premium amounts owed to it the initial premium payment made in accordance with the terms of the health insurance policy to effectuate coverage, for coverage in the 12-month period preceding the effective date. This is done in an effort to prohibit abuse of the grace period. Be aware that failure to pay premiums in a preceding 12-month period may result in the group or individual’s inability to effectuate new coverage until past-due premium payments and initial premium payments are satisfied. PIC accepts premium and cost-sharing payments from the following third-party entities from plan enrollees (in the case of a downstream entity, to the extent the entity routinely collects

Appears in 1 contract

Common use of Additional Member Rights and Responsibilities Clause in Contracts