Member Rights & Responsibilities
A guide to the rights and responsibilities of all Martin's Point health plan members.
All new and existing Martin's Point members receive communications regarding rights and responsibilities in their annual Evidence of Coverage Document.
For questions regarding our member rights and responsibilities, or to request a paper copy, please call Member Services at 1-866-674-8734.
Martin's Point members have the right to:
- Receive information about covered benefits and cost sharing.
- Receive information about Martin’s Point Health Plans, our services, licensure, certification, and accreditation status.
- Receive information about our practitioners, providers, and health care facilities, including information about the composition of our network.
- Receive information in a way that works for you, including in alternate languages and formats.
- Have a choice of health care providers that is sufficient to ensure access to appropriate high-quality health care.
- Have a right to a candid discussion of all medically necessary treatment options, regardless of cost of benefit coverage.
- Receive information on member satisfaction and rights and responsibilities.
- Be informed of the processes for accessing specialists and emergency services.
- Receive considerate and respectful care, with recognition of your personal dignity at all times.
- Have access to all of the health care and treatment services we provide, including care management information, consistent with available resources and generally acceptable standards.
- Have access to emergency health care services when and where the need arises.
- Refuse treatments to the extent permitted by law and government regulations and the right to be informed of the consequences of such refusal of treatment.
- Question the adequacy of care being provided.
- Have privacy and confidentiality concerning your medical care and records to the extent permitted by law. You have the right, and will be afforded the opportunity, to approve or refuse the release of such information, except when release is required by law or the federal government.
- Know the identity and professional status of the health care provider primarily responsible for providing and managing your care, as well as other health care personnel involved in your treatment.
- Participate in decisions involving your health care including mutually agreed-upon goals to the degree possible. Members who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators.
- Understand an explanation of the diagnosis, treatment, and prognosis of your illness.
- Be informed of possible complications, risks, benefits, and alternative treatments associated with consent or refusal for treatment in order to make knowledgeable decisions about your course of care.
- Be advised if the Martin’s Point Health Plan proposes to engage in or perform experimental research in order to make knowledgeable decisions about your care. You have the right to refuse to participate in experimental research.
- Receive care and treatment in a safe environment and to be informed of the facility’s rules and regulations that relate to patient and visitor conduct.
- Be informed of the Martin’s Point Health Plan member grievance and appeals process, designated for the initiation, review, and resolution of patient complaints and appeals. You have the right to file complaints and appeals with Martin’s Point, as outlined in the Grievances (Complaints) and Appeals Processes section in your Member Handbook or Evidence of Coverage.
- Not be charged more than the applicable cost sharing set forth in the Member’s plan documents for health care services that are, in whole or in part, Medicare/TRICARE covered services, which includes not being charged a “membership fee” or “service fee” in order to receive such services.
- Receive health care services free from discrimination consistent with the benefits covered in your policy.
Martin's Point members are responsible for:
- Becoming knowledgeable about your health plan coverage and health plan options, including all covered benefits, limitation, and exclusions; rules regarding use of network providers, coverage, and authorization; appropriate processes to secure additional information; and the process to appeal coverage decisions.
- Providing your PCP and other health care providers with information, to the best of your knowledge, regarding your past medical history and other matters relating to your health.
- Becoming involved in specific health care decisions.
- Complying with the medical and nursing treatment plan, including the follow-up care, agreed upon by you and your health care provider(s). This includes keeping appointments and notifying providers, in a timely manner, when an appointment cannot be kept. You also have the responsibility of letting your provider know whether or not you understand the treatment plan and what is expected of you.
- Meeting financial obligations, including paying applicable copayments at the time services are received and enrollment fees, as required.
- Being considerate of the rights of other patients, and of Martin’s Point Health Care personnel and network providers.
- Being respectful of the property of other persons and facilities.
- Reporting recommendations or questions you have to a Member Services Representative or Health Center Manager.
- Using our internal complaint and appeals processes to address concerns that may arise.
- Following provider facility rules and regulations affecting patient conduct, including no-smoking rules, parking regulations, etc.
- Reporting wrongdoing and fraud to appropriate resources or legal authorities.