Member Rights

How to Appoint a Representative

You, your prescribing doctor or someone you name may ask us for a coverage determination. The person you name would be your appointed representative.

You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other person(s) may already be authorized under State law to act for you. If you want someone to act for you, you and that person must sign and date a statement that gives that person legal permission to act as your appointed representative.

This statement must be sent to us at:

Martin's Point Generations Advantage
ATTN: Member Services
PO Box 9746 Portland, ME 04104-5040 

If you have questions or need to learn how to name your appointed representative, you can call Member Services toll-free at 1-866-544-7504 (TTY: 711). We’re available 8 am–8 pm, seven days a week from October 1 to March 31; and Monday through Friday the rest of the year.

You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

Rights & Responsibilities Upon Disenrollment

Since the Generations Advantage Prime (HMO-POS), Select (LPPO), Value Plus (HMO-POS) and Access (LPPO) plans are Medicare Advantage plans with Part D Prescription Drug coverage, your prescription coverage will end if you disenroll from one of these plans.

If you disenroll, you should consider signing up for a new Medicare Advantage plan with Part D Prescription Drug coverage or a Medicare Prescription Drug plan to ensure that you are covered for prescription drugs and avoid any "late enrollment penalty" that may apply.

Your options include:

• Enrolling in a different Medicare Advantage plan with Part D Prescription Drug coverage

• Using Original Medicare for your medical needs, plus enrolling in a stand-alone Part D Medicare Prescription Drug plan.

• If you do not choose one of these options, or obtain creditable prescription drug coverage elsewhere, you may have a late enrollment penalty if you decide to get Medicare prescription drug coverage at a later date.

A Note about Medigap Rights

If you will be changing to Original Medicare, you might have a special temporary right to buy a Medigap policy, also known as Medicare supplement insurance, even if you have health problems.

For example, if you are age 65 or older and you enrolled in Medicare Part B within the past six months or if you move out of the service area, you may have this special right. Federal law requires the protections described above. Your state may have laws that provide more Medigap protections.

According to the Maine Bureau of Insurance website, if you switch to original Medicare, your ability under Maine law to enroll in a Medicare supplement plan depends on how long you were enrolled in Medicare Advantage. Recent Maine legislation extended the Medicare Advantage "trial period" from one year to three years.

If you have questions about Medigap or any special temporary rights you may have, you should contact your State Health Insurance Assistance Program, Maine SHIP. SHIP services are sponsored in Maine by the Office of Elder Services, Maine's Area Agencies on Aging and Legal Services for the Elderly, Inc.

For help, call your local Area Agency on Aging at 877-353-3771 or Legal Services for the Elderly at 1-800-750-5353. They can provide information about Medigap policies in Maine.

Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week, for more information about trial periods. TTY users should call 1-877-486-2024.

Alliance (HMO) Plan Members: If you disenroll from the Generations Advantage Alliance (HMO) plan, this will not affect any prescription drug coverage you may have.

As a Martin’s Point health plan member, you have the right to:

• Receive information about covered benefits and cost sharing
• Receive information about Martin’s Point Health Plan, 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
• 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 your 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

As a Martin’s Point health plan member, you are responsible for:

• Becoming knowledgeable about your health plan coverage and health plan options, including all covered benefits, limitations and exclusions; rules regarding use of network providers, coverage, and authorization rules; appropriate processes to secure additional information; and the process to appeal coverage decisions
• Providing your PCP and other health care providers 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
• Making a good-faith effort to meet financial obligations, to include paying applicable copayments at the time the 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

Patient Rights and Responsibilities

Complete written policies and procedures regarding Martin’s Point Health Care services, including after-hours and emergency coverage, the patient grievance system, payment policies and fee schedules, treatment of unemancipated minors, and patients’ rights and responsibilities, are available at all Martin’s Point health care centers.

At Martin’s Point, we want to ensure you receive the best possible care and have a great experience every time you come to our office. We want you to leave your doctor’s visits feeling confident and in control of your health care. One way to do this is to understand your rights and responsibilities as described in this brochure. Thank you for trusting Martin’s Point as your health care partner. 

Patient Rights:

As a Martin’s Point Health Care patient, you and your family have the right to:

• Considerate and respectful care, with recognition of your personal dignity.
• Access all of the health care services we provide, consistent with available resources and accepted standards of care.
• Refuse treatment to the extent permitted by law; and to be informed of any alternative treatments and the complications, risks, and/or benefits of alternative treatments or of accepting or refusing a course of treatment.
• Privacy and confidentiality concerning your medical care and records, to the extent permitted by law.
• Authorize or refuse to authorize the release of your health care information, except when release is required by law.
• Know the identity and professional status of the health care provider responsible for managing your care.
• Participate in decisions about your health care.
• An easily understandable explanation of the diagnosis, treatment, and prognosis of your illness.
• Participate or refuse to participate in experimental research and to receive adequate information before making a decision regarding any offered experimental or research-level treatments or procedures.
• Receive care in a safe environment.
• Be informed of the facility’s rules and regulations that relate to patient and visitor conduct.
• Be informed of the patient grievance system and to report grievances, recommendations, or concerns to a Practice Administrator or Manager.

Patient Responsibilities:

As a Martin’s Point Health Care patient, you and your family are responsible for:

• Providing accurate and complete information regarding your medical history so we can provide you with appropriate care.
• Providing accurate and complete information about your health insurance so we can coordinate your care with your health plan.
• Being considerate of the rights of other patients and staff.
• Being respectful of other people’s property.
• Complying with the medical plan, including follow-up care, agreed upon by you and your provider.
• Letting your provider know whether you understand the medical plan and what is expected of you.
• Arriving 10 minutes before your scheduled appointments and informing us at least 24 hours before any appointment you may have to miss.
• Following the facility’s rules and regulations, including no-tobacco rules and parking regulations.