Unit 5: Member Rights & Responsibilities

1.5 Introduction

1.5 Member Rights & Responsibilities - Delaware

1.5 Member Rights & Responsibilities - New York

1.5 Member Rights & Responsibilities - Pennsylvania

1.5 Member Rights & Responsibilities - West Virginia

1.5 Medicare Advantage Member Rights & Responsibilities - Delaware

1.5 Medicare Advantage Member Rights & Responsibilities - New York

1.5 Medicare Advantage Member Rights & Responsibilities - Pennsylvania

1.5 Medicare Advantage Member Rights & Responsibilities - West Virginia

1.5 Member Rights & Responsibilities - Highmark Healthy Kids (CHIP)

1.5 Disclaimers

1.5 Introduction

Highmark will treat members in a manner that respects their rights and will clearly communicate our expectations of member responsibilities to members, practitioners, and Highmark staff to promote effective health care, maintain a mutually respectful relationship with our members, and enhance cooperation among members, practitioners, and Highmark.

Highmark will communicate the member rights and responsibilities to all newly participating practitioners at the time of orientation via the Highmark Provider Manual and the applicable website, and annually to existing practitioners via the website. A paper copy will be provided upon request.

Highmark will communicate the member rights and responsibilities to the member through the Member Handbook upon enrollment, via the member website, and annually in the member newsletter.

1.5 Member Rights & Responsibilities - Delaware

The member rights and responsibilities for Highmark Blue Cross Blue Shield (DE) commercial products are outlined below.

Members have the right to: 

1. Be treated with courtesy, consideration, respect, and dignity.
2. Have their protected health information (PHI) and health records kept confidential and secure, in accordance with applicable laws and regulations.
   1. Receive communications about how Highmark Blue Cross Blue Shield (DE) (Highmark Delaware) uses and discloses their PHI.
   2. Request restrictions on certain uses and disclosures of their PHI.
   3. Receive confidential communications of PHI.
   4. Inspect, amend, and receive a copy of certain PHI.
   5. Receive an accounting of disclosures of PHI.
   6. File a complaint when they feel their privacy rights have been violated.
3. Available and accessible services when medically necessary, including urgent and emergent care 24 hours a day, 7 days a week.
4. Receive privacy during office visits and treatment.
5. Refuse care from specific practitioners.
6. Know the professional background of anyone giving them treatment. 
7. Discuss their health concerns with their health care professional.
8. Discuss the appropriateness or medical necessity of treatment options for their condition, regardless of cost or benefit coverage for those options.
9. Receive information about their care and charges for their care.
10. Receive from their provider, in easy to understand language, information about their diagnoses, treatment options including risks, expected results, and reasonable medical alternatives.
11. All rights afforded by law or regulation as a patient in a licensed health care facility, including the right to refuse medications and treatment after possible consequences of this decision have been explained to them in their primary language.
12. Received information about Highmark Delaware, its policies, procedures regarding its products, services, practitioners and providers, complaint procedures, and members’/enrollees’ rights and responsibilities.
13. Prompt notification of termination or changes in benefits, services, or the provider network.
14. Play an active part in decisions about their health care including formulating an advance directive.
15. Receive benefits and care without regard to race, color, gender, country of origin, or disability.
16. File a complaint with Highmark Delaware and receive a response to the complaint within a reasonable period of time.
    1. This includes requesting an internal appeal or review by an independent Utilization Review Organization, or filing a petition for arbitration for decisions made about their coverage.
    2. To register a complaint or request an appeal, members are instructed to call the Customer Service number listed on their ID card.
17. Submit a formal complaint about the quality of care given by their providers.
18. Make recommendations regarding Highmark Delaware’s members’ rights and responsibilities policies.

Members have the responsibility to:

1. Double-check that any facilities from which they receive care are covered by Highmark Delaware. They can visit myhighmark.com or call the Customer Service number listed on their ID card to ask about a facility.
2. Show their ID card to all caregivers before having care.
3. Keep their appointments. If they will be late or they need to cancel, give timely notice (in accordance with the provider’s office policy). They may be responsible for charges for missed appointments.
4. Treat their providers with respect.
5. Provide truthful information (to the extent possible) about their health to their providers. This includes notifying their providers about any medications they are currently taking.
6. Understand their health and participate in developing mutually agreed upon treatment goals.
7. Tell their health care providers if they do not understand the care he or she is providing.
8. Follow the advice of their health care provider for medicine, diet, exercise, and referrals.
9. Follow the plans and instructions for care that they have agreed on with their practitioners.
10. Pay all fees in a timely manner.
11. Maintain their Highmark Delaware eligibility. Notify Highmark Delaware of any change in their family size, address, or phone number.
12. Tell Highmark Delaware about any other insurance they may have.

1.5 Member Rights & Responsibilities - New York

Members have the right to:

1. Be treated with courtesy, consideration, respect, and dignity.
2. Receive information about Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY), its services, practitioners and providers, and members’/enrollees’ rights and responsibilities.
3. Voice complaints or appeals about the health plan or the care given by their providers.
4. Make recommendations regarding Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) members’ rights and responsibilities policies.
5. Confidentiality of their medical records.
6. Candid discussions concerning appropriate or medically necessary treatment options for their condition(s), regardless of cost or benefit coverage.
7. Request to see the physician selected for their primary care services instead of another member of his/her office staff for an office visit, if they are willing to wait for an available appointment.
8. Information about all services available through the health plan, including how to obtain emergency and after-hours care.

As a patient, members have a right to expect the following from their physicians or other providers:

1. Refuse treatment to the extent permitted by law, and to be informed of the medical consequences of that action.
2. Know the professional background of anyone giving them treatment; information can be obtained from the provider or the administrator of any health care facility.
3. Receive information from their physician or other provider necessary to give informed consent prior to the start of any procedure.
4. Receive from their provider, in easy to understand language, complete and current information about their diagnoses, treatment options including risks, expected results, and reasonable medical alternatives; when it is not advisable to give such information to a member, the information shall be made available to an appropriate person on their behalf.
5. Play an active part in decisions about their health care including formulating an advance directive.
6. Submit a formal complaint about the quality of care given by their providers; they can refer to their member handbook or contact customer service.

Members have the responsibility to:

1. Establish themselves as a patient of the physician they have selected for their primary care services.
2. Show their ID card to all caregivers before having care.
3. Follow carefully the health plan’s policies and procedures as described in their member handbook and their contract(s) and rider(s).
4. Provide truthful information (to the extent possible) about their health to their providers. This includes notifying their providers about any medications they are currently taking.
5. Understand their health and participate in developing mutually agreed upon treatment goals.
6. Be sure that their primary care physician coordinates any health care they receive in order to receive the highest level of benefits, if applicable under the terms of your plan coverage.
7. Keep their health plan informed of their concerns about the medical care they receive.
8. Follow the plans and instructions for care that they have agreed on with their practitioners.
9. Pay all fees in a timely manner, including appropriate copayments/deductible/coinsurance or other patient responsibility to providers when services or supplies are received.
10. Notify Highmark Blue Cross Blue Shield (WNY) or Highmark Blue Shield (NENY) (whichever is applicable) of any changes that affect them or their family, such as family size, address, or phone number.
11. Submit all bills they receive from a non-participating provider within one year from the date of service.
12. Tell Highmark Blue Cross Blue Shield (WNY) or Highmark Blue Shield (NENY) about any other group health insurance they may have or if anyone becomes eligible for Medicare.

1.5 Member Rights & Responsibilities - Pennsylvania

The member rights and responsibilities for Highmark commercial products in Pennsylvania are outlined below.

Members have the right to:

1. Receive information about Highmark, its products and its services, its practitioners and providers, and your rights and responsibilities.
2. Be treated with respect and recognition of your dignity and right to privacy.
3. Participate with practitioners in decision making regarding your health care. This includes the right to be informed of your diagnosis and treatment plan in terms that you understand and participate in decisions about your care.
4. Have a candid discussion of appropriate and/or medically necessary treatment options for your condition(s), regardless of cost or benefit coverage. Highmark does not restrict the information shared between practitioners and patients and has policies in place, directing practitioners to openly communicate information with their patients regarding all treatment options regardless of benefit coverage.
5. Voice a complaint or file an appeal about Highmark or the care provided, and receive a reply within a reasonable time period.
6. Make recommendations regarding the Highmark Members’ Rights and Responsibilities policies.

Members have the responsibility to:

1. Supply to the extent possible, information that the organization needs in order to make care available to you, and that its practitioners and providers need in order to care for you.
2. Follow the plans and instructions for care that you have agreed on with your practitioners.
3. Communicate openly with the physician you choose. Ask questions and make sure you understand the explanations and instructions you are given and participate in developing mutually agreed upon treatment goals. Develop a relationship with your doctor based on trust and cooperation.

1.5 Member Rights & Responsibilities - West Virginia

The member rights and responsibilities for Highmark Blue Cross Blue Shield (WV) commercial products are outlined below.

Members have the right to:

1. Receive information about Highmark Blue Cross Blue Shield (WV) (Highmark West Virginia), its products and services, its practitioners and providers, and member rights and responsibilities.
2. Be treated with respect and recognition of their dignity and right to privacy.
3. Participate with practitioners in decision making regarding their health care. This includes the right to be informed of their diagnosis and treatment plan in terms they understand and to participate in decisions about their care.
4. Have a candid discussion of appropriate and/or medically necessary treatment options for their condition(s), regardless of the cost or benefit coverage. Highmark West Virginia does not restrict the information shared between practitioners and patients and has policies in place directing practitioners to openly communicate information with their patients regarding all treatment options regardless of benefit coverage.
5. Voice a complaint or appeal about Highmark West Virginia or the care provided, and receive a reply within a reasonable period of time.
6. Make recommendations regarding the Highmark West Virginia Members’ Rights and Responsibilities policies.

Members have the responsibility to:

1. Supply to the extent possible, information that the organization needs in order to make care available to them, and that its practitioners and providers need in order to care for them.
2. Follow the plans and instructions for care that they have agreed on with their practitioners.
3. Communicate openly with the physician they choose. Ask questions and make sure they understand the explanations and instructions they are given, and participate in developing mutually agreed upon treatment goals.
4. Develop a relationship with their doctor based on trust and cooperation

Members receiving case management services from Highmark West Virginia are informed by letter at the initiation of services that they have the following rights:

1. Right to access needed health and social services.
2. Right to be informed of choices regarding services.
3. Right to be informed of available health care benefits, as well as where, when, and how they obtain these benefits.
4. Right to treatment with dignity and respect.
5. Right to have their health care records kept confidential except when disclosure is required by law or permitted in writing by them with adequate notice.
6. Right to be well-informed of any treatment plan in terms they understand, and to have input regarding decisions involving their medical care and treatment plan.
7. Right to comprehensive and fair assessment and notification of alternative approaches.
8. Right to receive notifications and rationale of discharge, termination, or change of service.
9. Right to withdraw from a case management program.
10. Right to an appeal/grievance procedure.
11. Right to choose a particular community service agency or long-term care provider.
12. Right to refuse treatment or services, including case management services, and be informed of the implications of such a refusal relating to benefits eligibility and/or health outcomes.
13. Right to obtain information regarding the plan’s criteria for case initiation and case closure.
14. Right to have informed consent for services, advance medical care directives (including end of life directives), and power of attorney documents to be followed in the case management process.
15. Right to have assistance in seeking additional resources for resolution of legal questions.
16. Right to have services/treatment rendered consistent with the Americans With Disabilities Act, worker’s compensation, and other laws protecting the rights of consumers as applicable.
17. Right to have alternative approaches to care if the member and/or family are not able to participate in the assessment process.

1.5 Medicare Advantage Member Rights & Responsibilities - Delaware

Members in Medicare Advantage Freedom Blue PPO plans are informed through their Member Evidence of Coverage booklets that they have certain rights and responsibilities.

Medicare Advantage members have the right to:

1. Not be discriminated against because of race, color, age, religion, national origin, or mental or physical disability.
2. To receive help with communication, such as help from a language interpreter.
3. Be treated with dignity, respect, and fairness at all times.
4. Privacy of medical records and personal health information. Generally, health information will not be released to anyone who is not providing or paying for the member’s care without written permission from the member, except when allowed or required by law.
5. Review and obtain copies of medical records, and to ask providers to make additions or corrections to the records.
6. Obtain care from network and non-network providers. To choose a network provider (and be informed which physicians are accepting new patients). To see a women’s health specialist (such as a gynecologist) without a referral or prior authorization
7. Timely access to providers and to see specialists when care from a specialist is needed. “Timely access” means to get appointments and services within a reasonable amount of time.
8. Get full information from providers when obtaining medical care and to participate fully in decisions about their care. Providers must explain things in a way the member can understand. The member’s rights include knowing about all the treatment choices that are recommended for the member’s condition, regardless of cost or coverage. This includes the right to be told about any risks involved. Members must be told in advance if any proposed treatment is part of a research experiment and be given the choice of refusing experimental treatments.
9. Refuse treatment, including the right to leave a hospital or other medical facility against a physician’s advice, and to stop taking medication. The member accepts responsibility for the consequences of refusing treatment. 
10. Ask someone, such as a family member or friend, to help make health care decisions. This includes executing advance directives, such as a living will or power of attorney for health care, or to authorize someone to make decisions in the event the member becomes unable to make decisions for himself/herself.
11. Make a complaint or appeal if the member has concerns or problems related to coverage or care.
12. Get information about Highmark BCBSD Inc. (HBCBSD), which offers the Freedom Blue PPO product, health care coverage and costs, and network providers. Members may contact Member Services to request the following types of information:
    1. What services are covered and what the member has to pay;
    2. Explanation of any bills for services not covered;
    3. HBCBSD’s financial condition;
    4. Network providers and their qualifications;
    5. How Freedom Blue PPO pays physicians;
    6. Member rights and protections; and
    7. Summary of appeals and grievances Freedom Blue PPO has received.
13. Make recommendations regarding Highmark BCBSD Inc.’s, member rights and responsibilities policy.

Medicare Advantage members have the responsibility to:

1. Become familiar with their coverage, the rules they must follow to obtain care, and what they have to pay.
2. Give their physician and other health care providers the information they need to provide care. To follow the treatment plans and instructions that they and their physicians agree upon. To ask questions of their physician or other provider if they have them.
3. Act in a way that supports the care given to other patients and helps the smooth operation of the physician’s office, hospital, or other office.
4. Pay plan premiums and any copayments the member owes for covered services they receive.
5. To contact Highmark Blue Cross Blue Shield (DE) Member Services with any questions, concerns, problems, or suggestions.
6. Understand their health problems and participate in developing mutually agreed upon goals, to the degree possible.

1.5 Medicare Advantage Member Rights & Responsibilities - New York

Members in Medicare Advantage Freedom Value HMO, Senior Blue HMO, BlueSaver HMO, Freedom Plus HMO, Freedom Blue PPO, Freedom Nation PPO, and Forever Blue PPO plans are informed through their Member Evidence of Coverage booklets that they have certain rights and responsibilities.

Medicare Advantage members have the right to:

1. Not be discriminated against because of race, age, religion, gender, health, ethnicity, creed (beliefs), sexual orientation, national origin, or mental or physical disability.
2. Receive information in a way that works for you and is consistent with your cultural sensitivities (in languages other than English, in large print or other alternate formats, etc.)
3. Be treated with dignity, respect, and fairness at all times.
4. Privacy of medical records and personal health information. Generally, health information will not be released to anyone who is not providing or paying for the member’s care without written permission from the member, except where allowed or required by law.
5. Review and obtain copies of medical records, know how they have been shared with others, and to ask Highmark to make additions or corrections to the records.
6. Obtain care from network and non-network providers. To choose a network provider (and be informed which physicians are accepting new patients). To see a women’s health specialist (such as a gynecologist) without a referral or prior authorization
7. Timely access to providers and to see specialists when care from a specialist is needed. “Timely access” means to get appointments and services within a reasonable amount of time. You also have the right to get your prescriptions filled or refilled at any network pharmacies without long delays.
8. Get full information from providers when obtaining medical care and to participate fully in decisions about their care. Providers must explain things in a way the member can understand. The member’s rights include knowing about all the treatment choices that are recommended for the member’s condition, regardless of cost or coverage. This includes the right to be told about any risks involved. Members must be told in advance if any proposed treatment is part of a research experiment and be given the choice of refusing experimental treatments. 
9. Refuse treatment- including the right to leave a hospital or other medical facility- against a physician’s advice, and to stop taking medication. The member accepts responsibility for the consequences of refusing treatment. Ask someone, such as a family member or friend, to help make health care decisions. This includes executing advance directives, such as a living will or power of attorney for health care, or to authorize someone to make decisions in the event the member becomes unable to make decisions for themself.
10. Make a complaint or appeal if the member has concerns or problems related to coverage or care.
11. Members may contact Member Services to request the following types of information:
    1. Explanation of any bills for services not covered;
    2. The plan’s financial condition;
    3. Network providers and their qualifications;
    4. Pharmacies in our network and how we pay the providers in our network;
    5. Coverage information and rules to follow when using coverage
12. Make recommendations regarding Highmark
13. Understand their health problems and participate in developing mutually agreed upon goals, to the degree possible.

Medicare Advantage members have the responsibility to:

1. Become familiar with their coverage, the rules they must follow to obtain care, and what they have to pay.
2. Inform Highmark of any other health insurance coverage or prescription drug coverage.
3. Tell their doctor and other health care providers they are enrolled in our plan.
4. Give their physician and other health care providers the information they need to provide care. To follow the treatment plans and instructions that they and their physicians agree upon. To ask questions of their physician or other provider if they have them.
5. Be considerate and respect the rights of other patients. Act in a way that supports the care given to other patients and helps the smooth operation of the physician’s office, hospital, or other office.
6. Pay plan premiums and any copayments the member owes for covered services they receive.

1.5 Medicare Advantage Member Rights & Responsibilities - Pennsylvania

The following information is made available to members through the Medicare Advantage Freedom Blue PPO, Community Blue Medicare PPO/PPO Plus, Community Blue Medicare HMO, and Security Blue HMO Member Evidence of Coverage booklets and updates in the member newsletters. The Member Evidence of Coverage booklets are available for viewing in the Highmark Provider Manual’s Appendix.

Medicare Advantage members have the right to:

1. Be assured they will not be discriminated against in the delivery of health care services consistent with the benefits covered in their plan based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.
2. Receive considerate and courteous care, with respect for personal privacy and dignity.
3. Select their own personal physician/preferred provider or physician group from Highmark’s Medicare Advantage Primary Care Physician networks.
4. Expect their Primary Care Physician’s/network provider’s team of health care workers to provide or help them arrange for all the care that they need.
5. Participate in the health care process. If they are unable to fully participate in this discussion, they have the right to name a representative to act on their behalf.
6. Receive enough information to help them make a thoughtful decision before they receive any recommended treatment.
7. Be informed of their diagnosis and treatment plans in terms they understand and participate in decisions involving their medical care.
8. Talk openly with their Primary Care Physician and other network providers about appropriate and medically necessary treatment options for their condition, regardless of cost or benefit coverage.
9. Have reasonable access to appropriate medical services.
10. Be provided with complete information about their Medicare Advantage HMO/Medicare Advantage PPO, including the services it provides, the practitioners who provide care, and information on member rights and responsibilities.
11. Confidential health records, except when disclosure is required by law or permitted in writing by the member with adequate notice. Members have the right to review their medical records with their PCP or other network provider.
12. Express a complaint and to receive an answer to your complaint within a reasonable period of time.
13. Appeal a decision by Medicare Advantage if they feel they have been denied a covered service.
14. Immediate Quality Improvement Organization review of decisions for hospital discharges, as explained in the Centers for Medicare & Medicaid Services’ Important Message, which is given to Medicare members at the time of admission to a hospital, and in the Notice of Discharge and Appeal Rights given prior to discharge.
15. Call Member Services to request information about:
    1. How we control the use of medical services.
    2. The number of appeals and grievances we have received and how these cases were resolved.
    3. How we pay our participating doctors.
    4. The financial condition of our Plan.
16. Make suggestions about Medicare Advantage PPO and HMO policies on member rights and responsibilities.

Medicare Advantage members have the responsibility to:

1. Read all Medicare Advantage HMO and PPO materials carefully and immediately upon enrollment and ask questions when necessary. They have the responsibility to follow the rules of Medicare Advantage HMO/Medicare Advantage PPO membership.
2. Identify themselves as a Medicare Advantage HMO/Medicare Advantage PPO member when scheduling appointments, seeking consultations with their physician, and upon entering any Medicare Advantage HMO/Medicare Advantage PPO provider’s office.
3. Treat all Medicare Advantage HMO/Medicare Advantage PPO network physicians and personnel respectfully and courteously as your partners in good health care.
4. Communicate openly with the physician they choose. The member has the responsibility to develop a physician-patient relationship based on trust and cooperation.
5. Keep scheduled appointments or give adequate notice of delay or cancellation.
6. Ask questions and make certain that they understand the explanations and instructions they are given.
7. Consider the potential consequences if they refuse to comply with treatment plans or recommendations.
8. Pay any applicable copayments at the time of service.
9. Pay any applicable Medicare Advantage HMO/Medicare Advantage PPO premiums on time.
10. Pay their Medicare Part B premiums (and Part A, if applicable).
11. Help maintain their health and prevent illness and injury.
12. Help Medicare Advantage HMO/Medicare Advantage PPO maintain accurate and current medical records by being honest and complete when providing information to their health care professionals.
13. Express their opinions, concerns, or complaints in a constructive manner to the appropriate people at Medicare Advantage HMO/Medicare Advantage PPO.
14. Notify the Medicare Advantage HMO/Medicare Advantage PPO Member Service Department, Monday through Sunday, between 8 a.m. and 8 p.m. at 800-935-2583 (Medicare Advantage HMO) or 800-550-8722 (Medicare Advantage PPO) of any changes in their personal situation which may affect the Plan’s ability to communicate with them or provide health care to them, including any changes in their address or phone number, any extended trips or vacations, and of their return to the service area from a trip of up to six (6) consecutive months. TTY users, please call 711.
15. Understand their health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.

1.5 Medicare Advantage Member Rights & Responsibilities - West Virginia

Members in Medicare Advantage Freedom Blue PPO plans are informed through their Member Evidence of Coverage booklets that they have certain rights and responsibilities. The Freedom Blue PPO Member Evidence of Coverage booklet is available for viewing in the Highmark Provider Manual’s Appendix.

Medicare Advantage members have the right to:

1. Not be discriminated against because of race, color, age, religion, national origin, or mental or physical disability.
2. To receive help with communication, such as help from a language interpreter.
3. Be treated with dignity, respect, and fairness at all times.
4. Privacy of medical records and personal health information. Generally, health information will not be released to anyone who is not providing or paying for the member’s care without written permission from the member, except when allowed or required by law.
5. Review and obtain copies of medical records, and to ask providers to make additions or corrections to the records.
6. Obtain care from network and non-network providers. To choose a network provider (and be informed which physicians are accepting new patients). To see a women’s health specialist (such as a gynecologist) without a referral or prior authorization
7. Timely access to providers and to see specialists when care from a specialist is needed. “Timely access” means to get appointments and services within a reasonable amount of time.
8. Get full information from providers when obtaining medical care and to participate fully in decisions about their care. Providers must explain things in a way the member can understand. The member’s rights include knowing about all the treatment choices that are recommended for the member’s condition, regardless of cost or coverage. This includes the right to be told about any risks involved. Members must be told in advance if any proposed treatment is part of a research experiment and be given the choice of refusing experimental treatments.
9. Refuse treatment, including the right to leave a hospital or other medical facility against a physician’s advice, and to stop taking medication. The member accepts responsibility for the consequences of refusing treatment.
10. Ask someone, such as a family member or friend, to help make health care decisions. This includes executing advance directives, such as a living will or power of attorney for health care, or to authorize someone to make decisions in the event the member becomes unable to make decisions for himself/herself.
11. Make a complaint or appeal if the member has concerns or problems related to coverage or care.
12. Get information about Highmark Senior Solutions Company (“HSSC”), which offers the Freedom Blue product, health care coverage and costs, and network providers. Members may contact Member Services to request the following types of information:
    1. What services are covered and what the member has to pay;
    2. Explanation of any bills for services not covered;
    3. HSSC’s financial condition;
    4. Network providers and their qualifications;
    5. How Freedom Blue pays physicians;
    6. Member rights and protections; and
    7. Summary of appeals and grievances Freedom Blue has received.
13. Make recommendations regarding Highmark Senior Solutions Company’s member rights and responsibilities policy.

Medicare Advantage members have the responsibility to:

1. Become familiar with their coverage, the rules they must follow to obtain care, and what they have to pay.
2. Give their physician and other health care providers the information they need to provide care. To follow the treatment plans and instructions that they and their physicians agree upon. To ask questions of their physician or other provider if they have them.
3. Act in a way that supports the care given to other patients and helps the smooth operation of the physician’s office, hospital, or other office.
4. Pay plan premiums and any copayments the member owes for covered services they receive.
5. To contact Highmark West Virginia Member Services with any questions, concerns, problems, or suggestions.
6. Understand their health problems and participate in developing mutually agreed upon goals, to the degree possible. 

1.5 Member Rights & Responsibilities - Highmark Healthy Kids (CHIP)

Highmark makes health care programs available to uninsured children in Pennsylvania through the subsidized Children’s Health Insurance Program of Pennsylvania (CHIP) now called Highmark Healthy Kids (CHIP). Highmark is committed to providing CHIP enrollees with the highest quality care possible and is dedicated to serving them in a manner that respects their rights as individuals and maintains confidentiality about personal medical matters.

Until July 1, 2022, the following provider networks serviced children covered under CHIP: the Premier Blue Shield preferred provider network in the 21-county Central Region; the Keystone Health Plan West (KHPW) managed care network in the 29- county Western Region; and the First Priority Health (FPH) managed care network in the 13-county Northeastern Region. The children and parents have the right to timely and effective redress of complaints, grievances, and appeals about Highmark or the care provided by participating network providers.

Since July 1, 2022, Highmark has a HMO CHIP network that services all 62 counties of Pennsylvania.

Highmark encourages CHIP enrollees and their parents to know and exercise their rights and responsibilities as outlined below. Network participating providers who provide care to CHIP enrollees are expected to know and respect these rights and encourage member responsibilities.

Highmark Healthy Kids (CHIP) enrollees/parents have the following rights:

1. Receive information about Highmark, its products and services, its practitioners and providers, and members’ rights and responsibilities.
2. Be treated with respect and recognition of their dignity and right to privacy.
3. Participate with practitioners in decision-making regarding their health care. This includes the right to be informed of their diagnosis and treatment plan in terms that they understand and participate in decisions about their care.
4. Have a candid discussion of appropriate and/or medically necessary treatment options for their condition(s), regardless of cost or benefit coverage. Highmark does not restrict the information shared between practitioners and patients and has policies in place, directing practitioners to openly communicate information with their patients regarding all treatment options regardless of benefit coverage.
5. Voice a complaint or appeal about Highmark or the care provided, and receive a reply within a reasonable period of time.
6. To be free from any form of restraint or seclusions used as a means of coercion, discipline, convenience, or retaliation. 
7. To be free to exercise their rights and exercising these rights will not adversely affect the way Highmark treats them.
8. Make recommendations regarding the Highmark Members’ Rights and Responsibilities policies.

Highmark Healthy Kids (CHIP) enrollees/parents have the following responsibilities:

1. Supply to the extent possible, information that the organization needs to make care available to them, and that its practitioners and providers need to care for them.
2. Follow the plans and instructions for care that they have agreed on with their practitioners.
3. Communicate openly with the physician they choose, ask questions and make sure they understand the explanations and instructions they are given, and participate in developing mutually agreed upon treatment goals. Develop a relationship with their doctor based on trust and cooperation.

1.5 Disclaimers

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.

All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.