Member Rights and Responsibilities

Highmark Wholecare Medicaid and Medicare Dual Special Needs Plan (D-SNP) members have certain rights and responsibilities as members of Highmark Wholecare. To detail those rights and responsibilities in full, Highmark Wholecare maintains a Members Rights and Responsibilities statement, which is reviewed and revised annually.

Highmark Wholecare and its practitioner network do not and are prohibited from excluding or denying benefits to, or otherwise discriminating against, any eligible and qualified individual regardless of race, color, national origin, religious creed, sex, sexual orientation, gender identity, disability, English proficiency or age. Some additional rights and responsibilities are listed below.

Members have the right to:

1.    Be treated with respect, dignity, and privacy.

2.    Know about their rights and what they need to do.

3.    Use their rights without fear of punishment from Highmark Wholecare, their providers, or the State.

4.    Get easy-to-understand information about Highmark Wholecare. This includes our services, our providers, and their rights and responsibilities.

5.    Ask for their Member Handbook and other health care materials in ways they can understand. This means in other languages, large print, audio CD, or Braille – at no cost to them.

6.    Ask for a free interpreter or help to translate information – at no cost to them.

7.    Use interpreters who are not their family members or friends.

8.    Get all Highmark Wholecare benefits and services. This is true no matter their background, if they speak English well, if they have a disability, or if they are homeless.

9.    Not be treated unfairly because of their age, sex, race, where they were born, language needs, or how sick they are.

10. Choose their primary care provider and other health care providers.

11. Talk with their providers about their care choices. They can make decisions about their health, even if it means saying no to treatment. This is true no matter the cost or if it’s covered.

12. Make their own health care decisions. If they cannot make health care decisions by themselves, they have the right to have someone else help them make decisions. Or they can make decisions for themselves.

13. Be told about other treatment options or plans for care.

14. Ask another provider for their opinion about their health. This is called a second opinion.

15. Make a plan for their future medical care by creating an Advance Directive (living will).

16. Know how their health care providers are paid.

17. Get emergency care from any doctor, at any hospital, or in any place when they need it.

18. Keep their medical records and health information private. We will only share them if they tell us in writing that it is okay.

19. Get copies of their medical records and care plans. They can ask us to change or fix their medical records.

20. Choose any family planning doctor, whether they are in or out of our network.

21. Get care from a certified nurse midwife, or a certified children’s or family nurse practitioner.

22. Know that Highmark Wholecare can change benefits. We will mail them a letter when this happens.

23. Get information about services we don’t cover because of moral or religious reasons. We will also tell them how to get those services.

24. Ask about Highmark Wholecare programs to make care better (Quality Improvement). Also ask how we check that services are used correctly.

25. Get problems solved quickly about complaints, appeals, approvals, what is covered, and payment.

26. File a complaint (grievance) or an appeal if unhappy with their care, treatment, or decisions Highmark Wholecare makes.

27. Ask for a State Fair Hearing if they don’t agree with the decision about their appeal.

28. Not be held back or kept alone as punishment, to make things easier for staff, or to get back at them.

29. Find out how Highmark Wholecare decides if new technology, tests, or treatments will be a covered benefit.

30. Leave (disenroll) from Highmark Wholecare.

31. Give ideas about the rights and responsibilities of Highmark Wholecare members.

Members have a responsibility to:

1.    Tell Highmark Wholecare and their providers what they need to know to care for them. Also, tell them what they want or need.

2.    Learn about their health problems. Work with their provider to make treatment goals that they both agree on.

3.    Ask questions about their health, especially if they don't understand what their provider says.

4.    Follow their provider’s care plans and instructions as best as they can. Make sure they agree on them with their provider.

5.    Be part of decisions about their health care and treatment.

6.    Make and keep medical appointments and tell their provider if they can’t make it.

7.    Use doctors in the Highmark Wholecare network. They can see other doctors if it's an emergency or if we approve it.

8.    Get a referral from their primary care provider to see certain specialists.

9.    Use the emergency room only for real emergencies. Or use it if their doctor tells them to.

10. Respect other patients, clinic staff, and Highmark Wholecare staff.

11. Read and follow what is in their Member Handbook.

12. Learn what Highmark Wholecare covers. This includes benefits that are covered and those that are not, and any limits.

13. Always show their Member ID card and their Medicaid card.

14. Try their best to pay their copays. If they owe a copay at the pharmacy, they pay when they get their medicine.

15. Tell us right away if they get a bill they should not have. Also tell us if they have a complaint.

16. Know what laws Highmark Wholecare follows.

17. Report fraud and abuse.

18. Tell Highmark Wholecare and other groups (like the State, USPS, DMV) of changes in their life. This includes their address, phone number, family status, or other insurance.

19. Know that Highmark Wholecare is not workers’ compensation insurance.

The Member Rights and Responsibilities Statement can be found in the Medicaid Member Handbook, the Evidence of Coverage, or on our website at Medicaid Member Resources and Medicare Member Resources. For more information, please call Provider Services at: 

• Medicaid: 1-800-392-1147
• Medicare Assured: 1-800-685-5209