Our plan must honor your rights and cultural sensitivities as a member of the plan
Your plan is required to ensure that all services, both clinical and non-clinical, are provided in a culturally competent manner and are accessible to all enrollees, including those with limited English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds. Examples of how a plan may meet these accessibility requirements include, but are not limited to: provision of translator services, interpreter services, teletypewriters, or TTY (text telephone or teletypewriter phone) connection.
Our plan has free interpreter services available to answer questions from non-English speaking members. We can also give you information in braille, large print, or other alternate formats at no cost if you need it. We are required to give you information about the plan’s benefits in a format that is accessible and appropriate for you. To get information from us in a way that works for you, please call Member Services.
Our plan is required to give female enrollees the option of direct access to a women’s health specialist within the network for women’s routine and preventive health care services.
If providers in the plan’s network for a specialty are not available, it is the plan’s responsibility to locate specialty providers outside the network who will provide you with the necessary care. In this case, you will only pay in-network cost sharing. If you find yourself in a situation where there are no specialists in the plan’s network that cover a service you need, call the plan for information on where to go to obtain this service at in-network cost sharing.
If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, seeing a women’s health specialists or finding a network specialist, please call to file a grievance with Member Services at 1-800-927-6048 (TTY: 711). You may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights 1-800-368-1019 or TTY 1-800-537-7697.
We must ensure that you get timely access to your covered services and drugs
You have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services. We do not require you to get referrals to go to network providers.
You have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.
If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter 9 tells what you can do.
We must protect the privacy of your personal health information
Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.
- Your personal health information includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information
- You have rights related to your information and controlling how your health information is used. We give you a written notice, called a Notice of Privacy Practice, that tells about these rights and explains how we protect the privacy of your health information.
How do we protect the privacy of your health information?
- We make sure that unauthorized people don’t see or change your records.
- Except for the circumstances noted below, if we intend to give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you or someone you have given legal power to make decisions for you first.
- There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law.
- We are required to release health information to government agencies that are checking on quality of care.
- Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations; typically, this requires that information that uniquely identifies you not be shared.
You can see the information in your records and know how it has been shared with others
You have the right to look at your medical records held by the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made.
You have the right to know how your health information has been shared with others for any purposes that are not routine.
If you have questions or concerns about the privacy of your personal health information, please call Member Services.
We must give you information about the plan, its network of providers, and your covered services
As a member of Sentara Medicare Prime, you have the right to get several kinds of information from us.
If you want any of the following kinds of information, please call Member Services:
- Information about our plan. This includes, for example, information about the plan’s financial condition.
- Information about our network providers and pharmacies. You have the right to get information about the qualifications of the providers and pharmacies in our network and how we pay the providers in our network.
- Information about your coverage and the rules you must follow when using your coverage. Chapters 3 and 4 provide information regarding medical services. Chapters 5 and 6 provide information about Part D prescription drug coverage.
- Information about why something is not covered and what you can do about it. Chapter 9 provides information on asking for a written explanation on why a medical service or Part D drug is not covered or if your coverage is restricted. Chapter 9 also provides information on asking us to change a decision, also called an appeal.
We must support your right to make decisions about your care
You have the right to know your treatment options and participate in decisions about your health care
You have the right to get full information from your doctors and other health care providers. Your providers must explain your medical condition and your treatment choices in a way that you can understand.
You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:
- To know about all of your choices. You have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely.
- To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.
- The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result.
You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself.
You can contact the Virginia Insurance Counseling and Assistance Program (VICAP) for information about Advance Care Plans at 1-800-552-3402. TTY users should call 711.
Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:
- Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.
- Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself.
The legal documents that you can use to give your directions in advance of these situations are called advance directives. There are different types of advance directives and different names for them. Documents called living will and power of attorney for health care are examples of advance directives.
If you want to use an advance directive to give your instructions, here is what to do:
- Get the form. You can get an advance directive form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also contact Member Services to ask for the forms.
- Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.
- Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form who can make decisions for you if you can’t. You may want to give copies to close friends or family members. Keep a copy at home.
If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.
- The hospital will ask you whether you have signed an advance directive form and whether you have it with you.
- If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.
Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive.
What if your instructions are not followed?
If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the Virginia Insurance Counseling and Assistance Program (VICAP).
You have the right to make complaints and to ask us to reconsider decisions we have made
If you have any problems, concerns, or complaints and need to request coverage, or make an appeal, Chapter 9 of this document tells what you can do. Whatever you do – ask for a coverage decision, make an appeal, or make a complaint – we are required to treat you fairly.
What can you do if you believe you are being treated unfairly or your rights are not being respected?
If it is about discrimination, call the Office for Civil Rights
If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, sexual orientation, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you believe you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having:
- You can call Member Services.
- You can call the SHIP. For details, go to Chapter 2, Section 3.
- Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048).
How to get more information about your rights
There are several places where you can get more information about your rights:
- You can call Member Services.
- You can call the SHIP. For details, go to Chapter 2, Section 3.
- You can contact Medicare.
- You can visit the Medicare website to read or download the publication Medicare Rights & Protections. (The publication is available at: www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf.)
- Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048).
You have some responsibilities as a member of the plan
Things you need to do as a member of the plan are listed below. If you have any questions, please call Member Services.
• Get familiar with your covered services and the rules you must follow to get these covered services. Use this Evidence of Coverage to learn what is covered for you and the rules you need to follow to get your covered services.
o Chapters 3 and 4 give the details about your medical services.
o Chapters 5 and 6 give the details about your Part D prescription drug coverage.
• If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Chapter 1 tells you about coordinating these benefits.
• Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card whenever you get your medical care or Part D prescription drugs.
• Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.
o To help get the best care, tell your doctors and other health providers about your health problems. Follow the treatment plans and instructions that you and your doctors agree upon.
o Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.
o If you have any questions, be sure to ask and get an answer you can understand.
• Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices.
• Pay what you owe. As a plan member, you are responsible for these payments:
o You must pay your plan premiums.
o You must continue to pay a premium for your Medicare Part B to remain a member of the plan.
o For most of your medical services or drugs covered by the plan, you must pay your share of the cost when you get the service or drug.
o If you are required to pay a late enrollment penalty, you must pay the penalty to keep your prescription drug coverage.
o If you are required to pay the extra amount for Part D because of your yearly income, you must continue to pay the extra amount directly to the government to remain a member of the plan.
• If you move within our plan service area, we need to know so we can keep your membership record up to date and know how to contact you.
• If you move outside of our plan service area, you cannot remain a member of our plan.
• If you move, it is also important to tell Social Security (or the Railroad Retirement Board