Member Rights & Responsibility Statement

The member rights include the right:

To receive information about SWH's services, practitioners and providers, enrollment, informational or instructional materials, grievance and appeal rights and member's rights and responsibilities annually in a manner appropriate to their condition and ability to understand;
To receive reasonable accommodations if required;
To be treated with respect and recognition of their dignity and their right to privacy;
To participate with practitioners in making decisions about their healthcare including the right to refuse treatment;
To participate in a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage;
To voice complaints or appeals about SWH or the care provided;
To make recommendations regarding SWH's member rights and responsibility policy;
To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation;
To request and receive a copy of his or her medical record and request that the record be amended or corrected;
To not be balanced billed by a provider for any service;
To receive services in a culturally competent manner and non-discriminatory manner;
To receive updates and/or changes to the rights and responsibilities at least annually;
To annually receive the Evidence of Coverage; and
To exercise their member rights without negative consequences.

The member responsibilities include the responsibility to:

Provide, to the extent possible, information that SWH and its practitioners and providers need in order to care for a member;
Follow the plans and instructions for care that the member has agreed upon with the practitioner or provider;
Understand a member’s health problems and participate in developing mutually agreed upon treatment goals and care plans;
Get familiar with the covered services and the rules a member must follow to obtain the covered services;
Inform SWH if there is any other health insurance coverage or prescription drug coverage in addition to the SWH plan;
Tell the member’s doctor and other healthcare providers that the member is enrolled in a SWH plan;
Help doctors and other providers help the member by giving the doctors and providers information, asking questions, and following through on the care plan;
Be considerate by respecting the rights of other patients and acting in a way that is respectful of a healthcare practitioner or provider and the staff;
Pay what any healthcare bills that are owed;
Tell SWH if there is a change of residence; and
Call Member Services for help when there are questions or concerns.

Members are informed in the Evidence of Coverage that:

If they are female, they have access to women's healthcare, including breast exams, screening mammograms, Pap tests and pelvic exams.
They may obtain a second opinion from an in-network provider.
They may obtain a second opinion from an out-of-network provider through the prior authorization process.
If SWH is unable to provide a necessary and covered service through an in-network provider, that they may obtain out-of-network services through the prior authorization process and that the cost will be covered by SWH.

Last Updated 11/10/2015
H2224_2016_099 Approved 01/08/2016