Member Rights & Responsibility Statement

Member's rights include:
  • Right to receive information about SWH's services, practitioners and providers, enrollment notices, 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 (see ADA policy QM 010).
  • Rights for reasonable accommodations (see ADA policy QM 010).
  • Rights and responsibilities updates and changes are communicated to them annually through the Evidence of Coverage and member handbook.
  • Right to exercise those rights without negative consequences.
  • A right to be treated with respect and recognition of their dignity and their right to privacy.
  • A right to participate with practitioners in making decisions about their healthcare including the right to refuse treatment.
  • A right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
  • A right to voice complaints or appeals about SWH or the care provided.
  • A right to make recommendations regarding SWH's member rights and responsibility policy. 
  • A right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
  • A right to request and receive a copy of his or her medical record and request that they be made amended or corrected.
  • A right to not be balanced billed by a provider for any service.
  • SWH will assure that services are provided in a culturally competent manner to all members, including those with limited English proficiency or reading skills (i.e., translator and interpreter services will be available upon request) and those with diverse cultural or ethnic backgrounds.
  • The right to be assured that services are provided in a culturally competent and non-discriminatory manner.
Member's responsibilities include:
  • The responsibility to provide, to the extent possible, information that SWH and its practitioners and providers need in order to care for them.
  • The responsibility to follow the plans and instructions for care that they have agreed on with their practitioners.
  • The responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals and care plans.
  • Get familiar with your covered services and the rules you must follow to get these covered services.
  • If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us.
  • Tell your doctor and other healthcare providers that you are enrolled in our plan.
  • Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.
  • Be considerate to 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.
  • Tell us if you move.
  • Call Member Services for help if you have 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 10/11/2019