Understanding Your Rights

It is important you understand the rights you or your loved one is entitled to under Generations Healthcare HMO.

Your Right to be treated with fairness and respect

You have the right to be treated with dignity, respect, and fairness at all times. Generations Healthcare must obey laws against discrimination that protect you from unfair treatment. These laws say that we cannot discriminate against you (treat you unfairly) because of your race or color, age, religion, national origin, or any mental or physical disability you may have.

Your Right to the privacy of your medical records and personal health information

There are federal and state laws that protect the privacy of your medical records and personal health information. We keep your personal health information private as protected under these laws. Any personal health information that you give us when you enroll in this plan is protected. We will make sure that unauthorized people do not see or change your records. Generally, we must get written permission from you (or from someone you have given legal power to make decisions for you) before we can give your health information to anyone who is not providing your care or paying for your care. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care.

The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We are required to provide you with a notice that tells about these rights and explains how we protect the privacy of your health information. For example, you have the right to look at your medical records, and to get a copy of the records. There may be a fee charged 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 review your request and determine whether the changes are appropriate. You have the right to know how your health information has been given out and used for non-routine purposes. If you have questions or concerns about the privacy of your personal information and medical records, please call Customer Service at the phone 1-866-547-3060 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) every day.

Your Right to have your prescriptions filled within a reasonable period of time

You should get all of your prescriptions filled from a network pharmacy, that is, from pharmacies which contract with Generations Healthcare. You have the right to go to any network pharmacies in order to get your prescriptions filled at the benefit level. You have the right to timely access to your prescriptions. “Timely access” means that you can get your prescriptions filled within a reasonable amount of time.

Your Right to know your treatment choices and participate in decisions about your healthcare

You have the right to know about the different Medication Therapy Management Programs we offer and in which you may participate. You have the right to be told about any risks involved in your care. You have the right to refuse treatment. This includes the right to stop taking your medicine. If you refuse treatment, you accept responsibility for what happens as a result of refusing treatment.

You have the right to receive a detailed explanation from us if you believe that a network pharmacy has denied coverage for a drug that you believe you are entitled to receive or care you believe you should continue to receive. In these cases, you must request an initial decision.

Your Right to make complaints

You have the right to make a complaint if you have concerns or problems related to your coverage or care. “Appeals” and “grievances” are the two different types of complaints you can make. Which one you make depends on your situation.

If you make a complaint, we must treat you fairly (i.e., not discriminate against you). You have the right to get a summary of information about the appeals and grievances that members have filed against Generations Healthcare in the past. To get this information, call Customer Service at 1-866-547-3060 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) every day.

Your Right to get information about your medical and drug coverage and costs

Your Summary of Benefits tells you what you have to pay for medical and/or prescription drugs as a member of Generations Healthcare. If you need more information, please call Customer Service at number 1-866-547-3060 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-8958-2692) every day. You have the right to an explanation from us about any bills you may get for medical services or drugs not covered by Generations Healthcare. We must tell you in writing why we will not pay for a medical service or drug, and how you can file an appeal to ask us to change this decision.

Your Right to get information about Generations Healthcare and network pharmacies

You have the right to get information from us about Generations Healthcare. This includes information about our financial condition, about our network pharmacies, and about how Generations Healthcare compares to other Medicare Advantage or Part D Prescription Drug Plans. To get any of this information, call Member Service at 1-866-547-3060 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692 ) every day.

How to get more information about Your Rights

If you have questions or concerns about your rights and protections, please call Customer Service at 1-866-547-3060 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) every day.

In addition, the Medicare program has written a booklet called Your Medicare Rights and Protections. To get a free copy, call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or, you can visit www.medicare.gov to order this booklet or print it directly from your computer.

What can you do if you think you have been treated unfairly or Your Rights are not being respected?

If you think you have been treated unfairly or your rights have not been respected, what you should do depends on your situation.

If you think you have been treated unfairly due to your race, color, national origin, disability, age, or religion, please let us know. Or, you can call the Office for Civil Rights in your area.

For any other kind of concern or problem related to your Medicare rights and protections described in this section, you can call Customer Service at 1-866-547-3060 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) every day. You can also get help from your State Health Insurance Assistance Program (also known as SHIP).

What are your responsibilities as a member of Generations Healthcare?

Along with the rights you have as a member of Generations Healthcare, you also have some responsibilities. Your responsibilities include the following:

• Become familiar with your coverage and the rules you must follow to get care as a member. Please call Customer Service at 1-866-547-3060 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) every day if you have any questions.
• Give your healthcare provider(s) the information they need to care for you, and follow the treatment plans and instructions given to. Be sure to ask your healthcare provider(s) if you have any questions.
• Pay your plan premiums and any coinsurance/copayments you may owe for the covered medical services or drugs you get.

Let us know if you have any questions, concerns, problems, or suggestions. If you do, please call Customer Service at 1-866-547-3060 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) every day.