Member Rights and Responsibilities

MEMBER RIGHTS

To receive information about the organization, its services, its practitioners and providers and member rights and responsibilities.
To be treated with respect and recognition of their dignity and their right to privacy.
To participate with practitioners in making decisions about their health care.
To 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 the organization or the care it provides.
To make recommendations regarding the organization’s member rights and responsibilities policy.
To have access to a current list of network providers. Additionally, a member may access information on network providers’ education, training, and practice.
To select a health plan or switch health plans, within the guidelines, without any threats or harassment.
To receive information in a different format in compliance with the Americans with Disabilities Act if the member has a disability.
To select a primary care provider within the network. The member has the right to change their primary care provider or request information on network providers close to their home or work.
To know the name and job title of people providing care to the member. The member also has the right to know which physician is their primary care provider.
To a second opinion by a network physician, at no cost to the member, if the member believes that the network provider is not authorizing the requested care, or if the member wants more information about their treatment.
To privacy of their personal health information, consistent with state and federal laws, and Antidote policies.
To be kept informed of covered and non-covered services, program changes, how to access services, primary care provider assignment, providers, advance directive information, referrals and authorizations, benefit denials, member rights and responsibilities, and other Antidote rules and guidelines. Antidote will notify members at least 60 days before the effective date of the modifications. Such notices shall include the following:
To adequate access to qualified medical practitioners and treatment or services regardless of age, race, creed, sex, sexual orientation, national origin, or religion. Sex discrimination includes, but is not limited to, discrimination based on pregnancy, gender identity and sex stereotyping.
To have access to an interpreter when the member does not speak or understand the language of the area.
To execute an advance directive for health care decisions. An advance directive will assist the primary care provider and other providers to understand the member’s wishes about the member’s health care. The advance directive will not take away the member’s right to make their own decisions. Examples of advance directives include:
- Living Will
- Health Care Power of Attorney
- “Do Not Resuscitate” Orders
- Members also have the right to refuse to make advance directives. Members may not be discriminated against for not having an advance directive.

MEMBER RESPONSIBILITIES

To supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.
To follow plans and instructions for care that they have agreed to with their practitioners.
To understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
To treat all health care professionals and staff with courtesy and respect.
To show their I.D. card and keep scheduled appointments with their provider and call the provider’s office during office hours whenever possible if the member has a delay or cancellation.
To know the name of their assigned primary care provider. The member should establish a relationship with their primary care provider. The member may change their primary care provider verbally or in writing by contacting the Antidote Member Services Department.
To follow all health benefit plan guidelines, provisions, policies, and procedures.
To use any emergency room only when they think they have a medical emergency. For all other care, the member should seek care at an urgent care center, Antidote telehealth or call their PCP.
To give all information about any other medical coverage they have at the time of enrollment. If, at any time, the member gains other medical coverage besides Antidote coverage, the member must provide this information to Antidote.
To pay their monthly premium, all deductible amounts, copayment amounts, or cost- sharing percentages at the time of service.