Member Rights and Responsibilities

Member Rights

As a Saint Alphonsus Health Plan member, you have the right to: 

• Be treated with courtesy, dignity and respect at all times.
• Be protected from discrimination. Every company or agency that works with Medicare must obey the law. They can't treat you differently because of your race, color, national origin, disability, age, religion, or sex.
• Receive information in a way that you understand and is consistent with your cultural sensitivities. Our plan has free interpreter services available to answer questions from non-English speaking members. We can also give you information in braille, in large print, or other alternate formats at no cost if you need it.
• Receive information about the plan, its network of providers, and your covered services. This includes: 
  • Information about the plan’s financial condition.
  • 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.
  • Information about why something is not covered and what you can do about it.
• Choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services.
• 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.
• For female members, direct access to a women’s health specialist within the network for women’s routine and preventive health care services.
• Receive Medicare-covered services in an emergency.
• 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.
• Participate fully in decisions about your health care. This includes: 
  • Knowing 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.
  • Knowing 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.
• Give instructions about what is to be done if you are not able to make medical decisions for yourself. 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.
• Have your personal and health information kept private. We make sure that unauthorized people don’t see or change your records. Except where required by law, 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.
• Look at your medical records held by the plan, request additions or corrections to your medical records, and to get a copy of your records. 
• Know how your health information has been shared with others for any purposes that are not routine.
• Receive Saint Alphonsus Health Plan's Notice of Privacy Practices.
• Make complaints and to ask us to reconsider decisions we have made. See the Appeals and Grievances page for additional information. 

Member Responsibilities 

As a Saint Alphonsus Health Plan member, you also have responsibilities that require you to: 

• Be familiar with your covered services and the rules you must follow to get these covered services. Use your Evidence of Coverage to learn about your coverage options, limitations and exclusions. Please call Member Services when you have questions or concerns. 
• Inform Saint Alphonsus Health Plan of any other health insurance coverage or prescription drug coverage you have in addition to our plan. See Chapter 1 of your Evidence of Coverage for information on coordinating these benefits. 
• Tell your doctor and other health care providers that you are enrolled in our plan. Always show your member ID card before receiving medical care or Part D prescriptions drugs. 
• Help your doctors and other providers help you by giving them information, asking questions, and following through on your care. To help get the best care, tell your doctors and other health providers about your health problems, and follow the treatment plans and instructions that you and your doctors agree upon. Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements. 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:
  • You must continue to pay a premium for your Medicare Part B to remain a member of the plan.
  • 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.
  • If you are required to pay a late enrollment penalty, you must pay the penalty to keep your prescription drug coverage.
  • 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.
• Let us know if you move. If you move within our service area, please let us know so we can keep your membership record up to date and know how to contact you. It's also important to tell Social Security (or the Railroad Retirement Board) any time you have a change in address. If you move outside of our plan service area, you cannot remain a member of our plan. 

Making a Change to or Disenrolling From Your Plan 

Once enrolled in our plan, you can make changes only during certain times of the year.

The Annual Enrollment Period is from Oct. 15 to Dec. 7. During this time, you can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new plan, you can choose another Medicare Advantage plan (with or without drug coverage) or return to Original Medicare. Your membership will end in our plan when your new plan’s coverage begins on Jan. 1.

You have the right to make one change to your health coverage during the Medicare Advantage Open Enrollment Period from Jan. 1 through March 31. Your membership will end on the first day of the month after you enroll in a different Medicare Advantage plan or we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug plan, your membership in the drug plan will begin the first day of the month after the drug plan gets your enrollment request. 

Generally, you may not make changes at other times unless you qualify for a Special Enrollment Period. The enrollment time periods vary depending on your situation. To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.

If you have questions or would like more information about when you can end your membership, please call Member Services. 

Disenrollment Forms

Plan Disenrollment Form. Use this form to disenroll from Saint Alphonsus Health Plan.

Dental Disenrollment Form. Use this form to disenroll from your optional supplemental dental plan. You may disenroll from a supplemental dental plan without ending your membership in Saint Alphonsus Health Plan.

Additional Resources

• See Medicare.gov, Your Rights
• Evidence of Coverage, Chapter 8: Your rights and responsibilities
• Evidence of Coverage, Chapter 2: Ending your membership in the plan
• Legal forms, including Appointment of Representative and Advanced Directive documents