Member Rights and Responsibilities

Commercial Members Rights and Responsibilities

As a member of Optima Health, you are entitled to all covered benefits; however, you must learn how the health plan works, follow the proper procedures, and use the proper network (i.e., Plan doctors, hospitals, mental health providers, and other Plan specialists participating with Optima Health).

Optima Health Plan Members have the right to:

  1. Timely and Quality of Care:
    1. Access to Protected Health Information (PHI), medical records, physicians, and other healthcare professionals; and referrals to specialists when medically necessary.
    2. Continuity of care and to know in advance the time and location of an appointment, as well as the physicians and other health care professionals providing care.
    3. Receive the medical care that is necessary for the proper diagnosis and treatment of any covered illness or injury.
    4. Participate with physicians and healthcare professionals in:
      1. Discussing their diagnosis, the prognosis of the condition, and instructions required for follow-up care;
      2. Understanding the health problems and assisting to develop mutually agreed-upon goals for treatment;
      3. Decision-making regarding their healthcare and treatment planning; and
      4. A candid discussion of appropriate or medically necessary treatment options for their condition regardless of cost or benefit coverage.
    5. The right to affirm that all practitioners, providers, and employees who make utilization management (UM) decisions:
      1. Base decisions on appropriateness of care, services, and existence of coverage;
      2. Are not rewarded for issuing medical denials of coverage; and
      3. Do not encourage decisions that result in underutilization through financial incentives.
  2. Treatment with Dignity and Respect — Members will
    1. Be treated with respect, dignity, compassion and the right to privacy.
    2. Exercise these rights regardless of race, physical or mental ability, ethnicity, gender, sexual orientation, creed, age, religion or their national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for their care. Expect this right by both Plan and contracting physicians.
    3. Expect protection of all oral, written, and electronic information across the Plan, and information to plan sponsors and employers.
    4. Extend their rights to any person who may have the legal responsibility to make decisions on the member’s behalf regarding medical care.
    5. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
    6. Be able to refuse treatment or to sign a consent form if the member feels they do not clearly understand its purpose or cross-out any part of the form they do not want applied to their care, or change their mind about any treatment for which they have previously given consent and be informed of the medical consequences of this action.
  3. Receive Health Plan Information — Members will
    1. Receive information about their health plan, its services, its physicians, other health care professionals, facilities, clinical guidelines and member rights and responsibilities statements; and collection, use, and disclosure of PHI.
    2. Know by name, title, and organization the physicians, nurses or other health care professionals providing care.
    3. Receive information about medications (what they are, how to take them and possible side effects) and pharmacy benefit information (effective date of formulary change, new drugs available, or recalled medications).
    4. Receive clear information regarding benefits and exclusions of their policy, how medical treatment decisions are made/authorized by the health plan or contracted medical groups, payment structure, and the right to approve the release of information.
    5. Be advised if a practitioner proposes to engage in experimentation affecting care or treatment. The member may have the right to refuse to participate in such research.
    6. Be informed of policies regarding Advance Directives (living wills) as required by state and federal laws.
  4. Members Solve Problems in a Timely Manner by
    1. Presenting questions, concerns or complaints to a customer service specialist without discrimination and expect problems to be fairly examined and appropriately addressed.
    2. Voicing concerns or complaints to Optima Health about their health plan, if the care provided was inadequate, or feel their rights have been compromised. This includes the right to appeal an action or denial and the process involved.
    3. Making recommendations regarding the health plan members rights and responsibilities policies.

Member Responsibilities

Optima Health Plan Members, in addition to their rights, subscribers and their enrolled dependents have the responsibility:

  1. To identify themselves, and their family members as an Optima Health enrollee and present their identification card(s) when requesting healthcare services.
  2. To be on time for appointments and contact the physician or other healthcare personnel at once if there is a need to cancel or if they are going to be late for an appointment. If the physician, other healthcare personnel or facility, has a policy assessing charges regarding late cancellations or "no shows", the member will be responsible for such charges.
  3. To provide information about their health to physicians and other health care professionals so they may provide appropriate medical care.
  4. To actively participate and understand improving their health condition(s) by following the plans and instructions for care and treatment goals that they agreed upon with the physician or healthcare professional.
  5. To act in a manner that supports the care provided to other patients and the general functioning of the office or facility.
  6. To review the employee handbook and Plan documentation:
    1. To make sure the services are covered under the plan,
    2. To approve release of information and have services properly authorized before receiving medical attention,
    3. To follow proper procedures for illness before and after business hours, and
    4. For materials concerning health benefits (e.g. UM issues) and educate other covered family members.
  7. To accept financial responsibility for any copayment or coinsurance associated with services received while under the care of a physician or other healthcare professional or while a patient at a facility.
  8. To contact Optima Health if they have concerns, or if they feel their rights have been compromised.

For questions, concerns, or additional information, please visit or contact member services at the number on the back of your member ID card. TDD/TTY services and language assistance are available.