Member Rights and Responsibilities

At Blue Cross and Blue Shield of Texas (BCBSTX), we want to make sure our members get the health care they need. We also want to make sure our members’ rights are respected.

Member Rights

Parents, guardian, or legally authorized representative (LAR) and the child have the right to respect, dignity, privacy, confidentiality, and nondiscrimination. That includes the right to:

• Be treated fairly and with respect.
• Know that your child’s medical records and conversations with their doctors will be kept private and confidential.

You have a right to get information about BCBSTX, our services, doctors, providers and member rights and responsibilities.

You have the right to agree to or refuse medically necessary treatment and actively participate in treatment decisions regardless of cost or benefit coverage.

You have the right to have some additional time to choose a health care plan and primary care provider (PCP) for your child. The PCP is the doctor your child will see most of the time and who will coordinate his or her care. You have the right to change your child to another plan or doctor in a reasonably easy way. That includes the right to:

• Be told how to choose and change your child’s health plan and your child’s PCP.
• Choose any health plan you want for your child that is available in your area and choose a PCP from that plan.
• Change your child’s PCP.
• Change your child’s health plan without a cost, or a fee, to you.
• Be told how to change your child’s health plan or your child’s PCP.

You have the right to ask questions and get answers about anything you do not understand. That includes the right to:

• Have your provider explain your or your child's health care needs to you and talk to you about the different ways your health care problems can be treated.
• Be told why care or services were denied and not given.

You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to:

• Work as part of a team with your provider in deciding what health care is best for you.
• Say yes or no to the care recommended by your child's provider.

You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid, and get a timely response to complaints, appeals and fair hearings. That includes the right to:

• Make a complaint to your child’s health plan or to the state Medicaid program about your child’s health care, your child’s doctor, or your child’s health plan.
• MDCP/DBMD escalation help line for Members receiving Waiver services via the Medically Dependent Children Program or Deaf/Blind Multi-Disability Program. (Attachment W.)
• Get a timely answer to your complaint.
• Use the plan's appeal process and be told how to use it.
• Ask for an External Medical Review and State fair Hearing from the state Medicaid program and get information about how that process works.
• Ask for a State Fair Hearing without an External Medical Review from the state Medicaid program and receive information about how that process works.
  

You have the right to timely access to care for your child that does not have any communication or physical access barriers. That includes the right to:

• Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care your child needs.
• Get medical care in a timely manner.
• Be able to get in and out of a PCP's office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act.
• Have interpreters, if needed, during appointments with your child’s doctors and when talking to your child’s health plan. Interpreters include people who can speak in your and your child’s native language, help someone with a disability, or help you and your child understand the information.
• Be given information you can understand about your child’s health plan rules, including the health care services you can get and how to get them.
  

You have the right to not be restrained or secluded when it is for someone else's convenience, or is meant to force you or your child to do something you, or your child, do not want to do, or is to punish you nor your child.

You have a right to know that doctors, hospitals, and others who care for your child can recommend you about your child’s health status, medical care, and treatment. Your child’s health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services.

You have a right to make recommendations about the BCBSTX member rights and responsibilities policy.

Member Responsibilities

You must learn and understand each right your child has under the Medicaid program. That includes the responsibility to:

• Learn and understand your child’s rights under the Medicaid program.
• Ask questions if you do not understand your child’s rights.
• Learn what choices of health plans are available in your area.
  

You must abide by the health plan's and Medicaid's policies and procedures. That includes the responsibility to:

• Learn and follow your child’s health plan's rules and Medicaid rules.
• Choose your child’s health plan and a primary care provider quickly.
• Make any changes in your child’s health plan and primary care provider in the ways established by Medicaid and by the health plan.
• Keep your scheduled appointments.
• Cancel appointments in advance when your child cannot keep them.
• Always contact your child’s primary care provider first for his or her non-emergency medical needs.
  Be sure you have approval from your child’s primary care provider before going to a specialist.
  
• Understand when your child should and should not go to the emergency room.
  

You must share information about your child’s health with your child’s primary care provider and learn about service and treatment options. That includes the responsibility to:

• Tell your child’s primary care provider about your child’s health.
• Talk to the providers about your child’s health care needs and ask questions about the different ways your child’s health care problems can be treated.
• Help your child’s providers get your child’s medical records.

You must be involved in decisions relating to service and treatment options for your child, make personal choices, and take action to keep your child healthy. That includes the responsibility to:

• Work as a team with your child’s provider in deciding what health care is best for your child.
• Understand how the things your child does can affect his or her health.
• Do the best you can to stay healthy.
• Treat providers and staff with respect.
• Talk to your child’s provider about all of your medications
• Follow the care plans and instructions that you agreed on with your doctor or provider.

If you think your child has been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can review information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

For a complete list of member rights and responsibilities, check the Member Handbook and Your Rights for Appeal of an Adverse Determination.