Current through Register Vol. XLI, No. 38, September 20, 2024
8.1. A
prepaid limited health service organization shall demonstrate a commitment to
treating members with respect by developing written policies giving them the right
to:
a. Voice grievances about the PLHSO or care
provided;
b. Have information concerning
the PLHSO, its services, the providers providing care and members' rights and
responsibilities;
c. Participate in
decision-making regarding limited health services;
d. Be treated with respect and recognition of
their dignity and need for privacy; and
e. Permit the provider or other person designated
by the member or a court of competent jurisdiction to make and enforce all health
care decisions which the member could make if he or she had capacity or were
competent.
8.2. A PLHSO shall
develop a written policy addressing members' responsibilities for cooperating with
those providing limited health services by giving needed information to professional
staff to ensure appropriate care and by following instructions and guidelines given
by those providing limited health services.
8.3. All policies on members' rights and
responsibilities shall be provided in writing in clear and concise terms to all
members and participating providers and, at a minimum, shall address the following
procedures for, policies concerning or information regarding:
a. How to submit a claim for covered
services;
b. How to obtain limited
health services;
c. After-hours and
emergency coverage including the PLHSO's policy on when to directly access emergency
care or use 911-type services;
d.
Benefits and services included and excluded from membership;
e. Obtaining out-of-area coverage;
f. Special benefit provisions, such as co-payment,
higher deductibles and rejection of claims, that may apply to services outside the
system;
g. Member charges;
h. Notification of termination or change in any
benefits, services or delivery site/office;
i. Notification of termination of a coordinating
provider and the process for selecting a new provider;
j. Appealing decisions adversely affecting a
member's coverage, benefits or relationship to the PLHSO;
k. Changing providers;
l. Disenrollment of nongroup
subscribers;
m. Voicing complaints,
grievances and appeals;
n. Recommending
changes in policies and services;
o.
Points of access to limited health services;
p. The process by which a prepaid limited health
service organization determines whether or not to include new and emerging
technology or treatment as a covered benefit;
q. Provider names, qualifications and
titles;
r. Confidentiality;
s. Member satisfaction surveys that assess patient
complaints, requests to change providers or facilities and disenrollments; and
t. Policies and procedures for the care
and treatment of minors as well as adults who are unable to give informed
consent.
8.4. The prepaid
limited health service organization shall make reasonable accommodations for
providing to members with disabilities the PLHSO's policies on members' rights and
responsibilities.
