It's Your Choice 2018
Local Health Plan
Insurance for Employees
Patient Rights and Responsibilities
As a participant in this health insurance program, you have certain rights and responsibilities. By becoming familiar with them, you will be able to make the most of your health care. Our goals are to strengthen your confidence in a fair, responsive and high-quality health care system; to provide effective mechanisms to address your concerns; and to encourage you to take an active role in improving your health and health care.
You have the following rights
- Considerate, respectful care from all members of the health care system.
- Non-discrimination consistent with state and federal law.
- To change health plans annually.
- To a description of benefits presented in an understandable manner. Uniform Benefits are described in these It's Your Choice materials. Outlines of coverage for the Access Health Plan and Access HDHP are found here. If you select the Access Health Plan or Access HDHP, you will receive a certificate of coverage that describes your benefits. Your plan may also provide additional information regarding pre-certification requirements, etc.
- To select a primary care physician and to have access to appropriate specialty care. You have the right to a referral to a non-plan specialist for covered services if there is not a plan specialist who is reasonably available to treat your condition.
- A woman has the right to have access to an OB/GYN provider.
- A woman has the right to a minimum hospital stay of 48 hours following a normal delivery of a child or 96 hours following a cesarean delivery. The physician, in consultation with the mother, may discharge the mother and baby prior to the expiration of the minimum stay.
- To have continuous and appropriate access to a medical provider for the remainder of that calendar year if the medical provider leaves the plan (other than for misconduct, retirement or a move from the service area). A woman in her second or third trimester of pregnancy has access to that medical provider until the completion of postpartum care. This right only applies to medical providers that are listed in the available health plan's directory available during the It’s Your Choice Open Enrollment period.
- To have access to emergency care without prior-authorization from the health plan. If it is not reasonably possible to use a health plan hospital or facility, you have the right to obtain treatment at the nearest facility and have those charges covered by the health plan as if you did use the health plan's hospital or facility (however, be aware of your responsibilities when emergency care is received).
- To participate with your medical provider in treatment decisions.
- To confidentiality of medical information and your Social Security number.
- To execute a living will or durable power of attorney for health care if you are age 18 or older. These documents tell others what your wishes are in the event that you are physically or mentally unable to make medical decisions or choices yourself.
- To appeal any referral or claim denial through the health plan's grievance process. This review will be conducted in a timely manner. Grievances related to care that is urgently needed must be reviewed by the health plan within four working days. If you have exhausted all levels of appeal available through the health plan, you may submit a complaint to ETF, in care of the Office of Legal Services.
You will need to submit an ETF Insurance Complaint Form (ET-2405). You also have the right to request a departmental determination if you believe that a health plan did not comply with its contractual obligations.
In a health care system that protects patients’ rights, it is reasonable to expect and encourage patients to assume certain basic responsibilities. Greater personal involvement in your care increases the likelihood of achieving the best outcomes and helps support quality improvement and a cost-conscious environment.
You have the following responsibilities
- To review the It's Your Choice materials and information provided by your health plan during the It’s Your Choice open enrollment period. This information is important to determine if your health plan and/or your medical providers will continue to be available and whether your current health plan continues to best meet your needs for the following calendar year.
- To submit your application for coverage prior to the end of the enrollment period, if you select a different plan during the It’s Your Choice Open Enrollment period.
- To select a primary care physician who will oversee your total health care and to make a reasonable effort to establish a satisfactory patient-physician relationship.
- To become involved in your treatment options and/or treatment plan.
- To become knowledgeable about your health insurance coverage and your health plan provider, including covered benefits, limitations and exclusions, and the process to appeal coverage decisions. If you are covered under a Health Maintenance Organization (HMO) or preferred provider plan (PPO), to also become knowledgeable about the health plan's rules regarding use of network providers, prior authorizations and referrals.
- To authorize the release of relevant personal or medical information necessary to determine appropriate medical care, to process a claim or to resolve a dispute.
- To notify your health plan by the next business day, or as soon as reasonably possible, if you receive emergency or urgent care from a non-plan provider.
- To promptly report any family status changes to your payroll representative (or ETF if you are a retiree or continuant). These changes include marriage, divorce, creation or termination of a domestic partnership, death, a birth or adoption, or a dependent child losing eligibility. You should also report address or name changes, a change in your primary care provider and Medicare eligibility.
- To respond to the health plan's annual questionnaire on eligibility for any adult dependent who may be disabled. Coverage for dependents could be lost if the questionnaire is not returned to the health plan or the review is not completed.
- To notify your health plan if you obtain or lose other health insurance – including Medicare.
- To submit claims to the health plan in a timely manner, if applicable.
- To use the health plan's internal grievance process to address concerns that may arise.
Every effort has been made to ensure that this information is accurate, but may be subject to change. Please note revision dates located at the bottom of each page. In the event of conflicting information, federal law, state statute, state health contracts and/or policies and provisions established by the State of Wisconsin Group Insurance Board shall be followed.
This page was last modified on: 7/25/2017 4:32:38 PM