Member rights and responsibilities

As a member of Fallon Health, you have certain rights and responsibilities.

Member rights

As a Fallon Health member, you have the right to:

1. Be informed about how we work and your covered services.
2. Get information about the managed care organization (us), its services, its practitioners and providers, and your rights and responsibilities.
3. Be informed about how medical treatment decisions are made by our contracted providers or Fallon Health, including how they get paid.
4. Choose a qualified contracted primary care provider (PCP) and contracted hospital.
5. Know the names and qualifications of physicians and health care professionals involved in your medical treatment.
6. Get information about an illness, the course of treatment, and prospects for recovery in terms that you can understand.
7. Actively participate in decisions about your own health and treatment options, including the right to refuse treatment.
8. Get a second opinion on a medical procedure from an in-plan provider and have Fallon Health pay for that second opinion consultation. If you want a second opinion, ask your PCP to refer you to an in-network contracted provider for that second opinion. Prior approval from Fallon Health is required when a second medical opinion is being requested from a provider not in your plan's provider network.
9. Receive emergency services when you, as a prudent layperson acting reasonably, believe that an emergency medical condition exists.
10. Candidly discuss appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage. This should be discussed by your provider in a way you can understand and appropriate to your condition.
11. Be treated with dignity and respect, and to have your privacy respected.
12. Keep your personal health information private as protected under federal and state laws—including spoken, written, and electronic information across the organization. Unauthorized people don't see or change your records. You have the right to review and get a copy of certain personal health information (there may be a fee for printed copies).
13. Make complaints and appeals without discrimination. This includes complaints or appeals about us or the care provided by your providers. You should expect problems to be fairly reviewed and appropriately addressed.
• If your grievance involves an adverse determination (a decision not in your favor), and you're not satisfied with our final decision, you can file an external review (a review outside of Fallon Health).
• You can get the forms you need to request an external review by calling the Department of Public Health Office of Patient Protection at 1-800-436-7757 or by accessing their website at masshpc.gov/opp.
• Federal employees may ask the United States Office of Personnel Management for an external review by writing to:
  United States Office of Personnel Management
  Insurance Services Programs, Health Insurance Group 3
  1900 E. Street, NW
  Washington, DC 20415-3630
14. Exercise these rights regardless of your race, color, physical or mental ability, ethnicity, gender identity, sexual orientation, sex, creed, age, religion, national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for your care. Expect these rights to be upheld by both Fallon Health and our contracted providers.
15. Make recommendations regarding Fallon Health’s members’ rights and responsibilities policies.

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Member responsibilities

As a Fallon Health member, you have the responsibility to:

• Provide, to the extent possible, information that Fallon Health, your physician, or other care providers need in order to care for you.
• Do your part to improve your own health condition by following treatment plans, instructions, and care that you agreed on with your provider(s).
• Understand your health problems, and participate in developing new and existing, mutually agreed-upon treatment goals.

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