NY Manual
SHP Manual

New York Provider Manual
4.4 Eligibility Verification | 4.6 Member Services and Education

4.5 Member Rights and Responsibilities

A member’s relationship with Healthfirst guarantees a number of basic rights, including entitlement to high-quality, accessible, responsive and responsible healthcare; respectful and confidential treatment; and avenues to express dissatisfaction or receive assistance. In return, members are responsible for taking charge of their healthcare needs, using services appropriately, complying with member policies and procedures, and requesting assistance from Healthfirst to ensure that they are utilizing and receiving services appropriately.

Healthfirst member rights and responsibilities are outlined below. This information is provided to all new members as part of their orientation package. Providers participating with Healthfirst are expected to make every effort to support member rights.

Members Have the RIGHT to:

  • High-quality healthcare services provided in a professional and responsible way

  • Choose a PCP

  • Complete and current information about available treatments, including diagnosis and prognosis as applicable, in terms the member can be expected to understand

  • Have information provided to an appropriate person acting on the member’s behalf when it is not appropriate to give such information directly to the enrollee

  • Access to assistance for medical care through the PCP’s office by telephone 24 hours a day, 7 days a week

  • Privacy and confidentiality of their healthcare records, except as otherwise provided for by law

  • Refuse treatment, as far as the law allows, and to understand the consequences of refusing treatment

  • Receive information as necessary to give informed consent before the start of any procedure

  • Express their concerns or complaints to Healthfirst and receive a timely response

  • Receive considerate and respectful medical care and treatment from Healthfirst staff and providers without discrimination due to race, color, sex, age, national origin, sexual orientation, and/or physical or mental condition

  • Accept or refuse medical treatment, including life-support treatment

  • Information regarding advance directives

Members Have the RESPONSIBILITY to:

  • Enter into this agreement with the intent to follow the rules and procedures outlined in the Member Handbook, Summary of Benefits, or Subscriber Contract

  • Meet with their PCP and get a baseline physical exam

  • Receive all covered healthcare services through the PCP, except in true emergencies; self-referral services, including OB/GYN, diagnosis, and treatment of TB by public health agency facilities, or as otherwise described in their Healthfirst Member Handbook, Subscriber Contract, or Evidence of Coverage (EOC); and to follow recommended treatments

  • Use the emergency room only in the event of a true emergency

  • Treat Healthfirst staff and providers with common courtesy and consideration

  • Keep scheduled appointments or, if this is not possible, call in advance to cancel

  • Call Member Services if they need information or have any questions about the benefits, rules, or procedures described in their Healthfirst Member Handbook, Subscriber Contract, or EOC

Commercial Members

In addition to the above rights and responsibilities, many members in Healthfirst Leaf Plans or HMO A–D plans will have monthly premium responsibilities. Members will have to pay their premiums on time in order to maintain their insurance coverage. Members who receive no federal subsidies will have a 30-day grace period in which to pay their premium. Members who receive federal subsidies will have a 90-day grace period to pay their premium. If members fail to pay their premium at the end of their grace period, they will be disenrolled.