Member Rights & Responsibilities

Western Health Advantage's Member Rights and Responsibilities outline both your rights and your responsibilities as a member of WHA. You may request a separate copy of this Member Rights and Responsibilities Statement by contacting our Member Services staff.

What Are My Rights?

Member rights may be exercised without regard to age, sex, marital status, sexual orientation, race, color, religion, ancestry, national origin, disability, health status or the source of payment or utilization of services. Western Health Advantage member rights include, but are not limited to, the following:

• A right to receive information about our organization, our services, our practitioners and providers and your member rights and responsibilities.
• A right to be treated with respect and recognition of your dignity and right to privacy.
• A right to actively participate with practitioners in making decisions about your healthcare, to the extent permitted by law, including the right to refuse treatment or leave a hospital setting against the advice of the attending physician.
• A right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
• A right to voice complaints or appeals about the organization or the care it provides, and to expect that a process is in place to ensure timely resolution of the issue.
• A right to make recommendations regarding WHA's member rights and responsibilities policy.
• A right to know the name of the physician who has primary responsibility for coordinating your care and the names and professional relationships of others who may provide services including the practitioner's education, certification or accreditation, licensure status, number of years in practice, and experience performing certain procedures.
• A right to receive information about your illness, the course of treatment, and prospects for recovery in terms that can be easily understood.
• A right to receive information about proposed treatments or procedures to the extent necessary for you to make an informed decision whether to receive or refuse a course of treatment or procedure. Except in emergencies, this information shall include: a description of the procedure or treatment, medically significant risks associated with it, alternate courses of treatment or non-treatment including the risks involved with each, and the name of the person who will carry out a planned procedure.
• A right to confidential treatment and privacy of all communications and records pertaining to care you received in any health care setting. Written permission will be obtained before medical records are made available to persons not directly concerned with your care, except as permitted by law or as necessary in the administration of the Health Plan. WHA's policies related to privacy and confidentiality are available to you upon request.
• A right to full consideration of privacy and confidentiality around your plan for medical care, case discussion, consultation, examination and treatment including the right to be advised of the reason an individual is present while care is being delivered.
• A right to reasonable continuity of care along with advance knowledge of the time and location of an appointment, as well as, the name of the practitioner scheduled to provide your care.
• A right to be advised if the physician proposes to engage in, or perform, human experimentation within the course of care or treatment and the ability to refuse to participate in such research projects if desired.
• A right to be informed of continuing health care requirements following discharge from a hospital or practitioner's office.
• A right to examine and receive an explanation of bills for services regardless of the source of payment.
• To have these member rights apply to a person with legal responsibility for making medical care decisions on your behalf. This person may be your physician.
• A right to have access to your personal medical records.
• A right to formulate advance directives for health care.

What Are My Responsibilities?

It is the expectation of Western Health Advantage and its providers that enrollees adhere to the following member responsibilities to facilitate the provision of high level quality of care and service to members. Your member responsibilities include, but are not limited to, the following:

• A responsibility to supply information (to the extent possible) that WHA and our practitioners and providers need in order to provide care. This includes informing WHA's Member Services when a change in residence occurs or other circumstances arise that may effect entitlement to your coverage or eligibility.
• A responsibility to follow plans and instructions for care that you have agreed to with your practitioners..
• A responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
• A responsibility to know, understand and abide by the terms, conditions, and provisions set forth by Western Health Advantage. WHA's Evidence of Coverage and Disclosure Form (EOC/DF) contains this information. You may obtain a print copy of the EOC/DF by contacting Member Services.
• A responsibility to select a primary care physician (PCP) who will have primary responsibility for coordination of your care and to establish a relationship with your PCP.
• To follow preventive health guidelines, prescribed treatment plans, and guidelines/instructions that you have agreed to with your health care professionals and provide them with information relevant to your care.
• To schedule appointments, as needed or indicated, to notify the physician when it is necessary to cancel an appointment and to reschedule cancelled appointments if indicated.
• To show consideration and respect to the providers and their staff and to other patients.
• To inform WHA's Member Services department of any complaints or issues regarding the care or service provided by WHA or a participating provider.