Rights and Responsibilities

As a plan member, you have the right to:

  • Receive all the benefits to which you are entitled under your contract;
  • Receive quality health care through your providers in a timely manner and medically appropriate setting;
  • Considerate, courteous and respectful care;
  • Be treated with respect and recognition of your dignity and right to privacy.
  • Information about services, staff, hours of operation and your benefits, including access to routine services as well as after-hours and emergency services and members' rights and responsibilities;
  • Participate in decision-making with your physician about your health care;
  • Obtain complete, current information concerning a diagnosis, treatment and prognosis from a provider in terms that you can reasonably be expected to understand;
  • Refuse treatment as allowed by law, and be informed by your physician of the medical consequences;
  • Refuse to participate in research;
  • Confidentiality of medical records and information, with the authority to approve or refuse the redisclosure by us of such information, to the extent protected by law;
  • Receive all information needed to give informed consent for any procedure or treatment;
  • Access to your medical records as permitted by New York State law;
  • Express concerns and complaints about the care and services provided by physicians and other providers, and have us investigate and respond to these concerns and complaints;
  • Candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage;
  • Care and treatment without regard to age, race, color, sex or sexual orientation, religion, marital status, national origin, economic status or source of payment;
  • Voice complaints and recommend changes in benefits and services to staff, administration and/or the New York State Insurance Department or Department of Health, without fear of reprisal;
  • Formulate advance directives regarding your care. To obtain a Health Care Proxy form, contact us;
  • Contact one of our service departments to obtain the names, qualifications and titles of providers who are responsible for your care;
  • All information about your health plan, its services and its providers and procedures.
  • To make recommendations regarding the organization's members' rights and responsibilities.

As a member, you have the responsibility to:

  • Be an active partner in the effort to promote and restore health by:
    • openly sharing information about your symptoms and health history with your physician;
    • listening;
    • asking questions;
    • becoming informed about your diagnosis, recommended treatment and anticipated or possible outcomes;
    • following the plans of care you have agreed to (such as taking medicine and making and keeping appointments);
    • returning for further care, if any problem fails to improve; and
    • accepting responsibility for the outcomes of your decisions.
  • Participate in understanding their health problems ad developing mutually agreed upon treatment goals.
  • Have all care provided, arranged or authorized by your primary care physician (PCP);
  • Inform your PCP if there are changes in your health status;
  • Obtain services authorized by your PCP;
  • Share with your PCP any concerns about the medical care or services that your receive;
  • Permit us to review your medical records in order to comply with federal, state and local government regulations regarding quality assurance, and to verify the nature of services provided;
  • Respect time set aside for your appointments with providers and give as much notice as possible when an appointment must be rescheduled or cancelled;
  • Understand that emergencies arise for your providers and that your appointments may be unavoidably delayed as a result;
  • Respect staff and providers;
  • Follow the instructions and guidelines given by your providers;
  • Show your ID card and pay your visit fees to the provider at the time the service is rendered;
  • Become informed about our policies and procedures, as well as the office policies and procedures of your providers, so that you can make the best use of the services that are available under your contract;
  • Abide by the conditions set forth in your contract.

There are only certain times during the year when you may voluntarily end your membership in our Plan. The key time to make changes is the Medicare fall open enrollment period (also known as the "Annual Election Period"), which occurs from October 15 - December 7. This is the time to review your health care and drug coverage for the following year and make changes to your Medicare health or prescription drug coverage. Any changes you make during this time will be effective January 1. Certain individuals, such as those with Medicaid, those who get extra help or who move, may make changes at other times. For more information on other times during the year you may be eligible to voluntarily end your membership, please call Customer Care toll-free at 1-800-514-6930 (TTY/TDD 1-800-662-1220) 8 a.m. to 8 p.m., Monday – Friday. From Oct. 1 to Mar. 31, representatives will be available seven days a week from 8 a.m. to 8 p.m.

If you wish to leave Simply Prescriptions and you are not enrolling in another Medicare Prescription Drug Plan, you will need to submit a disenrollment request. You may send your request in writing to us at: PO Box 546, Buffalo, NY 14201-0546. Or, you may send your request to our fax number at 716-843-7860. Please be sure to sign and date your letter.

To obtain a copy of a disenrollment form, please call Customer Care toll-free at 1-800-514-6930 (TTY/TDD 1-800-662-1220) 8 a.m. to 8 p.m., Monday – Friday. From Oct. 1 to Mar. 31, representatives will be available seven days a week from 8 a.m. to 8 p.m..

During the fall open enrollment period, if you want to end your membership in our plan this is what you need to do:

  • If you are planning on joining another Medicare Prescription drug plan: Simply join the new Medicare Prescription drug plan. You will be disenrolled automatically from our plan when your new coverage begins on January 1.
  • If you are planning on enrolling in a Medicare Advantage plan: Request enrollment in the new plan. In most cases, you will be disenrolled automatically when your new plan's coverage begins on January 1.

Exception: If you are joining a Medicare Advantage Private Fee-for-Service plan and that plan does not offer drug coverage, or a Medicare Medical Savings Account (MSA) Plan, enrollment will not automatically disenroll you from our plan. Therefore, you will need to do the following:

  • To join a new Medicare prescription drug plan,
    • simply join the new Medicare prescription drug plan, or
    • If you do not want Medicare prescription drug coverage, find out how to request disenrollment from our plan by calling Customer Care toll-free at 1-800-514-6930 (TTY/TDD 1-800-662-1220) 8 a.m. to 8 p.m., Monday – Friday. From Oct. 1 to Mar. 31, representatives will be available seven days a week from 8 a.m. to 8 p.m. You may also call 1-800-MEDICARE (1-800-633-4227) to request disenrollment from our plan. TTY/TDD users should call 1-877-486-2048. Your enrollment in Original Medicare will be effective January 1.
  • If you would like to end your membership without joining any other Medicare health or prescription drug plan: Contact our Customer Care department to find out how to request disenrollment. You may also call 1-800-MEDICARE (1-800-633-4227)(24 hours a day, 7 days a week) to request disenrollment from our plan. TTY/TDD users should call 1-877-486-2048. Your enrollment in Original Medicare will be effective January 1.

Important: If you disenroll from a Medicare prescription drug plan and go without creditable prescription drug coverage (coverage that is at least as good as Medicare drug coverage), you may have to pay a penalty if you join later.

Simply Prescriptions may disenroll you for the following reasons:

  • You do not stay continuously enrolled in Medicare Part A or Part B (or both)
  • If Simply Prescriptions is no longer contracting with Medicare or leaves your service area
  • If you move out of the Simply Prescriptions service area or are away from the service area for more than 6 months
  • You materially misrepresent third-party reimbursement
  • You fail to pay your Plan premium
  • You engage in disruptive behavior, provided fraudulent information when you enrolled or abuse your enrollment card
  • If you let someone else use your Plan membership card to get medical care

If we end your membership in our Plan we will tell you our reasons in writing and explain how you may file a complaint against us if you want to.

We cannot ask you to leave the plan because of your health.
No member of any Medicare Prescription Drug Plan may be asked to leave the Plan for any health-related reasons or the number of prescriptions a member takes. If you ever feel that you are being encouraged or asked to leave Simply Prescriptions because of your health, you should call 1-800-MEDICARE (1-800-633-4227)(24 hours a day, 7 days a week); TTY/TDD 1-877-486-2048 - the national Medicare help line.

A plan may not be available to you the following year because by law, plan sponsors can choose not to renew their contract with CMS or reduce their service area and CMS may also refuse to renew the contract, thus resulting in a termination or non-renewal.

Simply Prescriptions contracts with the Federal Government and is a PDP plan with a Medicare contract. Enrollment in Simply Prescriptions depends on contract renewal. Submit feedback about your Medicare prescription drug plan at www.Medicare.gov or by contacting the Medicare Ombudsman. _.

This page last updated 10-01-2024.

 

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