Member Rights and Responsibilities
Blue Cross and Blue Shield of New Mexico wants to make sure our members get the health care they need. We also want to make sure our members’ rights are respected.
Your Rights
As a BCBSNM member, you have the right to:
- Health care when medically necessary. This health care can be determined by a medical professional or BCBSNM. You should be able to:
- Get health care that is free from discrimination.
- Be treated with respect and dignity and have your right to privacy recognized.
- Choose a PCP or provider from the BCBSNM network.
- Refuse care from certain providers.
- Know that some health care requires prior authorization from BCBSNM. If you and your provider do not get approval before you get care, it may not be covered by your health plan.
- Be given information about:
- BCBSNM's member rights and responsibilities policy. You should be able to give input about this policy.
- Policies and procedures for products, services, providers, appeals, and other information about the company.
- How to access covered health care and the providers in our network.
- Ask for and receive a paper copy of the Privacy Notice from the New Mexico Health Care Authority (HCA).
- Know that your MCO complies with applicable federal and state laws. These include:
- Civil Rights Act of 1964.
- Age Discrimination Act of 1975.
- Rehab Act of 1973.
- Education Amendments of 1972.
- Americans with Disabilities Act (ADA).
- Section 1557 of the Patient Protection and Affordable Care Act.
- Choose a health plan and/or switch health plans without threats or harassment.
- Be given the name and professional background of anyone involved in your care. This includes the name of who primarily handles your care.
- Choose a someone to make decisions about your care for you. This can be done by you or your legal guardian.
- Have an interpreter present when you do not speak or know the language that is being spoken.
- Work with your provider to decide on your health care. You should be able to:
- Gain knowledge of your physical and/or mental condition.
- Be involved in your treatment plan.
- Be able to refuse treatment and be told what may happen to your health if you do refuse. The risks should be explained in a language you understand.
- Family members, legal guardians, representatives or decision-makers also have this right, as appropriate.
- Talk with your provider about treatment options and alternatives. This should be done regardless of cost or benefit coverage. The information from you and your provider should be documented in your medical record. If you cannot understand the information, it should be explained to you. It should also be explained to your family, guardian, representative, or surrogate decision-maker.
- Give informed consent for medical care for physical and/or mental health conditions.
- Decide on advance directives for your health care. These decisions can be made by you or your legal guardian as allowed by law.
- Access your medical records as allowed by applicable federal and state laws. This means that you (and your legal guardian if you have one) have the right to:
- Your private records.
- Request to make a change to your records if you feel they are incomplete or wrong.
- Request that BCBSNM limit access to your medical records.
- Be notified if accidental disclosure occurs.
- Ask for a second opinion from another BCBSNM provider. This can be done by you or your legal guardian.
- File a grievance or appeal about BCBSNM or the care that you received. You should get an answer within a reasonable time. Complaints can be filed with BCSNM and/or HCA without fear of retaliation. You can also request a Fair Hearing with HCA for items that have been appealed.
- Be promptly notified when there are changes in benefits, services, or the provider network.
- Not be harassed by BCBSNM or its network providers during contractual disputes between BCBSNM and providers.
- Be free from any form of restraint or seclusion used to coerce, discipline, or retaliate. This is specified in federal or New Mexico regulations on the use of restraints and seclusion.
- Exercise your rights without concern that care will be negatively affected.
Your Responsibilities
As a BCBSNM member, you and your representative are responsible to:
- Give complete health information to help your provider give you the care you need.
- Follow the instructions and treatment plan you get from your provider. This may include medicines, diet, and exercise.
- Do your best to know about your physical health, long-term care, and/or mental health and work with your provider to come up with treatment goals.
- Make appointments ahead of time for provider visits
- Keep your appointments and be on time for them.
- Call your provider to reschedule or cancel at least 24 hours before your appointment.
- Tell your providers if you don't understand your health care.
- Treat your provider and other health care staff with respect and courtesy.
- Show your member ID card to each provider before you get medical care (or you may be billed for the service).
- Know the name of your primary care provider (PCP). You should have your PCP arrange your care.
- Call your PCP or the 24/7 Nurseline before you go to an emergency room (ER). They can help you if you need treatment for something that is not life-threatening. But you should go to an ER if:
- You have a severe medical condition that is life-threatening or could cause permanent damage your health.
- You are having thoughts of harm to yourself or others.
- Provide information to New Mexico HCA and BCBSNM of your current:
- Mailing address.
- Phone number (include any land line and cell phone, if available).
- Emergency contact information.
- Email address (if available).
- Tell New Mexico HCA and BCBSNM about changes to your phone number or address.
- Tell BCBSNM if you have other health insurance, including Medicare.
- Give your PCP a copy of your living will and advance directives. These can pertain to your physical or mental health care, and/or long-term care. They should be part of your medical records.
- Review and follow the .
