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3/19/2024

Member Rights and Responsibilities

Your Highmark Wholecare Medicaid and Medicare Assured patients have certain rights and responsibilities as members of our plan. To detail those rights and responsibilities in full, Highmark Wholecare maintains a Members’ Rights and Responsibilities statement, which is reviewed and revised annually. 

Highmark Wholecare and its practitioner network do not, and are prohibited from excluding or denying benefits to, or otherwise discriminating against, any eligible and qualified individual regardless of race, color, national origin, religious creed, sex, sexual orientation, gender identity, disability, English proficiency or age.  Some additional rights and responsibilities include:

Members have the right to:

  • Receive information from Highmark Wholecare in a way that works for them (in languages other than English, in Braille, in large print, or other alternate formats, etc.)
  • Be treated with fairness and respect at all times.
  • Receive timely access to covered services and drugs.
  • Have personal health information kept private and confidential.
  • Receive information from Highmark Wholecare about the Plan, its network of providers, covered services, and rights.
  • Have Highmark Wholecare support their right to make decisions about their care.
  • Issue a complaint and/or to ask Highmark Wholecare to reconsider decisions the Plan has made by filing an appeal.
  • Receive a written explanation in the event a medical service or Part D drug is not covered, or if their coverage is restricted in some way.
  • Know their treatment options and risks in a way they can understand.
  • Participate in decisions about their health care, including the right to refuse any recommended treatment.
  • Be given instructions about what is to be done if they are not able to make decisions for themselves. This includes maintaining an advance directive, such a living will or a power of attorney for health care. 
  • Contact the Department of Health and Human Services’ Office for Civil Rights if they believe their rights have not been respected due to their race, color, national origin, religious creed, sex, sexual orientation, gender identity, disability, English proficiency or age.

Members are responsible for:

  • Getting familiar with their covered services and the rules they must follow to get these covered services.
  • Informing Highmark Wholecare if they have any other health insurance coverage or prescription drug coverage in addition to our plan.
  • Telling their doctor and other health care providers that they are enrolled in our plan.
  • Helping their doctors and other practitioners care for them by providing needed information, asking questions, and following through on their care.
  • Respecting the rights of other patients and to act in a way that helps the smooth running of their doctor’s office, hospitals, and other offices.
  • Paying Medicare premiums, and any applicable copayments or late enrollment penalties.
  • Notifying Highmark Wholecare if they move, regardless of whether it is outside or inside of Highmark Wholecare’s service area.

The Member Rights and Responsibilities Statement can be found in the Medicaid Member Handbook,  the Evidence of Coverage, or on our website at Medicaid Member Resources and Medicare Member Resources. For more information, please call Provider Services at:  

  • Medicaid: 1-800-392-1147
  • Medicare Assured: 1-800-685-5209
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Legal Information

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.