Member Rights

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Regardless of how an individual obtains their Medicare benefit, every member has certain rights and protections as it relates to their health care. The following are the rights and protections for everyone with Medicare:

• Be treated with dignity and respect at all times.

• Be protected from discrimination. Every company or agency that works with Medicare must obey the law. They can't treat you differently because of your race, color, national origin, disability, age, religion, or sex.

• Have your personal and health information kept private.

• Get information in a way you understand from Medicare, health care providers, and, under certain circumstances, contractors.

• Get understandable information about Medicare to help you make health care decisions, including:

  • What’s covered.

  • What Medicare pays.

  • How much you have to pay.

  • What to do if you want to file a complaint or appeal.

  • Have your questions about Medicare answered.

  • Have access to doctors, specialists, and hospitals.

  • Learn about your treatment choices in clear language that you can understand and participate in treatment decisions.

• Get health care services in a language you understand and in a culturally-sensitive way.

• Get Medicare-covered services in an emergency.

• Get a decision about health care payment, coverage of services, or prescription drug coverage.

• When a claim is filed, you will get a notice letting you know what will and won’t be covered.

• If you disagree with the decision of your claim, you have the right to file an appeal.

• Request a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug coverage.

• If you disagree with a decision about your claims or services, you have the right to appeal.

• File complaints (sometimes called "grievances"), including complaints about the quality of your care.

In addition to the protections described above, every member of Solis has the following protections.

• Choose health care providers within the Solis plan, so you can get the health care you need.

• Get a treatment plan from your doctor.

• If you have a complex or serious medical condition, a treatment plan lets you directly see a specialist within the Solis plan as many times as you and your doctor think you need.

• Women have the right to go directly to a women's health care specialist without a referral within the Solis plan for routine and preventive health care services.

• Know how your doctors are paid.

• When you ask Solis health plan how it pays its doctors, Solis must tell you.

• Medicare doesn't allow Solis to pay doctors in a way that could interfere with you getting the care you need.

• Request an appeal to resolve differences with Solis.

• File a complaint (called a "grievance") about other concerns or problems with Solis.

• Get a coverage decision or coverage information from Solis before getting services.

• Request materials and/or assistance in language and formats other than written English, such as Braille, Audio or Sign language, if necessary.

• Expect that Solis will provide its Notice of Privacy Practices without his/her request.

Member Responsibilities

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Members have a responsibility to:

1. Notify the Company and Health Care Providers of any changes that may affect his/her participation, health care needs or benefits. Some examples include, but are not limited to, the following:

   • Change of address or phone number;

   • Other health insurance;

   • Special medical condition;

   • Change in PCP;

   • Relocation to another county or state.

2. Ensure his/her benefits are up to date and do not expire.

3. Ensure that all information is up to date.

4. Cooperate with the Company and Health Care Providers and follow guidelines given to him/her about the Company.

5. Follow the Health Care Provider’s instructions about his/her care. This includes:

   • Making appointments with the Health Care Provider

   • Canceling appointments when he/she cannot make the appointment; and

   • Contacting the Company when he/she has questions.

6. Treat Health Care Providers and staff with respect and dignity.

7. Discuss and agree upon goals for treatment with the Health Care Provider to the degree he/she is able to do so.

8. Communicate with his/her Health Care Provider to understand his/her health problems to the degree he/she is able to do so.

SOLIS Health Plans is a HMO with a Medicare contract and a contract with the Florida Medicaid Program. Enrollment in SOLIS Health Plans, Inc. depends on contract renewal. Atención: Si usted hable español, servicios de asistencia en español, de forma gratuita, están disponible para usted. Llame al 1 (844) 447-6547 (TTY 711).

Best Available Evidence (BAE)

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Centers for Medicare and Medicaid Services (CMS), created a policy to ensure Plan Sponsors like SOLIS accept certain forms of evidence indicating a member is eligible for low-income subsidy (LIS) even if our system does not indicate that information. To learn more about CMS Best Available Evidence (BAE) policy, click the following link https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Best_Available_Evidence_Policy.html