Your Rights and Responsibilities as a Member of our Plan

HealthSun must comply with applicable laws that protect you from discrimination and unfair treatment.

You have the right to be treated with courtesy, dignity, fairness, and respect at all times.

HealthSun does not discriminate on the basis of race, ethnicity, national origin, religion, sex, age, disability, health status, medical history, genetic information, or any other status protected by applicable law.

If you believe you have been treated unfairly, discriminated against, or your rights have not been respected, you may contact HealthSun Member Services at 1-877-336-2069 (TTY: 1 877-206-0500) or write to the HealthSun Civil Rights Coordinator at 11430 NW 20th Street, Suite 300, Miami, FL 33172. You may also contact the U.S. Department of Health and Human Services, Office for Civil Rights for assistance.

As a HealthSun member, you have the right to choose a Primary Care Provider (PCP) from the plan’s network to provide and coordinate your covered services.

You have the right to change your Primary Care Provider (PCP) for any reason, subject to applicable plan requirements and provider availability.

For help choosing or changing your PCP, please contact HealthSun Member Services at 1-877-336-2069 (TTY: 1-877-206-0500).

You also have the right to receive appointments and covered services within a reasonable amount of time. This includes timely access to specialists when you need that care and timely access to covered prescription drugs.

If you believe you are not receiving your medical care or covered prescription drugs within a reasonable amount of time, please contact HealthSun Member Services.

Federal and state laws protect the privacy of your medical records and personal health information.

HealthSun protects your personal health information as required by applicable law.

Your personal health information may include information you provided when you enrolled in the plan, as well as your medical records and other health-related information.

HealthSun takes steps to help ensure that unauthorized individuals do not see, use, or change your protected health information except as permitted or required by law.

In some situations, HealthSun may need your written authorization before sharing your health information. In other situations, disclosure may be permitted or required by law without your written authorization.

For more information about how HealthSun protects your health information, please refer to the HealthSun Notice of Privacy Practices.

You have the right, as permitted by law, to access medical or health information maintained by the plan and to request a copy of your records.

You may also have the right to request that certain information be corrected or amended.

You have the right to receive information about certain disclosures of your health
information as required by law.

If you have any questions or concerns about the privacy of your personal health information or your rights regarding your records, please contact HealthSun Member Services at 1-877-336-2069 (TTY: 1-877-206-0500), or refer to the HealthSun Notice of Privacy Practices.

You have the right to receive information about HealthSun Health Plans, your benefits, and your coverage in a way you can understand.

This information may include:

• Covered medical services and prescription drug coverage.
• Applicable costs, copayments, coinsurance, premiums, and other member financial responsibilities.
• Participating physicians, other health-care providers, and pharmacies.
• Rules you must follow to receive covered services.
• Coverage restrictions or limitations.
• Information about the qualifications of participating providers and pharmacies, as applicable.
• Other plan information available to members.

For detailed information about your coverage, please review your current Evidence of Coverage (EOC) and other applicable HealthSun plan materials.

You have the right to receive information about the providers and pharmacies participating in the HealthSun network.

For a current list of participating providers and pharmacies, please refer to the HealthSun Provider Directory and Pharmacy Directory or contact HealthSun Member Services at 1-877-336-2069 (TTY: 1-877-206-0500).

Your Evidence of Coverage explains:

• Which medical services are covered.
• What services are not covered or may have restrictions.
• The rules you must follow to obtain covered services.
• Your applicable cost-sharing responsibilities.
• Your prescription drug benefits, if included in your plan.

If you have questions about your coverage or the rules that apply to your plan, please contact HealthSun Member Services.

If a medical service, treatment, item, or prescription drug is not covered for you, or if your coverage is restricted in some way, you have the right to receive an explanation from HealthSun.

If you disagree with a coverage decision, you have the right to ask HealthSun to review or reconsider that decision through the applicable appeal process.

Your Evidence of Coverage explains your rights and the procedures for requesting coverage decisions, filing appeals, and making complaints or grievances.

You have the right to receive a full explanation of any charges that may be billed to you, including any applicable member financial responsibility.

If you have questions about a bill, payment responsibility, coverage decision, appeal, complaint, or grievance, please contact HealthSun Member Services at 1-877-336-2069 (TTY: 1-877-206-0500).

You have the right to receive information from your physicians and other health-care providers about your medical condition and treatment options in a way you can
understand.

You have the right to participate fully with your providers in decisions about your health care.

Your rights include:

• Knowing about your treatment choices. You have the right to receive information about medically necessary and appropriate treatment options recommended for your condition, regardless of cost or benefit coverage.
• Knowing about risks and alternatives. You have the right to receive information about the risks, benefits, and alternatives associated with your care.
• Participating in decisions. You have the right to participate with your physicians and other providers in making decisions about your care.
• Refusing treatment. You have the right to refuse recommended treatment, consistent with applicable law, after receiving information about the possible consequences of your decision.
• Receiving an explanation if coverage is denied. You have the right to receive information about coverage decisions and how to request reconsideration or appeal.

You have the right to make decisions in advance about the medical care you would want if you become unable to make health-care decisions for yourself.

These instructions are generally called advance directives and may include documents such as a living will or a health-care power of attorney, depending on applicable law.

You have the right to:

• Receive information and assistance regarding advance directives.
• Choose whether you want to complete an advance directive.
• Name an authorized person to make health-care decisions for you as permitted by law.
• Provide written instructions about the care you would want if you are unable to make decisions for yourself.
• Have your advance directive considered by your health-care providers, as required by law.

Your decision about whether to complete an advance directive will not affect your right to receive covered care.

If you have any questions about advance directives, please contact HealthSun Member Services at 1-877-336-2069 (TTY: 1-877-206-0500).

If you have a concern or problem involving your care, covered services, treatment by the plan or a provider, or another aspect of your membership, you have the right to make a complaint or file a grievance.

You also have the right to appeal certain coverage decisions and ask HealthSun to reconsider a decision, as applicable.

You may file a complaint if you believe you have not been treated with courtesy, dignity, fairness, or respect, or if you believe your rights have not been respected.
HealthSun must treat you fairly when you request a coverage decision, file an appeal, make a complaint, or file a grievance.

Your Evidence of Coverage provides additional information about coverage decisions, appeals, complaints, and grievances, including applicable procedures and timeframes. For assistance, please contact HealthSun Member Services at 1-877-336-2069 (TTY: 1-877-206-0500).

As a HealthSun member, you are responsible for understanding your benefits, coverage, and the rules you must follow to receive covered services. Your responsibilities include:

• Providing complete and accurate information. Give your physicians and other health-care providers the information they need about your health, ask questions when you do not understand something, and participate in your care.
• Following agreed-upon care instructions. Follow the treatment plan and instructions that you and your providers have agreed upon.
• Informing providers that you are enrolled in HealthSun. Show your HealthSun member identification card when receiving covered services, as appropriate.
• Respecting the rights of other members. Be considerate of other members and patients.
• Respecting physicians and other health-care providers. Treat your physicians, providers, and their staff with courtesy and respect.
• Paying applicable amounts owed. Pay any applicable premiums, copayments, coinsurance, late enrollment penalties, and other member financial responsibilities, as required by your plan.
• Keeping your information current. Notify HealthSun of applicable demographic changes or updates, including changes to your address or contact information.
• Understanding your plan materials. Review your Evidence of Coverage and other HealthSun plan materials so you understand your covered services and applicable plan rules.
• Contacting HealthSun when you need assistance. Contact HealthSun Member Services with questions, concerns, problems, or suggestions.

If you have any questions about your rights or responsibilities, your benefits, coverage, or any other aspect of your HealthSun membership, please contact HealthSun Member Services at 1-877-336-2069 (TTY: 1-877-206-0500).

You may also refer to your current Evidence of Coverage and other applicable HealthSun plan materials for additional information.