Our plan must honor your rights as a plan member. You have the following rights to help protect you:
  • We must provide information in a way that works for you (such as languages other than English, Braille, large print, or other alternate formats, etc.).
  • We must always treat you with fairness, respect, and dignity.
  • We must ensure that you get timely access to your covered services and drugs.
  • We must protect the privacy of your personal health information.
  • We must give you information about the plan, its network of providers, your covered services, and your rights and responsibilities.
  • You have the right to participate with practitioners in making decisions about your care.
  • You have the right to candidly discuss appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
  • You have the right to make complaints about our organization or the care we provide and to appeal (ask us to reconsider) our decisions.
  • You have the right to know the number of and what happened to appeals, grievances, and exceptions filed by our Members, which you may find out by asking us to send you this information.
  • You have the right to make recommendations and get more information about your rights and responsibilities.
You have some responsibilities as a member of the plan:
  • Get familiar with your covered services and the rules you must follow to get these covered services.
  • If you have any other health insurance or prescription drug coverage besides our plan, you are required to tell us.
  • Tell your doctor and other healthcare providers that you are enrolled in our plan.
  • Help your plan, doctors and other providers assist you by giving them information (to the extent possible) they might need, to provide you with care.
  • Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree you are able.
  • Follow through on the care that you have agreed to with your practitioners.
  • Be considerate.
  • Pay what you owe.
  • Tell us if you move.
  • Call Member Services for help if you have questions or concerns.
  • If you have any questions about your treatment or prescribed medications, you should ask your doctor.
  • If you do not understand something on your Explanation of Benefits statement, you should call our Customer Service.
  • If you disagree with a service or charge on your Explanation of Benefits statement, you should call our customer Service.
  • If you believe a provider, supplier, or vendor has potentially committed health care fraud, waste, or abuse, you should call the Compliance/FWA Hotline toll-free at (855) 730-7925 or send an email to compliancehotline@ulthp.com or investigatefwa@ulthp.com.
You also have certain Rights and Responsibilities if you disenroll:
  • Until your membership ends, you must keep getting your medical services and drugs through our plan.
  • Until your membership ends, you are still a member of our plan.
  • You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends.
  • If you are hospitalized on the day that your membership ends, you will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).
  • We cannot ask you to leave our plan for any reason related to your health.
  • You have the right to make a complaint if we end your membership in our plan.
Ultimate Health Plans must end your membership in the plan if any of the following happens:
  • If you are not continuously enrolled in Medicare Part A and/or Part B.
  • If you move out of the service area.
  • If you are away from our service area for more than six months.
    • If you move or take a long trip, you need to call Member Services to find out if your location is in our plan's area.
  • If you become incarcerated (go to prison).
  • If you lie or withhold information about other insurance you have that provides prescription drug coverage.
  • If you intentionally give us incorrect information when enrolling in our plan, that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
    • If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.
  • If you are required to pay the extra Part D amount because of your income, and you do not pay it, Medicare will disenroll you from our plan and you will lose your prescription drug coverage.
  • If you are enrolled in our Dual Special Needs Plan (D-SNP), and you lose your Medicaid eligibility, you may be eligible to enroll in one of our other plans.
Ultimate Health Plans is Accredited by the National Committee for Quality Assurance (NCQA). As an NCQA-accredited health plan, we are required to distribute a special rights and responsibilities statement. Ultimate Health Plans Members have:
  • A right to receive information about the organization, its services, its practitioners and providers, and member rights and responsibilities.
  • A right to be treated with respect, recognition of your dignity and right to privacy.
  • A right to participate with practitioners in making decisions about your health care.
  • A right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
  • A right to voice complaints or appeals about the organization or the care it provides.
  • A right to make recommendations regarding the organization’s member rights and responsibilities policy.
  • A responsibility to supply information (to the extent possible) that the organization and its practitioners and providers need to provide care.
  • A responsibility to follow plans and instructions for care that you have agreed to with your practitioners.
  • A responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.

For more information on Member Rights and Responsibilities including disenrollment procedures and situations, please review Ultimate Health Plans Evidence of Coverage (EOC).

For a printable version of the information above, please download this file:

Clinical Practice Guidelines

These Preventive Care Guidelines address routine health exams, diagnostic checkups, counseling and immunizations recommended for adults. Discuss these general guidelines with your doctor to stay as healthy as possible throughout the year.