Rights and Responsibilities
Your Rights
You have the right to:
- Be treated with respect and in a dignified way.
- Get written information from First Medical in English and Spanish. You also have the right to receive any written information in other languages or other alternative formats. After you inform First Medical, you have the right to receive all written information in the same format or language, unless you indicate otherwise to First Medical.
- Get information about First Medical, health care facilities, health care professionals, health services covered, and how to access services.
- Choose a Primary Medical Group, your PCP, and other doctors and providers within your Preferred Provider Network.
- Choose a dentist and a pharmacy among First Medical’s network.
- Contact your doctors when you want to and in private.
- Get proper medical care for you, when you need it. This includes getting emergency services, twenty-four (24) hours a day, seven (7) days a week.
- Be told in an easy-to-understand way about your care and all of the different kinds of treatment that could work for you, no matter what they cost or even if they aren’t covered.
- Help to make decisions about your health care. You can turn down care.
- Ask for a second opinion for a diagnosis or treatment plan.
- Make an Advanced Directive. Look at Part 6 of your Beneficiary Manual for more information.
- Get care without fear of physical restraint or seclusion used for bullying, discipline, convenience or revenge.
- Ask for and get information about your medical records as the federal and state laws say. You can see your medical records, get copies of your medical records, and ask to correct your medical records if they are wrong.
- File a complaint or an appeal about the medical care or First Medical services. Look at Part 7 of your Beneficiary Manual for more information. The complaint can be filed in First Medical’s office or in the Patience Advocate Office.
- Get services without being treated in a different way because of race, color, birthplace, language, sex, age, religion, or disability. You have a right to file a complaint if you think you have been treated unfairly. If you file a complaint or appeal, you have the right to keep getting care without fear of bad treatment from First Medical, your providers, or the Vital Plan.
- Choose an Authorized Representative to be involved in making decisions.
- Provide informed consent.
- Only have to pay the amounts for services listed in Part 4 of your Beneficiary Manual. You can’t be charged more than those amounts.
- Be free from harassment by First Medical or its Providers Network with respect to contractual disputes between First Medical and its Providers.
Consumer Civil Rights Notice
FMHP_23_136_INT_E_Aviso-sobre-los-Derechos-Civiles-de-los-Consumidores_English-Approved-11302023Your Right to Privacy (HIPAA)
Your health information is private. The law says that ASES and First Medical must protect your information. ASES and First Medical can share your information for your care, to pay your health claims, and to run the program. But we cannot share your information with others unless you authorize us. If you want to know more about what information we have, how we can share it, or what to do if you don’t want your health information shared with certain people, call First Medical at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805.
Notificacion-de-Practicas-de-Privacidad_Compliance-2024_EnglishYour Responsibilities
You have the responsibility to:
- Understand the information in your Beneficiary Manual and other papers that First Medical sends you.
- Give your doctor your health records and let them know about any changes in your health so that they can take care of you.
- Follow your doctor’s instructions. If you can’t follow your doctor’s instructions, let them know.
- Let your doctor know if you don’t understand something.
- Help to make decisions about your health care.
- Communicate your Advance Directive so your doctors know how you want to be treated if you are too sick to say so.
- Treat your health care provider and First Medical staff with respect and dignity.
- Let First Medical know if you have another insurance company that should pay your medical care.
- Let ASES know if you find out about a case of Fraud and Abuse in the Vital Plan.
Advance Directives
Advance Directives are your written wishes about what you want to happen, if you get too sick to be able to say. The written document that states your Advance Directives is called a Prior Declaration of Will Regarding Medical Treatment. You can use any word: Advance Directive or Advance Directives Regarding Medical Treatment.
Your doctor can give you information on how to make an Advance Directive. If you are in the hospital, the hospital staff can also give you information on Advance Directives. You can also call the Senior Citizens Advocate Office at (787) 721-6121. They have free information about Advanced Directives.
A Durable Power of Attorney is a paper that lets you name another person to make medical decisions for you. This person can only make decisions if you are too sick to make your own. He or she can say your wishes for you if you can’t speak for yourself. Your illness can be temporary.
You do not have to fill out these papers for an Advance Directive or a Power of Attorney. It is your choice. You may want to talk to a lawyer or friend before you fill out these papers.
To make all of these papers legal, you need to have a lawyer watch you sign the form. Instead of a lawyer, you could also have your doctor plus two additional witnesses watch you sign the form. The two additional witnesses have to be of legal age and they can’t be related to you by blood or marriage.
Once the papers are signed by everyone, it is your rule about what you want to happen to you if you get too sick to be able to say. It stays like this unless you change your mind.
These papers will only be used if you get too sick to be able to say what you want to happen. As long as you can still think for yourself, you can decide about your health care yourself.
Give a copy of the papers to your PCP and to your family members so they know what you want to happen to you, if you are too sick to say.
If you feel that First Medical or your doctors aren’t complying with your wishes, or if you have any complaints, you have the right to call the Vital Plan Call Center at 1-800-981-2737 or the Puerto Rico Patient Advocate Office at 1-800-981-0031. The phone call is free.
What is Fraud, Waste, and Abuse?
A deliberate act, intentional deception or manipulation made by a person with the knowledge that deception could result in some unauthorized benefit or financial gain for himself or another person.
It includes any act that constitutes Fraud under Federal or Puerto Rico laws.
You are responsible for reporting any situation that you understand may involve fraud against the Medicaid Program.
Fraud
An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. Includes any activity that constitutes fraud under applicable federal or state law.
Waste
Thoughtless or careless spending, mismanagement, or abuse of resources to the detriment (or potentially to the detriment) of the United States Government or FMHP resources. Waste also includes incurring unnecessary costs resulting from inefficient or ineffective systems or controls practices.
Abuse
Abuse is inappropriate behavior. It occurs when the practices of the Provider or beneficiary are inconsistent with fiscal, commercial or medical practices and result in an unnecessary cost to the Government Health Plan.
Some examples are:
- A person lies about facts in order to obtain or keep the Vital Plan coverage.
- A doctor bills you or makes you pay cash for covered services.
- One person uses someone else’s Vital Plan Card.
- A doctor bills you for services you didn’t get.
- A person sells or gives medicine to another person.
You can also help prevent Fraud, Waste, and Abuse.
Here are some things you can do:
- Do not give your Vital Plan Card to anyone else.
- Learn about your Vital Plan benefits.
- Keep records of your doctor visits, lab tests, and medications. Make sure you don’t get repeat services.
- Make sure your information is correct on a form before you sign it.
- Request and review the quarterly summary of services you receive. You can request a summary of services directly from First Medical.
How to report Fraud, Waste, and Abuse?
If you learn of or have been the victim of a possible case of Fraud, Waste or Abuse, you should tell us. You can call First Medical, 1-844-347-7800 TTY/TDD 1-844-347-7805, the Office of the Patient Advocate at (787) 977-0909 or ASES through the Vital Plan Call Center at 1-800-981-2737. You do not need to tell us your name, we will keep your information private. You will not lose your Vital Plan coverage if you report Fraud, Waste, or Abuse.
If you want more information, you can visit the ASES website at www.planvitalpr.com in the guidance section on Fraud, Misuse or Abuse you can download the incident referral document which you can use to report any situation of Fraud, Waste and/or Abuse. In addition, this section contains contact information for all agencies you can call to report any Fraud, Waste and/or Abuse. Once you complete the ASES referral, you have the option to indicate whether you do not wish to be contacted and/or remain anonymous.
Your call or written communication will be treated confidentially and your coverage of the Government of Puerto Rico Health Plan will not be affected by this referral. If the investigation shows that Fraud, Waste, or Abuse was committed, the case will be referred to the appropriate authorities.