Part 8 – Other Health Plan Provisions (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 79 provider does not act as an agent on behalf of or for Blue Cross Blue Shield HMO Blue. And, Blue Cross Blue Shield HMO Blue does not act as an agent for health care providers who participate in your health care network and have payment agreements with Blue Cross Blue Shield HMO Blue or for any other health care providers. Blue Cross Blue Shield HMO Blue will not interfere with the relationship between health care providers and their patients. You are free to select or discharge any health care provider. Blue Cross Blue Shield HMO Blue is not responsible if a provider refuses to furnish services to you. Blue Cross Blue Shield HMO Blue does not guarantee that you will be admitted to any facility or that you will get a special type of room or service. If you are admitted to a facility, you will be subject to all of its requirements. This includes its requirements on admission, discharge, and the availability of services. Assignment of Benefits You cannot assign any benefit or monies due from this health plan to any person, corporation, or other organization without Blue Cross Blue Shield HMO Blue’s written consent. Any assignment by you will be void. Assignment means the transfer of your rights to the benefits provided by this health plan to another person or organization. There is one exception. If Medicaid has already paid the health care provider, you can assign your benefits to Medicaid. Authorized Representative and Legal Representative You may choose to have another person act on your behalf concerning your health care coverage in this health plan. Some examples are a designated authorized representative or a documented legal representative. An authorized representative is a person you have chosen to help with your health care issues and to whom Blue Cross Blue Shield HMO Blue is allowed to disclose and discuss your protected health information (PHI). An authorized representative is not a person who has legal authority to act on your behalf. A legal representative is a person who has legal authority to act on your behalf in making decisions about your health care. They may be someone who has legal authority for: power of attorney for health care; guardianship; conservatorship; executor of estate; or health care proxy. A legal representative may also be a person documented through a court order to act on your behalf in making decisions about your health care. To designate an authorized representative or document a legal representative, you must let Blue Cross Blue Shield HMO Blue know in writing by completing the appropriate form(s). To get copies of these forms, you can call the Blue Cross Blue Shield HMO Blue customer service office. The toll free phone number to call is shown on your ID card. You may also log on to the Blue Cross Blue Shield HMO Blue Web site at www.bluecrossma.org to get a copy of these forms. In some cases, Blue Cross Blue Shield HMO Blue may consider your health care facility or your physician or other health care provider to be your authorized representative. For example, Blue Cross Blue Shield HMO Blue may tell your hospital that a proposed inpatient admission has been approved. Or, Blue Cross Blue Shield HMO Blue may ask your physician for more information if more is needed for Blue Cross Blue Shield HMO Blue to make a decision. Blue Cross Blue Shield HMO Blue will consider the health care provider to be your authorized representative for emergency medical care. Blue Cross Blue Shield HMO Blue will continue to send benefit payments and written communications regarding your health care coverage according to Blue Cross Blue Shield HMO Blue’s standard practices, unless you specifically ask Blue Cross Blue Shield HMO Blue to do otherwise. Changes to Health Plan Coverage Blue Cross Blue Shield HMO Blue may change the provisions of your coverage in this health plan. (When you are enrolled in this health plan as a group member, the plan sponsor may also change a part of the group contract.) For example, a change may be made to the cost share amount that you must pay for