Rights & Responsibilities

Know your rights and responsibilities

As a member of Aetna Better Health℠ Premier Plan, you have rights and responsibilities. For your convenience, we’ve listed these below. You’ll want to read and understand each one. If you have questions, please ask your care manager or call Member Services toll-free at 1-855-676-5772 (TTY 711), 24 hours a day, 7 days a week.

Your rights

We must tell you about our benefits and your rights in a way that you can understand. this includes in languages other than English and in other formats -- including Braille, large print and other alternate formats.

To get information from us in a way that’s best for you, please call Member Services at 1-855-676-5772 (TTY:711).

Our plan has people and free language interpreter services available to answer questions for non-English speaking members. We can also give you information in Braille, in large print or other alternate formats. If you are eligible for Medicare because of a disability, we are required to give you information about the plan’s benefits that is accessible and appropriate for you.

If you have any trouble getting information from our plan because of problems related to language or a disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and tell them that you want to file a complaint. Members with hearing impairment, call (TTY 1-877-486-2048).

See your member handbook for a detailed list of your rights.

 

Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person’s race, ethnicity, national origin, religion, gender, sexual orientation, age, mental ability, behavior, mental or physical disability, health status, receipt of health care, use of services, claims experience, appeals, medical history, genetic information, evidence of insurability, or geographic location within the service area.

If you have a disability and need help with access to care, please call Member Services at 1-855-676-5772 (TTY: 711). If you have a complaint, such as a problem with wheelchair access, Member Services can help.

See your member handbook for a detailed list of your rights.

As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services. Call Member Services to learn which doctors are accepting new patients. You also have the right to go to a women’s health specialist (such as a gynecologist) without a referral.

As a plan member, you have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.

See your member handbook for a detailed list of your rights.

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

Your “personal health information” includes the personal information you gave us when you enrolled in this plan, as well as your medical records and other medical and health information.

The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice,” that tells about these rights and explains how we protect the privacy of your health information.

How we protect your health information
We make sure that unauthorized people don’t see or change your records. In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.

There are certain exceptions that don’t require us to get your written permission first. These exceptions are allowed or required by law. For example, we’re required to release health information to government agencies that are checking on quality of care.

Because you are a member of our plan through Medicare, we are required to give Medicare your health information, including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to federal statutes and regulations.

You have a right to see your medical records
You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your health care provider to decide whether the changes should be made.

You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your personal health information, please call Member Services.

See your member handbook for a detailed list of your rights.

As a member of Aetna Better Health℠ Premier Plan, you have the right to get several kinds of information from us, in a way that works for you. This includes getting the information in languages other than English. It also includes large print or in another format

If you want any of the following kinds of information, please call Member Services.

Information about our plan
This includes:

  • Financial information
  • How members rate the plan
  • The number of appeals made by members
  • How to leave the plan

Information about our network providers, including our network pharmacies
You have the right to get information about:

  • How to choose or change primary care providers
  • The qualifications of our network providers and pharmacies
  • How we pay the providers in our network

Information about your coverage and rules you must follow
You have the right to get information about:

  • Services and drugs covered by the plan
  • Limits to your coverage and drugs
  • Rules you must follow to get covered services and drugs

Information about why something is not covered and what you can do about it
You have the right to get information about:

  • Asking us to put in writing why something is not covered
  • Asking us to change to cange a decision we made
  • Asking us to pay for a bill you have received

See your member handbook for a detailed list of your rights.

You have the right to know your treatment options and participate in decisions about your health care. You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand.

You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:

  • To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely.
  • To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.
  • To say “no” when you don’t want a treatment. You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result.
  • To receive an explanation if you are denied coverage for care. You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. The Evidence of Coverage tells how to ask the plan for a coverage decision.

 

Doctors, hospitals, and other providers in our network cannot make you pay for covered services. They also cannot charge you if we pay for less than the provider charged us.

See your member handbook for a detailed listing of your rights.

No one can make you stay in our plan if you do not want to. You can leave the plan at any time. If you leave our plan, you will still be in the Medicare and Michigan Medicaid programs. You have the right to get most of your health care services through Original Medicare or a Medicare Advantage plan. You can get your Medicare Part D prescription drug benefits from a prescription drug plan or from a Medicare Advantage plan.

If there is another MI Health Link plan in your service area, you may also change to a different MI Health Link plan and continue to receive the coordinated Medicare and Michigan Medicaid benefits. You can get your Michigan Medicaid benefits through Michigan’s original (fee-for-service) Medicaid.

See your member handbook for a detailed listing of your rights.

You have the right to know your treatment options and make decisions about your health care
You have the right to get full information from your doctors and other health care providers when you get services. Your providers must explain your condition and your treatment choices in a way that you can understand.

You have the right to say what you want to happen if you are unable to make health care decisions for yourself
Sometimes people are unable to make health care decisions for themselves. Before that happens to you, you can :

  • Fill out a written form called an advance directive to give someone the right to make health care decisions for you
  • Give your doctors written instructions about how you want them to handle your health care if you become unable to make decisions for yourself

Now is a good time to write down your advance directives because you can make your wishes known while you are healthy. Your doctor’s office has an advance directive you fill out to tell your doctor what you want done.

What to do if your instructions are not followed
In Michigan, your advance directive has binding effect on doctors and hospitals. However, if you believe that a doctor or a hospital did not follow the instructions in your advance directive, you may file a complaint with the Michigan Department of Licensing and Regulatory Affairs, Bureau of Health Care Services at 1-800-882-6006.

You have the right to get information about appeals and complaints that other members have filed against our plan. To get this information, call Member Services at 1-855-676-5772 (TTY: 711).

What to do if you believe you are being treated unfairly or your rights are not being respected
If you believe you have been treated unfairly — and it is not about discrimination —you can get help in these ways or if you want more information about your rights:

  • Call Member Services at 1-855-676-5772 (TTY: 711).
  • Call the State Health Insurance Assistance Program (SHIP). In Michigan, the SHIP is called the Medicare/Medicaid Assistance Program (MMAP).
  • Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.
  • You can call the Medicaid Beneficiary Hotline at 1-800-642-3195.

See your member handbook for a detailed listing of your rights.

How to contact the MI Health Link Ombudsman program:

 

 

 

Your responsibilities

As an Aetna Better Health PremierSM Plan member, you have responsibilities. These responsibilities include:

Learn exactly what your covered services are and the rules you need to follow to get them.

See your member handbook for a complete list of your responsibilities.

 

If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you must tell us.

Please call Member Services to let us know. We are required to follow Medicare and Medicaid rules to make sure that you are using all of your coverage in combination when you get covered services from our plan.

This is called “coordination of benefits” because it involves coordinating the health and drug benefits you get from our plan with any other health and drug benefits available to you. We’ll help you coordinate your benefits.

Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan member ID card whenver you get medical care or Part D prescription drugs.

See your member handbook for a complete list of your responsibilities.

Help your doctors and other providers help you by giving them information, asking questions and following through on your care.

  • To help your doctors and other health providers give you the best care, tell them what they need to know about you and your health. Learn as much as you can about your health problems. Follow the treatment plans and instructions that you and your doctors agree upon.
  • Make sure your doctors know all of the drugs you are taking. That includes over-the-counter drugs, vitamins, and supplements.
  • If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don’t understand the answer you are given, ask again.

See your member handbook for a complete list of your responsibilities.

We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals and other offices.

See your member handbook for a complete list of your responsibilities.

If you move, it’s important to tell us right away. Call Member Services.

  • If you move out of our plan service area, you cannot remain a member of our plan. We can help you figure out if you’ll be moving outside our service area. We also can let you know if we have a plan in your new area.
  • If you move within our service area, we still need to know. We need to keep your membership records up to date on how to contact you.

As a plan member, you are responsible for these payments:

  • Your patient pay amount for nursing facility services. This is determined by the local state Department of Human Services.
  • If you get any services or drugs that are not covered by our plan, for any reason, including but not limited, the provider is out of network, you are outside the service area or the drug is not on the formulary, you must pay the full cost.

See your member handbook for a complete list of your responsibilities.

Call Member Services at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week with questions or concerns.

We welcome any suggestions you may have for improving our plan.

We need to know if your money situation changes, or anything else. We need to make sure you are still eligible for Medicaid. You can call your care manager or the office where you applied for Medicaid.

Enrollees age 55 and older who are receiving long term care services may be subject to estate recovery upon their death. For more information, you may contact any of the following:

See your member handbook for a complete list of your responsibilities.

  • Know the name of your assigned PCP and your care manager.
  • Follow the instructions that you and your PCP have agreed on, including the instructions of nurses and other health care professionals. Ask what can happen if you don’t follow these instructions.
  • Pay your share of costs and/or room and board at the start of every month.
  • Schedule doctor’s appointments during office hours when possible instead of using urgent or emergency care.
  • Keep your doctor’s appointments and come on time. Call your doctor’s office beforehand when you can’t keep your appointment.