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Rights and responsibilities

As a plan member, you have rights and responsibilities. If you need help understanding your rights and responsibilities, call Member Services at 1-844-362-0934 (TTY: 711). You can also check your member handbook.

Your rights

Your rights

As a plan member, you have the right to:

 

  • Be treated with courtesy, consideration, respect, dignity and need for privacy

  • Be provided with information about the plan, its policies and procedures, its services, the practitioners providing care, and members rights and responsibilities and to be able to communicate and be understood with the assistance of a translator if needed 

  • Be able to choose a primary care physician (PCP) within the limits of the plan network, including the right to refuse care from specific practitioners

  • Participate in decision making regarding your health care, to be fully informed by the PCP, other health care provider or care manager of health and functional status, and to participate in the development and implementation of a plan of care designed to promote functional ability to the optimal level and to encourage independence 

  • Have a candid discussion of appropriate or medically necessary treatment options for your condition(s) regardless of cost or benefit coverage, including the right to refuse treatment or medication

  • Voice grievances about the plan or care provided and recommend changes in policies and services to plan staff, providers and outside representatives of your choice, free of restraint, interference, coercion, discrimination or reprisal by the plan or its providers 

  • File appeals about a plan action or denial of service and to be free from any form of retaliation

  • Formulate advance directives 

  • Have access to your medical records in accordance with applicable federal and state laws

  • Be free from harm, including unnecessary physical restraints or isolation, excessive medication, physical or mental abuse or neglect 

  • Be free of hazardous procedures

  • Receive information on available treatment options or alternative courses of care 

  • Refuse treatment and be informed of the consequences of such refusal

  • Have services provided that promote a meaningful quality of life and autonomy for you, independent living in your home and other community settings as long as medically and socially feasible, and preservation and support of your natural support systems 

  • Have available and accessible services when medically necessary

  • Access care 24 hours a day, 7 days a week, for urgent and emergency conditions — for life-threatening conditions, call 911

  • Be afforded a choice of specialist among participating providers

  • Obtain a current directory of participating providers in the plan including addresses and telephone numbers, and a listing of providers who accept members who speak languages other than English 

  • Obtain assistance and referrals to providers with experience in treatment of patients with chronic disabilities

  • Be free from balance billing by providers for medically necessary services that were authorized by the plan, except as permitted for copayments in your plan 

  • Get a second opinion

  • Receive prompt notification of termination or changes in benefits, services or provider network 

Additional rights for members in Managed Long Term Services and Supports (MLTSS)

You have additional rights in the MLTSS program. These include the right to:

 

  • Request and receive information on services available

  • Have access to and choice of qualified service providers

  • Be informed of your rights prior to receiving chosen and approved services

  • Receive services without regard to race, religion, color, creed, gender, national origin, political beliefs, sexual orientation, marital status or disability

  • Have access to appropriate services that support your health and welfare

  • Assume risk after being fully informed and able to understand the risks and consequences of the decisions made

  • Make decisions concerning your care needs 

  • Participate in the development of and changes to your plan of care

  • Request changes in services at any time, including add, increase, decrease or discontinue

  • Request and receive from your care manager a list of names and duties of any person(s) assigned to provide services to you under the plan of care

  • Receive support and direction from your care manager to resolve concerns about your care needs and/or complaints about services or providers

  • Be informed of and receive in writing facility-specific resident rights upon admission to institutional or residential settings

  • Be informed of all the covered/required services you are entitled to, that are required by and/or that are offered by the institutional or residential setting, and any charges not covered by the managed care plan while in the facility

  • Not to be transferred or discharged out of a facility except for medical necessity; to protect your physical welfare and safety or the welfare and safety of other residents; or because of failure, after reasonable and appropriate notice of nonpayment to the facility from available income as reported on the statement of available income for Medicaid payment

  • Have your health plan protect and promote your ability to exercise all rights identified in this document 

  • Have all rights and responsibilities outlined here forwarded to your authorized representative or court-appointed legal guardian

Your responsibilities

Your responsibilities

As a plan member, you have the responsibility to:

 

  • Use your ID cards when you go to health care appointments or get services and to not let anyone else use your card

  • Know the name of your PCP and your care manager if you have one 

  • Know about your health care and the rules for getting care

  • Tell the plan and the Division of Medical Assistance and Health Services (DMAHS) when you make changes to your address, telephone number, family size and other information 

  • Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible

  • Be respectful to the health care providers who are giving you care 

  • Schedule your appointments, be on time and call if you are going to be late to or miss your appointment

  • Give your health care providers all the information they need 

  • Tell the plan and DMAHS about your concerns, questions or problems

  • Ask for more information if you do not understand your care or health condition 

  • Follow your health care provider’s advice

  • Tell us about any other insurance you have 

  • Tell us if you are applying for or get any other health care benefits

  • Bring shot records to all appointments for children under 18 years old 

  • Give your doctor a copy of your living will or advance directive

MLTSS additional responsibilities
 

You also have these additional responsibilities in the MLTSS program. You have the responsibility to:
 

  • Provide all health- and treatment-related information, including medication, circumstances, living arrangements, informal and formal supports, to your care manager in order to identify care needs and develop a plan of care

  • Understand your health care needs and work with your care manager to develop or change goals and services

  • Work with your care manager to develop or revise your plan of care to facilitate timely authorization and implementation of services

  • Ask questions when additional understanding is needed

  • Understand the risks associated with your decisions about care

  • Report any significant changes on your health condition, medication, circumstances, living arrangements, informal and formal supports to you care manager

  • Tell your care manager about any problem that occurs or if you are dissatisfied with the services being provided 

  • Follow your health plan’s rules and those rules of institutional or residential settings

Disenrolling from our plan

 

You have the right to end your membership in our plan and enroll in another Medicare plan. Disenrolling from our plan will not affect eligibility for NJFamilyCare (Medicaid) or your right to re-enroll in our plan.

If you want to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan, you must ask to be disenrolled from our plan.

 

There are two ways you can ask to be disenrolled:

 

  • You can make a request in writing to us. Contact Member Services at 1-844-362-0934 (TTY: 711), 8 AM to 8 PM, seven days a week if you need more information on how to do this; or--
  • You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Generally, your membership will end on the first day of the month after we receive your request to switch to plans. 

 

If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can file a grievance or make a complaint about our decision to end your membership.

 

Have additional questions about ending your coverage? You can call us at 1-844-362-0934 (TTY: 711), 8 AM to 8 PM, seven days a week.

Have a question? We’re here for you.

Call us

You can find out more about your rights. Just call 1-844-362-0934 (TTY: 711). We're here from 8 AM to 8 PM, 7 days a week.