Your Member Rights & Responsibilities | Aetna Medicaid NJ HMO-SNP

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

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

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

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