Member Rights

Member Rights &Responsibilities

Aetna Better Health of New Jersey’s privacy policy states that members are afforded the privacy rights permitted under HIPAA and other applicable federal, state, and local laws and regulations, and applicable contractual requirements.

Aetna Better Health of New Jersey’s privacy policy states that members are afforded the privacy rights permitted under HIPAA and other applicable federal, state, and local laws and regulations, and applicable contractual requirements. Our privacy policy conforms with 45 C.F.R. (Code of Federal Regulations): relevant sections of the HIPAA that provide member privacy rights and place restrictions on uses and disclosures of protected health information (§164.520, 522, 524, 526, and 528).

Our policy also assists Aetna Better Health of New Jersey personnel and providers in meeting the privacy requirements of HIPAA when members or authorized representatives exercise privacy rights through privacy request, including:

  • Making information available to members or their representatives about Aetna Better Health of New Jersey’s practices regarding their PHI.
  • Maintaining a process for members to request access to, changes to, or restrictions on disclosure of their PHI.
  • Providing consistent review, disposition, and response to privacy requests within required time standards.
  • Documenting requests and actions taken.

Members may make the following requests related to their PHI (“privacy requests”) in accordance with federal, state, and local law:

  • Make a privacy complaint
  • Receive a copy of all or part of the designated record set
  • Amend records containing PHI
  • Receive an accounting of health plan disclosures of PHI
  • Restrict the use and disclosure of PHI
  • Receive confidential communications
  • Receive a Notice of Privacy Practices

A privacy request must be submitted by the member or member’s authorized representative. A member’s representative must provide documentation or written confirmation that he or she is authorized to make the request on behalf of the member or the deceased member’s estate. Except for requests for a health plan Notice of Privacy Practices, requests from members or a member’s representative must be submitted to Aetna Better Health of New Jersey in writing. 

In the event Aetna Better Health of New Jersey is made aware of an issue when the member is not demonstrating the responsibilities as outlined above, Aetna Better Health of New Jersey will make good faith efforts to address the issue with the member; educate the member on their responsibilities. Members have the following rights and responsibilities:

In the event Aetna Better Health of New Jersey is made aware of an issue when the member is not demonstrating the responsibilities as outlined above, Aetna Better Health of New Jersey will make good faith efforts to address the issue with the member; educate the member on their responsibilities. Members have the following rights and responsibilities:

Aetna Better Health of New Jersey members, their families and or guardians have the right to information related to their treatment or treatment options in a manner and language appropriate to the member’s condition and ability to understand. This includes, but is not limited to:

  • Names of participating providers and , if appropriate, the member’s case managers
  • Copies of medical records as allowed by law and the right to request that they be amended or corrected
  • A description of the Aetna Better Health of New Jersey services or covered benefits
  • A description of their rights and responsibilities as members, including the right to be free from any form of restraint, interference or seclusion used as a means of coercion, discrimination, reprisal, discipline, convenience, or retaliation by Aetna Better Health of New Jersey or its providers.
  • How Aetna Better Health of New Jersey provides for after‐hours and emergency health care services. This includes members’ right to available and accessible services when medically necessary, including availability of care 24 hours a day, seven days a week for urgent or emergency conditions. The 911 emergency response systems should be called whenever a member has a potentially life‐threatening condition.
  • Information about how Aetna Better Health of New Jersey pays providers, controls costs and the use of services
  • Summary results of member surveys and grievances
  • Information about the cost to a member if the member chooses to pay for a service that is not covered
  • Procedures for obtaining services, including authorization requirements
  • A description of how Aetna Better Health of New Jersey evaluates new medical procedures for inclusion as a covered benefit
  • Advance Directives where the member or his/her representative make legal decisions to withhold resuscitative services, or to forgo or withdraw life‐sustaining treatment
  • Receiving a provider directory in the welcome packet and upon request. The directory includes the address and phone numbers of participating providers as well as an indicator for non‐English languages spoken by the provider or staff.
  • Having a candid discussion of appropriate or medically necessary treatment options and alternative choices of care for their conditions, regardless of cost or benefit coverage
  • Information on Aetna Better Health of New Jersey’s benefits and provider network changes

Members have a right to respect, fairness, dignity, and the need for privacy. This includes, but is not limited to:

  • An ability to receive covered services without concern about payer source, race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, ability to pay or ability to speak English
  • Quality medical services that support personal beliefs, medical condition and background in a language the member can understand
  • Interpreter services for members who do not speak English or who have hearing impairment, or request written information in an alternative format
  • The right to be free from any form harm, including unnecessary physical restraint or isolation, excessive medication, physical or mental abuse or neglect
  • The right to be free of hazardous procedures
  • To have services provided that promote a meaningful quality of life and autonomy for members, independent living in members' homes and other community settings as long as medically and socially feasible, and preservation and support of members' natural support systems.

Members have a right to confidentiality and privacy. This includes, but is not limited to:

  • The right to privacy and confidentiality of health care information. Information will be distributed only if allowed by law
  • The right to ask how their health care information has been given out and used for non‐routine purposes
  • The right to talk to health care professionals and case managers privately.

Members have a right to participate in decision making about their health care, and/or have a representative facilitate care or treatment decisions when necessary. This includes, but is not limited to:

  • Choosing a Primary Care Provider (PCP), within the provider network, to help with planning and coordinating care
  • Timely access to providers and care from a specialist when it is needed; timely access to prescriptions from a network pharmacy
  • Being informed about any risks involved in care
  • The right to be fully informed by the PCP, other health care provider or case 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
  • Seeing a women’s health specialist without a referral
  • The right to be told in advance if a proposed care or treatment is part of a research experiment and the right to refuse experimental treatments
  • The right to change PCP if necessary
  • Requesting specific, condition‐related information from a PCP
  • Requesting information about procedures and who will perform them
  • Deciding who should be in attendance at treatments and examinations
  • Choosing to have a female in the room for breast and pelvic exams
  • Refusing a treatment, services, or PCPs, including leaving the hospital even though a doctor advises against it, and requesting an explanation of consequences. Eligibility or medical care does not depend on a member’s agreement to follow a treatment plan.
  • The right to stop taking medications when the medication is needed to protect the member or others from harm.
  • Written notification when health care services are reduced, suspended, terminated, or denied. Notification is accompanied by instructions.

Members have a right to seek emergency care and specialty services. These rights include:

  • Obtaining emergency services without prior approval from the PCP or Aetna Better Health of New Jersey when they have an emergency
  • Obtaining services from a specialist including those with experience in the treatment of chronic disabilities with prior authorization
  • Refusing care from a specialist the member was referred to and requesting another referral
  • Requesting a second opinion from another Aetna Better Health of New Jersey provider

Members have a right to report concerns to Aetna Better Health of New Jersey. This includes, but is not limited to:

  • Reporting complaints and grievances about the organization or quality of care or services, interpersonal relationships, failures to respect rights, or any other issues concerning the member’s health care services to Aetna Better Health of New Jersey or the New Jersey Department of Banking and Insurance. Members have the right to an answer to these complaints within a reasonable period of time
  • Filing appeals after a Aetna Better Health of New Jersey determination and then receiving a decision in a reasonable amount of time
  • Giving suggestions for changes to policies and services
  • Receiving a detailed explanation if a member believes that an Aetna Better Health of New Jersey provider has denied care the member believes they are entitled to receive.

Members have the right to be free from liability under certain circumstances. This includes:

  • Aetna Better Health of New Jersey’s debts in the event of insolvency.
  • Any covered services or services approved by Aetna Better Health of New Jersey with the exception of the member’s cost sharing responsibility as determined by the Division of Medical Assistance and Health Services (DMAHS). This applies to services provided by Aetna Better Health of New Jersey’s subcontractors and vendors.

Aetna Better Health of New Jersey members, their families, or guardians are responsible for:

  • Knowing the name of the assigned PCP and/or Case Manager
  • Familiarizing themselves about their coverage and the rules they must follow to get care
  • Respecting the health care professionals providing service
  • Sharing any concerns, questions or problems with Aetna Better Health of New Jersey
  • Providing all necessary health related information needed by the professional staff providing care, and requesting more explanation if a treatment plan or health condition is not understood
  • Following instructions and guidelines agreed upon with the health professionals giving care
  • Protecting their member identification card and providing it each time they receive services
  • Scheduling appointments during office hours, when possible
  • Arriving for appointments on time
  • Notifying the health care professionals if it is necessary to cancel an appointment
  • Disclosing other insurance they may have and/or applying for other benefits they may be eligible for
  • Bringing immunization records to all appointments for children less than eighteen (18) years of age.
  • Understanding their health problems and participate in developing mutually agreed upon treatment goals, to the degree possible
  • Reporting changes like address, telephone number and/or assets, and other matters that could affect the member’s eligibility to the office where the member applied for Medicaid services

For questions or concerns, please contact our Provider Services Department at 1‐855‐232‐3596.

Section 504 of the Rehabilitation Act of 1973 is a national law that protects qualified individuals from discrimination based on their disability. The nondiscrimination requirements of the law apply to organizations that receive financial assistance from any federal department or agency, including hospitals, nursing homes, mental health centers, and human service programs.

Section 504 prohibits organizations from excluding or denying individuals with disabilities an equal opportunity to receive benefits and services. Qualified individuals with disabilities have the right to participate in, and have access to, program benefits and services.

Under this law, individuals with disabilities are defined as persons with a physical or mental impairment that substantially limits one or more major life activities. People who have a history of physical or mental impairment, or who are regarded as having a physical or mental impairment that substantially limits one or more major life activities, are also covered. Major life activities include caring for one's self, walking, seeing, hearing, speaking, breathing, working, performing manual tasks, and learning. Some examples of impairments that may substantially limit major life activities, even with the help of medication or aids/devices, are Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), alcoholism, blindness or visual impairment, cancer, deafness or hearing impairment, diabetes, drug addiction, heart disease, and mental illness.

In addition to meeting the above definition, for purposes of receiving services, qualified individuals with disabilities are persons who meet normal and essential eligibility requirements.

Providers treating members may not, on the basis of disability:

  • Deny qualified individuals the opportunity to participate in or benefit from federally funded programs, services, or other benefits
  • Deny access to programs, services, benefits or opportunities to participate as a result of physical barriers