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    • Aetna Better Health® of Texas

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    Health and wellness

    Member rights and responsibilities

    Understanding your health plan is important. You have rights and responsibilities as a member of Aetna Better Health® of Texas STAR, STAR Kids, CHIP or CHIP Perinatal plans. We’ll help you understand your plan, so you can make smart health care choices.

    Your STAR member rights

    Your STAR member rights

    1. You have the right to respect, dignity, privacy, confidentiality, and nondiscrimination. That includes the right to:

      1. Be treated fairly and with respect.
      2. Know that your medical records and discussions with your providers will be kept private and confidential.
    2. You have the right to a reasonable opportunity to choose a health care plan and Primary Care Provider. This is the doctor or health care Provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or Provider in a reasonably easy manner. That includes the right to:

      1. Be told how to choose and change your health plan and your Primary Care Provider.
      2. Choose any health plan you want that is available in your area and choose your Primary Care Provider from that plan.
      3. Change your Primary Care Provider.
      4. Change your health plan without penalty.
      5. Be told how to change your health plan or your Primary Care Provider.
    3. You have the right to ask questions and get answers about anything you do not understand. That includes the right to:

      1. Have your provider explain your health care needs to you and talk to you about the different ways your health care problems can be treated.
      2. Be told why care or services were denied and not given.
    4. You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to:

      1. Work as part of a team with your Provider in deciding what health care is best for you.
      2. Say yes or no to the care recommended by your Provider.
    5. You have the right to use each Complaint and appeal process available through the Managed Care Organization and through Medicaid, and get a timely response to Complaints, appeals and fair hearings. That includes the right to:

      1. Make a Complaint to your health plan or to the state Medicaid program about your health care, your Provider, or your health plan. 
      2. Get a timely answer to your Complaint.
      3. Use the plan’s appeal process and be told how to use it.
      4. Ask for a fair hearing from the state Medicaid program and get information about how that process works.
    6. You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to:

      1. Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need.
      2. Get medical care in a timely manner.
      3. Be able to get in and out of a health care Provider’s office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act.
      4. Have interpreters, if needed, during appointments with your providers and when talking to your health plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information.
      5. Be given information you can understand about your health plan rules, including the Health Care Services you can get and how to get them.
    7. You have the right to not be restrained or secluded when it is for someone else’s convenience, or is meant to force you to do something you do not want to do, or is to punish you.
    8. You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a Covered Service.
    9. You have a right to know that you are not responsible for paying for Covered Services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for Covered Services.

    Your STAR member responsibilities

    Your STAR member responsibilities

    1. You must learn and understand each right you have under the Medicaid program. That includes the responsibility to:

      1. Learn and understand your rights under the Medicaid program.
      2. Ask questions if you do not understand your rights.
      3. Learn what choices of health plans are available in your area.
    2. You must abide by the health plan’s and Medicaid’s policies and procedures. That includes the responsibility to:

      1. Learn and follow your health plan’s rules and Medicaid rules.
      2. Choose your health plan and a Primary Care Provider quickly.
      3. Make any changes in your health plan and Primary Care Provider in the ways established by Medicaid and by the health plan.
      4. Keep your scheduled appointments.
      5. Cancel appointments in advance when you cannot keep them.
      6. Always contact your Primary Care Provider first for your non-emergency medical needs.
      7. Be sure you have approval from your Primary Care Provider before going to a specialist.
      8. h. Understand when you should and should not go to the emergency room.
    3. You must share information about your health with your Primary Care Provider and learn about service and treatment options. That includes the responsibility to:

      1. Tell your Primary Care Provider about your health.
      2. Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated.
      3. Help your providers get your medical records.
    4. You must be involved in decisions relating to service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility to:

      1. Work as a team with your Provider in deciding what health care is best for you.
      2. Understand how the things you do can affect your health.
      3. Do the best you can to stay healthy.
      4. Treat providers and staff with respect.
      5. Talk to your provider about all of your medications.

    Additional STAR member responsibilities while using rides or NEMT services

     

    1. When requesting NEMT Services, you must provide the information requested by the person arranging or verifying your transportation.
    2. You must follow all rules and regulations affecting your NEMT services.
    3. You must return unused advanced funds. You must provide proof that you kept your medical appointment prior to receiving future advanced funds.
    4. You must not verbally, sexually, or physically abuse or harass anyone while requesting or receiving NEMT services.
    5. You must not lose bus tickets or tokens and must return any bus tickets or tokens that you do not use. You must use the bus tickets or tokens only to go to your medical appointment.
    6. You must only use NEMT Services to travel to and from your medical appointments.
    7. If you have arranged for an NEMT Service but something changes, and you no longer need the service, you must contact the person who helped you arrange your transportation as soon as possible.

    Non-discrimination notice

    If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can visit the HHS Office of Civil Rights website.

    Your CHIP member rights

    Your CHIP member rights

    1. You have the right to get accurate, easy-to-understand information to help you make good choices about your child's health plan, doctors, hospitals, and other providers.
    2. Your health plan must tell you if they use a "limited provider network." This is a group of doctors and other providers who only refer patients to other doctors who are in the same group. “Limited provider network” means you cannot see all the doctors who are in your health plan. If your health plan uses "limited networks," you should check to see that your child's primary care provider and any specialist doctor you might like to see are part of the same "limited network."
    3. You have a right to know how your doctors are paid. Some get a fixed payment no matter how often you visit. Others get paid based on the services they give to your child. You have a right to know about what those payments are and how they work.
    4. You have a right to know how the health plan decides whether a service is covered or medically necessary. You have the right to know about the people in the health plan who decide those things.
    5. You have a right to know the names of the hospitals and other providers in your health plan and their addresses.
    6. You have a right to pick from a list of health care providers that is large enough so that your child can get the right kind of care when your child needs it.
    7. If a doctor says your child has special health care needs or a disability, you may be able to use a specialist as your child's primary care provider. Ask your health plan about this.
    8. Children who are diagnosed with special health care needs or a disability have the right to special care.
    9. If your child has special medical problems, and the doctor your child is seeing leaves your health plan, your child may be able to continue seeing that doctor for three months, and the health plan must continue paying for those services. Ask your plan about how this works.
    10. Your daughter has the right to see a participating obstetrician/gynecologist (OB/GYN) without a referral from her primary care provider and without first checking with your health plan. Ask your plan how this works. Some plans may make you pick an OB/GYN before seeing that doctor without a referral.
    11. Your child has the right to emergency services if you reasonably believe your child's life is in danger, or that your child would be seriously hurt without getting treated right away. Coverage of emergencies is available without first checking with your health plan. You may have to pay a copayment depending on your income. Copayments do not apply to CHIP Perinatal Members.
    12. You have the right and responsibility to take part in all the choices about your child's health care.
    13. You have the right to speak for your child in all treatment choices.
    14. You have the right to get a second opinion from another doctor in your health plan about what kind of treatment your child needs.
    15. You have the right to be treated fairly by your health plan, doctors, hospitals, and other providers.
    16. You have the right to talk to your child's doctors and other providers in private, and to have your child's medical records kept private. You have the right to look over and copy your child's medical records and to ask for changes to those records.
    17. You have the right to a fair and quick process for solving problems with your health plan and the plan's doctors, hospitals and others who provide services to your child.  If your health plan says it will not pay for a covered service or benefit that your child's doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right.
    18. You have a right to know that doctors, hospitals, and others who care for your child can advise you about your child’s health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.
    19. You have a right to know that you are only responsible for paying allowable copayments for covered services. Doctors, hospitals, and others cannot require you to pay any other amounts for covered services.
    Read More Read Less

    Your CHIP member responsibilities

    Your CHIP member responsibilities

    You and your health plan both have an interest in seeing your child's health improve. You can help by assuming these responsibilities.

     

    1. You must try to follow healthy habits. Encourage your child to stay away from tobacco and to eat a healthy diet.
    2. You must become involved in the doctor's decisions about your child's treatments.
    3. You must work together with your health plan's doctors and other providers to pick treatments for your child that you have all agreed upon.
    4. If you have a disagreement with your health plan, you must try first to resolve it using the health plan's complaint process.
    5. You must learn about what your health plan does and does not cover. Read your Member Handbook to understand how the rules work.
    6. If you make an appointment for your child, you must try to get to the doctor's office on time. If you cannot keep the appointment, be sure to call and cancel it.
    7. If your child has CHIP, you are responsible for paying your doctor and other providers copayments that you owe them. If your child is getting CHIP Perinatal services, you will not have any copayments for that child.
    8. You must report misuse of CHIP or CHIP Perinatal services by health care providers, other members, or health plans.
    9. You must talk to your provider about your medications that are prescribed.

    Non-discrimination notice

    If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can visit the HHS Office of Civil Rights website.

    Your CHIP Perinatal member rights

    Your CHIP Perinatal member rights

    1. You have a right to get accurate, easy-to-understand information to help you make good choices about your unborn child’s health plan, doctors, hospitals, and other providers.
    2. You have a right to know how the Perinatal providers are paid. Some may get a fixed payment no matter how often you visit. Others get paid based on the services they provide for your unborn child. You have a right to know about what those payments are and how they work.
    3. You have a right to know how the health plan decides whether a Perinatal service is covered or medically necessary. You have the right to know about the people in the health plan who decide those things.
    4. You have a right to know the names of the hospitals and other Perinatal providers in the health plan and their addresses.
    5. You have a right to pick from a list of health care providers that is large enough so that your unborn child can get the right kind of care when it is needed.
    6. You have a right to emergency Perinatal services if you reasonably believe your unborn child’s life is in danger, or that your unborn child would be seriously hurt without getting treated right away. Coverage of such emergencies is available without first checking with the health plan.
    7. You have the right and responsibility to take part in all the choices about your unborn child’s health care.
    8. You have the right to speak for your unborn child in all treatment choices.
    9. You have the right to be treated fairly by the health plan, doctors, hospitals, and other providers.
    10. You have the right to talk to your Perinatal provider in private, and to have your medical records kept private. You have the right to look over and copy your medical records and to ask for changes to those records.
    11. You have the right to a fair and quick process for solving problems with the health plan and the plan's doctors, hospitals and others who provide Perinatal services for your unborn child. If the health plan says it will not pay for a covered Perinatal service or benefit that your unborn child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right.
    12. You have a right to know that doctors, hospitals, and other Perinatal providers can give you information about your or your unborn child’s health status, medical care, or treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.
    Read More Read Less

    Your CHIP Perinatal member responsibilities

    Your CHIP Perinatal member responsibilities

    You and your health plan both have an interest in having your baby born healthy. You can help by assuming these responsibilities.

     

    1. You must try to follow healthy habits. Stay away from tobacco and eat a healthy diet.
    2. You must become involved in the decisions about your unborn child’s care.
    3. If you have a disagreement with the health plan, you must try first to resolve it using the health plan's complaint process.
    4. You must learn about what your health plan does and does not cover. Read your CHIP Perinatal Program Handbook to understand how the rules work.
    5. You must try to get to the doctor's office on time. If you cannot keep the appointment, be sure to call and cancel it.
    6. You must report misuse of CHIP Perinatal services by health care providers, other members, or health plans.
    7. You must talk to your provider about your medications that are prescribed.
    Read More Read Less

    Non-discrimination notice

    If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can visit the HHS Office of Civil Rights website.

    Have a question? We can help.

    You can call your local Member Services department anytime.
     

    Contact us

    You can also check your member handbook for answers. Just visit our “materials and forms” page.

     

    Materials and forms

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