Rights and responsibilities

As a member or the parent or guardian of a 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, member’s 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 PCP within the limits of the plan network, including the right to refuse care from specific practitioners.
• Participate in decision-making regarding their 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.
• 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 our 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.
• Available and accessible services when medically necessary.
• Access care 24 hours a day, seven 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 referral 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 co-payments in your plan.
• A second opinion.
• Prompt notification of termination or changes in benefits, series or provider network.
• Information about incentives we pay providers.
• Emergency care without prior approval.
• Family planning services from Aetna Better Health or any Medicaid provider.
• ·Decline care management services; Aetna Better Health still must manage your care.
• External appeal by an independent organization if you disagree with our decision on internal appeal (not all services qualify for review by Independent Utilization Review Organization (IURO).
• Disenroll and transfer to another NJ FamilyCare managed care plan at any time for cause; change plans within the first 90 days of joining Aetna Better Health and during the annual enrollment October 1 to November 15.
• 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.
• To assume risk after being fully informed and able to understand the risks and consequences of the decisions made.
• To 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 MLTSS 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 MLTSS 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 an institutional or residential settings.
• Comprehensive dental care.
• Be informed of all the covered/required services you are entitled to, required by and/or 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.

·       Appeal or request Medicaid Fair Hearing regarding eligibility for MLTSS or participation in the personal preference program (PPP).