Member Rights and Responsibilities

Know your rights and responsibilities

Your rights

• The freedom to exercise all member rights without any adverse effect on the member’s treatment by Aetna Better Health or participating providers
• Names of primary health care and participating providers and, if appropriate, care managers
• Copies of medical records as allowed by law
• A description of the Aetna Better Health services or covered benefits
• A description of their rights and responsibilities as members, including the right to refuse treatment
• How Aetna Better Health provides for after-hours and emergency health care services
• Information about how Aetna Better Health pays providers, controls costs and the use of services
• Summary results of member surveys and grievances
• Information about the cost to an 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 evaluates new technology for inclusion as a covered benefit
• What treatment choices or types of care are available to the member, and the benefits or drawbacks of each choice
• Advance directives - Aetna Better Health informs members of the their right to formulate advance directives
• Health care benefit or network changes
• Members have a right to respect, fairness and dignity. 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
• Interpreter services for members who do not speak English or who have impaired hearing or request written information in an alternative format

• The right to be free from any form of restraint or seclusion as a means of coercion, discipline, retaliation or convenience

A right to participate in decision making about their health care

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 participating primary care provider (PCP) to help with planning and coordinating care.
• The right to see a women’s health care provider without a referral.
• Timely access to providers and care from a specialist when it is needed; timely access to prescriptions from a network pharmacy.
• The right to know about all treatment options, no matter what they cost or whether they are covered
• The right to be told about any risks involved in care.
• 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.
• 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, 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.
• Written notification when health care services are reduced, suspended, terminated or denied; notification is accompanied by instructions on how to file a grievance or request a Fair Hearing from HFS.
• The right to receive information concerning the structure and operations of the health plan.

A right to seek emergency care and specialty services

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 when they have an emergency
• Obtaining services from a specialist with a referral from the PCP
• Refusing care from a specialist the member was referred to and requesting another referral
• Requesting a second opinion

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

• Privacy and confidentiality of health care information. Information will be distributed only as allowed by law
• The right to receive a copy of their medical records and to ask that additions or corrections be made to the records
• 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

A right to report concerns to Aetna Better Health

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

• Filing a grievance or appeal against Aetna Better Health or its providers.
• Requesting a fair hearing from HFS.
• Recommendations for changes to policies and services.
• The right to a detailed explanation if a member believes that an Aetna Better Health provider has denied care the member believes they are entitled to receive.

Your responsibilities

Aetna Better Health members 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.
• Informing Aetna Better Health of any changes in eligibility, or any other information that may affect membership, health care needs or access to benefits.
• Respecting the health care professionals providing service.
• Sharing any concerns, questions or problems with Aetna Better Health.
• 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.
• Disclosing other insurance they may have and/or applying for other benefits they may be eligible for.
• 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.
• Following instructions and guidelines given by those providing health care services.
• Members will provide consent to managed care plans, health care providers and their respective designees for the purpose of providing patient care management, outcomes improvement and research. For these purposes, members will remain anonymous to the greatest extent possible.

Aetna Better Health responsibilities

It is the responsibility of all Aetna Better Health staff to ensure that members’ rights are respected and that members are educated on their responsibilities in a manner and method easily understood by the member.

In the event that Aetna Better Health is made aware of an issue with a member not receiving the rights as identified above, Aetna Better Health will initiate an investigation into the matter and report the findings to the Quality Management Committee.

In the event Aetna Better Health is made aware of an issue when the member is not demonstrating the responsibilities as outlined above, Aetna Better Health will make good faith efforts to address the issue with the member; educate the member on their responsibilities; document the interaction in the call tracking system; and report the findings up to the Quality Management Committee.