Enrollee Rights and Responsibilities

You have a right to:

• Be treated with respect and dignity
• Know that when you talk with your doctors and other providers, it’s private
• Have an illness or treatment explained to you in a language you can understand
• Participate in decisions about your care
• Receive a full, clear, and understandable explanation of treatment options and risks of each option so you can make an informed decision, regardless of cost or benefit coverage. (Female enrollees only) Have direct access to a women’s health specialist within the network for the covered care necessary to provide women’s routine and preventive health care services. Also, female enrollees have a right to designate as their primary care providers (PCPs) participating providers or advanced-practicing registered nurses who specialize in obstetrics (OB) and gynecology (GYN).
• Refuse treatment or care
• Be able to see your medical records and to request that they be fixed if they are wrong
• Choose an eligible PCP from within AmeriHealth Caritas District of Columbia’s (DC) network and to change your PCP
• Make a complaint (“grievance”) about AmeriHealth Caritas DC or the care provided to you and receive an answer
• Request an appeal or a fair hearing if you believe AmeriHealth Caritas DC was wrong in denying, reducing, or stopping a service or item
• Receive family planning services and supplies from the provider of your choice
• Obtain medical care without unnecessary delay
• Ask for a chaperone to be present when you receive health care
• Receive information on advance directives and choose not to have or continue any life-sustaining treatment
• Receive a copy of the enrollee handbook
• Continue treatment you are currently receiving until you have a new treatment plan
• Receive interpretation and translation services free of charge if you need them, and refuse oral interpretation services
• Get an explanation of prior authorization procedures
• Receive information about AmeriHealth Caritas DC’s financial condition and any special ways we pay our providers
• Obtain summaries of customer satisfaction surveys
• Receive AmeriHealth Caritas DC’s Dispense as Written policy for prescription drugs
• Receive information about AmeriHealth Caritas DC, our services, our providers and other health care workers, our facilities, and your rights and responsibilities as a enrollee
• Make recommendations about AmeriHealth Caritas DC’s enrollee rights and responsibilities policy
• Be free from any form of restraint or seclusion used as coercion, discipline, convenience, or retaliation, as specified in other federal regulations on the use of restraints and seclusion
• Receive a second opinion from a qualified health care professional within the network, or arrange to obtain one outside the network, at no cost to you
• Be informed about cost sharing, if any, upon enrollment, annually, and at least 30 days prior to any change
• Be informed about how and where to access any benefits available under the District of Columbia plan but not covered under the contract, including any cost sharing, and how transportation is provided, upon enrollment, annually, and at least 30 days prior to any change
• Be informed that you may be required to pay the cost of services furnished while an appeal is pending, if the final decision is adverse to you
• Not be held liable for AmeriHealth Caritas DC’s debts in the event of AmeriHealth Caritas DC’s insolvency
• Use any hospital or other setting for emergency care
• Be treated no differently by providers or by AmeriHealth Caritas DC for exercising your rights listed here

You are responsible for:

• Treating those providing your care with respect and dignity
• Following the rules of the health care program and AmeriHealth Caritas DC
• Following instructions you receive from your doctors and other providers
• Going to appointments you schedule or that AmeriHealth Caritas DC schedules for you
• Telling your provider at least 24 hours before the appointment if you have to cancel
• Asking for more explanation if you do not understand your provider’s instructions
• Going to the emergency room only if you have a medical emergency
• Telling your provider about medical and personal problems that may affect your health to help the provider give you care
• Reporting to the Economic Security Administration (ESA) and AmeriHealth Caritas DC if you or family enrollees have other health insurance
• Trying to understand your health problems and participate in developing treatment goals
• Helping your provider in getting medical records from providers who have treated you in the past
• Telling AmeriHealth Caritas DC if you were injured as the result of an accident or at work