Enrollees Rights and Responsibilities

You have a right to:

• Receive enrollment notices, informational materials, and instructional materials in a manner and format that is easily understood
• Be treated with respect and due consideration for your dignity and right to privacy
• Receive information on available treatment options and alternatives regardless of cost or benefit coverage, presented in a candid manner appropriate to your condition and ability to understand
• Participate in decisions regarding your health care, including the right to refuse treatment
• Be free from any form of restraints or seclusion used as a means of coercion, discipline, convenience, or retaliation
• See and receive a copy of your medical records and request an amendment or change if incorrect
• Receive access to health care services that are available and accessible to you in a timely manner; coordinated; sufficient in amount, duration, or scope; and provided in a culturally competent manner to meet your specific needs.
• Know that when you talk with your doctors and other providers, it is private
• Have an illness or treatment explained to you in a language you can understand
• Receive a full, clear, and understandable explanation of treatment options and the risks of each option so you can make an informed decision, regardless of cost or benefit coverage
• Female enrollees only: To 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, to designate as your PCP a participating provider or an advanced-practicing registered nurse who specializes in obstetrics (OB) and gynecology (GYN).
• Refuse treatment or care
• Choose an eligible PCP and primary dental provider (PDP) from within AmeriHealth Caritas District of Columbia’s network and to change your PCP or PDP
• Make a grievance about the care provided to you and receive an answer
• Request an appeal or a state fair hearing if you believe AmeriHealth Caritas District of Columbia 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
• Receive information on advance directives and choose not to have or continue any life-sustaining treatment
• Receive a copy of AmeriHealth Caritas District of Columbia’s Enrollee Handbook and/orProvider Directory
• 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
• Refuse oral interpretation services
• Get an explanation of prior authorization procedures
• Receive information about AmeriHealth Caritas District of Columbia’s financial condition and any special ways it pays its providers
• Obtain summaries of customer satisfaction surveys
• Receive AmeriHealth Caritas District of Columbia’s “Dispense as Written” policy for prescription drugs
• Receive a list of all covered drugs
• Obtain a 72-hour dose of prescription drugs that are administered or taken daily or more than one time per day; and to have one full course of prescription drugs that are administered or taken less frequently than one time per day
• Receive information about AmeriHealth Caritas District of Columbia, including its services, practitioners and providers, and enrollee rights
• Receive information about your rights and responsibilities as an enrollee
• Make recommendations about AmeriHealth Caritas District of Columbia’s enrollee rights and responsibilities policy
• Request information about any of our providers, including medical school education, residency, and board certification
• Ask for a chaperone to be present when you receive health care
• Receive a second opinion from a qualified health care professional within the network, or, if necessary, 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
• To have AmeriHealth Caritas District of Columbia not prohibit, or otherwise restrict, a provider acting within the lawful scope of practice from advising or advocating on behalf of an enrollee who is his or her patient for the following:
• The enrollee’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered
• Any information the enrollee needs to decide among all relevant treatment options
• The risks, benefits, and consequences of treatment or non-treatment 
• The enrollee’s right to participate in decisions regarding his or her health care, including the right to refuse treatment, and express preferences about future treatment decisions
• Not be held liable for AmeriHealth Caritas District of Columbia debts in the event of AmeriHealth Caritas District of Columbia’s insolvency
• Use any hospital or other setting for emergency care
• Be informed about how and where to access any benefits available under AmeriHealth Caritas District of Columbia 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
• Receive transportation services free of charge
• Have freedom of choice among network providers
• Receive covered services from an approved out-of-network provider if AmeriHealth Caritas District of Columbia does not have an in-network provider who can perform a covered service
• Request a copy of clinical practice guidelines, have access to Utilization Management staff, or get an explanation of medical necessity review information
• Be treated no differently by providers, practitioners, or AmeriHealth Caritas District of Columbia for exercising your rights above
• In the case of a counseling or referral service that AmeriHealth Caritas District of Columbia does not cover because of moral or religious objections, be informed at least 90 days before the effective date of any policy for any particular service that the service is not covered and how to obtain information from the District about how to access those services

You are responsible for:

• Treating those providing your care with respect and dignity
• Following the rules of the DC Medicaid Managed Care Program and AmeriHealth Caritas District of Columbia
• Following agreed upon plans and instructions you receive from your doctors and other providers
• Going to scheduled appointments
• Telling your provider at least 24 hours before an appointment if you have to cancel
• Asking for more explanation if you do not understand your provider’s instructions
• Going to the emergency room (ER) only if you have a medical emergency
• Telling your primary care provider (PCP) or primary dental provider (PDP) about medical and personal problems that may affect your health
• Supplying information (to the extent possible) that AmeriHealth Caritas District of Columbia and its practitioners and providers need in order to provide care
• Reporting to the Economic Security Administration (ESA) and AmeriHealth Caritas District of Columbia if you or a family member has other health insurance or you have a change in your address or phone number
• Reporting to the Economic Security Administration (ESA) and AmeriHealth Caritas District of Columbia if there is a change in your family (for example, a death or birth)
• Trying to understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible
• Helping your PCP in getting medical records from providers who have treated you in the past
• Telling AmeriHealth Caritas District of Columbia if you were injured as the result of an accident or at work