As an Aetna HMO, PPO, or Medicare Member, You Have a Right to:Information
Know the names and qualifications of health care professionals involved in your medical treatment.
Get up-to-date information about the services covered or not covered by your plan, and any applicable limitations or exclusions.
Know how your plan decides what services are covered.
Get information about copayments and fees that you must pay.
Get up-to-date information about the health care professionals, hospitals and other providers that participate in the plan.
Be told how to file a complaint or appeal with the plan.
Know how the plan pays network health care professionals for providing services to you.
Receive information from health care professionals about your medications, including what the medications are, how to take them and possible side effects.
Receive from health care professionals as much information about any proposed treatment or procedure as you may need in order to give an informed consent or refuse a course of treatment. Except in an emergency, this information should include a description of the proposed procedure or treatment, the potential risks and benefits involved, any alternate course of treatment (even if not covered) or non-treatment and the risks involved in each, and the name of the health care professional who will carry out the procedure or treatment.
Be informed by participating providers about continuing health care requirements following discharge from inpatient or outpatient facilities.
Be advised if a health care professional proposes to use an experimental treatment or procedure in your care. You have the right to refuse to participate in research projects.
Receive an explanation regarding non-covered services.
Receive a prompt reply when you ask the plan questions or request information.
Receive a copy of the plan’s Member Rights and Responsibilities Statement.
Access to Care
Obtain primary and preventive care from the primary care physician you chose from the plan’s network.
Change your primary care physician to another available primary care physician who participates in the plan.
Obtain necessary care from participating network specialists, hospitals and other providers.
Be referred to participating network specialists who are experienced in treating your chronic illness.
Be told by your health care professionals how to schedule appointments and get health care during and after office hours, including continuity of care.
Be told how to get in touch with your primary care physician or a back-up physician 24 hours a day, every day.
Call 911 (or any available emergency response service) or go to the nearest emergency facility when you have a medical condition that manifests itself by acute symptoms of sufficient severity so that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person’s health.
Receive urgently needed medically necessary care.
The Freedom to Make Decisions
Exercise these rights regardless of your race, physical or mental disability, ethnicity, gender, sexual orientation, creed, age, religion, national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for your care.
Have any person who has legal responsibility to make medical care decisions for you exercise these rights on your behalf.
Refuse treatment or leave a medical facility, even against the advice of doctors (providing you accept responsibility and the consequences of the decision).
Complete an Advance Directive, Living Will or other directive and give it to your health care professionals.
Know that you or your health care professional cannot be penalized for filing a complaint or appeal.
Personal Rights
Be treated with respect for your privacy and dignity.
Have your medical records kept private, except when permitted by law or with your approval.
Help your health care professionals make decisions about your health care.
Input
Have your health care professional’s help in decisions about the need for services and in the complaint process.
Suggest changes in the plan’s policies and services.
As an Aetna HMO, PPO, or Medicare Member, You Have a Responsibility to:Exercise Your Rights
Choose a primary care physician from the plan’s network and form an ongoing patient-physician relationship.
Help your health care professional make decisions about your health care.
Follow Instructions
Read and understand your plan and benefits. Know the copayments and what services are covered and what services are not covered.
Follow the directions and advice you and your health care professionals have agreed upon.
See the specialists your primary care physician refers you to.
Make sure you have the appropriate authorization for certain services, including inpatient hospitalization and out-of-network treatment.
Show your member ID card to health care professionals before getting care from them.
Pay the copayments required by your plan.
Promptly follow your plan’s complaint procedures if you believe you need to submit a complaint.
Treat doctors and all providers, their staff, and the staff of the plan with respect.
Not be involved in dishonest activity directed to the plan or any health care provider.
Communicate
Tell your health care professionals if you do not understand the treatment you receive and to ask if you do not understand how to care for your illness.
Tell your health care professional promptly when you have unexpected problems or symptoms.
Consult with your primary care physician for referrals to non-emergency covered specialist or hospital care.
Understand that network doctors and other health care professionals who care for you are not employees of Aetna and that Aetna does not control them.
Call Member Services about your plan if you do not understand how to use your benefits.
Give correct and complete information to doctors and other health care professionals who care for you.
Advise Aetna about other medical insurance coverage you or your family members may have.
Treat doctors and all providers, their staff, and the staff of the plan with respect.
Ask your treating doctor about all treatment options and the doctor’s compensation arrangement with Aetna.
*Indemnity plans do not have a contracted provider network. Claim payment is based upon covered services, which are subject to deductible and coinsurance.
You may have additional rights and responsibilities depending upon any state law or regulation applicable to your plan.
