Member rights and responsibilities

As an Aetna HMO or PPO 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 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 consent to 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 health care providers about continuing health care requirements after you are discharged from inpatient or outpatient facilities.
• Be informed if a health care professional plans to use an experimental treatment or procedure in your care. You have the right to refuse to participate in research projects.
• Receive an explanation about 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.
• Get necessary care from participating network specialists, hospitals and other health care 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. This includes 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 with acute symptoms that are severe enough sufficient so that a prudent layperson, who has average knowledge of health and medicine, could reasonably expect the lack of immediate medical attention to result in serious danger to the person’s health.
• Receive urgently needed medically necessary care.

The Freedom to Make Decisions

• Use 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 make use of 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 punished 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 when you have to make decisions about the need for services and if you are involved in the complaint process.
• Suggest changes in the plan’s policies and services.

As an Aetna HMO or PPO 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 your 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 correct 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 Aetna’s Member Services department 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.
• Tell Aetna about other medical insurance coverage you or your family members may have.
• Ask your treating doctor about all treatment options, and how the doctor is paid by Aetna.

You may have additional rights and responsibilities depending upon any state law applicable to your plan.

Rights and Responsibilities of Medicare Advantage HMO, PPO, Private Fee for Service, or Special Needs Plan Members Without a Medicare Prescription Drug Benefit

As an Aetna Medicare Advantage HMO, PPO, Private Fee for Service, or Special Needs Plan Member without a Medicare prescription drug benefit, you have a right to:

Information

• Get information from Aetna about our plan. This includes information about our financial condition, and how our plan compares to other health plans.
• Get information from us about our network.
• Have individuals and translation services available to answer questions from non-English-speaking beneficiaries. We must provide information about our benefits that is accessible and appropriate for persons eligible for Medicare because of disability.
• Get an explanation from Aetna about any Part C medical care or service not covered by our plan.
• Receive in writing why we will not pay for or approve a Part C medical care or service, and how you can file an appeal to ask us to change this decision even if you obtain the Part C medical care or service from a provider not affiliated with our organization.
• Make a complaint if you have concerns or problems related to your coverage.
• Be treated fairly (that is, not be retaliated against) if you make a complaint.
• Get a summary of information about the appeals and grievances that members have filed against our plan in the past.
• Get more information about your rights. If you have questions or concerns about your rights and protections, you can
  • Call Member Services
  • Get free help and information from your State Health Insurance Assistance Program (SHIP).
  • Visit www.medicare.gov to read or download the publication, Your Medicare Rights & Protections.
  • Call 1-800-Medicare [(800) 633-4227]. TTY users should call (877) 486-2048.

Access to Care

• Choose a network health care provider. If you are a member of a Private Fee for Service plan you have the right to seek care from any health care provider in the United States who is eligible to be paid by Medicare and who agrees to accept Aetna’s terms and conditions of payment.
• Timely access to providers. “Timely access” means that you can get services within a reasonable amount of time.
• Go to a women’s health specialist (such as a gynecologist) in our plan without a referral.

The Freedom to Make Decisions

• Get full information from your health care providers when you go for medical care.
• Participate fully in decisions about your health care. Your health care providers must explain things in a way that you can understand. Your rights include knowing about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our Plan.
• Be told about any risks involved in your care.
• Be told beforehand if any planned medical care or treatment is part of a research experiment. You must and be given the choice of refusing experimental treatments.
• Refuse treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. This includes the right to stop taking your medication.
• Receive a detailed explanation from Aetna if you think a health care provider denied care that you believe you were entitled to receive or care you believe you should continue to receive. In these cases, you must request an initial decision, called an organization determination.
• Ask someone such as a family member or friend to help you with decisions about your health care.
• Give your doctors written instructions about how you want them to handle your medical care, such as “Advanced Directives,” Living Will,” and “Power of Attorney for Health Care,” if you become unable to make decisions for yourself.

Personal Rights

• Be treated with dignity, respect and fairness at all times. Aetna must obey laws that protect you from discrimination or unfair treatment. Aetna does not discriminate based on a person’s race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age or national origin.
• The privacy of your medical records and personal health information, according to federal and state laws that protect the privacy of your medical records and personal health information. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care.
• Receive a notice that tells you about privacy of your medical records and personal health information rights and explains how we protect the privacy of your health information.
• Look at medical records held at the plan, and to get a copy of your records.
• Ask Aetna to make additions or corrections to your medical records.
• Know how your health information has been given out and used for non-routine purposes.

Input

• Suggest changes in the plan’s policies and services.

As an Aetna Medicare Advantage HMO, PPO, Private Fee for Service, or special needs plan member without a Medicare prescription drug benefit, you have a responsibility to:

Exercise Your Rights

• Learn about your coverage and the rules you must follow to get care as a member.

Follow Instructions

• Tell health care providers when you are seeking care (unless it is an emergency) that you are enrolled in our plan, and present your plan membership card to the provider.
• Give your doctor and other health care providers the information they need to care for you.
• Follow the treatment plans and instructions that you and your doctors agree upon.
• Act in a way that supports the care given to other patients and helps the smooth running of your doctor’s office, hospitals and other offices.
• Tell our plan if you have additional health insurance and use all of your insurance coverage.
• Pay your plan premiums and copayments/coinsurance for your covered services.
• Pay for services that aren’t covered.

Communicate

• If you have any questions, ask your doctors and other health care providers and have them explain your treatment in a way you can understand.
• Let Aetna know if you move.
• Let us know if you have any questions, concerns, problems or suggestions.

Member Rights and Responsibilities for Medicare Advantage HMO, PPO, Private Fee for Service, or Special Needs Plan Members With a Medicare Prescription Drug Benefit

As a Member in a Medicare Advantage HMO, PPO, Private Fee for Service, or special needs plan with a Medicare Prescription Drug Benefit included in the plan design, you have a right to:

Information

Get information from Aetna about our plan. This includes information about how we are doing financially, and how our plan compares to other health plans.

• Get information from us about our network.
• Have questions from non-English-speaking beneficiaries answered. We make individuals and translation services available, and the information we provide about our benefits must be accessible and appropriate for people who are eligible for Medicare because of disability.
• Get an explanation from Aetna about any prescription drugs, Part C medical care or service not covered by our plan.
• Receive in writing why we will not pay for or approve a prescription drug, Part C medical care or service, and how you can file an appeal to ask us to change this decision even if you obtain the prescription drug, or Part C medical care or service from a pharmacy or provider not in the Aetna network.
• Receive an explanation from us about any utilization-management requirements, such as step-therapy or prior authorization, which may apply to your plan.
• Make a complaint if you have concerns or problems related to your coverage.
• Be treated fairly (that is, not be retaliated against) if you make a complaint.
• Get a summary of information about the appeals and grievances that members have filed against our plan in the past.
• Get more information about your rights. If you have questions or concerns about your rights and protections, you can
  • Call Aetna Member Services
  • Get free help and information from your State Health Insurance Assistance Program (SHIP).
  • Visit www.medicare.gov to view or download the publication Your Medicare Rights & Protections.
  • Call 1-800-Medicare [(800) 633-4227]. TTY users should call (877) 486-2048.

Access to Care

• Get full information from your health care providers when you go for medical care. This includes knowing about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan.
• Participate fully in decisions about your health care. Your health care providers must explain things in a way that you can understand. Your rights include knowing about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan.
• Know about the different medication therapy management programs we offer in which you may participate.
• Be told about any risks involved in your care.
• Be told beforehand if any planned medical care or treatment is part of a research experiment. You must be given the choice of refusing experimental treatments.
• Refuse treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. This includes the right to stop taking your medication.
• Receive a detailed explanation from Aetna if you think a health care provider has denied care you believe you were entitled to receive or care you believe you should continue to receive. In these cases, you must request an initial decision, called an organization determination.
• Ask someone such as a family member or friend to help you with decisions about your health care.
• Give your doctors written instructions about how you want them to handle your medical care, such as “Advanced Directives,” Living Will,” and “Power of Attorney for Health Care,” if you become unable to make decisions for yourself.

Personal Rights

• Be treated with dignity, respect, and fairness at all times. Aetna must obey laws that protect you from discrimination or unfair treatment. Aetna does not discriminate based on a person’s race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age or national origin.
• The privacy of your medical records and personal health information according to federal and state laws that protect the privacy of your medical records and personal health information. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care.
• Receive a notice that tells you about privacy of your medical records and personal health information rights and explains how we protect the privacy of your health information.
• Look at medical records held at the plan, and to get a copy of your records.
• Ask Aetna to make additions or corrections to your medical records.
• Know how your health information has been given out and used for non-routine purposes.
• Get information from us about our network pharmacies, health care providers and their qualifications, as well as information about how we pay our doctors.

Input

• Suggest changes in the plan’s policies and services.

As a member in a Medicare Advantage HMO, PPO, Private Fee for Service, or special needs plan with a Medicare Prescription Drug Benefit included in the plan design, you have a responsibility to:

Exercise Your Rights

• Learn about your coverage and the rules you must follow to get care as a member.

Follow Instructions

• Unless it is an emergency, when seeking care let health care providers know that you are enrolled in our plan and present your plan membership card to the provider.
• Give your doctor and other health care providers the information they need to care for you.
• Follow the treatment plans and instructions that you and your doctors agree upon.
• Act in a way that supports the care given to other patients and helps the smooth running of your doctor’s office, hospitals and other offices.
• Tell our plan if you have additional health insurance or drug coverage and use all of your insurance coverage.
• Pay your plan premiums and copayments/coinsurance for your covered services.
• Pay for services that aren’t covered.

Communicate

• Ask your doctors and other providers if you have any questions and have them explain your treatment in a way you can understand.
• Let Aetna know if you move.
• Let us know if you have any questions, concerns, problems or suggestions.