Member Rights and Responsibilities HMO or PPO Plan Members
As an Aetna HMO or PPO member, you have a right to:
- 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, genetic information, 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.
- Be treated with respect for your privacy and dignity.
- Have your medical records kept private, except when permitted by law or with your approval.
- Be involved in deciding on the kind of care you do or do not want.
- 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, including our Member Rights and Responsibilities policy.
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.
- 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.
- 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.