Member Rights and Responsibilities

Members' and potential members' bill of rights

You have the right:

1. To be treated with respect and with due consideration for his or her dignity and privacy.
2. To participate in decisions regarding his or her health care, including the right to refuse treatment.
3. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as stated in the federal regulations on the use of restraints and seclusion.
4. To be able to request and receive a copy of his or her medical records, and request that they be amended or corrected.
5. To receive health care services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid Fee-For-Service and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished.
6. To receive services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness, or medical condition.
7. To receive all information including but not limited to enrollment notices, informational materials, instructional materials, available treatment options, and alternatives in a manner and format that may be easily understood.
8. To receive assistance from both SCDHHS and First Choice in understanding the requirements and benefits of the plan.
9. To receive oral interpretation services free of charge for all non-English languages, not just those identified as prevalent.
10. To be notified that oral interpretation is available and how to access those services.
11. As a member and/or potential member, to receive information about the basic features of managed care, which populations may or may not enroll in the program and First Choice responsibilities for coordination of care in a timely manner in order make an informed choice.
12. To receive information on First Choice services, to include, but not limited to:
    • Benefits covered.
    • Procedures for obtaining benefits, including any authorization requirements.
    • Any cost sharing requirements.
    • Service area.
    • Names, locations, phone numbers of and non-English language spoken by current contracted providers, including at a minimum, primary care physicians, specialists, and hospitals.
    • Any restrictions on members' freedom of choice among network providers.
    • Providers not accepting new patients.
    • Benefits not offered by First Choice but available to members and how to obtain those benefits, including how transportation is provided.
13. To receive a complete description of disenrollment rights at least annually.
14. To receive notice of any significant changes in the benefits package at least thirty (30) calendar days before the intended effective date of the change. Notice of changes can be made by letter or included in the member newsletter. The benefits package includes services, benefits, and providers.
15. To receive information on the grievance, appeal and fair hearing procedures.
16. To receive detailed information on emergency and after-hours coverage, to include, but not limited to:
    • What constitutes an emergency medical condition, emergency services and post-stabilization services.
    • That emergency services do not require prior authorization.
    • The process and procedures for obtaining emergency services.
    • The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under the contract.
    • Members' right to use any hospital or other setting for emergency care.
    • Post-stabilization care services rules as detailed in 42 CFR§422.113(c).
17. To receive First Choice policy on referrals for specialty care and other benefits not provided by the member's PCP.
18. Have his or her privacy protected in accordance with the privacy requirements in 45 CFR parts 160 and 164 subparts A and E to the extent that they are applicable.
19. To exercise these rights without adversely affecting the way First Choice, its providers or SCDHHS treat the members.
20. To have a candid discussion of appropriate or medically necessary treatment options for his or her conditions, regardless of cost or benefit coverage.
21. To voice grievances or appeals about First Choice or the care it provides.
22. To make recommendations regarding First Choice's member rights and responsibilities.

Member responsibilities

It is up to you to:

1. Establish you or your children with a primary care provider (PCP) within 30 calendar days of entering the plan.
2. Not change your PCP without approval from First Choice.
3. Inform First Choice of any loss or theft of your ID card.
4. Present your ID card whenever using health care services.
5. Be familiar with First Choice procedures to the best of your ability.
6. If you have any questions or require additional information, contact the First Choice Member Services department to have your questions clarified.
7. Access preventive services.
8. Treat your PCP(s) and their staff with kindness and respect.
9. Provide your PCP(s), practitioners, providers and First Choice with accurate and complete medical information.
10. To understand your health problems and participate in developing mutually agreed upon treatment goals.
11. Follow the prescribed treatment of care recommended by the provider or let the provider know the reasons the treatment cannot be followed as soon as possible.
12. Obtain a referral from your PCP(s) before you go to the hospital your PCP(s) recommended.
13. Go to the emergency room only for emergencies.
14. Call your PCP(s) as soon as you or a family member feels ill. Do not wait. If you feel you have a life-threatening emergency, go to your closest hospital.
15. Make every effort to keep any agreed upon appointment or cancel an appointment in advance of when it is scheduled if you will be unable to attend.
16. Notify First Choice if your or your child/children's name, address, or phone number changes.
17. Inform First Choice of any change in your legal status regarding your authority to make decisions on behalf of your child or children.
18. To understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.