Your Rights and Responsibilities

Your rights as an AmeriHealth Caritas Next member

AmeriHealth Caritas Next complies with applicable federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex, gender identity or expression, or sexual orientation. AmeriHealth Caritas Next does not exclude people or treat them differently because of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex, gender, gender identity or expression, or sexual orientation.

AmeriHealth Caritas Next is committed to complying with all applicable requirements under federal and state law and regulations pertaining to member privacy and confidentiality rights.

As a member, you have the right to:

Receive information about the health plan, its benefits, services included or excluded from coverage policies, and network providers’ and members’ rights and responsibilities; written and web-based information that is provided to you must be readable and easily understood.
Be treated with respect and be recognized for your dignity and right to privacy.
Participate in decision-making with providers regarding your health care; this right includes candid discussions of appropriate or medically necessary treatment options for your condition, regardless of cost or benefits coverage.
Voice grievances or appeals about the health plan or care provided and receive a timely response. You have a right to be notified of the disposition of appeals or grievances and the right to further appeal, as appropriate.
Make recommendations regarding our member rights and responsibilities policies by contacting Member Services in writing.
Choose providers, within the limits of the provider network, including the right to refuse care from specific providers.
Have confidential treatment of personally identifiable health or medical information. You also have the right to access your medical record in accordance with applicable federal and state laws.
Be given reasonable access to medical services.
Receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, genetic information, color, religion, sex, gender, national origin, or source of payment.
Formulate advance directives. The plan will provide information concerning advance directives to members and providers and will support members through our medical record-keeping policies.
Obtain a current directory of network providers upon request. The directory includes addresses, phone numbers, and a listing of providers who speak languages other than English.
File a complaint or appeal about the health plan or care provided with the applicable regulatory agency and receive an answer to those complaints within a reasonable period of time.
Appeal a decision to deny or limit coverage through an independent organization. You also have the right to know that your provider cannot be penalized for filing a complaint or appeal on your behalf.
Obtain assistance and referrals to providers who are experienced in treating your disabilities if you have a chronic disability.
Have candid discussions of appropriate or medically necessary treatment options for your condition, regardless of cost or benefits coverage, in terms that you understand, including an explanation of your medical condition, recommended treatment, risks of treatment, expected results, and reasonable medical alternatives. If you are unable to easily understand this information, you have the right to have an explanation provided to your designated representative and documented in your medical record. The plan does not direct providers to restrict information regarding treatment options.
Have services available and accessible when medically necessary, including availability of care 24 hours a day, seven days a week, for urgent and emergency conditions.
Call 911 in a potentially life-threatening situation without prior approval from the plan, and to have the plan pay per contract for a medical screening evaluation in the emergency room to determine whether an emergency medical condition exists.
Continue receiving services from a provider who has been terminated from the plan’s network (without cause) in the time frames as outlined. This continuity of care allowance does not apply if the provider is terminated for reasons that would endanger you, public health, or safety, or which relate to a breach of contract or fraud.
Have the rights afforded to members by law or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language you understand.
Receive prompt notification of terminations or changes in benefits, services, or the provider network.
Have a choice of specialists among network providers following an authorization or referral as applicable, subject to their availability to accept new patients.

As a member, you have the responsibility to:

Communicate, to the extent possible, information that the plan and network providers need to care for you.
Follow the plans and instructions for care that you have agreed on with your providers; this responsibility includes consideration of the possible consequences of failure to comply with recommended treatment.
Understand your health problems and participate in developing mutually agreed-on treatment goals to the degree possible.
Review all benefits and membership materials carefully, and follow health plan rules.
Ask questions to ensure understanding of the provided explanations and instructions.
Treat others with the same respect and courtesy as you expect to receive.
Keep scheduled appointments or give adequate notice of delay or cancellation.