Rights and responsibilities

Your rights and responsibilities

As a plan participant, you have a right to:

• Get up-to-date information about the doctors and hospitals participating in the Plan.
• Obtain primary and preventive care from the PCP you chose from the Plan’s network.
• Change your PCP to another available PCP who participates in the Aetna network.
• Obtain covered care from participating specialists, hospitals and other providers.
• Be referred to participating specialists who are experienced in treating your chronic illness.
• Be told by your doctors how to make appointments and get health care during and after office hours.
• Be told how to get in touch with your PCP or a back-up doctor 24 hours a day, every day.
• Call 911 (or any available area emergency response service) or go to the nearest emergency facility in a situation that might be life-threatening.
• Be treated with respect for your privacy and dignity.
• Have your medical records kept private, except when required by law or contract, or with your approval.
• Help your doctor make decisions about your health care.
• Discuss with your doctor your condition and all care alternatives, including potential risks and benefits, even if a care option is not covered.
• Know that your doctor cannot be penalized for filing a complaint or appeal.
• Know how the Plan decides what services are covered.
• Know how your doctors are compensated for the services they provide. If you would like more information about Aetna’s physician compensation arrangements, visit their website at www.aetna.com. Select Find a Doctor from the drop-down menu under Quick Tools, then under “How do I learn more about:” select the type of plan you’re enrolled in.
• Get up-to-date information about the services covered by the Plan — for instance, what is and is not covered and any applicable limitations or exclusions.
• Get information about copayments and fees you must pay.
• Be told how to file a complaint, grievance or appeal with the Plan.
• Receive a prompt reply when you ask the Plan questions or request information.
• Obtain your doctor’s help in decisions about the need for services and in the grievance process.
• Suggest changes in the Plan’s policies and services.

As a plan participant, you have a right to:

• Choose a PCP from the Plan’s network and form an ongoing patient-doctor relationship.
• Help your doctor make decisions about your health care.
• Tell your PCP if you do not understand the treatment you receive and ask if you do not understand how to care for your illness.
• Follow the directions and advice you and your doctors have agreed upon.
• Tell your doctor promptly when you have unexpected problems or symptoms.
• Consult with your PCP for non-emergency referrals to specialist or hospital care.
• See the specialists your PCP refers you to.
• Make sure you have the appropriate authorization for certain services, including inpatient hospitalization and out-of-network treatment.
• Call your PCP before getting care at an emergency facility, unless a delay would be detrimental to your health.
• Understand that participating doctors and other health care providers who care for you are not employees of Aetna and that Aetna does not control them.
• Show your ID card to providers before getting care from them.
• Pay the copayments required by the Plan.
• Call Member Services if you do not understand how to use your benefits.
• Promptly follow the Plan’s grievance procedures if you believe you need to submit a grievance.
• Give correct and complete information to doctors and other health care providers who care for you.
• Treat doctors and all providers, their staff, and the staff of the Plan with respect.
• Advise Aetna about other medical coverage you or your family members may have.
• Not be involved in dishonest activity directed to the Plan or any provider.
• Read and understand your Plan and benefits. Know the copayments and what services are covered and what services are not covered.