Enrollee rights and responsibilities

Our enrollees have rights and responsibilities when participating in an MCO. Enrollee Services representatives serve as advocates for Amerigroup District of Columbia, Inc. enrollees.

Enrollees have the right to:

Privacy

• Be treated respectfully and with due consideration for dignity and privacy.
• Privacy during a visit with their doctor.
• Talk about their medical record with their PCP, ask for a summary of that record, and request to amend or correct the record as appropriate.
• Be properly educated about and helped to understand their illness and available healthcare options, including a candid discussion of appropriate clinically or medically necessary treatment options, including medication treatment options regardless of the cost or benefit coverage.
• Participate in decision‑making about the healthcare services they receive.
• Refuse healthcare (to the extent of the law) and understand the consequences of their refusal.
• Be free from any form of restraint, seclusion as a means of coercion, discipline, inconvenience, or retaliation as specified in other federal regulations on the use of restraints and seclusion.
• Decide ahead of time regarding the kinds of care they want if they become sick, injured, or seriously ill by making a living will.
• Expect their records (including medical and personal information) and communications will be treated confidentially.
• If under age 18 and married, pregnant, or have a child, be able to make decisions about their own healthcare and/or their child’s healthcare.
• Choose their PCP from the Amerigroup network of providers.
• Make a complaint to Amerigroup and get a response within 30 days.
• Have information about Amerigroup, its services, practitioners, and provider and enrollee rights and responsibilities.
• Receive information on the Notice of Privacy Practices as required by the Health Insurance Portability and Accountability Act (HIPAA).
• Get a current enrollee handbook and a directory of healthcare providers within the Amerigroup network.
• Choose any Amerigroup network specialist.
• Change their doctor to another Amerigroup network doctor if the doctor is unable to refer them to the Amerigroup network specialist of their choice.
• Be connected to healthcare providers for ongoing treatment of chronic disabilities.
• Have access to their PCP or a backup 24 hours a day, 365 days a year for urgent or emergency care.
• Receive care right away from any hospital when their medical condition meets the definition of an emergency.
• Receive post-stabilization services following an emergency condition in some situations
• Call the Amerigroup toll-free, 24-hour Nurse HelpLine. English: 866-864-2544; Spanish: 866-864-2545
• Call the Amerigroup toll-free Enrollee Services telephone line from 8 a.m. to 6 p.m. Eastern time, Monday to Friday.Know what payment methodology Amerigroup uses with healthcare providers.
• Receive assistance in filing a grievance and/or appeal and appeal through the Amerigroup internal system.
• File a grievance or appeal if they are not happy with the results of a grievance and receive acknowledgement within 10 days and a resolution within 30 days.
• Ask Amerigroup to reconsider previously denied coverage; upon receipt of the enrollee’s medical information, Amerigroup will review the request.
• Freely exercise the right to file a grievance or appeal such that exercising of these rights will not adversely affect the way the enrollee is treated.
• Receive notification to present supporting documentation for their appeal.
• Examine files before, during, and after their appeal.
• Request an administrative hearing when dissatisfied with the Amerigroup decision.
• Continue to receive benefits pending the outcome of an appeal decision or state administrative hearing if the appropriate rules are followed.
• Only be responsible for cost-sharing in accordance with 42 CFR 447.50-42 CFR 447.60 and District of Columbia provisions for Medicaid.
• To make recommendations regarding the Amerigroup Rights and Responsibilities Policy.