Member rights and responsibilities

Our members have rights and responsibilities. Our Member Services representatives serve as their advocates. Below are the rights and responsibilities of members.

Members have a right to:

1. Obtain a current directory of doctors within the Amerigroup Community Care network including addresses, telephone numbers, and a list of providers accepting members who speak languages other than English.
2. Choose any of the Amerigroup network specialists.
3. Be referred by the PCP to a specialist who has treated chronic disabilities.
4. Be able to get in contact with the PCP or a backup PCP 24 hours a day, 365 days a year for urgent care.
5. Call 911 without getting an approval from Amerigroup for an emergency medical condition.
6. Discuss with their doctors medical treatments they can have, even if not covered, as well as information on other care options.
7. File a grievance or appeal with Amerigroup or the state without penalty.
8. Be treated with respect and dignity and need for privacy.
9. Have information about Amerigroup, our services, policies and procedures, network providers, member rights and responsibilities, and any changes made.
10. Be able to communicate and be understood with the assistance of a translator if needed.
11. Refuse treatment to the extent of the law and be aware of the results. This includes the right to refuse to be a part of research.
12. Have an advance directive in effect.
13. Expect confidentiality of their records and communications.
14. Choose a PCP in the Amerigroup network, choose a new network PCP, and have privacy when seeing the provider.
15. Have a choice of specialists and information on how to obtain referral to a specialist or other provider.
16. Have their medical information given to a person of their choice, or to a person who is legally authorized, when concern for their health makes it inadvisable to give such information to them.
17. Assistance from an interpreter or TTY line.
18. Be free from being billed by providers for covered services that are medically necessary and were authorized by Amerigroup unless there is a copay.
19. Offer suggestions for changes in the way Amerigroup does business.
20. Be fully informed by the PCP, care/case manager, or other Amerigroup network providers and help make decisions about their health care.
21. Take part in developing and implementing a plan of care that promotes the best results and encourages independence.
22. Have services that promote quality of life and independence. Amerigroup wants to help keep and encourage their natural support systems.
23. Have your PCP decide if your benefits are medically necessary and should be covered.
24. Voice grievances about Amerigroup or the care provided and recommend changes to policies and services to Amerigroup staff, providers, and outside representatives of their choice free of limits, interference, force, discrimination, or attack by Amerigroup or Amerigroup providers. Amerigroup will not discriminate against a member or attempt to disenroll a member for filing a complaint or grievance/appeal against the HMO.
25. Refuse care from specific providers.
26. Have access to their medical records in accordance with federal and state laws.
27. Be free from harm, including unnecessary physical restraints or isolation, excessive medication, physical or mental abuse or neglect, and to be free of hazardous procedures.
28. Make recommendations regarding the member rights and responsibilities policy.
29. Receive a second opinion.

Members have a right to get information each year on:

1. Member rights and responsibilities.
2. Amerigroup benefits and services, including MLTSS, and how to obtain them.
3. Provisions for after-hours and emergency coverage. For MLTSS members, provision of key contact information such as the emergency after-hours number with immediate access to a staff member with access to the plan of care and who can make immediate service authorizations and perform care coordination functions.
4. The organization’s policy and procedure on referrals for specialty and ancillary services for MLTSS.
5. Charges to members, if charges apply, including paying charges, copays and fees, and the process if a bill is received.
6. Termination of or changes in benefits, services, healthcare facilities, or providers.
7. How to appeal decisions that affect their coverage, benefits, or relationship with Amerigroup.
8. How to change PCPs.
9. How to disenroll from Amerigroup.
10. How to file a complaint or grievance and how to recommend changes.
11. The percentage of Amerigroup network providers who are board-certified.
12. A description of how to get services, including authorization requirements, special benefit rules that may apply to services out-of-network, services covered by fee-for-service Medicaid, and out-of-area coverage and policies on referrals for specialty and ancillary care.

Receive a copy of the member handbook and/or provider directory by request by calling:

Member Services at

1-800-600-4441

TTY

711