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:
- Obtain a current directory of doctors within the Wellpoint network including addresses, telephone numbers, and a list of providers accepting members who speak languages other than English.
- Choose any of the Wellpoint network specialists.
- Be referred by the PCP to a specialist who has treated chronic disabilities.
- Be able to get in contact with the PCP or a backup PCP 24 hours a day, 365 days a year for urgent care.
- Call 911 without getting an approval from Wellpoint for an emergency medical condition.
- Discuss with their doctors medical treatments they can have, even if not covered, as well as information on other care options.
- File a grievance or appeal with Wellpoint or the state without penalty.
- Be treated with respect and dignity and need for privacy.
- Have information about Wellpoint, our services, policies and procedures, network providers, member rights and responsibilities, and any changes made.
- Be able to communicate and be understood with the assistance of a translator if needed.
- 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.
- Have an advance directive in effect.
- Expect confidentiality of their records and communications.
- Choose a PCP in the Wellpoint network, choose a new network PCP, and have privacy when seeing the provider.
- Have a choice of specialists and information on how to obtain referral to a specialist or other provider.
- 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.
- Assistance from an interpreter or TTY line.
- Be free from being billed by providers for covered services that are medically necessary and were authorized by Wellpoint unless there is a copay.
- Offer suggestions for changes in the way Wellpoint does business.
- Be fully informed by the PCP, care/case manager, or other Wellpoint network providers and help make decisions about their health care.
- Take part in developing and implementing a plan of care that promotes the best results and encourages independence.
- Have services that promote quality of life and independence. Wellpoint wants to help keep and encourage their natural support systems.
- Have your PCP decide if your benefits are medically necessary and should be covered.
- Voice grievances about Wellpoint or the care provided and recommend changes to policies and services to Wellpoint staff, providers, and outside representatives of their choice free of limits, interference, force, discrimination, or attack by Wellpoint or Wellpoint providers. Wellpoint will not discriminate against a member or attempt to disenroll a member for filing a complaint or grievance/appeal against the HMO.
- Refuse care from specific providers.
- Have access to their medical records in accordance with federal and state laws.
- 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.
- Make recommendations regarding the member rights and responsibilities policy.
- Receive a second opinion.
Members have a right to get information each year on:
- Member rights and responsibilities.
- Wellpoint benefits and services, including MLTSS, and how to obtain them.
- 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.
- The organization’s policy and procedure on referrals for specialty and ancillary services for MLTSS.
- Charges to members, if charges apply, including paying charges, copays and fees, and the process if a bill is received.
- Termination of or changes in benefits, services, healthcare facilities, or providers.
- How to appeal decisions that affect their coverage, benefits, or relationship with Wellpoint.
- How to change PCPs.
- How to disenroll from Wellpoint.
- How to file a complaint or grievance and how to recommend changes.
- The percentage of Wellpoint network providers who are board-certified.
- 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:
Members have a responsibility to:
- Inform the family doctor after getting emergency treatment.
- Treat their doctors, staffs, and Wellpoint employees with respect and dignity.
- Get information and consider treatments prior to receiving them.
- Discuss any problems with their doctor’s directions.
- Know what refusing treatment recommended by a doctor can mean.
- Assist the current family doctor in obtaining medical records from their previous doctor and assist the current doctor in completing the new record.
- Get permission from the family doctor or the doctor’s associates before seeing a consultant or specialist.
- Call Wellpoint and change the doctor before seeing a new doctor.
- Keep following Wellpoint policies and procedures until disenrolled with Wellpoint .
- Make and keep appointments, be timely, and call if needing to cancel an appointment or are late for an appointment.
- State grievances, concerns, and opinions in an appropriate and courteous way.
- Learn and follow the policies and procedures outlined in the Member Handbook.
- Supply information, to the extent possible, that the organization and its providers need to provide care. Become involved in their healthcare, work with the doctor about recommended treatment, and follow the plans and instructions for care agreed upon with the provider.
- Carry the Medicaid and Wellpoint ID cards at all times. Inform Wellpoint if cards are lost or stolen, if ID card information is incorrect, or if there are changes in name or address.
- Provide, to the extent possible, information needed by Wellpoint, the doctor, and professional staff involving their care including the names of any doctors they are currently seeing.
- Understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
It is the member’s responsibility to keep their address and phone number information current so that Wellpoint can send updated information or contact the member.
In addition to the above, MLTSS, offered by Wellpoint in New Jersey, has additional member rights, which include the following:
- To request and receive information on choice of services available.
- Have access to and choice of qualified service providers.
- Be informed of your rights prior to receiving chosen and approved services.
- Receive services without regard to race, religion, color, creed, gender, national origin, political beliefs, sexual orientation, marital status, or disability.
- Have access to appropriate services that support your health and welfare.
- To assume risk after being fully informed and able to understand the risks and consequences of the decisions made.
- To make decisions concerning your care needs.
- Participate in the development of and changes to the plan of care.
- Request changes in services at any time, including add, increase, decrease, or discontinue.
- Request and receive from your care manager a list of names and duties of any person(s) assigned to provide services to you under the plan of care.
- Receive support and direction from your care manager to resolve concerns about your care needs and/or grievances about services or providers.
- Be informed of, and receive in writing, facility-specific resident rights upon admission to an institutional or residential setting.
- Be informed of all the covered/required services you are entitled to, required by, and/or offered by the institutional or residential setting and any charges not covered by the managed care plan while in the facility.
- Not to be transferred or discharged out of a facility, except for medical necessity; to protect your physical welfare and safety or the welfare and safety of other residents; or, because of failure, after reasonable and appropriate notice of nonpayment to the facility from available income as reported on the statement of available income for Medicaid payment.
- Have your health plan protect and promote your ability to exercise all rights identified in this document.
- Have all rights and responsibilities outlined here forwarded to your authorized representative or court appointed legal guardian.
The MLTSS Program has additional member responsibilities, which include the following:
- Provide all health and treatment related information, including but not limited to, medication, circumstances, living arrangements, informal, and formal supports to the plan’s care manager in order to identify care needs and develop a plan of care.
- Understand your health care needs and work with your care manager to develop or change goals and services.
- Work with your care manager to develop and/or revise your Plan of Care to facilitate timely authorization and implementation of services.
- Ask questions when additional understanding is needed.
- Understand the risks associated with your decisions about care.
- Report any significant changes on your health condition, medication, circumstances, living arrangements, informal, and formal supports to the care manager.
- Notify your care manager should any problem occur or if you are dissatisfied with the services being provided.
- Follow your health plan’s rules and/or those rules of institutional or residential settings (including any applicable cost share).
- Notify your assigned care manager if there are any gaps in services/care.
- Let your family doctor know as soon as you can after you get emergency treatment.
- Talk about any problems about following your provider’s directions.
- Know what saying no to treatment recommended by a provider means.
- Carry your Medicare and Wellpoint ID card at all times.
- Report any lost or stolen cards to Wellpoint as soon as you can.
- Call Wellpoint if information on your ID card is wrong or if you have changes in name or address.
- Report any changes to your address and phone number by calling the Medicaid Hotline at 800-356-1561 (TTY 877-294-4356). If you have NJ FamilyCare, call 800-701-0710 (TTY 800-701-0720).
- Complete the NJ FamilyCare renewal process every year to ensure you keep your NJ FamilyCare benefits.
- And remember, it is your job to keep your address and phone number current so we can send you updated information or contact you.
To report fraud, contact:
NJ Medicaid Fraud Division hotline