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Member Rights and Responsibilities

Member Rights

As a member, you have certain rights. Carolina Complete Health wants to respect your rights and we expect our providers to respect your rights. Your rights are:

  • A right to receive information about Carolina Complete Health, its services, providers, and member rights and responsibilities.
  • A right to give your ideas for “Carolina Complete Health’s member rights and responsibilities policy.”
  • A right to be treated with respect, dignity, and privacy without regard for health status, sex, race, color, religion, national origin, age, marital status, sexual orientation, or gender identity.
  • A right to get information on care options in a way that you can understand, regardless of cost or coverage.
  • Give your approval of any plan for your care after that plan has been fully explained to you.
  • A right to participate in decisions about your health care, which includes the right to refuse treatment.
  • A right to seek second opinions.
  • A right to get help with care management from the PCP’s office.
  • A right to express a concern or appeal about Carolina Complete Health or the care you receive, and to receive a response in a reasonable period of time.
  • A right to State Fair Hearing system
  • A right to receive a copy of certain of your health plan records upon request (one copy is free of charge) and to ask that your records be amended or corrected where necessary.
  • A right to choose your health professionals and long-term supports and services providers to the extent possible and appropriate, as per 42 CFR §438.6(m).
  • A right to be given health care services, as per 42 CFR §§ 438.206 through 438.210.
  • A right to get health care services that are similar in amount and scope to those given under Medicaid Fee-For-Service. This includes the right to get health care services that will achieve the purpose for which the services are given.
  • A right to get services that are fitting and are not denied or reduced due to:
    • Diagnosis
    • Type of illness
    • Medical condition
  • A right to be given information in a manner and format you can understand. This includes:
    • Enrollment notices
    • Informational materials
    • Instructional materials
  • A right to treatment options and alternatives
  • A right to get free oral interpretation services for all non- English languages.
  • A right to be notified that interpretation services are available and how to access them.
  • A right to get adequate and timely information on Carolina Complete Health’s Physician Incentive Plan upon request.
  • Appoint someone you trust (relative, friend, or lawyer) to speak for you if you are unable to speak for yourself about your care and treatment (Refer to Advanced Directives).
  • Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.

Member Responsibilities

As a member, you have certain responsibilities. Treatment can work better if you do these things. Your responsibilities are:

  • Notify North Carolina Medicaid if:
    • Your family size changes,
    • You move out of the state or have other address changes, or
    • You get or have health coverage under another policy, other third parties, or there are changes to that coverage.
  • To inform Carolina Complete Health of the loss or theft of an ID card.
  • To inform Carolina Complete Health, your providers, and the State Medicaid program of any change of address or phone number.
  • To present the Carolina Complete Health ID card when using health care services.
  • To be familiar with Carolina Complete Health procedures to the best of your abilities.
  • To contact Carolina Complete Health to get information and have questions answered.
  • To give providers accurate and complete medical information.
  • To follow the care prescribed by the provider or to let the provider know why treatment cannot be followed, as soon as possible.
  • To keep appointments and follow-up appointments. To access preventive care services.
  • To live healthy lifestyles and avoid behaviors known to be harmful.
  • To understand your health problems and participate in developing treatment goals with your provider/doctor and other providers, to the degree possible.
  • To give accurate and complete information needed for care to Carolina Complete Health and all their health care and support providers.
  • To make your Primary Care Provider (PCP) aware of all other providers who are treating you, including behavioral health problems. (This is to ensure communication and coordination in care.)
  • To learn about Carolina Complete Health coverage provisions, rules, and restrictions.
  • To ask questions of your providers to learn the risks, benefits, and costs of treatment options and to make care decisions after carefully weighing all factors.
  • To follow Carolina Complete Health’s grievance process outlined in the Member Handbook if you have a disagreement with a provider.
  • To choose a Primary Care Provider (PCP).
  • To treat providers and staff with dignity and respect.
  • Call or go back to your Primary Care Provider (PCP) if you do not get better or ask for a second opinion.
  • Tell us if you have problems with any health care staff by calling Member Services at 1-833-552-3876 (TTY: 711).
  • Keep your appointments. If you must cancel, call as soon as you can.
  • Use the emergency department only for emergencies.
  • Call your Primary Care Provider (PCP) when you need medical care, even if it is after hours.