Member Rights

Members, legal guardians of members, and legally authorized surrogates for members have certain rights and responsibilities.  It is important that you know your rights and responsibilities.

• Information: You have the right to get from your Primary Care Provider (PCP) information about what might be wrong (to the level known), treatment and any known likely results. Your PCP can tell you about treatments that may or may not be covered by the plan, regardless of the cost.  You have a right to know about any costs you will need to pay. This should be told to you in words you can understand.  When it is not appropriate to give you information for medical reasons, the information can be given to a legally authorized person. Your doctor will ask for your approval for treatment unless there is an emergency and your life and health are in serious danger.
• You have the right to see your medical records.
• You have the right to be informed of changes within our CeltiCare network.
• You have the right to be kept informed of CeltiCare and Commonwealth Care covered and non-covered services, program changes,  how to access services, PCP assignment, providers, Advance Directive information, referrals and authorizations, benefit denials, member rights and responsibilities, and other CeltiCare rules and guidelines.  CeltiCare will notify you at least 60 days before the effective date of the modifications.  Such notices shall include the following:

o   Any changes in clinical review criteria

o   A statement of the effect of such changes on the personal liability of the insured for the cost of any such changes.

• You have a right to information about CeltiCare and the Commonwealth Care system.
• You have the right to a current list of CeltiCare providers.  You can also get information on your providers’ education, training, and practice.
• You have the right to talk to your provider about new uses of technology.  You can also ask CeltiCare for information on our quality plan, how members use the plan and how we review new technology.
• Respect & Dignity: You have the right to have considerate, respectful care at all times.  You have the right to have assistance in a prompt, courteous and responsible manner.  You have the right to be treated with dignity when receiving care. You have the right to be free from harassment by the health plan or the plan’s providers if there are any business disagreements between the plan and provider.
• You have the right to select a health plan or switch health plans, within the Commonwealth Care guidelines, without any threats or harassment.
• You have the right to privacy.
• Access: You have the right to adequate access to qualified health professionals.
• You have the right to access treatment or services that are medically necessary regardless of age, race, creed, sex, sexual preference, national origin or religion.
• You have the right to access medically necessary urgent and emergency services 24 hours a day and seven days a week.
• If you have a disability, you have the right to receive information in a different format in compliance with the Americans with Disabilities Act.
• Informed Consent: Members or their legal guardians or legal representatives have the right to join in decision making about their healthcare.  This includes working on any treatment plans and making care decisions.  You should know any possible risks, problems related to recovery, and the likelihood of success. You shall not have any treatment without consent freely given by you or your legally authorized surrogate decision-maker.  You will be informed of your care options. You have the right to know who is approving and who is performing the procedures or treatment.  All likely treatment and the nature of the problem should be explained clearly. You have a right to refuse treatment.  You have the right to a candid discussion of appropriate clinically or medically necessary treatment options for your condition, regardless of cost or benefit coverage
• Grievance: You have the right to file an Appeal or Grievance if you have had an unsatisfactory experience with CeltiCare or with any of our contracted providers or if you disagree with certain decisions made by CeltiCare.
• External Review: You have the right to apply for an independent external review with the Massachusetts Department of Public Health’s Office of Patient Protection for appeals or grievances not resolved to your satisfaction by CeltiCare.
• Rights and Responsibilities Policies: Members have a right to make recommendations regarding the organization’s Member Rights and Responsibilities policies.
• Refusal of Treatment: You may refuse treatment to the extent the law allows. You are responsible for your actions if treatment is refused or if the PCP’s instructions are not followed.  You should discuss all concerns about treatment with your PCP.  Your PCP can discuss different treatment plans with you, if there is more than one plan that may help you. You will make the final decision.
• Primary Care Provider (PCP): You have the right to pick your PCP within the plan network.  You also have the right to change your PCP or request information on CeltiCare doctors close to your home or work.
• Identity: You have the right to know the name and job title of people giving you care. You also have the right to know which doctor is your PCP.
• Language: You have the right to an interpreter when you do not speak or understand the language of the area.
• Second Opinions: You have the right to a second opinion by an in-network doctor, at no cost to you, if you believe your provider is not authorizing the requested care, or if you want more information about your treatment.
• Advance Directives: All CeltiCare members have a right to make Advance Directives for healthcare decisions.  CeltiCare members also have the right to refuse to make Advance Directives.  You should not be discriminated against for not having an Advance Directive.

Member Responsibilities

All members are responsible for learning how the CeltiCare plan works by reading the Evidence of Coverage.

• Giving Information: You should give accurate and complete information about present conditions, past illnesses, hospitalizations, medications, and other matters about your health.  You should make it known whether you clearly understand your care and what is expected of you.  You need to ask questions of your doctor until you understand the care you are receiving.  You need to review and understand the information you receive about CeltiCare.  You need to know the proper use of services covered by CeltiCare.
• Your Doctor’s Advice: You should follow the treatment plan suggested by providers of medical care.  You should ask questions if you do not understand any part of the treatment plan.  You should work with your PCP to develop treatment goals.  If you do not follow the treatment plan, you have the right to be advised of the likely results of your decision.
• ID Card: It is important that you show your CeltiCare ID card before you receive care.
• Emergency Room Use: You should use any emergency room only when you think you have a medical emergency.  For all other care, you should call your PCP.
• Appointments: You need to keep appointments.  If you cannot keep an appointment, you must call to cancel or reschedule.  You should schedule appointments during office hours whenever possible.
• Primary Care Provider (PCP): You should know the name of your assigned PCP. You should establish a relationship with your doctor.  You may change your PCP verbally or in writing by contacting our Member Services Department.
• Treatment: You should treat all CeltiCare staff, providers, and other members with respect and dignity.  Any concerns that you have about your care should be communicated to CeltiCare in a useful manner.
• Changes: You need to tell the Connector about any changes in your address, name, telephone number, or any changes in your family.
• Other Medical Insurance: When you enroll in CeltiCare, you need to give all information about any other medical insurance coverage you have.  If, at any time, you get other medical coverage besides your CeltiCare coverage, you must tell the Connector.
• Costs: If you access care without following CeltiCare rules, you may be responsible for the charges.  If applicable, you are responsible to pay your portion of the monthly Commonwealth premium and all co-payments at the time of service.