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Rights and Responsibilties

Know Your Rights as a WellCare of South Carolina Member.

As Our Member, You Have the Right To:

  • Get information about our plan, services, doctors and other health care providers
  • Get information about your rights and responsibilities
  • Know the names and titles of doctors and other health providers caring for you
  • Be treated with respect and due consideration for your dignity and privacy
  • Have your privacy protected in accordance with the privacy requirements in 45 CFR parts 160 and 164 subparts A and E, to the extent that they are applicable
  • Decide with your doctor on the care you get
  • Talk openly about care you need for your health, no matter the cost or benefit coverage, and the treatment choices and risks involved (the information must be given in a way you understand)
  • Have the risks, benefits and side effects of medications and other treatments explained to you
  • Know about your health care needs after you get out of the hospital or leave the doctor’s office
  • Refuse care, as long as you agree to be responsible for your decision.
  • Refuse to take part in any medical research
  • File a grievance or an appeal about our plan or the care we provide; also, to know that if you do, it will not change how you are treated
  • Not be responsible for our debts in the event of bankruptcy and not be held liable for:
    • Covered services provided to you for which the government does not pay us
    • Covered services provided to you for which the government or we do not pay the provider who furnished the services
    • Payments of covered services under a contract, referral or other arrangement to the amount those payments are in excess of the amount you would owe if we provided the services directly
    • Be free from any form of restraint or seclusion used as a means of force, discipline, convenience or revenge, as specified in the federal regulations on the use of restraints and seclusion
    • Ask for and get a copy of your medical records from your doctor; also, to ask that the records be changed/corrected if needed
    • Requests must be received in writing from you or the person you choose to represent you
    • The records will be provided at no cost
    • They will be sent within 14 days of receipt of the request
  • Have your records kept private
  • Make your health care wishes known through advance directives
  • Have a say in our member rights
  • Appeal medical or administrative decisions by using our grievance and appeals process
  • Exercise these rights no matter your sex, age, race, ethnicity, income, education or religion
  • Have our staff observe your rights
  • Have all the above rights apply to the person legally able to make decisions about your health care
  • Be furnished quality services in accordance with 42 CFR 438.206 through 438.210, including:
    • Accessibility
    • Authorization standards
    • Availability
    • Coverage
    • Coverage outside of network
    • The right to a second opinion
  • Receive health care services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid fee-for-service and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished
  • Receive services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness, or medical condition
  • Receive all information, including but not limited to enrollment notices, informational materials, instructional materials, available treatment options and alternatives in a manner and format that may be easily understood
  • Receive assistance from both SCDHHS and us in understanding the requirements and benefits of our plan
  • Receive oral interpretation services free of charge for all non-English languages, not just those identified as prevalent
  • Be notified that oral interpretation is available and how to access those services.
  • As a potential member, to receive information about the basic features of managed care:
    • Which populations may or may not enroll in the program
    • Our responsibilities for coordination of care in a timely manner in order to make an informed choice
  • Receive information on our services, to include but not limited to:
    • Benefits covered
    • Procedures for obtaining benefits, including any authorization requirements
    • Any cost-sharing requirements
    • Service area
    • Names, locations, telephone numbers of and non-English language spoken by current contracted providers, including at a minimum, primary care providers (PCPs), specialists and hospitals
    • Any restrictions on your freedom of choice among network providers.
    • Providers not accepting new patients
    • Benefits not offered by our plan but available to you and how to obtain those benefits, including how transportation is provided
  • Receive a complete description of disenrollment rights at least annually
  • Receive notice of any significant changes in the benefits package at least 30 calendar days before the intended effective date of the change
  • Receive information on the grievance, appeal and State Fair Hearing procedures
  • Receive detailed information on emergency and after-hours coverage, to include but not limited to:
    • What constitutes an emergency medical condition, emergency services and post-stabilization services
    • That emergency services do not require prior authorization
    • The process and procedures for obtaining emergency services
    • The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under our contract with SCDHHS
    • Your right to use any hospital or other setting for emergency care
    • Post-stabilization care services rules as detailed in 42 CFR §422.113(c)
  • Receive our policy on referrals for specialty care and other benefits not provided by your PCP
  • Exercise these rights without adversely affecting the way we, our providers or SCDHHS treat you

Know Your Responsibilities as a WellCare of South Carolina Member.

As Our Member, You Have the Responsibility To:

  • Read your member handbook to understand how our plan works
  • Carry your member ID card at all times
  • Give information that we and your doctors and providers need to give care
  • Follow plans and instructions for care that you have agreed on with your doctor
  • Understand your health problems
  • Help set treatment goals that you and your doctor agree to
  • Carry your Medicaid card at all times
  • Show your member ID card to each provider
  • Schedule appointments for all non-emergency care through your doctor
  • Get a referral from your doctor for specialty care
  • Cooperate with the people who provide your health care
  • Be on time for appointments
  • Tell the doctor's office if you need to cancel or change an appointment
  • Pay your co-payments to providers
  • Respect the rights of all providers
  • Respect the property of all providers
  • Respect the rights of other patients
  • Not be disruptive in your doctor’s office
  • Know the medicines you take, what they are for and how to take them the right way
  • Make sure your doctor has copies of all your previous medical records
  • Let us know within 48 hours, or as soon as possible, if you are admitted to the hospital or get emergency room care
  • Be responsible for cost-sharing only as specified under covered services co-payments

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Last Updated On: 4/20/2021