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.