Member Rights and Responsibilities

Your rights

  • You have the right to be treated with respect and with recognition of your dignity and right to privacy.
  • You have the right to be told about and understand any illness you have.
  • You have the right to be told in advance – in a manner you understand – of any treatment(s) and alternatives that a provider feels should be done.
  • You have the right to take part in decisions regarding your healthcare, including the right to refuse treatment as far as the law allows, and to know what the outcome may be.
  • You have the right to have an open and honest discussion of appropriate or Medically Necessary treatment options for your health conditions, regardless of cost or benefit coverage. You may be responsible for payment of services not included in the Covered and Excluded Services list for your coverage type.
  • You have the right to expect your healthcare Providers to keep your records private, as well as anything you discuss with them. No information will be released to anyone without your consent, unless required by law.
  • You have the right to request an interpreter when you receive healthcare. Call Member Services if you need help with this service.
  • You have the right to request an interpreter when you call or visit WellSense or Carelon Behavioral Health (for Behavioral Health). Call the Member Services department if you need help with this service.
  • You have the right to choose your own Primary Care Provider (PCP) and you can change your PCP at any time. You must call Member Services if you want to change your PCP.
  • You have the right to receive healthcare within the timeframes described in your member documents, and to file an Internal Appeal if you do not receive your care within those timeframes.
  • You have the right to voice a complaint and file a Grievance with Member Services, Carelon Behavioral Health, and/or the MassHealth Member Services center about services you received from the Plan or from a healthcare provider. You also have the right to Appeal certain decisions made by WellSense or Carelon Behavioral Health (for Behavioral Health). The reasons for Grievances and Internal Appeals are described in your member documents.
  • You have the right to talk about your health records with your provider and obtain a complete copy of those records. You also have the right to request a change to your health records.
  • You have the right to know and receive all of the benefits, services, rights and responsibilities you have under WellSense and/or MassHealth.
  • You have the right to have your member documents and any printed materials from WellSense translated into your primary language, and/or to have these materials read aloud to you if you have trouble seeing or reading. Oral interpretation services will be made available upon request and free of charge.
  • You have the right to ask for a Second Opinion about any healthcare that your PCP advises you to have. WellSense will pay for the cost of your Second Opinion visit.
  • You have the right to receive Emergency care, 24 hours a day, seven days a week. Please see your member documents for complete information.
  • You have the right to be free from any form of physical restraint or seclusion that would be used as a means of coercion, force, discipline, convenience or retaliation.
  • You have the right to freely exercise these rights without adversely affecting the way WellSense and its providers treat you.
  • You have the right to receive health treatment from WellSense providers without regard to race, age, gender, sexual preference, national origin, religion, health status, economic status, or physical disabilities. And no provider should engage in any practice, with respect to any WellSense Member, that constitutes unlawful discrimination under any state or federal law or regulation.
  • You have the right to disenroll from WellSense and change to another MassHealth health plan by calling the MassHealth Member Services center (MassHealth members).
  • You have the right to receive information about WellSense, our services, providers, and your rights and responsibilities.
  • You have the right to make recommendations about our Rights and Responsibilities statement.

Your Responsibilities

  • You should tell your healthcare provider your health complaints clearly and provide as much information as possible.
  • You should tell your healthcare provider about yourself and your health history.
  • You should talk to your PCP about seeking the services of a Specialist before you go to a hospital (except in cases of Emergencies or when you refer yourself for certain Covered Services).
  • You should treat your healthcare provider with dignity and respect.
  • You should keep appointments, be on time, and call in advance if you’re going to be late or have to cancel.
  • You should learn about your health problems and any recommended treatment, and consider the treatment before it’s performed.
  • You should partner with your healthcare provider and work out treatment plans and goals together.
  • You should follow the instructions and plans for care that you and your healthcare provider have agreed to, and remember that refusing treatment recommended by your healthcare provider might harm your health.
  • You should authorize your PCP to get copies of all your health records.
  • You must receive all of your healthcare from WellSense Health Plan providers, except in cases of Emergency or Family Planning Services or unless WellSense provides a Prior Authorization for out-of-Network care. For services not covered by WellSense that you get using your MassHealth Card, you may receive care from any MassHealth-contracted Provider.
  • You must not allow anyone else to use your WellSense or MassHealth ID cards to obtain healthcare services. See your member documents for more on healthcare fraud.
  • You must notify WellSense Member Services and the MassHealth Member Services center when you believe that someone has purposely misused WellSense or MassHealth benefits or services.
  • You must notify WellSense Member Services and the MassHealth Member Services center (MassHealth members) if you change your address or phone number.
  • You are responsible for payment of services not included in the Covered and Excluded Services list for your coverage type.