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 Service 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 Member Service 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 Service 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 Service, Carelon Behavioral Health 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 the plan.
  • 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 (including retaliation).
  • 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 be disenrolled from WellSense in certain situations. Please refer to the Section on Disenrollment in this EOC for more information.
  • 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. Members have the right to refuse services via telehealth and be asked to be seen in person. You have the right to be informed of any changes in state law that may affect your coverage. The plan will provide you with any updated information at least 30 calendar days before the effective date of the change whenever practical.