Member rights and responsibilities

Your rights

As a member of our plan, you have certain rights concerning your healthcare.

  • You have the right to receive information in an easily understandable and readily accessible format that meets your needs. For more information, refer to Section 2.16 of your Member Handbook (Other important information and resources: Alternative formats and interpretation services).
  • You have the right to be treated with respect and with due consideration for your dignity and privacy.
  • You have the right to receive information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand.
  • You have the right to participate in decisions regarding your health care, including the right to refuse treatment.
  • You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • You have the right to see, as well as request and receive a copy of your medical records, and the right to request that your medical records be amended or corrected.
  • You have the right to covered services and drugs that are available and accessible in a timely manner.
  • You have a right to care coordination.
  • You have the right to privacy and protection of your personal health information.
  • You have the right to receive information about our plan, our network providers, and your covered services.
  • You have the right to make decisions about your health care.
  • You cannot be retaliated against in any way by the plan or by the New Hampshire Department of Health and Human Services (NH DHHS) for exercising your rights.
  • You have the right to a second opinion. For more information, refer to Section 6.6 of your Member Handbook (Getting a second medical opinion).
  • You have the right to know what to do if you are being treated unfairly or your rights are not being respected. For more information, refer to Section 10.7 of your Member Handbook (How to file a grievance and what to expect after you file).
  • 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.
  • You have the right to exercise advance care planning for your health care decisions if you so choose. For more information, refer to Section 9.3 of your Member Handbook (Advance care planning for your health care decisions).
  • You have the right to make a complaint if a provider does not honor your wishes expressed in your advance directive. For more information, refer to Section 9.3 of your Member Handbook (Advance care planning for your health care decisions).
  • You have the right to leave our plan in certain situations. For more information, refer to Chapter 11 of your Member Handbook (Ending your plan membership).
  • You have the right to obtain benefits, including family planning services and supplies, from non-participating providers.
  • You have the right to be aware of when your plan chooses not to provide a service you need due to moral or religious reasons. We do not exclude services due to moral or religious reasons.
  • You have the right to file a grievance or appeal. For more information, refer to Section 10.7 of your Member Handbook (How to file a grievance and what to expect after you file).
  • You have the right to request information about our physician incentive programs.
  • You have the right to make recommendations regarding our member rights and responsibilities policy.

Your responsibilities

Below are things you need to do as a member of the plan. If you have any questions, please call Member Service (Phone numbers are printed on the back cover of your Member Handbook).

  • Get familiar with your covered services and the rules you must follow to get these covered services. Use your Member Handbook to learn what is covered, and the rules you need to follow to get your covered services.
    • Chapters 3 and 4 give the details about your health care services, including what is covered by the plan, what is not covered, and rules to follow.
    • Chapter 7 provides details about prescription drug coverage, including what you may be required to pay.
    • To be covered by WellSense Health Plan, you must receive all of your health care from the plan’s network providers except:
      • Emergency care;
      • Urgently needed care when you are traveling outside of the plan’s service area;
      • Family planning services; and
      • When we give you authorization in advance to get care from an out-of-network provider.
  • If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell WellSense Health Plan as soon as possible. Please call Member Service to let us know (Phone numbers are printed on the back cover of your Member Handbook). We are required to follow rules set by Medicaid to make sure that you are using all of your coverage. This is called “coordination of benefits” because it involves coordinating the health and prescription drug benefits you get from our plan with any other health and prescription drug benefits available to you. We will help you coordinate your benefits. For more information about coordination of benefits, refer to Section 1.5 of your Member Handbook (How other insurance works with our plan).
  • Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card and your New Hampshire Medicaid card whenever you get your covered services, including medical or other health care services and prescription drugs.
  • Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.
    • To help your doctors and other health care providers give you the best care, learn as much as you are able to about your health conditions. Give your health care providers the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon.
    • Make sure your doctors and other health care providers know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.
    • Talk to your PCP about seeking services from a specialist before you go to one, except in an emergency.
    • Keep appointments, be on time, and call in advance if you are going to be late or have to cancel your appointment.
    • Authorize your PCP to get necessary copies of all of your health records from other health care providers.
    • If you have any questions, be sure to ask. Your doctors and other health care providers will explain things in a way you can understand. If you ask a question and you do not understand the answer you were given, ask again.
  • Request interpretation services if you need them. Our plan has staff and free language interpreter services available to answer questions from non-English speaking members. If you are eligible for New Hampshire Medicaid because of a disability, we are required to give you information about the plan’s benefits that is accessible and appropriate for you at no cost. For more information, refer to Section 2.16 in your Member Handbook (Other important information and resources: Alternative formats and interpretation services).
  • Respect other members, plan staff and providers. For information about when members may be involuntarily disenrolled for threatening or abusive behavior, refer to Section 11.2 in your Member Handbook (When you may be involuntarily disenrolled from the plan).
  • Pay what you owe. As a plan member, you are responsible for these payments, as applicable:
    • For prescription drugs covered by the plan, you must pay a copayment, if required. However, any inability to pay your copayment does not prevent you from getting your prescription filled. Refer to Chapter 7 in your Member Handbook (Getting covered prescription drugs) to learn what you must pay for your prescription drugs.
    • If you get any health care services or prescription drugs that are not covered by our plan or by other insurance you have, you are responsible for the full cost.
    • If you disagree with our decision to deny coverage for a health care service or prescription drug, you can request an appeal. For information about how to request an appeal, refer to Chapter 10 in your Member Handbook (What to do if you want to appeal a plan decision or “action”, or file a grievance).
  • Tell the plan if you move. If you are going to move or have moved, it is important to tell us as soon as possible. Call Member Service (Phone numbers are printed on the back cover of your Member Handbook).
  • Do not allow anyone else to use your WellSense Health Plan or New Hampshire Medicaid membership cards.  Refer to Section 2.15 in your Member Handbook (How to report suspected cases of fraud, waste or abuse). Notify us when you believe someone has purposely misused your health care benefits.
  • Call Member Service for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan. (Phone numbers for Member Service are printed on the back cover of your Member Handbook).