Enrollees are informed of their rights and responsibilities through the Enrollee Handbook. Sunshine Health providers are also expected to respect and honor Enrollee's rights.
Sunshine Health Enrollees have the following rights and responsibilities:
• To be treated with respect and with due consideration for his/her dignity and the right to privacy and non-discrimination as required by law.
• To receive information about Sunshine Health providers and Enrollee rights and responsibilities. • To participate with their providers in making decisions regarding their healthcare. This includes
the right to refuse services.
• To exercise these rights without adversely affecting the way Sunshine Health and its providers treat the Enrollees.
• To receive the following materials: o Enrollment notices o Information materials o Instructional materials
o Available treatment options and alternatives, in a manner and format that may be easily understood.
• To receive family planning services from any participating Medicaid doctor without prior authorization.
• To get information about your rights and responsibilities, as well as the Sunshine Health providers and services.
• To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in the Federal regulations on the use of restraints and seclusion.
• To receive healthcare services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid FFS. And to receive healthcare services that are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished. (Also 42 CFR 438.206 & 438.210).
• To request and receive a copy of your medical/case record. (Also 45 CFR 164.524). • To request that your medical/case record be corrected (Also 45 CFR 164.526).
• To receive notice of any significant changes in the Benefits Package at least 30 days before the intended effective date of the change.
• To a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
• To receive assistance from both Florida Medicaid and Sunshine Health in understanding the requirements and benefits of the health plan.
• To receive notice if Sunshine Health will not provide services due to moral or religious reasons within 30 days before the service.
• To receive services in a culturally competent manner, including Enrollees with limited English ability and diverse cultural and ethnic backgrounds.
• As a potential Enrollee, to receive information about the basic features of managed care; which populations may or may not enroll in the program and Sunshine Health's responsibilities for coordination of care in a timely manner in order to make an informed choice.
• To receive information about Sunshine Health, its benefits, services and providers. • To receive information on the following:
o Benefits covered.
o Procedures for obtaining benefits, including any authorization requirements. o Cost sharing requirements.
o Service area.
o Names, locations, telephone numbers and non-English languages spoken by current Sunshine Health providers.
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o Any restrictions on Enrollee’s freedom of choice among network providers. o Providers not accepting new Enrollees.
o Benefits not offered by Sunshine Health but available to Enrollees and how to obtain those benefits, including how transportation is provided.
• To privacy of healthcare needs and information as required by federal law (Standards for Privacy of Individually Identifiable Health Information).
• To choose a provider and to change to another provider at any time. • To receive timely access to care.
• To get care from a provider not in Sunshine Health's network if your doctor and case manager says the care is medically needed and is not available from one of our providers.
• To allow or refuse their personal information be sent to another party for other uses unless the release of information is required by law (Also 45 CFR 164.524).
• To receive services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness, or medical condition.
• To receive information on the Grievance, Appeal and Medicaid Fair Hearing procedures. • To voice grievances or file appeals about Sunshine Health decisions that affect their privacy,
benefits or the care provided.
• To file for a Medicaid Fair Hearing and receive documents used in a Fair Hearing at no cost to the Enrollee.
• To expect their medical/case records and care be kept confidential as required by law. • To make an advance directive, such as a living will.
• To choose a person to represent them for the use of their information by Sunshine Health if they are unable to.
• To receive translation services free of charge for all non-English languages.
• To be notified that oral interpretation is available and how to access those services. • To receive a complete description of disenrollment rights at least annually.
• To received detailed information on emergency and after-hours coverage, to include, but not limited to:
o What constitutes an emergency medical condition, emergency services, and post- stabilization services.
o That Emergency Services do not require prior authorization. o The process and procedures for obtaining Emergency services.
o The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under the contract.
o Enrollee's right to use any hospital or other setting for emergency care. o Post-stabilization care services rules in accordance with Federal guidelines. • To make recommendations regarding Sunshine Health's Enrollee rights and responsibilities
policy.
• To inform Sunshine Health of the loss or theft of their ID card. • To present their ID card when using healthcare services.
• To be familiar with Sunshine Health procedures to the best of their ability.
• To call or contact Sunshine Health to obtain information and have questions clarified. • To provide information (to the extent possible) that Sunshine Health and its practitioners and
providers need in order to provide care.
• To follow the prescribed treatment (plans and instructions) for care that has been agreed upon with your practitioners/providers.
• To inform your Case Manager on reasons you cannot follow the agreed upon plan of care. • To understand your health problems and participate in developing mutually agreed-upon goals
to the degree possible.
• To keep your medical appointments and follow-up appointments. • To access preventive care services.
• To follow the policies and procedures of Sunshine Health and the State Medicaid program. • To be honest with providers and treat them with respect and kindness.
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• To follow the steps of the appeal process.
• To notify Sunshine Health, DCF and your providers of any changes that may affect your enrollment, healthcare needs or access to benefits. Some examples may include:
o If you have a baby. o If your address changes.
o If your telephone number changes. o If you are covered by another health plan. o If you have a special medical concern.