Member Rights and Responsibilities

As a Sunshine Health Member you have the right:

  • To be treated with respect and with due consideration for his or her dignity and privacy.
  • To receive information on available treatment  options and alternatives, in a way the member can understand.
  • To participate in decisions regarding his/her healthcare, including the right to refuse treatment.
  • To complete information about their specific condition and treatment options, regardless of cost or benefit coverage.
  • To seek second opinions.
  • To get  assistance with care coordination from the PCP office.
  • To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other Federal regulations on the use of restraints and seclusion.
  • To express a concern or appeal about Sunshine Health or the care it provides and receive a response in a reasonable period of time.
  • To be able to  get a copy of his/her medical records, (one copy free of charge) and ask that they be amended or corrected.
  • To choose his/her health professional to the extent possible and appropriate.
  • To have someone act on your behalf if you are unable to do so.
  • To exercise his or her rights, and that the exercise of those rights does not adversely affect the way the health plan and its providers treat the enrollee.
  • To receive healthcare services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid Fee-For- Service and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished.
  • To receive services that are appropriate and are not denied or reduced because of diagnosis, type of illness, or medical condition.
  • To receive all material and information in a way the member can easily understand.
  • To receive oral interpretation services free of charge for all non-English languages.
  • To be notified that interpretation services are available and how to access those services.

As a Sunshine Health Member, you have the responsibility to:

  • Inform Sunshine Health of the loss or theft of an ID card.
  • Present the Sunshine Health ID card when using healthcare services.
  • Be familiar with Sunshine Health procedures to the best of the member’s abilities.
  • To call or contact Sunshine Health to obtain information and have questions clarified.
  • To provide participating network providers with accurate and complete medical information.
  • Following the prescribed treatment of care recommended by the provider or letting the provider know the reasons the treatment cannot be followed, as soon as possible.
  • To make every effort to keep any agreed upon appointments, and follow-up appointments; and access preventive care services.
  • To live healthy lifestyles and avoid behaviors known to be detrimental.
  • To provide accurate and complete information to all healthcare providers.
  • To become knowledgeable about Sunshine Health coverage provisions, rules and restrictions.
  • To ask questions of providers to determine the potential risks, benefits, and costs of treatment alternatives, and then making care decisions after carefully weighing all pertinent factors.
  • To follow the grievance process established by Sunshine Health (as outlined in the Member Handbook) if there is a disagreement with a provider.