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.
To make recommendations regarding the organization’s member rights and responsibilities policy.

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.