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.