Member Rights and Responsibilities

Your Member Rights

Peach State provides covered services to all members without regard to:

  • Age
  • Disability
  • Marital Status
  • Race
  • Sex
  • Income
  • Health Status
  • Arrest or Conviction
  • Religion
  • Sexual Preference
  • Color
  • Birth Nation
  • Military Participation
  • Language

All services that are covered and medically necessary may be obtained.  All services are provided in the same way to all members.

Peach State providers who refer members for care do so the same way for all.

Translation services are available if you need them. This includes sign language. This service is free.

The right to appeal any denied service according to state guidlelines.

You have the right:

  • To have all your personal information including your medical records kept private.
  • To be given choices about your healthcare. To know all of your options.
  • To never worry about someone forcing you to do something because it makes his or her job easier.
  • To talk with your doctor about your medical records; ask for and receive a copy of your medical records; ask for a summary of your record; request that your medical records be changed or corrected; and have your records kept private
  • To be able to request information on the Quality Assessment Performance Improvement Program (QAPI). The QAPI program assures that all members receive quality care and appropriate care. The QAPI program focuses on improving clinical care and non-clincal care which will result in positive health outcomes.
  • To file a complaint against a doctor, hospital, the service/care you received, or Peach State. If you file a complaint, no one can stop you from continuing to get services.
  • To file an appeal when you are unhappy about the outcome of a complaint or decision.
  • To know how to file an administrative review for a decision not to pay fro a service or limit coverage
  • To know that you or your doctor will not be penelized for filing a compliant or administrative reveiw
  • To not pay if Peach State runs out of money to pay their bills.
  • To not pay for healthcare even if Medicaid or PeachCare for Kids and Peach State does not pay the doctor who treated you.
  • To have medical services available to you under your Peach State plan in accordance to 42 CFR 438.20 through 438.210 which are the federal QAPI access standards
  • To be free from any Peach State debts in the event of insolvency and liability for covered services in which the state does not pay Peach State
  • To never pay more than what Peach State would charge, if Peach State has to have someone else manage your care.
  • To only have a small co-payment and/or deductible, as allowed by state laws and DCH regulations as described in the Member Handbook.
  • To only be billed by a provider if you have agreed to the following:
    • You signed a Member Acknowledgement Statement which makes you responsible for services not covered by Peach State
    • You agreed ahead of time to pay for services that are not covered by Peach State or Medicaid
    • You agreed ahead of time to pay for services from a provider who is not in the network and/or did not receive a prior authorization ahead of time, and requested the service anyway.
    • To not be billed for any service covered by Medicaid. If you get a bill for services Peach State should have paid, call Member Services at 1-800-704-1484. When you call, give the Member Services Staff:
      • Date of service
      • Name of provider
      • Total amount of the bill
      • Phone number on the bill
      • To be free from receiving bills from providers for medically needed services that were authorized or covered by Peach State
      • To be treated with dignity, respect and privacy from Peach State staff, providers, physicians and their office staff.
      • To have access to a PCP 24 hours a day, 365 days a year for urgent care.
      • To choose a Peach State doctor (PCP) and be told which hospitals to use.
      • To change your doctor without a reason.
      • To know about other doctors who can help you with treatment.
  • To know your rights and responsibilities with Peach State and to call if you have questions or comments or want to make recommendations about our member rights and responsibilities policy
  • To get information about Peach State’s organization and services, providers, physicians, hospitals, policies and procedures, your rights and responsibilities and any changes made.
  • To get a second opinion
  • To know about all the services you will get. This includes:

Hours of operation.

How to get emergency care after hours.

How to get services if you are out of town.

What may not be covered.

What has limited coverage.

  • To be told if your services change. To be told if we cancel a service.
  • To be told if your doctor is no longer available.
  • To tell us and your doctor if you need help talking to your doctor. You will not have to pay if you are hearing impaired or if you do not speak English.
  • To know all information about your doctor(s) so they can care for you.
  • To tell your doctor what you like and don’t like about your care.
  • To speak with your physician about decisions related to your health care including the right to refuse medical or surgical treatment to the extent of the law and to refuse to take part in medical research.
  • To help set treatment plans with your physician, talk to your physician openly and understand your health care options: regardless of cost or benefit coverage.
  • To understand your health problems and to speak with your physician about your treatment plans which you and your doctor agree.
  • Decide ahead of time the kind of care you want if you become sick, injured or serisouly ill by making a living will or advance directive.
  • Decide ahead time the person you want to make decisions about your care if you are not able to by making a durable power of attorney
  • To be free from any form of restraint or seclusion as a means of force, discipline, convenience or revenge.
  • To exercise these rights. Also, to know if you do, it will not change how you are treated by the plan, its doctors and providers.

Member Responsibilities

You have a responsibility:

  • To give information about yourself to the Peach State organization, providers, physicians, and hospitals in order to help set treatment goals.
  • To give information about you and your health to your PCP.
  • To understand your health problems and how to take your medicines the right way.
  • To ask questions about your health care.
  • To follow your instructions for care agreed upon by you and your physician or hospital.
  • To help set treatment goals with your PCP.
  • To read the Member Handbook to understand how [Peach State] works.
  • To call Peach State and ask questions when you don’t understand.
  • To always carry your Peach State Member ID card.
  • To always carry your Medicaid or PeachCare for Kids Member ID card.
  • To show your ID cards to each provider.
  • To schedule appointments for care with your doctor.
  • To go to the emergency room when you have an emergency.
  • To notify Peach State as soon as possible if you go to the emergency room.
  • To get a referral from your PCP for specialty care.
  • To cooperate with people providing your health care.
  • To be on time for appointments.
  • To notify the doctor’s office if you need to cancel an appointment.
  • To notify the doctor’s office if you need to change your appointment time.
  • To respect the rights of all providers.
  • To respect the property of all providers.
  • To respect the rights of other patients.
  • To not be disruptive in your doctor’s office.
  • To keep all your appointments. To be on time and cancel within twenty-four (24) hours if you cannot make it.
  • To treat your provider with dignity and respect.