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Consumer Bill of Rights

Know Your Rights: Consumer Bill of Rights.
The Right to Information About Your Plan and How it Works
  • The right to information on what health care services are covered and any limitations on that coverage.
  • The right to obtain a current directory of doctors within the network.
  • The right to know how your managed care plan pays its doctors so you know if financial incentives or disincentives are tied to medical decisions.
The Right to Ask Questions and to File Complaints, Appeals and Lawsuits
  • The right to no “gag rules” – doctors are allowed to discuss all treatment options even if they are not covered services
  • The right to file appeals with the managed care plan concerning denials or limitations of a covered service.
  • The right to file complaints with the managed care plan regarding any aspect of the plan’s health care services, including quality of care, choice, accessibility of providers and network adequacy.
  • The right to receive no retaliation against you or your doctor for filing complaints or appeals.
  • The right to independent review of the plan’s decision to deny or limit covered services; if you have exhausted the managed care plan’s internal appeal process, you have the right to appeal that decision through the
    Independent Health Care Appeals Program.
  • The right to sue your HMO for losses if you or a covered member of your family sustain serious injury or death that you believe is the result of the HMO’s denial or delay of approval of medically necessary covered services.
The Right to Appropriate Treatment
  • The right to have a doctor – not an administrator – make the decision to deny or limit coverage.
  • The right to change primary care providers without having to wait more than two weeks.
  • The right to access a primary care provider 24 hours a day, 365 days a year for urgent care.
  • The right to call 911 in a potentially life-threatening situation without prior approval.
  • The right to go to an emergency room without first contacting the HMO when it appears to the member that serious harm could result from not obtaining immediate medical treatment.
  • The right to coverage of a medical screening exam in a hospital emergency room to determine whether an emergency medical condition exists.
  • The right to a choice of participating specialists for referrals.
  • The right of a consumer with a chronic disability to be referred to an experienced specialist.
  • The right to coverage of certain preventative care, including childhood immunizations, lead screening, certain cancer screenings, testing for glaucoma, cholesterol and blood glucose levels.
  • The right to a minimum amount of time in the hospital after giving birth or having a mastectomy.
  • The right to receive continued coverage form a doctor who stops being part of the network for up to four months, and longer for certain medical conditions.

This information can also be found in the New Jersey HMO Performance ReportĀ