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Member Rights & Responsibilities

Your Rights

As a member of Amerigroup, you have a right to:
  • Be cared for with respect without regard for health status, sex, race, color, religion, national origin, age, marital status or sexual orientation (if you have questions or concerns about this right, call 1-800-600-4441 and ask for extension 34925 or visit www.myamerigroup.com)
  • Be told where, when and how to get the services you need from Amerigroup
  • Be told by your Primary Care Provider (PCP) what is wrong, what can be done for you and what will likely be the result in a language you understand
  • Get a second opinion about your care
  • Give your approval to any treatment or plan for your care after that plan has been fully explained to you
  • Refuse care and be told what you may risk if you do
  • Get a copy of your medical record, talk about it with your PCP and ask that your medical record be amended or corrected, if needed
  • Be sure that your medical record is private and will not be shared with anyone except as required by law or contract or with your approval
  • Get a copy of the Notice of Privacy Practices that tells you your rights on Protected Health Information (PHI) and the responsibility of Amerigroup to protect your PHI; this includes the right to know how Amerigroup handles, uses and gives out your PHI
  • PHI is defined by HIPAA Privacy Regulations as information that:
    • Identifies you or can be used to identify you
    • Comes from you or has been created or received by a health care provider, a health plan, your employer or a health care clearinghouse
    • Has to do with your physical or mental health condition, providing health care to you, or paying for providing health care to you
  • Use the Amerigroup complaint system to settle any complaints, or you can complain to the New York State Department of Health or the local Department of Social Services any time you feel you are not fairly treated
  • Use the state fair hearing system
  • Appoint someone (relative, friend, lawyer, etc.) to speak for you if you are unable to speak for yourself about your care and treatment or if you simply want someone else to speak for you
  • Have access to a PCP or a backup PCP 24 hours a day, 365 days a year for urgent care; this information is on your Amerigroup member ID card
  • Choose a PCP, choose a new PCP and have privacy during a visit with a health care provider
  • Be referred to a non-network provider if Amerigroup does not have an appropriately trained provider in our network
  • Get needed medical services within a reasonable amount of time
  • Take part in making decisions about your health care with your health care provider
  • Receive information on available treatment options and alternatives, regardless of cost or benefit coverage
  • Receive considerate, respectful care in a clean, safe environment free of unnecessary restraints
  • Choose any of our Amerigroup network specialists after getting a referral from your PCP
  • Be referred to specialists who are experienced in treating disabilities, if needed
  • Receive information about Amerigroup, its services, policies and procedures, providers, member rights and responsibilities, and any changes made
  • Receive information about all benefits and services available from Amerigroup
  • Request information about the plan, including clinical review criteria used by the plan in a utilization review decision on a specific disease or condition
  • Get a current directory of doctors within the Amerigroup network
  • Know how Amerigroup pays health care providers so you know if there are financial incentives or disincentives tied to medical decisions
  • Decide ahead of time the kind of care you want if you become sick, injured or seriously ill by making a living will
    • If you are younger than age 18, expect that you will be able to participate in and make decisions about your own and your child’s health care if you are married.
  • Continue as a member of Amerigroup despite your health status or need for care
  • Call our Nurse HelpLine 24 hours a day, 7 days a week toll free at 1-800-600-4441
  • Call our Member Services department toll free at 1-800-600-4441 from 7:00 a.m. to 7:00 p.m. weekdays, except for state holidays
  • Get help from someone who speaks your language
  • Make suggestions about the Amerigroup member rights and responsibilities policy

Your Responsibilities

As a member of Amerigroup, you have a responsibility to:
  • Find out how your health care plan works
  • Carry your Amerigroup ID card at all times; you should report any lost or stolen cards to Amerigroup immediately; you should also contact Amerigroup if information on your ID card is wrong or if you have changes in name, address or marital status
  • Show your ID cards to each provider and tell Amerigroup about any health care providers you are currently seeing
  • Work with your PCP to guard and improve your health; give Amerigroup and your health care provider the information he or she needs to take care of your medical needs
  • Listen to your PCP’s advice and ask questions when you are in doubt
  • Know and get involved in your health care; you should talk with your health care provider about recommended treatment; you should then follow the plans and instructions for care agreed upon with your provider
  • Get information to understand your health problems and consider treatments so you can participate in developing mutually agreed upon treatment goals before services are performed
  • Call or go back to your PCP if you do not get better or ask for a second opinion
  • Treat health care staff with the same respect you expect
  • Tell us if you have problems with any health care staff by calling Member Services
  • State your complaint or concern clearly
  • Keep your appointments; if you must cancel, call as soon as you can
  • Use the emergency room for emergencies; get your covered, nonemergency medical services from Amerigroup providers
  • Call your PCP when you need medical care, even if it is after office hours
  • Get a referral from your PCP before you go to a hospital or see a specialist (except for emergencies and self-referral services)
  • Ask your PCP how to take your medicines the right way
  • Be responsible for copays as described in this member handbook
  • Be aware that refusing treatment your or your child’s provider suggests may have serious consequences for your or your child’s health
  • Tell your PCP about your health
  • Authorize your PCP to get a copy of your old medical records
  • Learn and follow Amerigroup health plan membership rules