Member Rights and Responsibilities

Members are informed of their rights and responsibilities through the Member Handbook. Absolute Total Care providers are also expected to respect and honor member’s rights.

Member Rights

Absolute Total Care members have the following rights:

  • To choose a primary care provider (PCP) and to change to another PCP.
  • To voice grievances or file appeals about Absolute Total Care decisions that affect their privacy, benefits or the care provided.
  • To request and receive a copy of their medical records.
  • To make recommendations regarding Absolute Total Care's member rights and responsibilities policy.
  • To request that their medical records be amended or corrected.
  • To file for a State Fair Hearing with SCDHHS.
  • To make an advance directive, such as a living will.
  • To receive information about Absolute Total Care, its benefits, its services, its practitioners, providers, member rights and responsibilities.
  • To be treated with respect and with due consideration for his/her dignity and the right to privacy and non-discrimination as required by law.
  • To participate with their providers and practitioners in making decisions regarding their healthcare, including the right to refuse treatment.
  • To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in the Federal regulations on the use of restraints and seclusion.
  • To receive healthcare services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid Fee-For-Service (FFS) 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 solely because of diagnosis, type of illness, or medical condition.
  • To receive assistance from both SCDHHS and Absolute Total Care in understanding the requirements and benefits of the health plan.
  • To have a candid discussion about appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
  • To receive information on the Grievance, Appeal and State Fair Hearing procedures.
  • To expect their medical records and care be kept confidential as required by law.
  • To receive Absolute Total Care's policy on referrals for specialty care and other benefits not provided by the member’s PCP.
  • To privacy of healthcare needs and information as required by federal law (Standards for Privacy of Individually Identifiable Health Information).
  • To exercise these rights without adversely affecting the way Absolute Total Care, its providers or SCDHHS treat the members.
  • To allow or refuse their personal information to be sent to another party for other uses unless the release of information is required by law.
  • To receive timely access to care, including referrals to specialists when medically necessary without barriers.
  • To receive materials – including enrollment notices, information materials, instructional materials, available treatment options and alternatives, etc. - in a manner and format that may be easily understood.
  • To get a second opinion from a qualified healthcare professional.
    • You have the right to a second opinion about your care.
    • This means talking to a different provider about an issue to see what they have to say. The second provider is able to give you their point of view. This may help you decide if certain services or methods are best for you. If you want to hear another point of view, tell your PCP.
    • Choose an Absolute Total Care contracted provider to give you a second opinion. There is no charge to you. Your PCP or Member Services can help you find a provider. If you are unable to find a provider in the Absolute Total Care network, we will help you find a provider outside the network. There is no charge to you if you need a second opinion from a provider outside the network.
    • Any tests that are ordered for a second opinion must be given by a provider in the Absolute Total Care network. Your PCP will look at the second opinion and help you decide on a treatment plan that will work best for you.
  • To receive oral interpretation services free of charge for all non-English languages.
  • To be notified that oral interpretation is available and how to access those services.
  • As a member, they have the right to receive information about the basic features of managed care; which populations may or may not enroll in the program and Absolute Total Care's responsibilities for coordination of care in a timely manner in order to make an informed choice.
  • To receive information on the following:
    • Benefits covered.
    • Procedures for obtaining benefits, including any authorization requirements.
    • Cost sharing requirements.
    • Service area.
    • Names, locations, telephone numbers of non-English language speaking Absolute Total Care providers, including at a minimum, PCPs, specialists and hospitals.
    • Any restrictions on member’s freedom of choice among network providers.
    • Providers not accepting new patients.
    • Benefits not offered by Absolute Total Care, but available to members and how to obtain those benefits, including how transportation is provided.
  • To receive a complete description of disenrollment rights at least annually.
  • To receive notice of any significant changes in the Benefits Package at least 30 days before the intended effective date of the change.
  • To receive detailed information on emergency and after-hours coverage, to include, but not limited to:
    • What constitutes an emergency medical condition, emergency services, and post-stabilization services
    • That Emergency Services do not require prior authorization.
    • The process and procedures for obtaining Emergency services.
    • The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under the contract.
    • Member’s right to use any hospital or other setting for emergency care.
    • Post-stabilization care services rules in accordance with Federal guidelines.

Member Responsibilities

Absolute Total Care members have the following responsibilities:

  • To choose a person to represent them for the use of their information by Absolute Total Care if they are unable to.
  • To inform Absolute Total Care of the loss or theft of their ID card.
  • To present their ID card when using healthcare services.
  • To be familiar with Absolute Total Care procedures to the best of their ability.
  • To call or contact Absolute Total Care to obtain information and have questions clarified.
  • To provide information (to the extent possible) that Absolute Total Care and its practitioners and providers need in order to provide care.
  • To follow the prescribed treatment (plans and instructions) for care that has been agreed upon with their practitioners/providers.
  • To inform their provider on reasons they cannot follow the prescribed treatment of care recommended.
  • To understand their health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.
  • To keep their medical appointments and follow-up appointments.
  • To access preventive care services.
  • To follow the policies and procedures of the SCDHHS Medicaid Plan.
  • To be honest with providers and treat them with respect and kindness.
  • To get regular medical care from their PCP before seeing a specialist.
  • To follow the steps of the appeal process.
  • To notify SCDHHS, Absolute Total Care and their providers of any changes that may affect their membership, healthcare needs or access to benefits. Some examples may include:
    • If they have a baby.
    • If their address changes.
    • If their telephone number changes.
    • If they or one of their children are covered by another health plan.
    • If they have a special medical concern.
    • If their family size changes.
  • To keep all their scheduled appointments; be on time for those appointments, and cancel 24 hours in advance if they cannot keep an appointment.