Member Rights and Responsibilities

Member rights

AmeriHealth Caritas Florida and its network of primary care providers (PCPs) and other providers of services do not discriminate against members based on race, national origin, sex, religion, disability, age, sexual orientation, or any other basis prohibited by law.

AmeriHealth Caritas Florida is committed to complying with all applicable requirements under federal and state law and regulations pertaining to member privacy and confidentiality rights. As a member, you have the right to:

  1. Getting information about:
    • AmeriHealth Caritas Florida and its health care providers.
    • Your rights and responsibilities.
    • Your benefits and services.
    • The cost of health care services and any required cost sharing.
  2. Have AmeriHealth Caritas Florida and its health care providers treat you with dignity and respect.
  3. Talk with your health care provider about:
    • Treatment plans.
    • Information on available treatment options and alternatives, given in a way you understand.
    • The kinds of care you can choose to meet your medical needs, regardless of cost or benefit coverage.
  4. Receiving care that is at least equal to service offered by similar health plans.
  5. Receiving detailed information about emergency and after-hours options. Some details include:
    • Emergency services do not require prior approval.
    • You can use any hospital for emergency care.
    • We give you lists of emergency conditions.
    • You will learn what to do after you have received emergency care.
  6. Be a part of decisions about your health care, including the right to refuse treatment. Your decision to do so will not negatively affect the way AmeriHealth Caritas Florida, its health care providers, or the state treat you.
  7. Being free from any form of limitations used to discipline, for convenience, or in retaliation.
  8. Talking to your PCP about family planning. These services are available without prior approval. Family planning services are available from any Medicaid provider.
  9. Being told about free translation services. We will arrange support for any language you speak. You’ll be told about free services for members with vision and hearing loss. You’ll receive the communication services you need to help make choices about your care. We can teach you more. Please call Member Services at 1-855-355-9800 (TTY/TDD 1-855-358-5856).
  10. Accessing the Notice of Privacy Practices. This tells you when, why, and with whom we must sometimes share your protected health information (PHI).
  11. Seeing your PHI.
  12. Having your privacy protected in accordance with Health Insurance Portability and Accountability Act (HIPAA) requirements.
  13. Seeing a list of the people who have asked to see your PHI.
  14. Getting a copy of your PHI in our records.
  15. Requesting a copy of your medical records and asking that your PHI be updated if it is not correct.
  16. Receiving information about the grievance, appeal, and Medicaid Fair Hearing process. We will arrange support for any language you speak.
  17. Having health care services provided in accordance with both state and federal regulations.
  18. Getting yearly updates about the disenrollment process.
  19. Receiving updates on major changes in your benefits. You’ll be notified at least 30 days in advance.
  20. Be given an opportunity to provide suggestions for changes to AmeriHealth Caritas Florida’s rights and responsibilities policy.
  21. Voice complaints about and/or appeal decisions made by AmeriHealth Caritas Florida and its health care providers. Call Member Services at 1-855-355-9800 (TTY/TDD 1-855-358-5856). We will arrange support for any language you speak.

Member responsibilities

Keeping yourself and your family healthy can be easy. Here is the list of what you need to do.

  1. Read your member handbook. Call Member Services if you have questions.
  2. Choose your new PCP when you get your welcome kit. Help your new PCP care for you and your family. Fill out all information sheets carefully. Help your PCP get your records from your previous doctor. Give, as much as possible, information that AmeriHealth Caritas Florida needs to process claims, and information providers need to give care.
  3. Help your providers manage your care. Understand your health problems and take part in developing treatment goals. Follow plans and instructions for care from your providers. If your care plan does not work, tell your provider. He or she wants you to feel better. He or she will adjust your care plan to make it work.
  4. Keep your appointments for all regular care. Examples are child health check ups (CHCUPs), family planning, and health screenings.
  5. Get a referral from your PCP before you see a specialist or out-of-network provider or go to the hospital. Only go to the hospitals or specialists your PCP recommends. If you visit an out-of-network provider, you will need prior authorization by calling 1-855-371-8074.
  6. If your member ID card is ever lost or stolen, call Member Services.
  7. Present your member ID card any time you receive medical services from a doctor, hospital, clinic, or pharmacy.
  8. Call your PCP when you feel sick. Do not wait. Go to the nearest ER if you feel your life is in danger.
  9. Call Member Services if any information about you or your family changes, including your mailing and home address. This helps us avoid most problems. If your address has changed, please log in to your My ACCESS account and update your address. You can also contact the ACCESS Customer Call Center toll free at 1-866-762-2237. You must also contact the Social Security Administration (SSA) toll free at 1-800-772-1213 or visit the SSA website
  10. Be kind to everyone involved in your care. Be on time for your appointments. Call the doctor’s office if you cannot keep your appointment.

Patient responsibility for facility-based services

Patient responsibility is the cost of Medicaid facility-based services not paid for by the Medicaid program and is the amount a member must contribute toward the cost of their care. This amount is determined by the Department of Children and Families and is based on income and type of placement. Members are required to pay this patient responsibility as determined by the Department of Children and Families.

To file a complaint or to request more information, call the following toll-free numbers:

AmeriHealth Caritas Florida member service line
1-855-355-9800, 24 hours a day, 7 days a week

AHCA statewide consumer telephone line
1-888-419-3456, 8 a.m. - 6 p.m.