Get the Most from Your Coverage
You Deserve Quality Healthcare. And you also deserve to have the information you need to get the most from your coverage. Goals for quality are set and reviewed by your health plan to make sure you get the care you need.
This information is part of a Quality Program designed to improve the services and care you receive. It provides details about your coverage and services available to you.
Contact Member Services to learn more about the Quality Program.
Get More Information
Member Services to get:
- A paper copy of your Member Handbook, Privacy Notice or anything on your health plan website
- Help finding a doctor and making an appointment
- Help speaking with a care manager
- Help with an appeal for a service that’s been denied
- Help with a ride to your appointment
Know Your Rights
Being a member means there are things you should expect from your health plan. These are some of your rights:
- You should have access to all the services available to members
- You should be treated with courtesy and respect
- You should be able to get a copy of your medical record
- You should know your medical data will be kept private. There are policies in place to guard your health records and protected health information.
It’s also important to know what you can do to get the most from your coverage:
- Ask questions if you don’t understand your rights
- Be sure to keep your scheduled appointments
- Keep your Member ID Card with you so you have it at appointments
- Tell your doctor if you have gotten care in an emergency room.
As a Care1st member you have certain rights.
You have a right to:
- Members who are determined to have a Serious Mental Illness and who are enrolled in one plan for both physical health and behavioral health services may request a different plan for their physical health services. This is called an opt-out request. An opt-out will only be approved if the member or their designee is able to show harm or unfair treatment in:
- Getting healthcare,
- Receiving quality healthcare,
- Protecting member privacy and rights, or
- Choosing a provider.
If you would like to ask for an opt-out, contact Member Services at 1-866-560-4042 (TTY/TDD 711).
Care1st complies with all federal and state laws, including: Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 80, The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91, The Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972 (regarding education programs and activities), Titles II and III of the Americans with Disabilities Act; and section 1557 of the Patient Protection and Affordable Care Act.
- File a complaint or an appeal about the managed care organization or network providers. Complaints and appeals can be filed with Care1st or AHCCCS.
- Get information on the structure and operation of Care1st or its subcontractors.
- Get information on whether or not Care1st has Physician Incentive Plans (PIP) that affect the use of referral services, the right to know the types of compensation arrangements the Contractor uses, the right to know whether stop-loss insurance is needed, and the right to a summary of member survey results, in accordance with PIP regulation.
- Get polite and courteous care. You will be treated fairly and with respect no matter your race, ethnicity, national origin, gender, age, religion, behavioral health condition (intellectual) or physical disability, sexual preference, genetic information, ability to pay, or ability to speak English.
- Confidentiality and confidentiality limitations. See Notice of Privacy Practices for details.
- Information about the coordination of care concerning schools and state agencies that may occur as appropriate and within the limits of applicable regulations. See Notice of Privacy Practices for details.
- Get a second opinion at no cost to you from another Care1st healthcare professional or from someone outside the network if the Care1st network is not sufficient.
- Discuss treatment options, regardless of cost or benefit coverage, presented in a manner appropriate to your condition and ability to understand the information.
- Get information about formulating Advance Directives.
- Ask for a copy of your medical records annually at no cost to you.*
- Inspect your medical records at no cost to you.
- Get a reply within 30 days to your request for a copy of your records.**
- Ask that your medical records be updated or corrected.
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
- Get information on beneficiary and plan information, the organization, services, practitioners and providers as well as member rights and responsibilities.
- Be treated with respect and with due consideration for your dignity and privacy.
- Participate in decisions regarding your healthcare, refuse any medical treatments, and to be told what will happen if you do not get treatment.
- Be given information about Care1st providers, including their qualifications and the languages other than English that they speak.
- Use any hospital or other setting for emergency care.
- Have your medical records and any information about your health care be private and confidential.
- Choose your PCP from Care1st’s list of PCPs. You also have the right to change PCPs if you wish to do so.
- Get services in a language that you understand at no cost to you. You have the right to get an interpreter if you have limited English or if you are hearing impaired.
- Know and understand your medical problems and healthcare conditions so that you can make informed decisions about your healthcare. Ask and be told the cost you would pay if you chose to pay for a service that Care1st does not cover.
- Get a summary of Care1st’s member survey results.
- Be told in writing of any changes to your services.
- Be told in writing when Care1st reduces, suspends, terminates, or denies any service requested by a provider. Be told what to do if you do not agree with Care1st’s decision.
- Get a copy of member rights and responsibilities and the right to make recommendations regarding Care1st rights and responsibilities policy.
- File a complaint with Care1st regarding the adequacy of a Notice of Adverse Determination letter you got. You have the right to Contact AHCCCS Medical Management at MedicalManagement@azahcccs.gov if Care1st does not resolve your concern of adequacy with the Notice of Adverse Determination letter you got. (Outside Maricopa County: 1-800-962-6690)
- Decide who you want to be at your treatments and exams.
- Tell Care1st about any problems, complaints, or grievances you have with your healthcare services, your providers, or Care1st.
- Have available upon request the criteria that decisions are based on. Have your medical records transferred from your previous provider to your new provider within 10 days of your request.
- Exercise your right and that the exercise of those rights shall not adversely affect service delivery to you [42 CFR 438.100(c)].
*Your right to access medical records may be denied if the information is psychotherapy notes, compiled for, or in a reasonable anticipation of a civil, criminal or administrative action, protected health information subject to the Federal Clinical Laboratory Improvement Amendments of 1988 or exempt pursuant to 42 CFR 493.3(a)(2).
**The response may be the copy of the medical record or a written denial that includes the basis for the denial and information about how to seek review of the denial in accordance with 45 CFR Part 164. (AMPM 410-B9e).
As a Care1st member, you have certain responsibilities.
You have the responsibility to:
- Respect your providers, their staff, and the other people who provide services to you.
- Carry your ID card with you at all times and identify yourself as a Care1st member before you get any services.
- Understand your health problems and participate in making mutually-agreed-upon treatment goals, to the degree possible. Tell your PCP or other Care1st providers if you do not understand your condition or your treatment plan.
- Give your PCP or other Care1st providers complete information about your health and all ongoing care you get. Tell them about past problems or illnesses you have had, if you have ever been in the hospital, and all drugs and medicines that you are taking. Tell them whenever you see other providers, when you are prescribed medicines, or if you have to go to a hospital or emergency room.
- Tell your PCP or other Care1st providers about any changes in your health or medical condition.
- Tell Care1st Member Services, your PCP, and other Care1st providers about any other insurance you have.
- Keep your AHCCCS eligibility up to date. Keep all of your AHCCCS eligibility appointments and tell your eligibility worker when anything that could affect your eligibility changes in your household.
- Keep your ID card safe. Do not throw it away. You may not loan, sell, or give your ID card to another person. Letting someone else use your ID card is fraud. If you do loan or give the card to someone else, you could lose your AHCCCS eligibility. You could also have legal action taken against you.
- Tell Care1st or AHCCCS if you suspect fraud or abuse by a provider or another member.
- Know the name of your PCP. Keep your PCP’s name, address, and telephone number where you can easily find it.
- Take an active part in managing your healthcare and take care of problems before they become serious. Ask questions about your care.
- Follow your provider’s instructions carefully and completely. Make sure that you understand these instructions before you leave your provider’s office.
- Take all your medications and take part in programs that help to keep you well.
- Make appointments with your PCP during office hours instead of using urgent care or the emergency room for things that are not urgent or emergencies.
- Keep all of your scheduled appointments and be on time. Call the provider’s office ahead of time if you need to cancel an appointment or if you are going to be late.
- Bring your children’s shot records to all of their PCP visits.
- Pay your copay when needed.
- Call or write Member Services when you have questions, problems, or grievances (complaints).
- Schedule your transportation at least three days in advance. Notify transportation if you need to change or cancel your appointment.
Please call or write to Member Services with questions or comments about this.
The full list of rights and responsibilities is also in your Member Handbook.
Getting the Care You Need
As children get older, they should change from seeing a pediatrician to seeing an adult doctor. Teens don’t need checkups as often as young kids do, but they should see their PCP at least once a year. Regular visits will help them stay up to date on vaccines. If teens have a condition such as diabetes or asthma, it’s very important that they keep seeing their doctors and not miss a visit. Call your health plan if you need help finding an adult provider.
Care Management is for members who may need extra help taking care of their health. Some people have several health conditions and see more than one doctor. Others need help arranging the services their doctors may have ordered. Working with a care manager lets you understand major health problems, work well with your doctors and get the care you need.
You should get high quality medications and the right treatment for your conditions. But not all drugs are covered. And some may need to be approved before they’re covered. The Preferred Drug List (PDL) is located on your health plan website. It is updated regularly and lists drugs that are covered by insurance. Talk to your doctor or pharmacist to review the PDL and answer questions about your medications.
If a service is denied, you have the right to appeal that decision. You will be sent a letter explaining how to make an appeal. All appeal requests are decided according to your request, condition and benefits.
The Utilization Management (UM) Department looks at your health records and may also talk with your doctor to decide if a service you need is covered. These decisions are not based on financial reasons. And doctors and staff are not rewarded for saying no to care. All UM decisions are based on:
- If the service is medically necessary
- If the service works well
- If the service is right for you
You should be able to schedule an appointment with your PCP and get medical care when you need it. You may have to wait a little longer to get in to see certain other types of providers, like specialists. Call your health plan if you can’t get an appointment in a timely manner.
New medicines, tests and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by your health plan. Your plan covers care that is medically necessary. Not every new medical service is covered for all members.
Your PCP is the doctor you’ll see for routine checkups and care. Your PCP will help find other types of healthcare providers if you need one. You can also search Find-a-Provider on your health plan website.