What to do if You have a Problem with your Health Plan.

When it comes to matters of health, it is important to speak up if you are dissatisfied with the quality of care, the services provided, or if you believe you are entitled to more or different benefits than you are receiving. Health plans, government programs - such as Medicare and Medi-Cal - and agencies that oversee health plans have formal procedures for you to follow if you have a problem.

Some Reasons People Have Problems

Problems come up for many different reasons. The most common ones come from dissatisfaction with:

General Issues to Consider

Determine what you want. Decide whether you just want someone to know what happened to you, or if you are seeking a change and/or a resolution. Think about what you would consider a fair or positive solution to your problem. Know what you want!
Write it Down.

Check your contract. If you believe that you have been denied a covered benefit, service, or timely access, look in the Evidence of Coverage (EOC) you received when you signed up with your health plan. If you write a complaint, state the specific benefit the same way as it is written in the EOC. If you can't find the EOC, ask your health plan's customer service department to send you one.

Seeking to Resolve your Problem

First, talk to your doctor. If you are dissatisfied with service from your doctor or other health professional, speak with him or her directly and see if you can come to a better understanding. Your relationship with your doctor should be a partnership. You have the right to speak to him or her about your concerns, and he or she should have the opportunity to fix the problem. You may be able to choose another doctor if you remain dissatisfied.

Next, call your health plan. Many problems and concerns are resolved at your health plan's customer service department (also called "member services"). The health plan has an obligation to help you resolve your problems. Be sure to ask for and write down the name of the person assisting you so that you can speak with him or her again if you need to call back.

When you call your health plan, your complaint will probably be recorded, either by entering your information on a computer or by taping it as part of the health plan's monitoring of customer service. You should be told if a tape recording is being made. This is one way that health plans can measure the satisfaction of their members, but it also means that whatever you say could become part of your record.
Be Persistent.

Talk to your employer. If you get your health coverage through your own or your spouse's job, the human resources or benefits manager may be able to help resolve any questions about benefits and health plan policies. If you received an employee handbook, check it to see if there is a procedure to follow regarding questions or problems with your health benefits.

Formal Grievance and Complaint Procedures

If you are not satisfied with the resolution of your problem, you can file a formal grievance. You will probably need to submit your description of the problem in writing.
Keep Originals.

Check your contract Check your health plan documents (your Evidence of Coverage) for a description of your health plan's grievance process. A health plan customer service representative can send you a complaint or grievance form and guide you in filling it out. You have a right to a timely response, especially if your disagreement is over denied medical services you feel you should receive. The grievance material should tell you how long the health plan can take to respond to both emergency and non-emergency grievances.
Keep Originals.

Resolution of your grievance. You should expect a formal written response from the health plan acknowledging your complaint and a description of what the health plan will do to resolve it. You should be advised in writing of the health plan's decision. This response should tell you what was decided and why. You should also be told what to do if you wish to appeal a decision you feel is not fair.

Appealing a Decision

You may request a review of any decision. In some cases you may be able to appear before a committee assembled to hear your case. You may have to file a written request, usually within a limited amount of time from the date you received the letter from the health plan advising you of the decision.

Ask the health plan if you can bring someone with you to the hearing to help you present your grievance, such as an attorney. But remember, this is not a court of law and the procedures are informal. You will be asked to present your case in your own words in front of the health plan's committee. In addition, you will have to respond to their questions.
Action Steps.

When is a Decision "Final"? - Binding Arbitration and Legal Options

Many plans use a procedure called "binding arbitration" as the last step for the resolution of grievances and claims. In most cases. you will have signed an agreement to follow this procedure when you signed your enrollment application. Binding Arbitration means that the decision of the arbitrator is final.

Whether or not you have an arbitration agreement, you may have additional legal rights if you disagree with the health plan's decision. While it is probably a last resort, you may want to get an attorney to represent you and take your case to court.

Additional Action Steps.
The resources available to you beyond your health plan depend on the sort of plan you are in and who pays for your care.

If you are in any kind of HMO, whether through your job, Medicare, or Medi-Cal, or if you have coverage through Blue Cross or Blue Shield, you can contact the California Department of Corporations (DOC).

(800) 400-0815
The DOC oversees health plans. However, unless your problem is an emergency, the DOC requires that you try to resolve your problemwith your health plan for at least 60 days before the DOC will take your complaint.

If you are in a Preferred Provider Organization (PPO) or most other types of plans, the California Department of Insurance regulates these plans.

(800) 927-4357

If your employer or union is "self-insured", your benefits may be managed or "administered" by another company whose name might sound like an insurance company. Self-insured plans are also called "ERISA" plans, meaning they are covered by the federal Employee Retirement Income Security Act. Your rights to appeal may be different. If you are not sure if your employer or union is self-insured, ask your benefits administrator or union representative. You may also contact the federal Department of Labor (DOL), which regulates self-insured plans.

(415) 975-4600
In general, DOL does not provide any assistance to individuals. However, DOL will track your complaint to see if there is a pattern of problems with a particular self-insured plan.

If you are on Medicare, you may contact the Health Insurance Counseling and Advocacy Program (HICAP).

(800) 434-0222
HICAP provides objective information regarding consumers' rights in Medicare. Other resources for Medicare beneficiaries include the regional Health Care Financing Administration (HCFA), the federal regulator of Medicare programs,
(415) 744-3617
and California Medical Review, INC. (CMRI)
(800) 841-1602
to report a concern about the quality of care that you have already received.

If you are enrolled in a Medi-Cal HMO, your additional resources include
Maximus (also called Health Care Options)

(800) 430-4263
if you have problems with your enrollment or eligibility,
California Department of Health Services Medi-Cal Managed Care Ombudsman,
(888) 452-8609

or your eligibility worker whose name and telephone number appear on notices you get from the county.

If you have purchased coverage throughan insurance agent, ask him or her to assist you in resolving your complaint.

If you still have questions or concerns, call the HEALTH RIGHTS HOTLINE.

Because health care coverage can be complicated, the HEALTH RIGHTS HOTLINE is here to assist consumers. The HEALTH RIGHTS HOTLINE is a totally independent, free service which provides information and assistance to consumers. We have trained counselors who will answer your questions about your rights and explain how to exercise them. While you are usually the best person to make your case, if you are confused or need assistance, a trained member of our staff can help you or direct you to the appropriate agency.


519 - 12th Street
Sacramento, CA 95814

Sacramento (916) 551-2100
Toll Free (888) 354-4474
TDD (916) 551-2180
FAX (916) 551-2158

El Dorado * Placer * Sacramento * Yolo

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Write it Down! Before calling your health plan or another group with your complaint, write down the entire problem. Putting what happened in order by date is helpful. Some health plans may have a form for you to fill out describing your concern or complaint. Call the customer service number listed in your health plan materials to ask. Be sure to describe any efforts you have already made to resolve the problem. List who you talked to and when.
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Be Persistent - follow-up with your health plan. Most health plans are required to resolve consumer complaints within thirty days or less, depending on the issue. If you have an emergency, the health plan is required to resolve your complaint quickly. Ask your health plan when you can expect a response in writing. Follow-up with the plan if you do not hear back in a reasonable amount of time.
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Keep Originals and attach copies to any complaint. If you have received a bill for services that you don't feel you should pay or have any other documents which relate to your problem, make photocopies and include the copies with your complaint. Remember to keep the originals.
Use Cerified Mail and keep copies. When you are mailing an important document, such as your formal grievance, it is a good idea to send it Certified Mail with Return Receipt Requested so that you can verify the date your grievance was redeived by your health plan. Remember to always keep a copy of your documents
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Action Steps for appealing a decision:

Meet complaint or appeals deadlines. Some health plans have very specific rules about how soon after they respond to your complaint you must appeal or take another step. Make sure you understand the health plan's procedures and meet required deadlines. If you do not understand the procedures, ask a customer service representative.

Understand the Appeals Process. You have a right to know who will be present at an appeal hearing and who will make the decision. Ask your health plan. Depending on the issue, you may want to consider having your physician attend the hearing or prepare a letter in support of your position.
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