Complaints About Health Plan (September 1, 2004)

You have many rights and protections when it comes to health plans, especially if your plan is an HMO. (To learn the difference between types of plans, go to What type of health plan is best for me?). Until recently, though, there were few ways to get your problems solved without going to court.

The California Medical Association has worked to make it possible for patients to solve their problems with health service plans, including HMOs, in a faster, less complicated way. We sponsored a law that lays out grievance procedures that can be used for any concern, for example a charge that your health plan refused to pay or an instance when you had to wait an unreasonably long time to see a doctor.

These instructions will take you through the process of filing a complaint and tell you what to expect along the way. You'll want to follow somewhat different guidelines if your problem is an emergency.

The first step is to tell your health plan about your problem in writing. We suggest that you:

Write your letter as soon as possible, while all the facts are still fresh in your mind.

Explain the situation in a brief, clear way, including facts (names, dates, places, etc.) whenever possible.

Tell your plan exactly what you want them to do to solve the problem.

Include copies of any papers that relate to the problem (statements, checks, etc.)

Try to stick to the facts and avoid exaggerating.

Here is a sample letter you may wish to use as a guide:

DRAFT Sample Letter of Complaint with Health Plan

Alternatively, you can file a complaint on-line - just go to the health plan's website and click on the button labeled "General forms".

Each plan has it's own process for dealing with complaints. Your plan may respond to your letter by asking you to fill out a form, provide additional information or speak to a plan representative. As you go through this process, keep copies of all written communications. If you speak to someone, in person or on the phone, write down the date and what was said. The law requires the plan to send you written notice that it has received your complaint within 5 days which includes the name, telephone number and address of the plan representative handling the grievance. The law also requires the plan to send you a written response within 30 days of receiving your complaint. This response must clearly explain the reasons for the plan's decision. If your complaint involved the delay or denial of health care services, the plan must describe the clinical reasons for its decision, any standards it used, and the specific provisions of your health plan contract that the plan believes apply to exclude coverage.

If you're not happy with the way your health plan has responded to your complaint or your health plan has not responded in 30 days, the next step is to contact a state agency that can take further action.

If you have traditional insurance, you will need to take your complaint to the California Department of Insurance and fill out a Request for Assistance form. You can reach them through their website at www.insurance.ca.gov or by calling their consumer hotline at 1-800-927-HELP.

If you have an HMO, Blue Cross, or Blue Shield, you will need to contact the Department of Managed Health Care Consumer Help Line at 1-888-HMO-2219 or TDD 1-877-688-9891.

The DMHC generally requires that you first file a complaint with your health plan before you file a complaint with the Department of Managed Health Care. You should contact your health plan for information about their complaint process. You can also call the DMHC Consumer Help Line (1-888-HMO-2219) or access the Contact Your Health Plan section for assistance.

This complaint process involves a review of all information, including relevant medical records, provided by both you and your health plan. The Department will try to resolve your complaint within 30 days. To file your complaint with the Department you should complete the Complaint Form and fax the form along with any documents that may support your complaint to the HMO Help Center at 916-229-0465.

Under the law, your doctor can assist you as you go through the complaint process. You can request that your doctor attend any informal meetings requested by the DMHC.

Keep in mind that if your plan requires that you resolve problems through arbitration, you still have the option of going to the DMHC beforehand. You also have the right to take legal action or go to a mediator (if the plan agrees) without going through the DMHC first.

If the DMHC concludes your case is eligible for review by qualified, independent physicians through California's independent external review system, it will immediately inform you of that option. At your request, it will also help you take advantage of that right. CMA strongly encourages you to use this system if it is offered as it has resolved many disputes in favor of patients.

If you are in a situation where your health is seriously threatened and you need fast assistance in dealing with a health plan problem, you will want to inform your plan and the DMHC in writing immediately. If the complaint involves an immediate threat to your health call the DMHC Help Line right away at 1-888-HMO-2219 or TDD 1-877-688-9891.

If you have traditional insurance, call the California Department of Insurance at 1-800-927-4357 and explain your situation. If necessary, they will contact your insurance company by phone to resolve your complaint, instead of going through their usual process, which commonly takes from 30 to 90 days.

Assistance available from the federal Department of Labor. If your health plan is provided by your employer, you may also ask for assistance from the Employee Benefits Security Administration by calling 1-800-444-EBSA (3272). You should have the following information ready when you call:

• The beneficiary’s name and daytime telephone number;
• A brief explanation of the problem;
• Evidence that a claim for benefits has been filed;
• Name, address and telephone number of the employer or plan official to be contacted;
• The enrollee’s permission to inquire on the enrollee’s behalf, if necessary;
• Employment dates, birth date, Social Security number, policy number or other identification numbers.

Medicare patients are entitled to special grievance and appeal rights. Your health plan is required by law to give you a complete written explanation of your rights. Medicare also maintains a web site, www.medicare.gov, which is very helpful. You may also file a complaint with Lumetra, a Medicare contractor that provides its service for Medicare beneficiaries.

You may also wish to contact one or more of the organizations listed below:

Name of Organization	Contact Information
Center for Health Care Rights	520 S. Lafayette Park Place, Suite 214 Los Angeles, CA 90057 (213) 383-4519; FAX (213) 383-4598 Toll free in Los Angeles County: 1 (800) 824-0780 www.healthcarerights.org
Health Consumer Alliance	Statewide Office 2639 South La Cienega Blvd. Los Angeles, CA 90034 (310) 204-4900 or (310) 204-6010; FAX (310) 204-0891 www.healthconsumer.org Fresno(800) 675-8001 Los Angeles(800) 896-3203 Orange(800) 834-5001 or (714) 571-5200 San Diego(877) 734-3258 San Francisco(800) 551-5554 or (415) 982-1300 San Mateo(800) 381-8898 or (650) 558-0915
Health Insurance Counseling and Advocacy Programs	(800) 434 0222
Department of Managed Health Care	Department of Managed Health Care California HMO Help Center 980 Ninth Street, Suite 500 Sacramento, CA 95814-2725 Voice: (888) HMO-2219 FAX: (916) 229-0465 TDD: (877) 688-9891 E-mail: helpline@dmhc.ca.gov www.dmhc.ca.gov

Other Links:

• Complaints About Health Plans