News

Help Center to the rescue!

By Cindy Ehnes, Director, California Department of Managed Health Care

With national health care reform looming, consumers and those with chronic diseases will need more help than ever to navigate our health care system.  The California Department of Managed Health Care (DMHC) is the nation’s only stand-alone managed care regulatory agency, touching the lives of more than 21 million health plan enrollees. 

The DMHC is the State agency that oversees all California HMOs, and Anthem Blue Cross and Blue Shield PPOs.  We make sure that health plans follow the law and that health plan members receive the right care at the right time. 

The Help Center at the DMHC is here to explain your health care rights and help you understand how to use your health care benefits.  We make sure that health plans follow the law and address member complaints on time. The Help Center is a free consumer assistance/protection program whose mission is to help people resolve problems with their health plans, such as the following:

·       Denials of care and treatment

·       Denials of prescriptions drugs and therapies

·       Delays in getting referrals, authorizations and diagnostic tests

·       Problems coordinating timely medical care

·       Claims, billing and co-pay issues

·       Keeping existing providers when health plan network contracts change

·       Continuing coverage on Cobra and Cal-Cobra

·       Cancellations of coverage

·       Access to language assistance

We are staffed with analytical, clinical and legal experts who review health plan members’ complaints and administer the State’s Independent Medical Review (IMR) program where health plan denials of medically necessary or experimental treatments are sent to an independent review organization for a final determination. 

The Help Center has assisted more than 1 million consumers resolve complaints and problems with health plans. The Help Center has also recovered more than $11 million for consumers in payments or reimbursements owed by health plans, resolved more than 4,500 urgent cases within three days, and referred more than 9,000 cases to the independent medical review (IMR) process. In 2008 alone, nearly 60 percent of health plan treatment denials sent to IMR were overturned, resulting in requested healthcare services being provided to consumers.  Although not all types of health insurance coverage is under our jurisdiction we are here to help and can connect people to the appropriate agency or resource.

To find out more about the Help Center or Independent Medical Review, go to www.healthhelp.ca.gov  or call 1-888-466-2219.