California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 6 - Appeals on Cancellation › Section 1300.65.4 - Grievance Form for Cancellations, Rescissions, and Nonrenewals of an Enrollment or Subscription

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Grievances to the Director pursuant to
				  Health and Safety Code section
				  1365(b)
				  may be made electronically, verbally, or in writing signed by the enrollee,
				  subscriber, or group contract holder (or their legal representative).
(b) An enrollee, subscriber, or group
				  contract holder is not required to use a specific form to submit a written
				  grievance to the Director pursuant to Health and Safety Code section
				  1365(b)(1).
				  An enrollee, subscriber, or group contract holder may submit a written
				  grievance using any form that, at a minimum, contains the information
				  enumerated in California Code of Regulations, title 28, section
				  1300.65.4(d), and
				  addressed to:
DEPARTMENT OF MANAGED HEALTH CARE
HELP CENTER
980 9TH STREET, SUITE 500
SACRAMENTO, CA 95814
(c) The plan shall make readily available to
				  its members a form that, at a minimum, contains the information enumerated in
				  California Code of Regulations, title 28, section
				  1300.65.4(d).
(d) An enrollee, subscriber, or group
				  contract holder may submit a written grievance using a form that, at a minimum,
				  contains fields for, or notice of, the following information:
(1) Full name of enrollee, subscriber, or
				  group contract holder filing the grievance;
(2) Name and identification number(s) of all
				  enrollees affected;
(3) Name of
				  parent or guardian, if filing for minor child enrollee;
(4) Date of birth;
(5) Gender, as follows:
Gender: [] Male [] Female [] Other .
					 ___________________________
(6) Mailing address;
(7) Daytime phone number;
(8) Evening phone number;
(9) Email address;
(10) Health plan name;
(11) Health plan membership number;
(12) Medical group name, if
				  applicable;
(13) Employer, if
				  applicable;
(14) Medi-Cal
				  identification number, if applicable;
(15) Medicare or Medicare Advantage
				  identification number, if applicable;
(16) Date enrollee received notice that
				  coverage was or will end;
(17) Date
				  enrollee filed a grievance with an entity other than the Department, if
				  applicable;
(18) Copies of plan
				  notice(s) and correspondence(s) received, if any;
(19) Copies of enrollee correspondence(s)
				  sent, if any;
(20) Copies of proof
				  of payment for the last paid coverage period;
(21) A Medical Release, if necessary, as
				  follows:
MEDICAL RELEASE
I request that the Department of Managed Health Care (DMHC)
					 make a decision about my problem with my plan. I request that the DMHC review
					 my Cancellation of Health Coverage Grievance Form to determine if my grievance
					 qualifies for the DMHC's Consumer Complaint process. I allow my providers, past
					 and present, and my plan to release my medical records and information to
					 review this issue. These records may include medical, mental health, substance
					 abuse, HIV, diagnostic imaging reports, and other records related to my
					 grievance. These records may also include non-medical records and any other
					 information related to my grievance. I allow the DMHC to review these records
					 and information and send them to my plan. My permission will end one year from
					 the date below, except as allowed by law. For example, the law allows the DMHC
					 to continue to use my information internally. I can end my permission sooner if
					 I wish. All the information that I have provided on this sheet is true.
Enrollee, Legal Guardian, or Parent
					 Signature:___________________________
Date:___________________________
Please see the instruction sheet for mailing or faxing
					 information.
(22) An
				  Authorized Assistant Form, if necessary, as follows:
AUTHORIZED ASSISTANT FORM
If you want to give another person permission to assist you
					 with your grievance, complete Parts A and B below.
If you are a parent or legal guardian submitting this
					 grievance for a child under the age of 18, you do not need to complete this
					 form.
If you are filing this grievance for an enrollee who cannot
					 complete this form because the enrollee is either incompetent or incapacitated,
					 and you have legal authority to act for this enrollee, please complete Part B
					 only. Also attach a copy of the power of attorney for health care decisions or
					 other documents that say you can make decisions for the enrollee.
PART A: ENROLLEE
I allow the person named below in Part B to assist me in my
					 grievance filed with the DMHC. I allow the DMHC staff to share information
					 about my medical condition(s) and care with the person named below. This
					 information may include mental health treatment, HIV treatment or testing,
					 alcohol or drug treatment, or other health care information.
I understand that only information related to my grievance
					 will be shared.
My approval of this assistance is voluntary and I have the
					 right to end it. If I want to end it, I must do so in writing.
Enrollee Signature: ______________________________
					 Date:______________________________
PART B: PERSON ASSISTING ENROLLEE
Name of Person Assisting (print):
					 ___________________________
Signature of Person Assisting:
					 ___________________________
Street Address: ___________________________
City: ______________________________ State: _______________
					 Zip: ___________________________
Relationship to Enrollee:
					 ___________________________
Daytime Phone Number: __________ Evening Phone Number:
					 ___________________________
Email Address (if
					 available):___________________________
My power of attorney for health care decisions or other
					 legal document is attached: __________(check if applicable)
(23) An Instruction Sheet, as follows:
GRIEVANCE/COMPLAINT FORM INSTRUCTION
					 SHEET
If you have questions, call the Help Center at
					 1-888-466-2219 or TDD at 1-877-688-9891. This call is free.
How to File:
1.
				  File online at www.HealthHelp.ca.gov. [This is the fastest way.]
OR
Fill out and sign the Cancellation of Health Care Coverage
					 Grievance Form.
2. If you
				  want someone to help you with your grievance, complete the Authorized Assistant
				  Form.
3. Include documents
				  requested on the Cancellation of Health Care Coverage Grievance Form, such as
				  notices from your health plan, billing statements, and proof of
				  payment.
4. If you are not
				  submitting online, please mail or fax your form and any supporting documents
				  to:
DEPARTMENT OF MANAGED HEALTH CARE
HELP CENTER
980 9TH STREET, SUITE 500
SACRAMENTO, CA 95814-2725
FAX: 916-255-5241
What Happens Next?
The Help Center will send you a letter telling you if your
					 grievance has been accepted. If your grievance is accepted, a decision about
					 your issue will be made within 30 days. You will be notified in writing of the
					 decision.
(24) The
				  Information Practices Act of 1977 Notice, as follows:
INFORMATION PRACTICES ACT OF 1977
					 NOTICE
The Information Practices Act of 1977 (California Civil
					 Code section
					 1798.17)
					 requires the following notice.
* California's Knox-Keene Act gives the DMHC the authority
					 to regulate health plans and investigate the grievances of health plan
					 members.
* The DMHC's Help Center uses your personal information to
					 investigate your problem with your health plan.
* You provide the DMHC this information voluntarily. You do
					 not have to provide this information. However, if you do not, the DMHC may not
					 be able to investigate your grievance.
* The DMHC may share your personal information, as needed,
					 with the plan and providers to investigate your grievance.
* The DMHC may also share your information with other
					 government agencies as required or allowed by law.
* You have a right to see your personal information. To do
					 this, contact the DMHC Records Request Coordinator, DMHC, Office of Legal
					 Services, 980 9th Street Suite 500, Sacramento CA 95814-2725, or call
					 916-322-6727.
(25)
				  Explanation of reason for filing the grievance; and
(26) Signature of
				  enrollee.