Issue link: https://digital.copcomm.com/i/431369
The People's Guide 2015 46 Medi-Cal 7. Hearings, Grievances, and Leaving a Managed Care Health Plan If your health plan denies services or you are not satisfied with the services, you have many options. You can file a grievance with your health plan. Your health plan must tell you how to file a grievance. The health plan must resolve your grievance within 30 days, or less if you have an emergency. If you are still not satisfied complain in writing to the Department of Managed Health Care HMO Help Center, IMR Unit, 980 Ninth Street, Suite 500, Sacramento, CA 95814-2725. Their phone number is (888) 460-2219, TDD (877) 688-9891. Or you can go to their website at www.hmohelp.ca.gov. Mandatory participants in health plans can change to a different plan for any reason. Voluntary participants can change plans or can go back to regular Medi-Cal for any reason. To change or leave a health plan, call Health Care Options at (800) 430-4263 and request a "choice form." If you want help with complaints and grievances call an advocacy group for assistance or call: Health Care Consumer Center (800) 896-3203 Managed Care Ombudsman (888) 452-8609 Department of Managed Care (888) HMO-2219 Medi-Cal Managed Care Ombudsman (888) 452-8609 You can also find information online at http://www.dmhc.ca.gov/ You can call (800) 400-0815 if your health plan gives you problems. If your health plan is denying you care because it does not think it is medically necessary, but you disagree, you can ask for an inde- pendent medical review which is done by a group of doctors and professionals who do not work for your health plan. You have the right to ask for a fair hearing. (see page 66, "Hearings and Complaints.") While waiting for a state hearing, the health plan must continue to provide medical services to you, if you request the hearing before the effective date of the intended action. 8. Mental Health Managed Care Mental Health services for Medi-Cal recipi- ents are also provided through a managed care system. See page 52. You will also receive a packet in the mail about dental managed care. Enrolling in a dental plan is optional; you don't have to enroll. If you choose not to enroll, you can still use your Medi-Cal card with any dentist who accepts Denti-Cal to get dental services. 5. Medical Exemptions and Continuity of Care Most participants must enroll in a health plan; unless you apply for and receive a "Medical Exemption" in order to keep regular fee for service Medi-Cal. You may be able to get an exemption if you have a "complex medical condition" such as pregnancy, kidney disease, diabetes, HIV/ AIDS, cancer, asthma, or multiple scle- rosis, or receive skilled nursing services at your home, AND if the doctor or clinic that treats you is not part of any available offered health plan and you would lose them if you joined a plan . The state is now making it very difficult to get medical exemptions and you may need an advocate to assist you and your doctor. See "Good Advice (pg. 68) for advocate listing. You and your doctor must fill out a form called "Request for Medical Exemption From Plan Enrollment" (which is in the packet that you get in the mail) and send it to the state. Do this before the date you would have choose a health plan. If the state denies your exemption, file an appeal. You should be able to stay in regular Medi-Cal while a decision is made on your appeal. The exemption is good for up to 12 months. After the 12 months, you will get another packet in the mail to complete, or you must request another Medical Exemption. You may call Heath Care Options if you have questions, or you can call the Health Consumer Center at (800) 896-3203 for assistance. 6. Fees In both health plans and regular Medi-Cal, you may have to pay $1.00 for prescrip- tions and many services unless you are pregnant, over age 64, or under age 19. Also, there may be a charge of $5.00 for non-emergency care given in the emer- gency room. The state is currently not collecting these fees. Medi-Cal for Teens If you are between 12 and 21 years old, you can apply for "Minor Consent Services" to get free and confidential medical treat- ment without parental consent related to: • Drug or alcohol abuse (except metha- done treatment) • Sexually transmitted infections • Pregnancy and abortion • Family planning • Outpatient mental health (not overnight in a hospital) • Sexual abuse If you are under 21 and living with your parents, or temporarily away such as in school, you may apply for Minor Consent Medi-Cal to cover these specific services without your parents' consent or knowl- edge. If you are a minor who is living on your own you may complete a regular Medi-Cal application. Your parents won't be required to give in- formation about their income or resources or pay toward the medical services, unless you want Medi-Cal for services other than those listed above. DPSS won't tell your parents or send let- ters to your home without your permission. ''Minor Consent Services" are available regardless of your immigration status and cover more services than restricted Medi-Cal. To apply, fill out the regular Medi-Cal application and another short form for Minor Consent Services at DPSS or with a DPSS Worker at the site where you are receiving care. You will have to fill out a new short form each month you need treat- ment, except for mental health services. For that, you need a letter from a mental health professional explaining that you meet certain conditions for getting mental health services and how long you will need treatment. You will still have to complete the short form each month to update your eligibility. If you already get Medi-Cal through your parents' case, you may already have a plastic Medi-Cal card, but do not use it for Minor Consent services.