State Consumer Assistance

You might want to try talking to your doctor about the problem first.

To file a complaint:​

• ​​Call the Member/Customer Service phone number for your health plan. You can also file a complaint by letter or email.
• State clearly that you want to file a formal complaint and then explain the problem.
• If your problem is urgent, be sure to tell your health plan. Or call one of the state help centers listed above right away.
• You can ask your doctor, or a doctor outside of your health plan, to help you by writing a letter explaining why you need the service.
• You must file your complaint with your plan within 6 months after the incident or action that is the cause of your problem.
• After you file your complaint, your health plan must give you a decision within 30 days, or 3 days if your health problem is urgent.
• If you disagree with your health plan’s response to your grievance, you can usually appeal to a state agency or other oversight organization.

Contact a state help center if:

• Your problem is urgent.
• You filed a complaint with your plan and you disagree with your plan’s decision. (Your plan’s response letter will also tell you where you can go for an appeal.)
• You filed a complaint with your health plan and your plan didn’t respond.
• Your health plan would not give you complaint forms or take your complaint.
• You have questions about your complaint rights or need complaint or IMR (appeal) forms.

Examples of issues you can get help with:

• Your plan denied an experimental or investigational treatment for a serious condition.
• Your plan canceled your coverage.
• It is taking too long get an appointment with a doctor or referral to a specialist.
• Your plan didn’t pay a bill or insurance claim correctly.
• You are having trouble getting your plan to provide interpreter services or information in your language.
• You have a disability and are having trouble getting accessible health care services.

Problems with Medi-Cal Eligibility or Enrollment

For most issues about applying for or renewing Medi-Cal coverage, you can contact your local county office for help. You also can contact your local office if you lost your BIC, have questions about your Medi-Cal coverage status, or need guidance about where to file a complaint.

If you disagree with a Medi-Cal program decision about your eligibility or enrollment, you have the right to appeal through a State Fair Hearing.

Problems getting services using a Medi-Cal Health Plan

Most Medi-Cal members get their health care services through a managed care health plan. If you have a problem getting care, you can contact your Medi-Cal health plan’s member services for help.

• You have the right to file a complaint (also called a grievance) with your health plan.
• For many Medi-Cal plans, members can appeal a grievance decision with the Department of Managed Health Care (www.dmhc.ca.gov, 1-888-466-2219). But some plans may have a different complaint process.

State Fair Hearings

This is sometimes called a Medi-Cal Fair Hearing. You can ask for a State Fair Hearing to appeal a Medi-Cal program decision or denial whether you have fee-for-service Medi-Cal, are in a Medi-Cal health plan, or were denied Medi-Cal coverage.

• The California Department of Social Services oversees State Fair Hearings. A State Fair Hearing is a review by an administrative law judge.
• If you received a Notice of Action in the mail with a Medi-Cal decision you disagree with, you can appeal that decision by asking for a hearing. Follow the instructions on the back of the notice.
• You also can request a hearing by contacting the Department of Social Services at 1-800-743-8525 or 855-795-0634.
• There is usually a time limit. You must ask for the hearing within 90 days of the action by the Medi-Cal program or plan.

More Resources

• For more information and resources, visit the Medi-Cal website.
• For additional guidance about Medi-Cal managed care plans or mental health coverage, contact the Medi-Cal Office of the Ombudsman.
• For questions or problems about Medi-Cal dental services, contact the Medi-Cal Dental Telephone Service Center at 1-800-322-6384.
• For help with Medi-Cal pharmacy services, contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.
• For questions about a billing issue for Medi-Cal fee-for-service, contact the Medi-Cal Telephone Service Center at 1-800-541-5555.

Help for Medicare problems and complaints

Medicare can be complicated, but there are people who can help you.

• California’s HICAP program provides free help with many kinds of Medicare questions and problems. HICAP is the Health Insurance Counseling and Advocacy Program. You can make an appointment to meet with a HICAP Counselor in your area. Call 1-800-434-0222 or visit www.aging.ca.gov/hicap.
• You can also call the federal Medicare program for general questions at 1-800-MEDICARE (1-800-633-4227). If needed, they can refer you to the Medicare Beneficiary Ombudsman for help with a complaint or appeal.

Original Medicare appeals

For help with problems with your Part A (hospitalization) or Part B (outpatient services) coverage:

• You can file an appeal if Medicare does not pay for a service you need. Ask your doctor for a letter of support.
• Every 3 months, you should receive a Medicare Summary Notice. The back of this notice tells you how to file an appeal. To learn more, call 1-800-MEDICARE or visit www.medicare.gov/claims-and-appeals/index.html.
• For help with an appeal, call HICAP at 1-800-434-0222.

Medicare Advantage appeals

All Medicare Advantage plans have a member services office you can call for help. Look on your plan’s membership card for this phone number.

• If your plan denies a service you need, start by filing an appeal with your plan. Your plan must reply in 7 days. If your problem is urgent, file an expedited appeal. Your plan must reply in 72 hours.
• If your plan says it will not pay your bill, you have 60 days to file an appeal with your plan. The plan has 60 days to respond to your appeal.
• Ask a doctor to help you tell the plan why you need the care. The doctor does not have to be a part of your plan.
• For help with an appeal, call HICAP at 1-800-434-0222.

If your hospital, home health, nursing home, or rehab care is ending

If you are receiving one of these services and it is ending too soon, call Livanta at 1-877-588-1123. The federal government contracts with Livanta to help Medicare members in California.

• If you dispute a hospital discharge by calling Livanta, you will be able to remain in the hospital while your case is being reviewed.

If you get poor quality care

You can call Livanta at 1-877-588-1123 about problems with the quality of your care while using your Medicare coverage. For example:

• You got the wrong medicine.
• You had unnecessary surgery or diagnostic testing.
• You had a delay in getting a service.
• You received poor care or treatment.

If you have Medicare Advantage, you can start by talking to your plan’s member services office before calling Livanta. Tell your plan that you want to file a grievance. You can ask them to send you a grievance form. Fill out the form and mail it back.

• Your plan must take action within 30 days after it gets your grievance form.
• If your plan still will not help or does not reply within the time limit, call Livanta.