Section 1300.65.4 - Grievance Form for Cancellations, Rescissions, and Nonrenewals of an Enrollment or Subscription (California Code of Regulations)

§ 1300.65.4. Grievance Form for Cancellations, Rescissions, and Nonrenewals of an Enrollment or Subscription

(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.

(1. New section filed 7-30-2019; operative 10-1-2019 (Register 2019, No. 31).)

Note: Authority cited: Section 1344, Health and Safety Code. Reference: Section 1365, Health and Safety Code.

Disclaimer: Lawrina makes great effort to keep legal information accurate and updated. However, we cannot guarantee that Section 1300.65.4 Grievance Form for Cancellations, Rescissions, and Nonrenewals of an Enrollment or Subscription is an exact copy of the official text as updates may have been made. Please check the accuracy of the information provided against the official resources.

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