Ensure Your Medi-Cal Managed Care Plan Provides Equal Coverage For Mental Health And Substance Use Disorder Benefits

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This pub tells you about Medi-Cal Managed Care Plans. It tells you what to do if the plan denies a service. It tells you what to do if the plan does not coordinate your care with the county. It tells you what to do if it is not giving you equal coverage for mental and physical health conditions. 

 

If your Medi-Cal Managed Care Plan denied a service, is not coordinating your care with county-administered mental health services, or is not providing equal coverage for mental and physical health conditions, then you can take action. 

Submit a complaint to your health plan.

Contact “member services” to submit a complaint to your Medi-Cal Managed Care plan.  The member service number can be found on your Medi-Cal Managed Care plan’s benefits card.  If the dispute is not resolved in your favor, you may request a fair hearing or you can file a complaint with the Department of Managed Health Care (DMHC). You can go directly to DMHC if the situation is urgent.  

Request a fair hearing.

You have 90 days from the date of the notice to request a hearing.  It can take up to 90 days from the date of your request to get a hearing decision.  When a mental health service is discontinued by your Medi-Cal Managed Care Plan, you can keep the same benefits while you wait for a hearing if you submit the hearing request within 10 days of the date of the notice. This is referred to as “aid paid pending”.

Hearing requests can be sent to:

California Department of Social Services
State Hearing Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA  94244-2430

Contact DMHC to submit a complaint.

If your health problem is urgent, or if you already filed a complaint and are not satisfied with your Medi-Cal Managed Care plan's decision, contact DMHC.  An urgent problem is a serious threat to your health. You can also file a complaint if your health plan does not make a decision within 30 days.

The DMHC Complaint Form can be found at:      

https://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.aspx

 You may submit a complaint to DMHC either online, mailing or facsimile: 

  • Online: Complete the Independent Medical Review Complaint Form (https://www.dmhc.ca.gov/FileaComplaint.aspx).
  • Mail: Print, complete and submit the Complaint Form to:
    Department of Managed Health Care
    980 9th Street, Suite 500
    Sacramento, CA 95814-2725
  • Facsimile: Print, complete and submit Complaint Form to (916) 255-5241

This information is provided to you through the combined effort of the following organizations:

Disability Rights California
(916) 504-5800/ (800) 776-5746   

Legal Aid Society of San Diego, Inc.
(877) 534-2524

Mental Health Advocacy Project
(408) 293-4790  

Mental Health Advocacy Services, Inc.
(213) 389-2077

 

 

The California Mental Health Services Authority (CalMHSA) is an organization of county governments working to improve mental health outcomes for individuals, families and communities.  Prevention and Early Intervention programs implemented by CalMHSA are funded by counties through the voter-approved Mental Health Services Act (Prop 63).  Prop. 63 provides the funding and framework needed to expand mental health services to previously underserved populations and all of California’s diverse communities.