“Health plans are required by law to have a grievance process in place to resolve consumers’ complaints and ensure access to appropriate care,” said DMHC Director Shelley Rouillard. “L.A. Care failed to comply with laws surrounding the grievance and appeals system and must correct their deficiencies to ensure consumers know their health care rights and how to act on them.”
This enforcement action is a result of 21 cases involving 63 consumer grievance violations that occurred during 2014 through 2017. In these cases, L.A. Care deprived enrollees of their rights to medical care. The plan has acknowledged its failure to comply with the law, and the Department has determined that an administrative penalty and Corrective Action Plan are warranted. The corrective actions include employee training and increased oversight of the grievance and appeals system.
For more information on this enforcement action visit: http://wpso.dmhc.ca.gov/enfactions/docs/3200/1540563178967.pdf
A health plan’s grievance program informs enrollees of their full grievance and appeal rights and protections afforded to them under the law, such as the right to file a complaint with the DMHC if they are dissatisfied with the health plan’s decision, or pursue an Independent Medical Review.
A robust grievance program also allows health plans to track and trend grievances for the purpose of uncovering systemic problems, thereby providing the opportunity for quality improvement.
If a consumer is experiencing an issue with their health plan or is having difficulty accessing care, they can file a grievance with their plan. If they are not satisfied with their health plan’s resolution of the grievance or have been in their plan’s grievance system for 30 days, they should contact the DMHC Help Center for assistance at 1-888-466-2219 or online at www.HealthHelp.ca.gov.
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About DMHC:
The DMHC protects the health care rights of approximately 26 million Californians and ensures a stable health care delivery system. The Department has helped more than 2 million Californians resolve health plan problems through the Help Center. Information and assistance are available at www.HealthHelp.ca.gov or by calling 1-888-466-2219.