HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

Appeal Rights In Medi-Cal Health and Dental Plans

If you are in a Medi-Cal health plan or dental plan, you have the right to file a complaint or grievance with the plan. You also have a right to have someone outside the plan - a judge from the state Medi-Cal office - hear your story and decide what is right.

You have the right to appeal to the state Medi-Cal office if:

• your eligibility for Medi-Cal has changed or ended, or
• if your health plan or dental plan, doctor, dentist or pharmacist reduces or stops a medical service you think you need.

You must be given an opportunity to tell an independent judge why you think the action is wrong. The state must hold the hearing within 30 working days of your request. The judge must make a decision within 75 days after the hearing.

You can ask for a state hearing from Medi-Cal AND file a grievance or complaint with your plan at the same time. You do not need to do one before the other.

Many Types of Problems Can Be Brought to a State Hearing

You can ask for a hearing if you are:

• Changed from a Medi-Cal health plan back to Fee-For-Service without your consent
• Told by the county that you can no longer receive Medi-Cal
• Told by your doctor that he or she will no longer accept you as a patient
• Told by your doctor that you cannot have a referral to a specialist that you want
• Told by your doctor that you cannot have a particular medical treatment or medication that you think you need and that is covered by Medi-Cal
• Told by your doctor or pharmacist that your medication has to be changed because your old medicine is no longer available under Medi-Cal
• Told by your doctor that you cannot continue to see a specialist, such as a psychologist or a physical therapist, because you have used up all your allowed visits
• Told by your doctor or health plan that a treatment you think you need is not "medically necessary"
• Told by your plan or by Medi-Cal that you cannot change to a different health plan or dental plan

These are just some examples. Remember, you can ask for a hearing if your doctor, dentist or health plan or dental plan denies, reduces or stops a medical service you think you need.

How to Request a State Hearing

You can request a state hearing by calling the state hearing office toll-free at (800) 952-5253. Or you can put your request in writing and mail it to:

State Hearings
744 P Street
M.S. 19-37
Sacramento, CA 95814

If you mail your request, be sure to include your name, address and telephone number, the name of your health plan or dental plan, your social security number and a statement about what you feel is wrong and why.

Your Eligibility or Care Can Continue While Your Case Is Heard

If your Medi-Cal eligibility is being changed or ended, or a medical service you receive is being reduced or stopped, you have the right to continue your Medi-Cal eligibility or to continue to receive the medical service until after a decision is made on your case. To continue your eligibility or continue to receive the service while your case is being heard and decided, you MUST

• Ask for a hearing quickly - within 10 days of the date on the written notice or, if you do not get a written notice, within 10 days of the date of the action or decision you disagree with, AND
• Tell the state hearing office when you ask for the hearing that you want your eligibility or the service to continue until a decision is made on your case.

Be sure to Meet the 90-Day Deadline for Requesting a Hearing

If you want to request a hearing about a decision or action taken against you within 10 days (as discussed above) you must make the request within 90 days of:

• The date on a written notice about the decision or action that you disagree with; OR
• The date the decision or action that you disagree with occurred (if you do not receive a written notice about the decision or action).

Call the HEALTH RIGHTS HOTLINE

Health care coverage can be complicated, but you do have rights. The HEALTH RIGHTS HOTLINE can assist you personally if you live in one of the following California counties: El Dorado, Placer, Sacramento, or Yolo. The HEALTH RIGHTS HOTLINE is a totally independent, free service that provides information and assistance about your rights as a health care consumer. Trained counselors will answer your questions and help you resolve issues with your health plan. If you need assistance, give us a call.