HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

Health Rights Hotline Sample Letter

Cover Letter to State Regulatory Agency 

State regulatory agencies may be able to help you resolve your problem with your health plan, medical group, or provider. You might also want to send copies of your grievance or appeal to appropriate state agencies so that they are aware of the problem you have experienced. These services are free to health care consumers. Following is a sample letter to the California Department of Managed Health Care (the Department), the regulatory agency that oversees Health Maintenance Organizations, or HMOs) in California. This letter provides a basic format for requesting help from a regulatory agency; it may be changed to send to other state agencies. Be sure to add your own facts to this letter. You can also call any of the agency phone numbers listed to get more information or, in some cases, file your complaint over the phone.

Here are some tips for using this letter:

• Use only the parts of the letter that are appropriate based on your facts—there may be some suggested language in the sample letter that does not apply to your situation.
• Places where you can insert your information are identified by brackets ("[ ]"), and the description of the information to add is underlined. You should replace the brackets and the sample description with your own information, where it applies.
• Advice to you about what to write is in parenthesis ("{ }"), and the advice itself is in italics. You should delete these sections from your letter.
• Before sending your complaint to a regulatory agency, you should call the agency to make sure they regulate the type of plan you are in and can assist with the kind of problem you are experiencing.
• The sample letter is addressed to California Department of Managed Health Care, but depending on your coverage, the DMHC is not necessarily the right agency for you to complain to. Please read the agency descriptions that follow to determine which agency you should address your letter to.

  California Department of Managed Health Care
  (888) 466-2219
  Oversees HMOs, Blue Cross PPOs, and Blue Shield PPOs. You can also submit a complaint online through the DMHC’s web site at www.dmhc.ca.gov/pcs/pcs.asp.

  California Department of Insurance, Consumer Complaints
  300 S. Spring Street
  South Tower
  Los Angeles, CA 90013
  (800-927-4357)
  DOI regulates traditional “disability” insurance, indemnity plans, and PPOs (other than Blue Cross or Blue Shield PPOs).

  California Department of Health Services
  State Office of the Ombudsman
  MS 4412
  PO Box 997413
  Sacramento, CA 95899-7413
  (888-452-8609)
  www.dhs.ca.gov
  The DHS Office of the Ombudsman helps consumers resolve problems with Medi-Cal managed care plans (for example, Medi-Cal HMOs).

  Lumetra
  1 Sansome Street Suite 600
  San Francisco, CA 94104-4448
  (800-841-1602)
  http://www.lumetra.com/medicaremembers/qualityofcare/index.asp
  Lumetra reviews medical records of Medicare enrollees who have complaints about the quality of care they received or who are facing an early discharge from an acute care hospital. You may wish to call Lumetra first to discuss your problem; if you decide to make a formal complaint, Lumetra will help you write it.

  U.S. Department of Labor
  Employee Benefits Security Administration
  (866-444-3272)
  www.dol.gov/ebsa
  
  In Northern California:
  San Francisco Regional Office
  71 Stevenson Street, Suite 915
  San Francisco, CA 94105
  
  In Southern California:
  Los Angeles Regional Office
  1055 East Colorado Blvd., Suite 200
  Pasadena, CA 91106-2341
  
  DOL reviews claim disputes with the Federal Employees’ Health Benefits Program (FEHBP) and regulates employer-sponsored health benefits plans that fall under federal ERISA law .

• Each regulatory agency has its own rules for when it will assist consumers. You may be required to work with your health plan before receiving help from the agency. For example, California Health & Safety Code § 1374.30(j)(3), the law that describes the DMHC’s Independent Medical Review process for helping managed care enrollees, requires you to take certain steps before the DMHC will step in. You can ask the DMHC to help you if: (1) You have already filed a grievance or appeal with your health plan, and you have received a decision from your health plan that you do not agree with; (2) you have not received a decision from your health plan after working with your health plan for thirty (30) days or more; or (3) if it is an emergency situation. The DMHC can also help you if it determines that your case needs immediate attention, even if it is not an emergency. The DMHC will decide this on a case-by-case basis, and it may refer you back to your plan if it decides that your plan has not had the opportunity to respond to your concerns and your case does not require immediate attention.
• There are different laws that apply to different types of health care coverage. The laws that apply in your circumstances may depend on where you live, what type of health plan you have, and how you get your coverage. Check your plan member handbook, Evidence of Coverage (EOC), or Summary Plan Description (SPD) for information about the agency that regulates your health plan, then check with the agency to see what set of laws apply to your case. Remember, it is not necessary to quote the law in your letter, but doing so may help make your case stronger.
• If your need for treatment is urgent, you may have special rights to have your case decided quickly. Contact your health plan or check your plan member handbook for information on “expedited review” or “urgent appeals,” and check with the state agency you are sending a letter to for information on how to get expedited review of your case. The section of the sample letter in UNDERLINED BOLD CAPITALIZED ITALICS is a sample of language that can be used in cases involving an immediate and serious threat to health.
• Attachments - You should attach to your letter copies of any information that helps explain your case. Be sure to include a copy of the grievance or appeal that you filed with your plan and all supporting material. Support from your doctor is usually very important if you are requesting your health plan or medical group to cover a certain procedure or treatment. See the Health Right's Hotline's Action Guides, "How to Appeal a Health Plan or Medical Group Decision" and "Learning About Your Medical Condition," for more information on what you may want to attach to your letter. At the end of the letter are examples of the sort of attachments you might want to include. In some cases, a letter may have no attachments; in other cases, there may be many.

Health Rights Hotline
Sample Cover Letter to State Regulatory Agency
(see tips for using this letter)

[date]
California Department of Corporations
Complaint Unit
320 W. 4th Street Suite 750
Los Angeles, CA 90013-1105

To Whom it May Concern:

On [date] I filed an [appeal or grievance] with [name of health plan or medical group]. I am requesting the Department's assistance in resolving my difficulties with my [plan or group] because {select one of the following reasons why you are requesting the department's assistance}

• I am not satisfied with the answer I have received from my plan to my [grievance OR appeal];
• My plan has failed to respond to my complaint, and it has been more than sixty days;
• IT IS AN URGENT SITUATION AND I NEED IMMEDIATE ASSISTANCE.

A copy of my [appeal or grievance] is enclosed. Please let me know if more information is needed. You may contact me at [telephone phone number].

Thank you, in advance, for your attention to this matter.

 Sincerely,

[your name] 

Enclosures: {Material and documentation you can consider attaching:}

Copy of [grievance or appeal], including attachments (medical records, letters from doctors, etc.).