What should I do if my treatment is denied?
If your medical plan makes a decision that
you disagree with, such as not covering the medication or therapy your doctor
has ordered, you usually start by appealing with the plan itself.
If your plan denies the initial internal
appeal, ask it to review its decision. At the same time, immediately request a
state fair hearing. You can always withdraw from the hearing later if you’re
able to resolve the problem directly with your health plan. Request a state
fair hearing by calling 855-795-0634 or email your request to shdcsu@dss.ca.gov.
Before your hearing, gather medical evidence
to bolster your case. Ask your doctors to write letters of support. Your doctor
can also participate in the hearing by phone. You can also get help from health
care advocacy groups, such as the Health Consumer Alliance: healthconsumer.org or
888-804-3536.
The state Department of Social Services
conducts the hearings. The case must be decided within 90 days after the
Medi-Cal recipient requests the hearing. An enrollee whose health is in danger
from delay may request an expedited hearing. If a judge agrees, a hearing will
be scheduled within 10 days of the request and a decision rendered within five
days after all evidence has been submitted.
If you’re unhappy with the state fair hearing
decision, you may be able to request a rehearing or even take your case to
civil court. You also can contact the Medi-Cal
Managed Care Office of the Ombudsman at 888-452-8609 or MMCDOmbudsmanOffice@dhcs.ca.gov.
This advice applies to the 22 California
counties with a County Organized Health System (COHS) plan. This includes Santa
Barbara County and San Luis Obispo County, which are covered by CenCalHealth, a
COHS plan. In these counties, the local COHS plan is the only Medi-Cal plan available
to you, and it is exempt from certain requirements.
In some counties, there’s another
option.
Other California counties have non-COHS
plans, which are regulated by the state
Department of Managed Health Care. In those counties, clients have access
to something called an Independent
Medical Review (IMR), which allows them to appeal their plan’s
decision to an independent physician (or physicians) who are experts in the
conditions being reviewed. If the health issue is urgent, the client can
request an expedited IMR to be conducted within a week. If it is not urgent, it
is usually decided within 30 days.
The IMR is faster than the fair hearing
process—which is supposed to take less than 90 days but has been known to take 6-8
months. The IMR is conducted by doctors, not administrative law judges.
This option could potentially be extended
to all counties.
Some state lawmakers, such as state
senator Bill Monning (a Democrat representing Monterey, Santa Cruz and San Luis
Obispo), want to bring all COHS plans under the Department of Managed Care so
that their clients have access to an IMR too. Some COHS systems, including
CenCal Health, resist that idea, saying it would bring another layer of
regulation and additional costs. Others are more receptive, including the Health
Plan of San Mateo—a COHS plan which voluntarily agreed to be regulated by the
Department of Managed Care so that its enrollees can request an IMR.
Original article here: http://www.sacbee.com/news/local/health-and-medicine/ask-emily/article43886232.html#storylink=cpy
