The government agency you need to contact about health coverage issues will depend on the type of health insurance plan you have.
HEALTH MAINTENANCE ORGANIZATION PLANS.
For problems with your HMO, including issues of medical care, prescriptions, preventive testing and mental health services, contact the state Department Managed Health Care. The department regulates all HMOs in California.
The Department of Managed Health Care's Consumer Help Line is available 24-hours daily toll-free at (888) HMO-2219 or (877) 688-9891 (TDD). If your dispute involves a serious or imminent threat to your health, such as the denial of treatment, inform the center that your call concerns an urgent matter. The department's website also explains the complaint process and your health care rights.
TRADITIONAL FEE-FOR-SERVICE PLANS.
If you are having problems with Indemnity Policies or traditional fee-for-service health insurance coverage (e.g., Blue Cross/Blue Shield), contact Consumer Services in the California Department of Insurance. The department regulates all indemnity plans.
PREFERRED PROVIDER ORGANIZATIONS.
If you are having problems with your Preferred Provider Organization, you need to contact the Department of Managed Care if it involves an HMO or the Department of Insurance if the underwriting company is a licensed insurance company.
SELF-INSURED HEALTH PLANS.
If you are having problems with your Self-Insured Health Plans (Single Employer Self-Insured Plans), you likely will need to contact the U.S. Department of Labor, Employee Benefits, Security Administration since most self-insured health plans fall under the Employee Retirement Income Security Act (ERISA). However, the federal administration agency does not regulate self-insured health plans that are sponsored through school districts, other municipalities, and churches. If you are a member of this type of plan, you can file a complaint with the plan directly or you may seek a legal remedy through a court.
MULTIPLE EMPLOYER WELFARE ARRANGEMENTS.
If you are having problems with health coverage under Multiple Employer Welfare Arrangements (MEWAs), contact the California Department of Insurance. MEWAs permit employer members of trade, industry, professional and other associations to create trust funds for the purpose of offering health care benefits to employees. Only MEWAs issued a certificate of compliance by November 30, 1995 from the Department of Insurance are allowed to operate in the state.
For an informative overview of health insurance, see the Health Brochure prepared by the California Department of Insurance.