Consumer Assistance at the Department of Managed Health Care
The Department of Managed Health Care (DMHC) is a state regulator that oversees most Californians’ health care coverage. Its Help Center addresses complaints from members of HMOs and other health plans licensed by the department.
DMHC Help Center
Main phone number: 1-888-466-2219
Hours of operation: Monday-Friday, 8:00 a.m. – 6:00 p.m.
Service for urgent issues available after hours and on state holidays.
Complaint Data Highlights
The highlights below are based on information DMHC reported to OPA about its consumer assistance service center and the complaint cases it reviewed in 2020. More details can be found in the DMHC section of the full Annual Complaint Data Report.
Consumer assistance volume in 2020: 130,233 phone calls, emails, and other consumer contacts
Complaint volume in 2020: 15,884 complaints
Complaint review time in 2020: 24 days on average
Complaint resolution times ranged from 0-183 days.
- The above statistics include cases with review times counted prior to completion of the complaint application, when initial information was first received from the consumer. DMHC’s time standard for its review of standard complaints is 30 days after receipt of a complete complaint application.
- DMHC usually requires that consumers file a complaint (grievance) with their health plan before the department will review their complaint.
- There is a faster process for urgent health issues.
Top ten reasons for complaints:
- Medical Necessity Denial (15% of complaints)
- Co-Pay, Deductible, and Co-Insurance Issues (13%)
- Delays/No Response (9%)
- Quality of Care (8%)
- Denial of Coverage (7%)
- Out-of-Network Benefits (7%)
- Misrepresentation (6%)
- Billing/Reimbursement Issue (5%)
- Access to Care (5%)
- Pharmacy Benefits (4%)
Top five results of the complaint review:
- Health Plan Position Substantiated (50% of complaints)
- Advised Complainant (14%)
- Compromise Settlement/Resolution (12%)
- No Jurisdiction (8%)
- Health Plan Position Overturned (7%)