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DMHC's Role

 

Overview

The Department of Managed Health Care (DMHC) is the country’s first government agency solely dedicated to regulating health plans and assisting consumers to resolve disputes with health plans. The DMHC oversees full-service health plans, including all California HMOs and some PPOs, as well as specialized plans such as dental and vision. Overall, the DMHC regulates more than 90 percent of the commercial health care marketplace in California.

Created by consumer-sponsored legislation in 1999, the DMHC is funded by health plan assessments, with no taxpayer contributions. The DMHC’s main priorities are to protect the rights of approximately 20 million enrollees, educate consumers about their rights and responsibilities, ensure the financial stability of the managed health care system, and assist Californians in navigating the changing health care landscape.

Key Functions

To protect consumers, DMHC offers several services, including:

  • Consumer Help Center – Since its establishment, the DMHC consumer Help Center (1-888-466-2219 or www.healthhelp.ca.gov) has helped more than 1.5 million Californians resolve issues with their health plans.
  • LicensingHealth plans are required to apply for and maintain a license to operate as a health plan in California. The DMHC reviews all aspects of the plan’s operations to ensure compliance with California law. This includes, but is not limited to, Evidences of Coverage, contracts with doctors and hospitals, provider networks, and complaint and grievance systems
  • Rate ReviewThe DMHC reviews proposed premium rate increases to make sure health plans are providing detailed information to the public to justify proposed increases. While the DMHC does not have the authority to deny rate increases, the DMHC’s efforts improve accountability in health plan rate setting. The DMHC has saved policyholders approximately $64 million since January 2011, when the new California rate review law went into effect.
  • Financial SolvencyThe DMHC actively monitors the financial stability of health plans and medical groups to ensure that plans, and those entities they contract with, can meet their financial obligations to consumers.
  • EnforcementThe DMHC works to aggressively monitor and take timely action against plans that violate the law. The DMHC has assessed more than $50 million in fines and penalties against health plans and required plans to make the necessary changes to comply with the law.