Congratulations! You have health coverage. This is a big step toward your enhanced health and well-being. Now that you are covered, it is important to understand your health plan benefits, know your rights as a consumer, and learn what actions to take if your coverage changes or a health care service has been denied. Whether you need to file a complaint, discover more about your health condition, or learn about your rights, let us point you in the right direction.
What Is Covered Now That I'm Insured?
California law states that health plans must cover many basic health care services and benefits when they are medically necessary. A definition of what is medically necessary can be found in your health plan contract, otherwise known as your Evidence of Coverage. Below you’ll find which basic services and benefits are covered by your health plan, and which are not.
Basic Health Care Services and Essential Health Benefits
Health plans must cover basic health care services, which include: doctor visits; hospital services; inpatient services (when you have to stay overnight in the hospital); and outpatient services (such as minor surgery in a surgery center). Other basic services include:
- Diagnostic laboratory tests, such as blood tests, STD (sexually transmitted diseases) tests, pregnancy tests, and some cancer screening tests
- Diagnostic services, such as x-rays and mammograms
- Preventive and routine care, such as vaccinations and checkups
- Behavioral health care including treatment for serious emotional disturbances of a child and substance use disorders
- Emergency and urgent care, including treatment for serious emotional disturbances of a child and substance use disorders
- Rehabilitation therapy, such as physical, occupational, and speech therapy
- Some home health or nursing home care after a hospital stay
- Pregnancy care
Additional Benefits that Health Plans Must Cover
- Standing referrals for patients with AIDS (you do not have to get a referral and approval each time you see an AIDS specialist)
- Diabetes services and supplies
- Routine costs of clinical trials for cancer treatment
- Prosthetic devices or reconstructive surgery after a mastectomy (removal of a breast)
- Prosthetic devices to restore a method of speaking for a patient after a laryngectomy (removal of the vocal cords), not including electronic voice-producing machines
- Reconstructive surgery to correct or repair birth defects, developmental abnormalities (something that is not normal in the way a child grows), trauma or injury, infection, tumors, or disease to improve function (the way a part of the body works) or to create as normal an appearance as possible
- Services related to diagnosis, treatment, and management of osteoporosis (weak bones), including bone mass measurement and other FDA-approved tests and medications
- General anesthesia for dental procedures (in certain cases)
Services That Are Not Required
Most medical health plans do not cover dental care, eyeglasses, and hearing aids. Only some plans cover durable medical equipment, such as wheelchairs and oxygen. What is covered differs from plan to plan.
Diabetes Services and Supplies
If you have diabetes (insulin-using diabetes, non-insulin-using diabetes, or gestational diabetes), your health plan must cover the following, even if you can get them without a prescription:
- Blood glucose monitors and testing strips
- Blood glucose monitors designed for people with vision problems
- Insulin pumps and supplies needed to use the pump (in certain cases)
- Urine strips to test for ketones
- Lancets and lancet puncture devices
- Pen delivery systems for taking insulin (in certain cases)
- Podiatric devices to prevent or treat foot problems related to diabetes
- Insulin syringes
- Visual aids, except eyeglasses, to help people with vision problems take the proper dose of insulin
- Out-patient training, education, and medical nutrition therapy to help a person with diabetes use covered equipment, supplies, and medications properly
If your health plan covers prescription drugs, it must cover the following diabetes drugs:
- Insulin
- Other prescription drugs to treat diabetes
- Glucagon
Find Information About Your Health Plans and Benefits
- Go to your health plan's website for information about your benefits.
- Websites of licensed health plans and other insurance agencies can give you information on costs and benefits.
- Contact the DMHC Help Center toll free at 888-466-2219 for help with your health plan.
- Learn how to use your health plan and obtain other educational materials from California's Office of the Patient Advocate (OPA).
- Visit OPA's Health Care Quality Report Card to find out how your health plan measures up.
File a Complaint
Health plan members, also known as enrollees, should file a complaint (also known as an appeal or grievance) if you have a problem with your health plan. To do so, first contact your health plan to file a complaint. You can file a complaint with your health plan over the phone or in writing. You may also be able to file a complaint through your health plan's website.
If your health problem is urgent, you already filed a complaint with your health plan and are not satisfied with the decision, or it has been more than 30 days since you filed a complaint with your health plan, you may submit an Independent Medical Review Application/Complaint Form with the DMHC. If you need assistance you may contact the Help Center at 1-888-466-2219.
Enrollees can file a consumer complaint with the DMHC for a variety of issues, including, but not limited to: balance billing, the denial of coverage for any health care service for any reason, a dispute about the amount paid on a claim, a copay dispute, the cancellation of your coverage, or if you have a complaint about care provided to you by one of your providers.
Enrollees can also apply for an Independent Medical Review (IMR) with the DMHC when a health care service or treatment has been denied, modified or delayed. An IMR is a review of your case by independent doctors who are not part of your health plan. You have a good chance of receiving the service or treatment you need by requesting an IMR. If the IMR is decided in your favor, your plan must cover the service or treatment you requested. An IMR is free to enrollees.
For your convenience, all of the issues you are experiencing can be submitted to the DMHC on one Independent Medical Review Application/Complaint Form.
Find Information About Health and Diseases
- There is a lot of useful health information on the Internet, but be sure to talk to your doctor before you make a decision about a treatment.
- Compare information on more than one website.
- Look for information based on research, not personal opinions.
- Look for information that is up-to-date.
- For more information on evaluating health information sites, visit Medline Plus. This site is sponsored by the federal government, and the information is based on solid medical research.
You Have Rights Under Health Care Reform
- To buy individual coverage, even if you have a pre-existing condition.
- To stay on a parent’s health plan until age 26.
- To get many preventive care services without a co-pay, co-insurance, or deductible.
- To have no lifetime dollar limits on basic health care services.
- To purchase health insurance or determine Medi-Cal eligibility through the California Health Benefit Exchange, Covered California website.
Helpful Hints
- If you are told that you cannot get the care you need, ask for the reason in writing.
- Talk to your doctor about your problem.
- When you make a phone call, take notes. Write down the date of your call, the name of the person you talk to, and what the person says.
- Act soon. If you wait longer than 6 months, you may lose the right to file a complaint, ask for an Independent Medical Review, or take other actions against your health plan.
- All phone numbers that start with 1-800, 1-866, 1-877 or 1-888 are toll-free. There is no cost to call them.
- Make a list of questions before you call.
- You may want to have someone with you for extra support and to help you think of questions.
- If you are deaf or hard of hearing, call the California Relay Service at 7-1-1. They help people with telephones and TTYs (Telecommunications Device for the Deaf) talk to each other.
- If you have a speech disability, call 1-800-854-7784 to use the Speech-to-Speech Relay services.