§ 53892. Problem Resolution Process for Members.

(a) Any member of a plan may request assistance by telephone, facsimile, in writing, or in person from the Health Care Options Program in resolving problems associated with mandatory or voluntary enrollment or disenrollment in the Two-Plan Model Program or assignment to a plan.

(b) If the Health Care Options Program is not able to resolve the problem through the procedures for processing enrollment and disenrollment specified in section 53889, then the Health Care Options Program shall first direct the beneficiary to the plan in which the beneficiary is a member, unless the beneficiary has already been to the plan to attempt to resolve problems resulting from plan enrollment or disenrollment. If the beneficiary wishes to disenroll from the plan, the Health Care Options Program shall advise the beneficiary of the options to:

(1) Be referred to the plan's problem resolution process.

(2) Be referred to the department's Medi-Cal Managed Care Ombudsman and the Department of Managed Health Care's Office of the Patient Advocate.

(c) If the beneficiary is referred to a plan's problem resolution process, the Ombudsman or the Department of Managed Health Care's Office of the Patient Advocate, the Health Care Options Program shall provide an estimated time frame within which the member shall be contacted by the plan, the Ombudsman or the Department of Managed Health Care's Office of the Patient Advocate.

(d) If the beneficiary still wishes to disenroll, the Health Care Options Program shall process the disenrollment request as specified in sections 53889 and 53891.

(e) If the member and the plan have been unsuccessful in resolving the problem to the member's satisfaction, but the member does not want to disenroll, the plan shall forward the problem to the department's Ombudsman by the next working day following the day on which the member indicates he/she does not want to disenroll.

(1) The plan shall tell the beneficiary when the beneficiary may expect to be contacted by the Ombudsman.

(f) In addressing issues under the problem resolution process, the Health Care Options Program, the department's Ombudsman, and the plan shall perform these functions in a manner consistent with cultural and linguistic requirements prescribed by the contract between the plan and the department.

HISTORY

1. New section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).

2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).

3. Amendment of section and Note filed 12-19-2000 as an emergency; operative 12-19-2000. Submitted to OAL for printing only pursuant to section 147, SB 485 (Ch. 722/92) (Register 2000, No. 51).

Note

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 10950, 14087.3, 14087.4 and 14450, Welfare and Institutions Code.