This program is administered
by the Managed Risk Medical Insurance Board (MRMIB).

Appeals Process

What types of decisions can I appeal?

You can file an appeal if you believe an eligibility, start date, or disenrollment decision was made incorrectly by Healthy Families. To "file an appeal" means to ask the program to reconsider a decision it has made about your child's eligibility.

The appeals process includes three separate levels of review:

First level appeal

This appeal must be filed within 60 days from the date of the decision letter. This process requires a written appeal from the applicant or authorized representative. The disagreement must be about eligibility (i.e. denial), disenrollment, or the start date of coverage decision made by Healthy Families.

Healthy Families will review and respond to your appeal in writing within 30 days. Send your first level appeal to:

Healthy Families
Attn: Appeals Department
P.O. Box 138005
Sacramento, CA 95813-8005

The postmark on the envelope or the date a fax is sent will be considered the filing date. Appeals filed after the deadline will be treated as program review requests.

To file an appeal complete the form included with the decision letter.

Whether you use our form or write your own letter, you must do the following when you file your request for a first level appeal:

• Send us a copy of the written notice or tell us which decision you disagree with; and
• Explain why you think our decision is wrong. If you think we made a mistake about the facts of your case, please tell us. If you think we violated a program rule, such as a law or regulation or other written policy, please tell us; and
• Tell us how you want this appeal to be resolved (what you want us to do); and
• Give us any other information you want us to consider; and
• Be sure to include your Family Member Number on each paper you send to Healthy Families.

Second level appeal

If you disagree with the Healthy Families decision of the first level appeal, you can file a second level appeal with the Executive Director of the Managed Risk Medical Insurance Board (MRMIB). MRMIB is the agency that oversees Healthy Families. File your second level appeal within 30 days from the date of the first appeal decision letter. Second level appeals are written appeals from an applicant or authorized representative about the decision on the first level appeal. Mail your second level appeal to:

Executive Director
Managed Risk Medical Insurance Board (MRMIB)
PO Box 2769
Sacramento, CA 95812-2769

You may also fax your appeal to 1-916-327-6560.

Your appeal will be reviewed and a response will be sent in writing.

Third level administrative hearing

If you disagree with the decision of the MRMIB Executive Director, you have the right to request an administrative hearing. You will have 30 days from the date of the MRMIB Executive Director' decision letter to request an administrative hearing. The notice from MRMIB will contain all the information that you will need to file a request for an administrative hearing. You will be notified in writing of the date, time and place of the administrative hearing.

Program Reviews

In addition to the appeals process, the program accepts “program reviews.” Program Reviews are informal reviews of issues, such as new income documentation, billing questions, account balances, and other complaints and questions that are not formal appeals or do not meet the appeal deadlines.

Can I request continued coverage for my child until a decision on my appeal is made?

If you appeal the disenrollment decision before the disenrollment date, your child will receive Continued Enrollment (CE). CE means that your child will continue to be enrolled in Healthy Families until a decision is made on your first level appeal. Healthy Families must receive your written request for CE before the disenrollment date. Healthy Families cannot review appeals over the phone.

You can submit your Continued Enrollment form online through Health-e-App. Go to www.healtheapp.net for more information.

You can use the Continued Enrollment Form that is included with the disenrollment notice to file your appeal or write us a letter. You can also download a Continued Enrollment Form.

Mail your appeal to:

Healthy Families
Attn: Review Unit
P.O. Box 138005
Sacramento, CA 95813-8005

You can also fax your appeal to 1-866-848-4974.

Benefits Complaint Process

You may file a complaint if you are not satisfied with a decision made by your provider or plan. A complaint is also called a grievance. A complaint can be written or verbal. Examples of complaints are:

• You have a bill/claim and need assistance in getting it paid.
• Your plan does not pay you back for emergency or urgent care that you had to pay out of pocket.
• You can’t get a service, treatment, or medicine you need.
• You have to wait too long for an appointment.
• You received poor care or were treated rudely.
• Your plan denies a service and says it is not medically necessary.

Can I complain about a health, dental or vision plan decision?

If you are unhappy with something your child’s health, dental, or vision plan did (or did not do), you must first attempt to resolve your problems with the plan by filing a complaint with your plan. You can obtain a copy of your plan’s complaint policy and procedure by calling the Member Service number in your Evidence of Coverage (EOC) document or Certificate of Insurance (COI). To begin the complaint process, call, write, or fax your plan at the address and telephone number located in your EOC or COI.

You will receive these booklets from your child’s health, dental, and vision plans. Call the plans directly and ask for a copy if you don’t have one. Your child will not be dropped from the plan or suffer a penalty if you do this.

What if I am not satisfied with my Plan’s response to my complaint?

If you are unable to resolve your complaint with your plan, you may also contact the Department that licenses the plan for assistance. Either the California Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI) are responsible for regulating health, dental, and vision plans in California.

If medical care for your child is denied, delayed or modified by your plan or provider you may be eligible for an Independent Medical Review (IMR). The DMHC and CDI are also responsible for providing IMRs. If you are eligible, the IMR process provides an impartial review of medical decisions made by a plan related to the medical necessity of proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. There is no cost to you for the IMR process.

Which Department Regulates My Plan?

If you have an Evidence of Coverage (EOC) Booklet, your health, dental or vision plan is regulated by DMHC. Contact them at: 1-888-HMO-2219 www.hmohelp.ca.gov

If you have a Certificate of Insurance Booklet, your plan is regulated by the CDI. Contact them at:
1-800-927-HELP (4357) www.insurance.ca.gov. If you need assistance in distinguishing which department regulates your plan, call us toll free at 1-800-880-5305 and we can assist you.