About the DMHC

Mission

The California Department of Managed Health Care protects consumers’ health care rights and ensures a stable health care delivery system. 

Organization Overview

Office of the Director

Director
Provides leadership and guidance to the employees of the Department of Managed Health Care while working with external stakeholders toward an accountable and viable managed health care delivery system that promotes healthier Californians.

Chief Deputy Director
Oversees the day-to-day operations, which include an aggressive approach to improving overall efficiencies and performance management.

Deputy Director for Communications and Planning
Ensures integrated and consistent communications throughout the Department and with external stakeholders.

Deputy Director of Health Policy and Stakeholder Relations
Fosters proactive and effective relations between the Department and its stakeholders, while serving as primary advisor to the Director on critical issues and providing strategic planning and policy direction on emerging issues and industry trends.

Deputy Director of Legislative Affairs
Analyzes proposed, pending and recently enacted legislation and advises the Department on any and all legislative matters.    

General Counsel
Advises the Director and Chief Deputy Director on general legal matters and coordinates legal counsel among the Department’s divisions.

Chief Medical Officer
Serves as the Department’s chief clinical consultant on a wide variety of regulatory and legislative initiatives, and is responsible for the stewardship of clinical and provider network adequacy issues and the clinical integrity in Department programs.

Help Center

The Help Center assists consumers with health care issues and ensures that managed care patients receive the medical care and services to which they are entitled.

Contact Center

The Contact Center receives, reviews, and processes all incoming correspondence and addresses consumer telephone inquiries. The Contact Center answers thousands of calls per month from consumers with questions about or problems with health care issues. The Contact Center’s regular phone hours are from 8 a.m. to 6 p.m. Monday through Friday excluding state holidays and weekends. Help Center clinical staff are available after hours for urgent calls from consumers with an imminent threat to their health. The Contact Center has bilingual staff and telephonic interpretation services in over 100 languages and a TDD device or use of the California Relay Service for those who are hearing impaired. The Contact Center also processes incoming written correspondence including applications for Independent Medical Review and complaint forms. The Contact Center is responsible for educating consumers regarding non-jurisdictional issues, medical group or health plan closures, community resource referrals and health plan contact information as well as mailing forms, applications and informational brochures. Contact Center staff collect basic data, including demographic information, on callers to track problems and trends.

Independent Medical Review and Complaint Branch

The Independent Medical Review and Complaint Branch (ICB) responds to consumers’ disputes with their respective DMHC-regulated health plan through the Independent Medical Review (IMR) and standard complaint processes. The ICB reviews IMR applications to determine if the issue qualifies for an IMR. Issues that qualify for an IMR include; (1) health care services that are denied, delayed, or modified as not medically necessary; (2) health care services that are denied, delayed or modified as investigational or experimental; or (3) denials of reimbursement requests for urgent or emergency medical services. ICB staff utilizes on-site legal and clinical staff for assistance and direction with complex cases and clinical issues. Standard complaints not eligible for an IMR are generally reviewed and resolved within 30 days. Standard complaints reviewed and resolved include coverage benefit denials, quality of care concerns, access to care issues, coordination of care issues, and deductible/out-of-pocket maximum accumulations.

Legal Affairs and Policy Development Unit

The Help Center’s Legal Affairs and Policy Development Unit (HC Legal) investigates and resolves the most complex consumer complaints the Help Center receives including those complaints involving unsettled legal, policy or health plan compliance issues. HC Legal typically resolves assigned complaints within 30 days and then communicates case findings to the consumer, health plan, and/or provider(s) in a letter. HC Legal refers all Help Center complaints involving health plan non-compliance issues to the DMHC’s Offices of Enforcement, Plan Monitoring, Licensing, or Legal Services for further review.

In addition to its case handling and compliance functions, HC Legal also provides legal advice and counsel to the following groups: (1) Help Center and DMHC executive management on policies, laws, and regulations affecting the DMHC and the health care industry; (2) Help Center analysts and clinical staff concerning IMR and benefit coverage dispute cases through the Legal Liaison program; and (3) community-based organizations and consumer advocates with respect to the applicability of the Knox-Keene Act and implementing regulations as well as navigating health plan and DMHC consumer complaint processes.

Provider Complaint Unit

The Provider Complaint Unit is responsible for accepting provider complaints involving unfair payment patterns. The Provider Complaint Unit tracks and trends complaints and forwards to the Department's auditing groups trending claims payment issues which may be used in routine and non-routine financial audits of health plans and their delegated payors.

The Provider Complaint Unit is also responsible for coordinating two Independent Dispute Resolution Processes (IDRP) for emergency and non-emergency services, respectively.

The Emergency Services IDRP was established to afford non-contracted providers who deliver Emergency Medical Treatment & Active Labor Act (EMTALA) required services a fast, fair and cost-effective way to resolve claim payment disputes with health plans or capitated providers concerning the “reasonable and customary” value of services rendered. The Emergency Services IDRP is voluntary and non-binding as to both providers and payors.

New legislation enacted in 2016 (AB 72) established the Non-Emergency Services IDRP. AB 72 protects consumers from surprise medical bills for non-emergency services rendered by a noncontracting provider at a contracted facility on or after July 1, 2017. AB 72 also takes consumers out of any ongoing billing disputes by creating a binding IDRP to allow non-contracting providers and payors to dispute the appropriate reimbursement amount for non-emergency services. DMHC has contracted with an independent dispute resolution organization for the AB 72 Non-Emergency Services IDRP, which begins processing disputes on September 1, 2017.

Clarify Support Team

The Clarify Support Team is responsible for the development, implementation, training and support of the Help Center database applications – principally the Help Center’s Customer Relationship Management system, Clarify. Staff prepare reports and provide data regarding information available via the Help Center's database.

Management Support Services

Management Support Services is comprised of two branches: Business Services and Community Program and Special Projects. The Business Services branch is responsible for Help Center personnel, training, contracts, purchasing, facility and office management, and management reports. The Community Program and Special Projects branch is responsible for Consumer Outreach and Assistance program grants, the Disability Assistant program, the Help Center monthly report, and legislative analysis. Through the grant program, a network of community-based organizations provides direct, local assistance for consumers with their health plan eligibility and coverage issues.

Office of Enforcement

The Office of Enforcement handles the litigation needs of the Department, representing the Department in actions to enforce the managed health care laws and in actions that are brought against the Department. Cases may be referred to this Office from the Help Center, the Office of Health Plan Oversight, the Office of Patient Advocate, and other divisions that review the activities of health care service plans for compliance with the managed health care laws. Employees of this Office conduct investigations, prepare pleadings and briefs, and appear in all courts of California. The Office has two divisions

Division of Health Plan Standards
The Division of Health Plan Standards is responsible for handling actions (cases) involving health plans' compliance with the non-financial requirements of the managed health care laws, including the quality, accessibility, and continuity of care and the denial of treatment and claims in enforcing the managed health care laws. Cases are received from other divisions as well as initiated upon receipt of information from other sources.

Division of Financial Solvency
The Division of Financial Solvency is responsible for handling actions involving compliance with the financial requirements of the law, including the reporting and solvency requirements.

The mission of the Office of Legal Services (OLS) is to help set standards of consistency, efficiency, and transparency for the managed health care marketplace. Our motto is “together we set the standard.”

The OLS provides legal and policy advice to the Director, Chief Deputy Director, Assistant/Deputy Directors, and programs of the DMHC, and recommends and develops necessary and appropriate statutes and regulations to administer the Knox-Keene Act. Representing the Director and the DMHC before various public and private agencies and forums, the OLS also serves as primary contact to the legislative branch and liaison of intergovernmental affairs.

Designed to serve as a general legal office, the OLS maintains flexibility to adapt to the changing needs of the DMHC. During 2010, for example, the OLS was called upon to help implement federal health care reform laws at the state level. The OLS continues to play a key role in coordinating DMHC implementation of those federal laws on a continuous basis.

Legal services are provided by the OLS in connection with arbitrations, budget matters, ethical guidelines, information technology, internal procedures, interpretive opinions, legislation, litigation strategy, open meetings, personnel administration, public contracts, records management, rulemaking, and tort liability.

In addition, the OLS supports a Policy Council of DMHC management, advises the Financial Solvency Standards Board, and administers the Consumer Participation Program.

The management team of OLS consists of an Assistant Deputy Director serving as principal policy adviser to the Executive Staff and as OLS program manager, an Assistant Chief Counsel, and two Staff Managers.

Reorganized in 2010, OLS has two teams to perform its work: a Division of Law and Legislation is comprised of legal counsel and a Division of Legal Administration with analysts and administrative staff.

Office of Administrative Services - (OAS)

Provides a variety of administrative support services to the Department, including:

Accounting
Maintains the accounting system and prepares the Department’s year-end financial statements. Processes vendor payments, travel expense claims, revolving fund checks, revenue receipts, and payroll warrant releases.

Budget Office
Prepares the annual Governor's Budget, revenue and expenditure projections, office allotments and the annual assessments. Reviews budget change proposals and provides office consultation and training.

Business Management Services
Provides business services such as contracts, procurement, space planning, telecommunications, records management, safety and building security, central reception, mail service, inventory control and copy center services.

Equal Employment Opportunity (EEO)
Provides EEO advisor services, EEO counseling, and EEO training. Coordinates the EEO discrimination and complaint process, upward mobility program, Americans with Disabilities Act program, and reasonable accommodation program.

Human Resources
Provides departmental personnel and payroll services, including: benefits, transactions, position control, classification and pay, examinations, labor relations, worker’s compensation and supervisor consultations. Provides administrative and management support services to department staff, including administrative policy and procedures oversight.

Office of Technology and Innovation

Division of Application Support
Provides Webmaster and application development and support for the public Internet Web sites (DMHC and OPA), department Intranet (OTIS) and the department Web portals and other Web-based applications.

Provides project management and programming support to the following projects: FSSB, Financial Exam Reporting and the Help Center.

Provides Clear Basic and Crystal Reports programming and support for the HMO Call Center application.

Designs, develops, implements and supports Departmental Microsoft SQL databases and performs backup database administrator functions and assists in network and desktop support as needed.

Division of Support Services
Provides support services for and procurement of PC desktops, laptops and the associated suite of productivity software.

Staffs the IT Help Desk to respond to both PC administrators and Department employees for problem resolution.

Provides administration for databases and the Exchange/Outlook email application.

Maintains the Department's network, file and printer servers and application servers.

Ensures the security of data through the implementation of virus detection software and intruder detection.

Office of Financial Review

Division of Financial Oversight
Monitors and evaluates the financial viability of health plans to ensure continued access to health care services for the enrollees/patients of California. This is accomplished by reviewing financial statements, analyzing financial arrangements and other information submitted as part of the licensing, material modification, and amendment process; and by performing routine and non-routine examinations.

Premium Rate Review
Reviews proposed health plan premium rate increases, analyzes the justification for such increases, educates the public to expand consumer understanding of how premium rates are established and promotes more accountability within the health care industry.

Division of Provider Solvency and Support
Monitors the financial stability of Risk Bearing Organizations through the analyses of financial data and corrective action plans. Investigates and provides meaningful and appropriate regulatory resolutions to claim payment disputes through identifying unfair payment practices and unfair billing patterns.

Office of Plan Licensing

Works toward assuring that licensed health plans provide the delivery of preventive and other medically necessary health care services in an appropriately organized and financially stable managed health care setting.

Office of Plan Monitoring

The Office of Plan Monitoring monitors plan compliance with the law and evaluates access and the adequacy of plan networks.

Division of Plan Surveys
The Division is responsible for evaluating and promoting health plan regulatory compliance and quality improvement as related to health care delivery systems. The Division's public health and clinical professionals plan and conduct on-site evaluations of all licensed health plans at least every three years and issue reports to the public that discuss plan performance in the areas of health care accessibility, utilization management, quality improvement and member grievances/appeals.

Division of Provider Networks
The Division of Provider Networks reviews plan provider networks to ensure networks have the right types of providers necessary to deliver services promised under enrollees’ contracts, meet geographic access requirements, meet provider to enrollee ratio requirements, and have a sufficient number of providers to offer appointments within timely access standards.