Office of the Director
The Director’s Office provides leadership and guidance to the employees of the Department of Managed Health Care (DMHC) and works with external stakeholders to achieve the mission of the Department.
DMHC Help Center
The DMHC Help Center (HC) educates consumers about their health care rights, resolves consumer complaints against health plans, helps consumers understand their coverage and assists consumers in getting timely access to appropriate health care services. The DMHC Help Center provides direct assistance in all languages to health care consumers.
Office of Plan Licensing
As part of the licensing process, the Office of Plan Licensing (OPL) reviews all aspects of a health plan’s operations, including benefits and coverage (Evidences of Coverage), template contracts with doctors and hospitals, provider networks, mental health parity and complaint and grievance systems. After licensure, the OPL monitors health plans and any changes made to plan operations, including changes in service areas, contracts, benefits or systems. The OPL also periodically identifies specific licensing issues for focused examination or investigation.
Office of Plan Monitoring
The Office of Plan Monitoring (OPM) monitors health plan networks and delivery systems. The OPM conducts routine surveys and non-routine surveys when a specific issue or problem requires a focused review of a health plan’s operations. A routine survey of each licensed health plan is performed every three years. The OPM also monitors health plan provider networks and the accessibility of services to enrollees by reviewing the geographic standards, provider-to-patient ratios and timely access to care. Additionally, OPM reviews health plan block transfer filings when a contract terminates between a health plan and a hospital or provider group.
Office of Financial Review
The Office of Financial Review (OFR) monitors health plan financial statements and filings, and analyzes health plan reserves, financial management systems and administrative arrangements. The OFR conducts routine financial examinations of each health plan every three to five years and initiates non-routine financial examinations as needed.
OFR also administers the Department’s premium rate review program, which has saved Californians hundreds of millions of dollars in health care premiums. The DMHC’s rate review program holds health plans accountable through transparency and ensures consumers get value for their premium dollar. When the DMHC finds a proposed rate change to be unreasonable, the health plan must notify impacted members of the unreasonable finding.
Office of Enforcement
The Office of Enforcement represents the Department in actions to enforce the managed health care laws. The primary purpose of an enforcement action is to change plan behavior to comply with the law. Enforcement actions include issuing cease and desist orders, imposing administrative penalties (fines), freezing enrollment and requiring corrective actions. When necessary, the DMHC may pursue legal action to ensure health plans follow the law.
Office of Legal Services
The Office of Legal Services (OLS) provides legal, legislative, and policy analysis and advice to the DMHC. OLS also develops necessary and appropriate regulations to administer the Knox-Keene Health Care Service Plan Act of 1975.
Office of Administrative Services
The Office of Administrative Services (OAS) provides a variety of administrative support services to the Department, including accounting, budgets, business management services, and human resources.
Office of Technology and Innovation
The office of Technology and Innovation (OTI) provides technology support to the Department including hardware, software and information security services.