Fall 2025
Message from the Director
The Department of Managed Health Care (DMHC) is proud to celebrate its 25th anniversary. Since its inception in 2000, the DMHC has been committed to expanding coverage and access, protecting health care rights, and ensuring a stable health care delivery system. As we celebrate this milestone and prepare for the road ahead, our guiding purpose continues to be protecting the health care rights of health plan members.
Building on the accomplishments of the past 25 years, I am pleased to announce the release of the DMHC’s five-year strategic plan. The strategic plan outlines our priorities for the next five years to hold health plans accountable, protect health plan members’ rights, and improve health care access, quality and value for all Californians. It also confirms the organizational values that will guide the Department’s work in the coming years. I want to thank my DMHC colleagues and our valued stakeholders for their collaboration and helpful insights throughout the strategic planning process.
With a number of recent changes by the federal government, I want to highlight that health plan members in DMHC-licensed plans should continue to have access to COVID-19 tests, vaccines and treatment. California law requires health plans to cover vaccines recommended by the California Department of Public Health (CDPH), in addition to vaccines recommended by federal agencies. That means health plans must continue to cover COVID-19 vaccinations with no cost-sharing or prior authorization. The DMHC’s Know Your Health Care Rights on COVID-19 fact sheet includes important information about COVID-19 tests, vaccines and treatment.
I encourage health plan members having trouble accessing the health care services they need, including COVID-19 tests, vaccinations or treatment, to contact their health plan. If the member is not satisfied with their plan’s response, or has an urgent issue, they can file a complaint with the DMHC Help Center at www.DMHC.ca.gov or by calling 1-888-466-2219 (TDD: 1-877-688-9891) for help.
As always, thank you for your continued support and interest in the DMHC’s important work.
Sincerely,
Mary Watanabe
Director
DMHC Announces New Five-Year Strategic Plan
The DMHC finalized its five-year strategic plan outlining the strategic priorities that will guide the Department’s work from 2026 through 2030. The strategic plan lays out a roadmap to improving health care access, quality and value, and empowering all Californians to live healthier lives. The DMHC also updated its mission statement to reflect the Department’s commitment to ensuring health plan members have access to equitable, high-quality, timely and affordable health care within a stable health care delivery system.
To achieve the Department’s new mission and vision, the DMHC’s strategic priorities over the next five years will focus on holding health plans accountable by enforcing California’s strong consumer protection laws, supporting regulatory changes that protect health plan members’ rights, and encouraging partnership and collaboration with stakeholders. The DMHC’s vision will be realized when all Californians under the Department’s jurisdiction can easily access high-quality, affordable health care.
The strategic plan positions the DMHC to address the opportunities and challenges ahead in an evolving health care landscape. You can find more information about the DMHC's strategic plan on the Department’s website.
California Takes Action to Protect Coverage of Preventive Care Services
On September 17, 2025, Governor Newsom signed Assembly Bill (AB) 144 protecting access to preventive care services. AB 144 requires health plans in California to cover preventive care services recommended by the federal government as of January 1, 2025, or recommended by the California Department of Public Health (CDPH), with no cost-sharing or prior authorization for health plan members. The DMHC issued All Plan Letter (APL) 25-015 providing information and guidance to licensed health plans on the protections enacted under AB 144.
California requires health plans to cover preventive care services and immunizations recommended by the federal United States Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP) and the U.S. Health Resources and Services Administration (HRSA). Health plans must continue to cover those recommended services. To ensure continued coverage, AB 144 allows CDPH to modify or expand the list of covered preventive care services and immunizations based on guidance and recommendations from trusted medical and scientific organizations, such as the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP).
Preventive care and early detection can save lives. The DMHC encourages health plan members to talk with their provider to understand their specific health care needs and all appropriate preventive care services.
Health Plans Must Cover COVID-19 Vaccines
DMHC-licensed health plans in California must continue to cover COVID-19 vaccines, as well as RSV and flu vaccines, with no cost-sharing or prior authorization for health plan members.
In collaboration with California’s partners in the West Coast Health Alliance (WCHA), CDPH issued immunization recommendations that go beyond federal guidance, ensuring COVID-19 vaccines remain accessible and Californians are informed by evidence-based, scientific guidance.
AB 144 requires health plans to cover CDPH-recommended immunizations, including COVID-19 vaccines for children and adults, and during pregnancy. DMHC’s All Plan Letter to licensed health plans summarizes the new requirements under AB 144 and CDPH recommendations regarding COVID-19, RSV and flu vaccinations.
The DMHC’s COVID-19 fact sheet provides important information about health plan coverage for COVID-19 vaccines, tests and treatment. Visit the CDPH Public Health for All for more information on immunization requirements and resources.
CalHHS Launches Webinar Series on Federal Policy Changes
The California Health and Human Services Agency (CalHHS) recently launched a new webinar series focused on changes to federal policy and the state’s actions to protect and preserve the rights of Californians, including access to science-backed care.
The DMHC participated in a recent webinar focused on changes to state law requiring health plans to cover COVID-19, RSV and flu vaccines. The webinar features DMHC Director Mary Watanabe, CDPH Director and State Public Health Officer Dr. Erica Pan and CalHHS Secretary Kim Johnson highlighting the new state requirements.
Californians are encouraged to contact their health plan, health care provider or local pharmacy to schedule a vaccine appointment or visit MyTurn.ca.gov. You can find more information on CalHHS’s webinar series at www.chhs.ca.gov.
Health Plans Must Assist Members Impacted by Natural Disasters
Health plans are required to ensure health plan members impacted by natural disasters, including floods, earthquakes and wildfires, can continue to access appropriate and medically necessary health care services. This could include speeding up approvals for care, replacing lost prescriptions and ID cards, or quickly arranging health care services at other facilities if a hospital or doctor’s office is not available due to the disaster.
The DMHC’s natural disaster fact sheet provides more information, in English and Spanish, about what health plans are required to do to help members impacted by a natural disaster.
DMHC Reviews 2026 Health Plan Rate Filings
Federal enhanced premium tax credits (EPTCs) are currently set to expire at the end of 2025 as the federal government has failed to take action to extend this important mechanism that has made health care more affordable for millions of Americans. The impact of the loss of the EPTCs will significantly increase the cost of health insurance coverage, and it is estimated to cause many to lose their coverage because they will no longer be able to afford it.
Under state law, the DMHC reviews health plan premium rate changes for individual and small group health plans. With the uncertainty around the extension of the EPTCs this year, the DMHC coordinated closely with Covered California, the state’s health benefit exchange, and instructed health plans to submit two sets of rate filings that included one scenario if the EPTCs were extended and one scenario if the EPTCs were not.
The DMHC is watching what is happening at the federal level very closely, and will continue to work with Covered California and licensed health plans to be as flexible as possible with the goal of keeping as many affordable options as possible available for consumers. Since the federal government has not taken action to extend EPTCs, the final rates highlighted below assume EPTCs will not be extended.
The DMHC reviewed 12 individual market rate filings with an effective date of January 1, 2026. This included 11 filings from health plans offered through Covered California. For the 12 individual market rate filings, the final rate increases ranged from 7% to 20.3%, with an average increase of 10% across all health plans. The rate filings and the final rates are available on the Department’s website.
The DMHC also reviewed 12 small group market rate filings with an effective date of January 1, 2026. For the 12 small group market rate filings, the final rate increases ranged from 3% to 26.7%, with an average increase of 9.2% across all health plans. The rate filings and final rates are available on the Department’s website.
The DMHC’s rate review program includes actuaries who perform an in-depth review of proposed changes requiring health plans to demonstrate proposed rate changes are supported by data, including underlying medical costs and trends. The DMHC does not have the authority to approve or deny rate increases; however, the Department’s rate review efforts hold health plans accountable through transparency and ultimately has saved Californians hundreds of millions of dollars. To date, the DMHC’s review of health plan premium rate changes has saved members over $296 million.
Additionally, the DMHC reviewed 36 large group market filings from 22 health plans. Health plans with large group products are required to file specified information at least annually and 120 days before any change in methodology, factors or assumptions that would affect the rate paid by a large group market employer or contract holder. The DMHC reviewed the health plans’ methodology, factors and assumptions used to develop rates to determine whether they are unreasonable or not justified.
DMHC Releases 2024 Annual Report
The DMHC’s 2024 Annual Report highlights the Department’s key achievements and ongoing efforts to protect health plan members and ensure a stable health care delivery system. The report features stories about health plan members assisted by the DMHC Help Center in 2024 and includes highlights of the Department’s work to hold health plans accountable.
The DMHC now protects the health care rights of 30.2 million people in California, representing three out of every four Californians, and assisted 3.1 million health plan members through the DMHC Help Center. The Department regulates the majority of health care coverage in the state, overseeing 140 licensed health plans, including 97% of state-regulated commercial and public enrollment.
To learn more about the Department’s achievements in 2024, read the Annual Report and Infographic on the DMHC's website.
DMHC Enforcement Actions
The DMHC’s Office of Enforcement takes action against health plans that violate the law. The primary goal of an enforcement action is to protect health plan members and change the health plan’s behavior to comply with the law.
The DMHC took enforcement action against Cigna HealthCare of California, Inc. (Cigna), including $500,000 in fines, for improperly reviewing and denying health care claims payments submitted by providers as not medically necessary. The Department also found that Cigna’s medical necessity review for certain claims did not comply with the health plan’s policy for modifying or denying claims. Cigna agreed to pay the fine and implement corrective actions.
The Department took enforcement action against Blue Cross of California Partnership Plan, Inc. (Blue Cross), including $500,000 in fines, for failing to correct deficiencies identified in a medical survey, or audit, of the plan’s operations. The DMHC’s medical survey of Blue Cross found 17 deficiencies, including failing to properly handle and resolve health plan member complaints, also called grievances or appeals. A follow-up review found 11 uncorrected deficiencies which were referred to the DMHC’s Office of Enforcement. Blue Cross agreed to pay the fine and will implement corrective actions to improve its grievance and appeal process.
The DMHC took enforcement action against California Physicians’ Service (Blue Shield of California), including $300,000 in fines, for mishandling several claims payments, delaying reimbursement payments to a plan member for approved care over a five-year period. In this case, Blue Shield approved a plan member’s request for health care services from an out-of-network provider at an in-network rate. The plan then denied or mishandled payments for 36 claims connected to the delivery of these services from 2020 through 2024. The DMHC Help Center resolved the plan member’s complaints and referred the matter to the Department’s Office of Enforcement for further investigation. Blue Shield paid the fine and completed correction actions to improve claims processing.
The Department took enforcement action against Blue Cross of California (Anthem Blue Cross), including $750,000 in fines, for sending thousands of denial letters to health plan members with the wrong regulator's information related to members’ appeal rights. Health plan members have the right to request an appeal if their health plan denies, delays or changes their request for medical services. In this case, a pharmacy benefit manager (PBM) for Anthem Blue Cross sent 5,252 denial letters to members with incorrect information on the regulator the member can appeal to if they disagree with the plan’s denial. The health plan implemented correction actions to ensure accurate information is included in denial letters.
DMHC Social Media Toolkits
The DMHC works to educate and inform health plan members about their rights and health plan requirements through social media outreach. The Department has developed social media toolkits available in both English and Spanish to help raise awareness about the rights health plan members have in DMHC-regulated plans and provide information about the appeal process if a member is denied care. You can help the Department spread awareness by sharing these resources with your social media audience.
Regulations Update
Provider Directories
The purpose of this regulation is to codify and further specify the requirements of SB 137 (Hernandez, 2015) by updating and promulgating the requirements of the Uniform Provider Directory Standards and by enumerating and defining the scope of requirements for a provider directory or directories and the obligations of health plans regarding provider directories.
The DMHC submitted the rulemaking package to the Office of Administrative Law (OAL) for public notice of rulemaking action on December 31, 2024. Three public comment periods were held from January 10, 2025, through February 24, 2025; May 13, 2025, through May 28, 2025; and, July 15, 2025, through July 30, 2025. The DMHC is currently working to finalize the regulation for submission to OAL.
DMHC Help Center
The DMHC Help Center protects health plan member rights, resolves member complaints, and helps members navigate and understand their coverage ensuring access to health care services.
The DMHC encourages health plan members experiencing issues with their health plan to first file a complaint, sometimes called a grievance or appeal, with their health plan. Common issues include getting timely access to care, receiving an inappropriate charge or bill, or a denial or delay in care or treatment. If a member does not agree with their health plan's response to their complaint or the plan takes more than 30 days to address the grievance for non-urgent issues, the member can contact the DMHC Help Center. The DMHC Help Center will work with the member and health plan to resolve the issue. The health plan member can file a complaint with the DMHC Help Center at www.DMHC.ca.gov, or by calling 1-888-466-2219 for more information. If the health plan member has an urgent grievance, they do not need to file with their health plan first. A health plan member with an urgent grievance can file directly with the DMHC Help Center. If the health plan member has an urgent grievance, they do not need to file with their health plan first. A health plan member with an urgent grievance can file directly with the DMHC Help Center.
If a health plan denies, changes or delays a request for health care treatment or services, denies payment for emergency treatment or refuses to cover experimental or investigational treatment, a health plan member can apply for an Independent Medical Review (IMR) through the DMHC Help Center. Independent providers will review the case, and the health plan must follow the IMR determination. Approximately 73% of health plan members who file an IMR with the DMHC receive the requested treatment or service from their health plan. For more information about the IMR process or to apply for an IMR, please visit www.DMHC.ca.gov.
DMHC Career Opportunities
The DMHC has many exciting career opportunities available and is committed to attracting, hiring, and retaining quality employees who can help fulfill the mission of the Department to ensure health plan members have access to equitable, high-quality and affordable health care within a stable health care delivery system. More information about careers with the DMHC is located on the CalCareers website and the DMHC website under career opportunities. We encourage you to see what the DMHC has to offer!
DMHC Web Banners
You can help the DMHC raise awareness about health plan member rights and the DMHC Help Center. The Department created the following web banners to help raise awareness of the DMHC Help Center.
If your organization is interested in hosting the DMHC web banners on your website, please visit the DMHC website or email stakeholder@dmhc.ca.gov. The web banners are also available in additional languages, including Spanish.
About DMHC
The mission of the DMHC is to ensure health plan members have access to equitable, high-quality, timely, and affordable health care within a stable health care delivery system. The DMHC accomplishes this important mission by regulating health plans, enforcing California’s strong consumer protection laws and assisting health plan members. For more information visit www.DMHC.ca.gov.