Fall 2026
Message from the Director
Last month, the Department of Managed Health Care (DMHC) released the 2025 Annual Report – Special Edition, celebrating our 25th Anniversary. The report also recognizes the 50th anniversary of the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act) and the 15th anniversary of the Affordable Care Act (ACA).
As we celebrate 25 years of protecting health care rights, the DMHC remains committed to working towards achieving the Department’s mission of ensuring health plan members have access to equitable, high-quality, timely and affordable health care within a stable health care delivery system. I encourage you to read about the history of health care in California and DMHC’s achievements in the 2025 Annual Report – Special Edition and the Department’s five-year strategic plan outlining the priorities and organizational values that will guide our work in the coming years.
Additionally, with the start of flu season, I want to remind health plan members that DMHC-licensed plans are required to continue to cover COVID-19 vaccines, as well as respiratory syncytial virus (RSV) and flu vaccines, with no cost-sharing or prior authorization. The Department’s Know Your Health Care Rights on COVID-19 fact sheet, available in Spanish and English, provides important information about health plan coverage for COVID-19 vaccines, tests and treatment.
The DMHC Help Center is an important resource available to assist health plan members having trouble accessing the health care services they need. The first step is to file a complaint, also called a grievance or appeal, with your health plan. If you do not agree with your health plan’s response or your health plan takes more than 30 days to respond, the next step is to contact the DMHC Help Center for assistance at ww.DMHC.ca.gov or by calling 1-888-466-2219 (TDD: 1-877-688-9891).
As always, thank you for your support and continued interest in the DMHC.
Sincerely,
Mary Watanabe
Director
DMHC Releases 2025 Annual Report – Special Edition
The DMHC’s 2025 Annual Report – Special Edition recognizes the Department’s 25th anniversary, along with the 50th anniversary of the Knox-Keene Act and the 15th anniversary of the Affordable Care Act (ACA). These important milestones demonstrate the ongoing progress towards a health care system that is more accessible, equitable and accountable.
This special edition report highlights the DMHC’s key achievements over the past 25 years and includes expanded sections on the Knox-Keene Act and the ACA. The report also highlights the Department’s work to hold health plans accountable and features stories about health plan members assisted by the DMHC Help Center in 2025.
The DMHC was created 25 years ago as the nation’s first agency solely dedicated to overseeing managed care health plans. The Department protects the health care rights of more than 30 million people in California and regulates the majority of health care coverage in the state, including 96% of state-regulated commercial and public enrollment. The DMHC Help Center has assisted 3.2 million health plan members with resolving complaints against their health plans including coverage disputes, billing issues and access to health care services.
The DMHC Recognized for Outstanding Leadership by the Asian Pacific State Employee Association (APSEA)
The DMHC was recently honored with the Catalyst Award for Outstanding Leadership by the Asian Pacific State Employees Association (APSEA). DMHC Chief Deputy Director Dan Southard accepted the award on behalf of the Department at the APSEA 2026 State of Belonging Symposium. The Catalyst Award recognized the DMHC for leadership excellence, inspiring others to excel, and demonstrating a commitment to learning, collaboration, and professional growth.
DMHC Chief Deputy Director Dan Southard accepting the Catalyst Award from California Racial Equity Commissioner Amy Tong
DMHC Chief Deputy Director Dan Southard with colleagues from the DMHC’s Diversity, Equity, Inclusion and Belonging (DEIB) office and Disability Advisory Committee (DAC)
The State of Belonging Symposium brought together California state employees, leaders and policymakers to discuss belonging, equity, inclusion and strategies to strengthen the public workforce. DMHC Director Mary Watanabe joined Deputy Treasurer Stephanie Tom, Assemblymember Stephanie Nguyen, and California Department of Public Health (CDPH) Director Dr. Erica Pan for a panel discussion on health equity, policy, leadership and advancing equitable outcomes for California communities.
DMHC Director Mary Watanabe (center) with Deputy Treasurer Stephanie Tom (left) and California Department of Public Health Director Dr. Erica Pan (right)
APSEA, founded in 1975, advocates for members’ interests and works with the community to promote career opportunities, cultural awareness, and supports young adults in career advancement by sponsoring scholarships through the APSEA Foundation. APSEA also hosts training workshops, provides networking opportunities, and supports other Asian Pacific Islanders community-based organizations.
Vaccine Access and Availability
With flu season underway, the Department wants health plan members to be aware that DMHC-licensed plans must cover immunizations, including COVID-19, flu and RSV vaccinations, with no cost sharing or prior authorization.
In 2025, Governor Newsom signed Assembly Bill (AB) 144, requiring health plans to cover preventive care, including immunizations, recommended by the federal government as of January 1, 2025, or recommended by the California Department of Public Health (CDPH). In collaboration with California’s partners in the West Coast Health Alliance (WCHA), CDPH issued vaccine recommendations based on evidence-based, scientific guidance from trusted organizations such as the American Academy of Pediatrics, the American College of Obstetrics and Gynecologists, and the American Academy of Family Physicians.
The DMHC’s All Plan Letter to licensed health plans summarizes requirements under AB 144 and CDPH recommendations regarding vaccinations.
Visit the CDPH Public Health for All website for more information and resources on vaccine recommendations. The Department’s Know Your Health Care Rights on COVID-19 fact sheet also provides important information about health plan coverage for COVID-19 vaccines, tests and treatment.
Health plan members having trouble accessing the health care services they need, including vaccinations, should contact their health plan. If the member is unsatisfied 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.
Health Plans Must Assist Members Impacted by Disasters
The DMHC is reminding health plan members of the assistance health plans are required to provide during a state of emergency caused by a disaster.
Health plans are required to ensure health plan members impacted by disasters, including wildfires, floods and earthquakes, continue to have appropriate access to 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 Department’s Know Your Health Care Rights on Accessing Health Care During Disasters fact sheet, available in English and Spanish, provides more information on health plan requirements during disasters.
DMHC Reviews 2027 Health Plan Rate Filings
Under state law, proposed premium rate changes for individual and small group health plans must be filed with the DMHC. Actuaries perform an in-depth review of these proposed changes and ask health plans to demonstrate that 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 have saved Californians hundreds of millions of dollars by negotiating lower premium increases when rate changes aren’t supported. To date, the DMHC’s review of premium rates has saved members over $296 million.
The DMHC reviewed 13 individual market rate filings with an effective date of January 1, 2027. This included 12 filings from health plans offered through Covered California, including one new entrant, CalOptima. For the 13 individual market rate filings, the final rate increases ranged from 3% to 20.5%, with an average increase of 10.3% across all health plans.
The DMHC also reviewed 12 small group market rate filings with an effective date of January 1, 2027. For the 12 small group market rate filings, the final rate increases ranged from 1.2% to 22.6%, with an average increase of 11% across all health plans.
The 2027 rate filings and the final rates are available on the Department’s website at www.RateReview.dmhc.ca.gov.
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 fined California Physicians’ Service (Blue Shield of California) $800,000 for grievance system failures that delayed DMHC’s resolution of member complaints. The plan repeatedly submitted late or incomplete responses to DMHC inquiries, impacting 58 member complaints, also called grievances or appeals.
The DMHC fined Blue Shield of California $300,000 for wrongfully denying payments for newborn care in two separate cases. In addition, the Department found the plan did not properly address and resolve member complaints related to the payment denials.
Regulations Update
Health Equity and Quality Regulation
The purpose of this regulation is to codify the requirements under AB 133 (Committee on Budget, 2021) and specify the health equity and quality (HEQ) measures, reporting requirements and processes health plans must use to submit HEQ data to the DMHC. The Department submitted the rulemaking package to the Office of Administrative Law for public notice of rulemaking action on July 14, 2026. The initial public comment period was open from July 24, 2026, through September 8, 2026. The DMHC is in the process of reviewing the public comments received and anticipates a second public comment period later this year.
Prescription Drug Reporting Process for Health Care Service Plans
The purpose of this regulation is to codify the reporting form and processes health plans must use when reporting annual prescription drug cost information to the DMHC. The Department submitted the rulemaking package to the Office of Administrative Law for public notice of rulemaking action on March 3, 2026. The initial public comment period was open from March 13, 2026, through April 27, 2026. The second public comment period was open from September 2, 2026, through September 17, 2026. The DMHC is reviewing the public comments received.
DMHC Social Media Toolkits
The DMHC educates 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 health plan member rights and provide information about the appeal process if a member is denied care. Follow the DMHC on Facebook, X, LinkedIn and YouTube and spread awareness by sharing these resources with your social media audience.
DMHC Help Center
The DMHC Help Center assists health plan members with navigating and understanding their health care rights, coverage and benefits, and helps resolve member complaints against health plans.
The DMHC encourages 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 for 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 their 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 issue, they do not need to file with their health plan first. A health plan member with an urgent issue 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, the health plan member can apply for an Independent Medical Review (IMR) through the DMHC Help Center. Independent providers will review the case, and the plan must follow the IMR determination. 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 Department’s mission. More information about careers with the DMHC can be found on the CalCareers website and the DMHC website under Career Opportunities. Follow us on LinkedIn for more career opportunities and updates. We encourage you to see what the DMHC has to offer!
DMHC Web Banners
You can help the DMHC raise awareness about health plan members’ 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.