Congratulations! You have health coverage. This is a big step toward your enhanced health and wellbeing. Now that you are covered, it’s important to understand your plan’s benefits, know your rights as a consumer, learn what actions to take if your coverage changes or a health care service has been denied. Whether you need to file a complaint, learn more about health conditions, or discover your new rights, let us point you in the right direction towards helpful resources and information.
What Is Covered Now That I'm Insured?
California law states that health plans must provide many basic health care services and benefits when they are medically necessary. A definition of what is medically necessary can be found in your health plan contract, i.e., Evidence of Coverage. Below you’ll find which basic services and benefits are covered by a health plan, and which are not.
Basic Health Care Services
Health plans must cover basic services, which include, doctor, hospital services, inpatient services (when you have to stay overnight in the hospital) and outpatient services, such as minor surgery in a surgery center. Other basic services include:
- Laboratory tests to diagnose problems. These include blood tests, STD (sexually transmitted diseases) tests, pregnancy tests, and some cancer screening tests.
- Diagnostic services, like x-rays and mammograms
- Preventive and routine care, like vaccinations and checkups
- Mental health care for some serious conditions
- Emergency and urgent care—even if you are outside your health plan's service area
- Rehabilitation therapy, such as physical, occupational and speech therapy
- Some home health or nursing home care after a hospital stay
- Pregnancy care
Additional Benefits that Health Plans Must Cover
- Standing referrals for patients with AIDS (This means that you do not have to get a referral and approval each time you see an AIDS specialist.)
- Diabetes services and supplies
- Routine costs of clinical trials for cancer treatment
- Prosthetic devices or reconstructive surgery after a mastectomy (removal of a breast)
- Prosthetic devices to restore a method of speaking for a patient after a laryngectomy (removal of the vocal cords). This does not include electronic voice-producing machines.
- Reconstructive surgery to correct or repair birth defects, developmental abnormalities (something that is not normal in the way a child grows), trauma or injury, infection, tumors, or disease. The purpose of the surgery must be to improve function (the way a part of the body works) or to create as normal an appearance as possible.
- Services related to diagnosis, treatment, and management of osteoporosis (weak bones), including bone mass measurement and other FDA-approved tests and medications
- General anesthesia for dental procedures in certain cases
Services That Are Not Required
Most medical health plans do not cover dental care, eyeglasses, and hearing aids. Only some plans cover durable medical equipment, such as wheelchairs and oxygen. What is covered differs from plan to plan.
Diabetes Services and Supplies
If you have diabetes (insulin-using diabetes, non-insulin-using diabetes, or gestational diabetes), your health plan must cover the following, even if you can get them without a prescription:
- Blood glucose monitors and testing strips
- Blood glucose monitors designed for people with vision problems
- Insulin pumps and supplies needed to use the pump, in certain cases
- Urine strips to test for ketones
- Lancets and lancet puncture devices
- Pen delivery systems for taking insulin, in certain cases
- Podiatric devices to prevent or treat foot problems related to diabetes
- Insulin syringes
- Visual aids, except eyeglasses, to help people with vision problems take the proper dose of insulin
- Out-patient training, education, and medical nutrition therapy to help a person with diabetes use the covered equipment, supplies, and medications properly
If your health plan covers prescription drugs, it must cover the following diabetes drugs:
- Other prescription drugs to treat diabetes
Find Information About Your Health Plans and Benefits
- Go to your health plan's website for information about your benefits.
- Websites of licensed health plans and other insurance agencies can give you information on costs and benefits.
- Contact the DMHC Help Center toll free at 888-466-2219 for help with your health plan.
- Receive your Free How to Use Your Health Plan guide and other educational materials from California's Office of the Patient Advocate (OPA).
- Visit OPA's Health Care Quality Report Card to find out how your health plan measures up
View All Health Plans
Health Care Quality Report Card
Keep Your Health Coverage (COBRA)
Individual Conversion Plans (HIPAA)
File a Complaint
Health plan members, also known as enrollees should file a complaint (also known as an appeal or grievance) if you have a problem with your health plan. To do so, first contact your health plan to file a complaint. You can file a complaint with your health plan over the phone or in writing. You may also be able to file a complaint on your health plan's website.
If your health problem is urgent, if you already filed a complaint with your health plan and are not satisfied with the decision, or it has been more than 30 days since you filed a complaint with your health plan you may submit an Independent Medical Review Application/Complaint Form with the DMHC. If you need assistance you may contact the Help Center at 1-888-466-2219.
Enrollees can file a Consumer Complaint with the DMHC for complaint issues such as balance billing, billing for services that your health plan states is not a covered benefit, if you have a dispute regarding the amount paid on a claim, a copay dispute, cancellation of your coverage or if you have a complaint about the provider’s attitude.
Enrollees can also apply for an Independent Medical Review (IMR) with the DMHC when a health care service or treatment has been denied, modified or delayed. An IMR is a review of your case by independent doctors who are not part of your health plan. You have a good chance of receiving the service or treatment you need by requesting an IMR. If the IMR is decided in your favor your plan must authorize the service or treatment you requested. IMR’s are free to enrollees.
For your convenience, both of these complaint types can be submitted to the DMHC on one Independent Medical Review Application/Complaint Form.
Submit and Independent Medical Review/Complaint
Find Information About Health and Diseases
- Start with a website or phone number listed on this website.
- There is a lot of useful health information on the Internet, but be sure to talk to your doctor before you make a decision about a treatment.
- Compare information on more than one website.
- Look for information based on research, not personal opinions.
- Look for information that is up-to-date.
- For more information on evaluating health information sites, visit Medline Plus. This site is sponsored by the federal government, and the information is based on solid medical research.
You Have New Rights Under Health Care Reform
To buy individual coverage for children under age 19 who have pre-existing conditions.
To stay on a parent’s health plan until age 26.
To get many preventive care services without a co-pay, co-insurance or deductible.
To have no lifetime dollar limits on basic health care services.
To purchase health insurance or determine Medi-Cal eligibility through the California Health Benefit Exchange, Covered California.
Health Care Reform – The Affordable Care Act
- If you are told that you cannot get the care you need, ask for the reason in writing.
- Talk to your doctor about your problem.
- When you make a phone call, take notes. Write down the date of your call, the name of the person you talk to, and what the person says.
- Act soon. If you wait longer than 6 months, you may lose the right to file a complaint, ask for an IMR, or take other action against your health plan.
- All phone numbers that start with 1-800, 1-866, 1-877 or 1-888 are toll-free. There is no cost to call them.
- It is a good idea to make a list of questions before you call.
- You may want to have someone with you for extra support and to help you think of questions.
- If you are deaf or hard of hearing, call the California Relay Service at 7-1-1. They help people with telephones and TTYs (Telecommunications Device for the Deaf) talk to each other.
- If you have a speech disability, call 1-800-854-7784 to use the Speech-to-Speech Relay services.