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Californians are fortunate to have the strongest patients' rights laws in the nation. The DMHC is here to make sure these laws are followed and that all health plan members get the right care at the right time. Find out how in this section.
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Organization Overview
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 Financial Solvency Standards Board
Leads the Department's efforts to ensure better accountability and financial stability throughout the managed health care system.
Deputy Director for Communications and Planning
Ensures integrated and consistent communications throughout the Department and with external stakeholders. These external stakeholders include, but are not limited to, enrollees/patients, health plans, providers, advocacy groups, legislators, as well as federal, state, and county agencies.
Deputy Director for Plan and Provider Relations
Manages the lines of communication within the Department and with health plans, hospitals, physicians, nurses, and other providers to assure early intervention for the resolution of patient/enrollee issues. This deputy director guides the Department towards developing partnerships that share responsibilities with everyone in managed health care.
The Help Center assists consumers with health care issues and ensures that managed health care patients receive the medical care and services to which they are entitled.
Division of Consumer Assistance
The Division receives, reviews, and processes all incoming correspondence and telephone calls. The Call Center responds to thousands of calls from consumers requesting general information or assistance. The Call Center is available from 7 a.m. to 7 p.m. on weekdays, and is not staffed over the weekend, although it does accept urgent calls. The Call Center provides services for Spanish speaking consumers, in addition to telephonic interpretation services in over 100 other languages and a TDD device for the hearing impaired. The Initial Review Branch handles all incoming written correspondence including applications for Independent Medical Reviews and Complaint forms. Both units are responsible for educating the consumer regarding non-jurisdictional issues, medical group or health plan closures, community resource referrals, health plan contact information as well as mailing forms, applications and informational brochures and handouts.
Division of Complaint Management and Clinical Review
The Division educates consumers regarding their health care rights and responsibilities and responds to their health care concerns. Employees make every effort to expeditiously resolve issues with health care plans and providers at the lowest possible level. Complaints are typically reviewed and resolved within the 30-day mandate. The Division ensures that consumers receive an Independent Medical Review when dissatisfied with a health care service plan's decision concerning: (1) services denied due to a plan's finding that the requested care is investigational or experimental; (2) denied, delayed or modified health care services following a plan's finding that the service is not medically necessary; or (3) denials of enrollee reimbursement claims out-of-plan medical services obtained for urgent or emergency care. Clinical personnel are available to provide the necessary knowledge and guidance to ensure that the best interests of the consumer are served.
Division of Legal Affairs and Policy Development
The Division reviews consumer complaints and determines whether health plans are in compliance with applicable laws. The Division's findings are then communicated to the consumer, health plan, or provider. Systemic issues are referred to the Office of Enforcement, Office of Health Plan Oversight, Division of Plan Surveys or to the Division of Licensing for further action.
The Division is responsible for the development of regulations regarding consumer grievances in addition to the analysis and approval of the health plans' grievance processes; and the development of office policies regarding complaints and independent medical reviews.
Division of Management Support Services
The Division is comprised of three branches: Business Services, Technical Support and Compliance Oversight. Business Services supports the office regarding personnel issues, training, equipment and supplies, management reports and other typical administrative duties. Technical Support is responsible for the development, implementation, training and support of all Help Center Database applications. Staff prepares reports and provides data regarding information available via the Help Center's Database. Compliance Oversight is responsible for ensuring that internal business processes are accurate, timely and adhere to office standards; that health plans comply with statutory requirements; and perform the review of health plan filings regarding the Grievance Process, Cultural Linguistics and Quarterly Reports.
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. Employees also offer advice and assistance to health plans in these areas and assist other areas of the Department in evaluating issues relating to health care delivery and managed care operations.
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.
Provides a variety of administrative support services to the Department. Including:
Accounting
Processes vendor payments, travel expense claims, revolving fund checks, revenue receipts, and payroll warrant releases. Maintains the accounting system and prepares the Department’s year-end financial statements.
Budget Office
Prepares the annual Governor's Budget, revenue and expenditure projections, office allotments and the annual assessments. Reviews budget change proposals (BCP) and provides office consultation and training.
Contracts Office
Provides Department contract services including Requests for Proposals, Invitations for Bid, Standard Agreements, Inter-Agency Agreements, and office consultation and training.
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 Department personnel and payroll services including: recruitment, examinations, classification and pay, transactions, position control, labor relations, benefits, worker’s compensation and supervisor consultations.
Strategic Planning and Management Support
Provides administrative and employee support services including: administrative policy and procedures oversight, strategic planning, performance measurement, employee training and employee wellness programs.
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.
Division of 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.
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.
The Office of Provider Oversight is responsible for monitoring the financial stability of Risk Bearing Organizations through the analyses of financial data and corrective action plans. In addition, this Office is responsible for investigating and providing meaningful and appropriate regulatory resolutions to claim payment disputes through identifying unfair payment practices and unfair billing patterns.
