DPSS ePolicy

To convert existing policy to the new webpage - No content changes.

Revision of existing policy and/or form(s)

What changed?

1. Clarified procedures for submitting a Managed Care Ombudsman online form.
2. Included Managed Care Ombudsman Urgent Services - Frequently Asked Questions (FAQs).

The purpose of this policy release is to inform staff of the online form that is available on the Department of Health Care Services (DHCS) website for urgent Medi-Cal Managed Care Ombudsman requests.

The Office of the Ombudsman assists beneficiaries in resolving urgent managed care enrollment issues.  To better assist beneficiaries, DHCS created an online submittal process.  All standard managed care changes must continue to be processed through Health Care Options at 1-800-430-4263.

The online form was developed by the State to:

• Increase efficiency and response times to urgent Medi-Cal Managed Care Ombudsman requests.
  
• Ensure a secure transmission for Personal Health Information.
  
• Allow processing of these requests with minimal required information.
  

Authorized usage of the online form is restricted to the Medi-Cal Eligibility Data System (MEDS) Liaison or designated backup when requesting the following expedited services:

• Plan Changes;
• Plan Enrollments;
• Plan Disenrollments; and
• Removal of 59 Holds.
  

The requirements listed below must be present when submitting urgent requests to correct managed care health plan data: 

• Complete online form with all current data displayed on MEDS (e.g., residential address and county code);
  
• MEDS record must display active in that month; and
  
• Beneficiary must not have used any medical services within the current month (e.g., prescriptions, doctor visits).
  

Kaiser Permanente Health Plan (Kaiser)

Individuals requesting to be enrolled in Kaiser must meet one of the additional requirements below: 

• Was a Kaiser member within the last 12 months;
  
• Has an immediate family member who is currently enrolled with Kaiser (family linkage), includes being a Kaiser member’s:
  • Spouse or domestic partner;
  • Dependent child under 26 years of age;
  • Stepchild under 26 years of age;
  • Disabled dependent over 21 years of age;
  • Parent or stepparent of a beneficiary under 26 years of age; or
  • Grandparent, guardian, foster parent or other relative of a beneficiary under 26 years of age with appropriate documentation of familial relationship.
• Are currently a foster child, or former foster child; or
• Have both Medicare and Medi-Cal (dual eligible).
  

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