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Appeals Process
What types of decisions can
I appeal?
You can file an appeal if you
believe an eligibility, start date, or
disenrollment decision was made
in violation of the program rules.
To “file an appeal” means to ask
the program to reconsider a
decision it has made about your
child’s eligibility.
The appeals process includes
three separate levels of review:
First level appeal
This appeal
must be filed within 60 days from
the date of the decision letter.
This process requires a written
appeal from the applicant or
authorized representative. The
disagreement must be about
eligibility (denial), disenrollment,
or the start date of coverage
decision of the program.
Healthy Families will review and
respond to your appeal in writing
within 30 days. Send your first
level appeal to:
Healthy Families
Attn: Appeals Department
PO Box 138005
Sacramento, CA 95813-8005
The postmark on the envelope or
the date a fax is sent will be
considered the filing date. Appeals
filed after the deadline will be
treated as program review
requests.
To file an appeal complete the
form included with the decision
letter.
Whether you use our form or
write your own letter, you must
do the following when you file
your request for a first level
appeal:
- Send us a copy of the written
notice or tell us which decision
you disagree with; and
- Explain why you think our
decision is wrong. If you think
we made a mistake about the
facts of your case, please tell
us. If you think we violated a
program rule, such as a law or
regulation or other written
policy, please tell us; and
- Tell us how you want this
appeal to be resolved (what
you want us to do); and
- Give us any other information
you want us to consider; and
- Be sure to include your Family
Member Number on each
paper you send to Healthy
Families.
Second level appeal
If you
disagree with the Healthy
Families decision of the first level
appeal, you can file a second level
appeal with the Executive
Director of the Managed Risk
Medical Insurance Board
(MRMIB), the agency that
administers the program. File
your second level appeal within
30 days from the date of the first
appeal decision letter. Second
level appeals are written appeals
from an applicant or authorized
representative regarding the
decision on the first level appeal.
Mail your second level appeal to:
Executive Director
Managed Risk Medical
Insurance Board (MRMIB)
PO Box 2769
Sacramento, CA 95812-2769
You may also fax your appeal to
1-916-327-6560.
Your appeal will be reviewed and a
response will be sent in writing.
Third level administrative
hearing
If you disagree with the
decision of the MRMIB Executive
Director, you have the right to
request an administrative hearing.
You will have 30 days from the
date of the MRMIB Executive Director’s decision letter to
request an administrative hearing.
The notice from MRMIB will
contain all the information that
you will need to file a request for
an administrative hearing. You
will be notified in writing of the
date, time and place of the
administrative hearing.
Program Reviews
In addition to
the above appeals process, the
program has discretion to provide“program reviews,” which are
informal reviews of issues, such
as new income documentation,
billing questions, account
balances and other complaints and
questions that are not subject to a
formal appeal or do not meet the
appeal deadlines.
Can I request continued
coverage for my child until
a decision on my appeal is
made?
If you appeal the disenrollment
decision before the disenrollment
date, your child will receive
Continued Enrollment (CE).
CE means that your child will
continue to be enrolled in Healthy
Families until a decision is made
in your first level appeal. Healthy
Families must receive your
written request for CE before the
end of the month in which the
disenrollment will occur. Healthy Families cannot review appeals
over the phone.
You can use the Continued
Enrollment Form that is included
with the disenrollment notice to
file your appeal or write us a
letter. You can also download a
Continued Enrollment Form.
Mail your appeal to:
Healthy Families
Attn: Review Unit
P.O. Box 138005
Sacramento, CA 95813-8005
You can also fax your appeal to
1-866-848-4974.
Can I appeal a health,
dental or vision plan
decision?
If you are unhappy with
something your health, dental or
vision plan did (or did not do),
you must resolve your problems
with the plan according to its
policies and procedures. Your
child will not be dropped from the
plan or suffer a penalty if you do
this. The procedures are listed in
the Evidence of Coverage (EOC)
or Certificate of Insurance (COI)
Booklet. You will receive these
booklets from your child’s health,
dental and vision plans. You may
review these documents prior to
selecting an insurance plan. Call the plans directly and ask for a
copy.
If you are unable to resolve your
dispute with the plans, and your
insurance plan is licensed by the
state, contact the state government
agency, Department of Managed
Health Care or Department of
Insurance which licenses the
insurance plan. The number is in
the EOC or COI Booklet.
Note: Enrollment in many health
insurance plans requires that you
waive your right to a jury trial
and agree to have some or all
claims or disagreements decided
by binding arbitration. This
requirement may include
malpractice issues. See which plans require binding arbitration.
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