Sara Jasper, JD
Staff Attorney
The Therapist
November/December 2016

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California’s Medicaid system, known as Medi-Cal, is the largest of its kind in the nation. As of August 2015, 12.65 million Californians are covered by Medi-Cal. The large number of Medi-Cal beneficiaries has put a considerable strain on a system which providers and beneficiaries often find difficult to navigate. This article offers information about the resources available to providers who work within the system and the beneficiaries who rely on the system for their care.

The first stop for a provider assisting a Medi- Cal beneficiary with services would be with the Medi-Cal Mental Health Ombudsman and/or the Medi-Cal Managed Care Ombudsman.

Medi-Cal Mental Health Ombudsman
Established by the Department of Health Care Services in April of 1999, the Department of Mental Health Managed Care Ombudsman Service was designed to help beneficiaries, their advocates, and service providers navigate Medi-Cal’s mental health system.

The Ombudsman’s office assists beneficiaries, their advocates, and providers with the following:

• Navigating through the Medi-Cal Mental Health Managed Care System
• Finding information in order to access appropriate mental health services
• Connecting beneficiaries with the right person/department to resolve a problem
• Addressing concerns or grievances about services
• Connecting beneficiaries with local resources in their counties Connecting beneficiaries with consumers’ rights services

The Mental Health Ombudsman’s office can be reached by calling 1-800-896-4042. With the exception of state holidays, this toll-free information line is available Monday through Friday from 8 a.m. to 5 p.m. The Mental Health Ombudsman’s office can also be reached via email at MHOmbudsman@ dhcs.ca.gov. With the exception of state holidays, the office responds to inquiries Monday through Friday from 8 a.m. to 5 p.m. The Mental Health Ombudsman’s Teletypewriter or TTY system can be reached at 1-800-896-2512.

Medi-Cal Managed Care Ombudsman
The Medi-Cal Managed Care Ombudsman is the result of Title 22 California Code of Regulations Section 53893. The Ombudsman serves as an objective resource to resolve issues between Medi-Cal managed care beneficiaries , their providers and Medi-Cal Managed Care Plans. Duties of the Ombudsman include:

• Assisting beneficiaries in obtaining health care through Medi-Cal managed care plans
• Removing inappropriate barriers to accessing care, such as urgent enrollment and disenrollment problems
• Educating and informing managed care plans
• Educating beneficiaries on how to use the managed care system effectively, including assisting members in understanding and exercising their rights to file a grievance, an appeal or to request a State hearing.
• Offering information and referrals to other programs.
• Identifying ways to improve the effectiveness of the Medi-Cal managed care program

The Ombudsman’s phone system was upgraded and is now a full call-center system that allows for 80 lines to be in use, has self-service menu options that include an option for mental health service questions, a queued callback feature, and real-time monitoring of calls for beneficiaries. The queued callback feature allows beneficiaries to request a call back without losing their place in line. According to the DHCS, this feature has increased customer satisfaction and retention and decreased caller abandonment.

During a Stakeholder Advisory Committee meeting held on August 11, 2016, the DHCS staff reported that the Ombudsman had received a total of 123,044 calls between January and June. The Ombudsman handled 69,199 calls. 29,327 calls were handled through the self-service menu. 24, 518 calls were abandoned. Of the 29,327 self-service calls, 764 of those calls were related to mental health issues and services. The ombudsman responded to 4,861 emails and processed 22,199 requests from county offices. On average, the Ombudsman’s 16 permanent and five temporary DHCS staff process 600 calls and emails each month.

The Medi-Cal Managed Care Ombudsman can be reached by calling 1-888-452-8609 Monday through Friday from 8 a.m. to 5 p.m., with the exception of State holidays. The Medi-Cal Managed Care Ombudsman’s website can be accessed by visiting http://www. dhcs.ca.gov/services/medi-cal.

Outside Resources Recommended by the Mental Health Ombudsman
Providers may find the following information helpful when searching for client resources and services outside of the Medi-Cal system.

The National Suicide Prevention Lifeline:
Clients in crisis may call the hotline, 1-800- 273-8255, at any time, on any day of the week to be connected with a skilled, trained counselor to receive help.

The California Department of Aging, Long-term Care Ombudsman Program:
The primary responsibility of the program is to investigate and resolve complaints made by, or on behalf of, individual residents in long-term care facilities. The State crisis line, 1-800- 231-4024, takes calls and refers complaints 24 hours a day, 7 days a week.

The California Department of Developmental Services:
Through this agency, the State provides services and support to individuals with developmental disabilities. These disabilities include intellectual disability, cerebral palsy, epilepsy, autism and related conditions. Services are provided through state-operated developmental centers and community facilities, and contracts with 21 non-profit regional centers. The regional centers serve as a local resource to help find and access the services and supports available to individuals with developmental disabilities and their families. More information about services and who is eligible to receive services is available by calling 916-654-1690. The TTY number is 916-654-2054.

The California Department of Social Services Ombudsman for Foster Care:
This agency offers information on the rights of children and youth who are placed in foster care. The program provides advocacy services to foster children and youth and those who reach out on their behalf. The Department’s toll-free number is 1-877-846-1602. The Department can also be contacted via email at fosteryouthhelp@dss.ca.gov. Complaints may be filed online at http://www.dss.cahwnet.gov/ ombudsman/complaints.

Disability Rights California:
This protection and advocacy organization offers information on disability rights, resources for persons with disabilities in California, and list of advocacy contacts throughout California. Those in need of legal assistance should call 1-800-776-5746. The TTY number is 1-800-719-5798. For help with non-legal issues, citizens in Northern California may call 916-504-5800. Southern California residents may reach the DRA at 213-213-8000.

The California Office of Patients’ Rights (COPR):
The COPR is a Unit of Disability Rights California and is contracted with the Department of Health Care Services to provide patients’ rights investigative and advocacy services as required by California Welfare & Institutions Code Section 5370.2. The COPR’s Patients’ Rights Advocacy Directory can be found at http://www. disabilityrightsca.org/Opr/pra_directory.pdf.

County Behavioral Health Directors Association of California:
The Association offers a Directory of California County Mental Health Departments, including Mental Health Plan Access telephone numbers and 24-hour Crisis Lines. The directory can be found at http://www.dhcs.ca.gov/services/MH/ Documents/CMHDA.pdf.

The National Long-Term Care Ombudsman Resource Center:
Long-term care ombudsmen are advocates for residents of nursing homes, board and care homes and assisted living facilities. Ombudsmen provide information about how to find a facility and what to do to get quality care. The Center’s resources and services can be accessed by visiting http:// ltcombudsman.org.

U.S. Department of Justice, Americans with Disabilities Act:
Information about the Americans with Disabilities Act (ADA) as it applies to individuals with disabilities, as well as businesses, state and local governments, or others inquiring about general or specific ADA requirements, laws, regulations, reports and publications regarding the ADA, can be found at https://www.ada.gov.

The California Department of Rehabilitation (DOR):
The DOR is an employment and independent living resource for people with disabilities. Information about the Department’s services and resources for providers and their disabled clients is available at http://www.rehab.cahwnet.gov.

Medi-Cal Beneficiary and Provider Helpline
Providers, who have a question, need assistance or want to report a problem, may also call 1-800-541-5555 to reach the Medi-Cal Provider Service Center.

Providers should have the following information available when calling:

• The Medi-Cal beneficiary’s ID number
• The last four digits of the Medi-Cal beneficiary’s Social Security Number
• The Medi-Cal beneficiary’s date of birth

The Service Center can assist with the following issues:

• Payment issues: Providers who are not receiving payment for services billed to the Medi-Cal program may need to change the mailing address on file with the DHCS. The DHCS must be notified within 35 days of the date of a change to providers’ businesses and/or pay-to address. A copy of the Supplemental Change form (DHCS 6209) can be found at www.dhcs.ca.gov under the Providers and Partners link. Submit the completed forms to the address listed on the forms. Once the changes are made, the Provider Enrollment Division can instruct member on how to submit a request to have payments re-issued.
• Medi-Cal beneficiary and provider applications
• Medi-Cal Services
• Finding a health care provider
• Filing a complaint

Providers who would like to report an access-to-care issue may email the DHCS at https://apps.dhcs.ca.gov/AutoForm2/Page/ SecureCode.aspx.

Other Resources for Providers
Provider Overpayments
1-916-650-0490
P.O. Box 997425, MS 4720
Sacramento, CA 95899-7425

Provider Enrollment Division
1-916-323-1945
P.O. Box 997412, MS 4704
Sacramento, CA 95899-7412

Automated Phone Center
1-800-766-4346

Small Provider Billing Unit
1-916-636-1275

Medi-Cal Rates
1-916-552-9600
P.O. Box 997417, MS 4612
Sacramento, CA 95899-7417

As this article demonstrates, there are a variety of resources available to Medi-Cal beneficiaries, their advocates and service providers. Those who work within and rely upon the Medi-Cal system are encouraged to use these resources to ask questions, file complaints, and receive assistance with service issues.

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Sara Jasper, JD, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.

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This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.