The Ombuds Office at Covered California is an objective, independent resource that helps consumers with problems or issues they have not been able to resolve after calling the service center, filing a complaint or filing an appeal.
If you have not tried to solve your problem through those methods, see the Helpful Resources section below for information on how to do so.
If we cannot help you, we will explain why we could not and will try to refer you to another resource.
When should I contact the Ombuds Office?
Contact the Ombuds Office for help if it has been more than 30 days since you submitted your complaint and you have not received an update, or you sought assistance from the service center but were still unable to resolve your issue.
You should also contact the Ombuds Office if you:
- Want to learn about your appeal rights.
- Want information about Covered California policies and procedures.
- Need guidance for using our independent contractor, Health Consumer Alliance (HCA), which provides free legal advice and representation, including assistance filing a complaint or grievance and arranging a hearing.
- For more information on the services HCA provides, please see the Helpful Resources section below. Or, call HCA at (888) 804-3536.
Please download and complete our contact form and return it by email, fax or by mail.
You may also contact us directly:
- Email: firstname.lastname@example.org
- Call us toll free at (888) 726-0840 from 8 a.m. to 5 p.m., Monday through Friday (excluding state-observed holidays). Assistance is available in multiple languages.
- Fax: (888) 726-0841
When contacting us, please include a summary of your problem, your Covered California case number (if you have one), a phone number and the best time for us to reach you.
We will do our best to help resolve your issue as quickly as possible (within 30 days for most cases). How long it takes us to research your case depends on how complicated your issue is. We will keep in touch with you along the way.
To file a complaint for issues such as problems with the website, Covered California staff or Certified Enrollment Counselors, download and complete the Covered California Complaint Form.
How to file an appeal (request a State Fair Hearing to appeal a Covered California eligibility determination)
Your eligibility notice explains the programs you are eligible for and the programs for which you do not qualify. In the event that one of the following situations applies to you, you have the option to file an appeal. You may file an appeal by downloading and filling out the Request for a State Fair Hearing to Appeal a Covered California Eligibility Determination form.
- Depending on your eligibility results, you may appeal any of the following:
- You were denied enrollment into a health plan offered by Covered California.
- The amount of premium assistance (tax credits that help pay your monthly premium) is not correct.
- The level of cost-sharing reduction (help paying your out-of-pocket expenses) is not correct.
- You were denied eligibility for an exemption from the individual shared responsibility provision.
- Covered California did not process your information in a timely manner.
- Covered California stated that you were not a U.S. citizen, U.S. national or a lawfully present individual living in the United States.
- Covered California stated that your application was incomplete.
- You do not have other health coverage (such as Medi-Cal or employer-sponsored insurance) that prevents you from qualifying for insurance through Covered California.
- Covered California stated that you are not a California resident.
- Covered California stated that you did not pay your premiums by your due date.
- Covered California stated that your income is too low to qualify for coverage through Covered California.
The Covered California Service Center provides support to consumers by responding to questions, helping them enroll in health plans and resolving challenges.
The Service Center can help with the following:
- Comparing health plans available in your area.
- Applying for coverage.
- Reporting a change on your application.
- Obtaining your Form 1095-A.
- Filing an appeal or a complaint.
Contact the California Department of Health Care Services (DHCS) for help with Medi-Cal, the program that offers free or low-cost health coverage for California residents who meet eligibility requirements.
DHCS can help with any Medi-Cal concern, including:
- Expedited plan enrollment, plan changes and plan disenrollment.
- Access-to-care issues.
- Ordering a Benefits Identification Card (BIC), if your local county office is unable to help.
- Updating county codes (when consumers move to another county).
- Referrals to appropriate agencies for concerns outside of their scope.
The DHCS Ombudsman Office can help if you are seeking to:
- Navigate through the Medi-Cal Managed Care system.
- Find information to help access mental health services.
- Address concerns or grievances about services.
- Help members with urgent enrollment problems.
- Resolve a Medi-Cal-related issue or help you escalate the issue.
Customers should not contact DHCS for Medicare or Social Security questions or concerns. Please contact the nearest Social Security Administration office, or call (800) 772-1213.
Medi-Cal Helpline: (800) 541-5555.
DHCS Ombudsman Office: (800) 452-8609, or email email@example.com.
Visit the Department of Managed Health Care (DMHC) Help Center if you have already filed a grievance with your health insurance company, or if there is an imminent threat to your health.
If you are experiencing an issue with your health plan or are having difficulty accessing care, you can file a grievance with your insurance company. If you are not satisfied with your health insurance company’s resolution of the grievance or have been in their grievance system for 30 days, contact the DMHC Help Center for assistance.
If you are experiencing an imminent or serious threat to your health, contact the DMHC Help Center immediately.
The DMHC Help Center can assist with the following types of complaints:
- Cancellation of coverage.
- Denials or delays of care or services.
- Billing problems.
- Quality of care.
- Coordination of care.
- Access problems, including not getting a timely appointment.
- Issues with providers, medical groups and pharmacies.
The California Department of Insurance (CDI) is a consumer-protection agency that regulates insurance companies, agents and brokers. CDI ensures that insurance products and services are available to consumers in a timely manner, and that they deliver fair and equal benefits.
Contact CDI for any questions or concerns with the following:
- Independent Medical Review applications (IMR).
- Concerns with health insurance coverage or companies.
- Licensing and other information for agents and brokers.
- Health care coverage information for seniors.
- Checking the status of an individual’s or agency’s license.
- Resolving insurance-related consumer complaints.
- Investigating and prosecuting insurance fraud.
California Department of Insurance Website
CDI Consumer Resources
CDI Seniors Information Center
Check the license status for agents or brokers, or obtain insurance company information.
File a complaint or complete an Independent Medical Review application.
The Health Consumer Alliance (HCA) offers free legal advice and representation, including assistance with filing complaints and grievances and pursuing hearings. The HCA is a network of 10 consumer-assistance programs operated by community-based legal services.
HCA provides free legal assistance in any language to consumers who are having problems with:
- Their health coverage.
- Enrolling in a plan.
- Renewing their coverage.
- Payment processing.
- Disconnects between Covered California and Medi-Cal.
- Using their coverage.
- Affording insurance or services.
- Obtaining timely services from any health care entity.
At any time, you can contact HCA at (888) 804-3536.