Ombuds Office

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. Please note that if you have not used the methods above (calling the service center, filing a complaint or filing an appeal), the Ombuds Office will refer you back to the established process prior to investigating your issue.

If we can't help you, we will explain why we could not and will try to refer you to another resource.

Note: The Ombuds Office does not provide legal advice. Our independent contractor, Health Consumer Alliance (HCA), provides free legal advice and representation, including assistance filing a complaint or grievance and arranging a hearing.

When should I contact the Ombuds Office?

You should contact the Ombuds Office if you:

  • Have contacted the Covered California service center, have had your issue escalated and the timeframe for resolution has passed. The service center should provide you with an incident or reference number. 
  • Have filed an appeal and a decision from the Administrative Law Judge has been issued.
  • Have filed a Covered California complaint and it has been more than 30 days and you have not received an update.

Contact Us

Please download and complete our contact form and return it by email, fax or by mail.

You can also contact us directly:

  1. Email: ombuds@covered.ca.gov
  2. 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.
  3. Fax: (888) 726-0841
  4. Mail:

                 Covered California
                 Attn: Ombuds Office
                 1601 Exposition Blvd.
                 Sacramento, CA 95815

When contacting us, please include all of the following:

  • A summary of your problem.
  • Your Covered California case number.
  • An incident or reference number provided by the service center.
  • A phone number where you can be reached.
  • The best time for us to reach you.

We will reach out to you with any follow-up questions and will keep in touch with you along the way. We'll do our best to help resolve your issue as quickly as possible, usually within 30 days for most cases. This timeframe may be affected by how complex your issue is and how much research your case requires.

If you have an issue with your account, a Covered California representative can escalate your case to a specialized group for assistance. Please see the chart in the Helpful Resources for response and resolution timeframes.  

Helpful Resources

 

The Covered California Service Center provides support to consumers by responding to questions, helping them enroll in health plans and resolving challenges. Call the service center during normal business hours at (800) 300-1506 (TTY: [888] 889-4500).

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 or filing a dispute form for your Form 1095-A.
  • Filing an appeal or a complaint.
  • Answering questions regarding your coverage.

If you have an issue with your account, a Covered California representative can escalate your case to a specialized group for assistance. 

 

Issue Description Initial Contact In Resolution In

Access to Care
(urgent)

Immediate care or medications are required.

(If this is a medical or psychiatric emergency, please dial 911.)

1–2 business days

5 business days

Access to Care
(non-urgent)

Medical treatments, appointments or prescriptions that are not life threatening are required (needed within 30 calendar days).

3 business days

15 business days

Lost Coverage

Coverage is lost because of an error and needs to be reinstated.

(This does not apply if your plan was canceled because you did not pay your premium.)

10 business days

30–45 calendar days

Issues With Your Proof of Coverage for Taxes (Form 1095-A)

Information on your Form 1095-A is incorrect.

(Form 1095-A is a document you will receive from Covered California that is required to complete your federal income tax filing.)

You can file a dispute with Covered California if you think the information on your form is incorrect. File a dispute here.

10 business days

30 calendar days

Advanced Premium Tax Credit (APTC) Discrepancy

Your APTC needs to be corrected or updated.

(APTC is federal financial help with your monthly premium.)

10 business days

30–45 calendar days

Your Plan Coverage Start Date

You need to change the start date of your health plan enrollment.

10 business days

30–45 calendar days

Appeals-Process Questions

You filed a Request for a State Fair Hearing to appeal a Covered California issue and have not received initial contact, or you are waiting for a response from an appeals analyst regarding the appeals process. Get more information on how to file an appeal.

1–3 business days

Up to 90 calendar days

General Complaints

You filed a Covered California Complaint Form and have not been contacted, or you have an issue for which you cannot file an appeal. See the full list of reasons for filing an appeal. Complaints involve issues such as problems with the website or Covered California staff.

1–5 business days

30 calendar days

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. You may also contact your local county office. 

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 Medi-Cal 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.

Contact Information

Medi-Cal Helpline: (800) 541-5555.
DHCS Ombudsman Office: (888) 452-8609, or
Email: mmcdombudsmanoffice@dhcs.ca.gov.

Related Links

California Department of Health Care Services Website
County Social Services Offices

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 (PDF).

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 (PDF).

  • 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.

Related Links

Filing an Appeal or Complaint
Request for a State Fair Hearing to Appeal a Covered California Eligibility Determination Form

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.

Contact Information

DMHC Help Center: (888) 466-2219.

Related Links

California Department of Managed Health Care Website
DMHC Help Center
DMHC Independent Medical Review/Complaint Form

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.

Related Links

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.
  • Eligibility.
  • 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.

Contact Information

(888) 804-3536

Call 9:00 a.m. to 5:00 p.m., Monday through Friday. You will get a call back if you leave a message after business hours.

Related Links

Health Consumer Alliance Website