You have a right to a timely mental health appointment at Kaiser.
Under California law, Kaiser is required to offer you an initial mental health appointment within 10 business days of your request. If your appointment is urgent, Kaiser must provide an appointment within 48 hours. These time-elapsed standards are known as California’s “Timely Access Regulations.”
You have a right to receive comprehensive mental health care at Kaiser.
Under both California and federal law, Kaiser is required to provide equal coverage for mental health treatment as it does for other physical illnesses and injuries. The legislation that mandates this is known as the “Mental Health Parity Act.”
For example, if your health plan policy covers hospitalization of unlimited duration, then your policy should not limit treatment in a mental health facility to a specific number of days.
You have a right to directly challenge Kaiser for their withholding of mental health services.
Under California law, Kaiser is required to maintain an internal “grievance” process in order to handle consumer complaints. Through this process, you can request reconsideration of a decision by Kaiser to deny you appointments or care.
According to Kaiser, a grievance can be related to any dissatisfaction pertaining to a “referral, provision of or reimbursement for services or supplies, or other financial resolution.” Kaiser states that complaints about the standard of practice or quality of care are “generally treated as a grievance.”
You have a right to file an external complaint with the State of California regarding Kaiser.
Under California law, after you have exhausted Kaiser’s internal grievance process, you can request an “Independent Medical Review” (IMR) from the state if Kaiser does one of the following:
•If Kaiser denies, modifies, or delays a covered health care service.
•If Kaiser denies reimbursement for an emergency or urgent medical service.
•If Kaiser denies – for members suffering from a serious debilitating or life-threatening condition – a covered service on the grounds that the service is “experimental or investigational.”
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FREQUENTLY ASKED QUESTIONS
Timely mental health appointments
•What should I do if Kaiser offers me an initial appointment that would make me wait more than 10 business days before I’m seen?
•Where can I get more information about the Timely Access Regulations?
Obtaining appropriate mental health care
•What do the Mental Health Parity laws require?
•What’s the difference between the California Mental Health Parity Act and Federal Mental Health Parity Act?
•Can I get weekly therapy from Kaiser?
•I’ve heard that Kaiser has a short-term therapy model. Does Kaiser offer long-term therapy?
A grievance versus a complaint
•What is the difference between a “grievance” and a “complaint”?
Filing a grievance within Kaiser
•How do I file a grievance with Kaiser?
•How long will it take for my grievance to be acknowledged and subsequently decided?
•What about if I am a Medicare member – how does a grievance work in this case?
•Can I file a grievance on behalf of my son/daughter/family member?
•English isn’t my first language. Can I get help and assistance when filing a grievance?
Filing a complaint with the State of California
•What are the steps required to file a complaint with the state?
•Does it cost anything to file a complaint with the state?
•Where can I get more information about how to file a complaint with the state?
Filing a complaint with the Federal Government
•How can I file a complaint with the Federal Government?
•What else can I do if I am dissatisfied with the quality of care at Kaiser?
• • • • • • • • • • • • • • • • • • • • •
– TIMELY MENTAL HEALTH APPOINTMENTS –
What should I do if Kaiser offers me an initial appointment that would make me wait more than 10 business days before I’m seen?
Ask to talk to a supervisor or manager. You can remind the supervisor of their – and Kaiser’s – obligation, per state law, to offer you an initial appointment sooner than this. If they’re unresponsive, your next step should be to contact Kaiser Member Services online at kp.org or by phone at 1-800-464-4000. Make sure to take notes about your conversations, including the date and time of your call(s) and the names of the Kaiser officials whom you talk to.
Where can I get more information about the Timely Access Regulations?
The Department of Managed Health Care’s website has a whole section devoted to California’s Timely Access Regulations. (Direct link here: https://www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCareRights/TimelyAccesstoCare.aspx)
What do the Mental Health Parity laws require?
Equal coverage for mental health services as is provided for physical illnesses.
What’s the difference between the California Mental Health Parity Act and the Federal Mental Health Parity Act?
Federal Mental Health Parity requires HMOs to provide coverage for:
•Individual & group therapy visits for diagnostic evaluation & psychiatric treatment
•Visits for the purpose of monitoring drug therapy
There are no visit limits on the above covered services on plans with Federal Mental Health Parity.
Couples counseling may be covered if you are being treated for a mental health disorder and it’s determined that it’s medically necessary to bring your spouse or significant other into therapy as part of your treatment plan. Kaiser states that couples counseling is “not covered for the purpose of relational problems.”
California Mental Health Parity requires HMOs to provide care and treatment for Serious Emotional Disturbances (SED) of children plus the following severe mental health diagnoses:
•Bipolar disorder (manic-depressive illness)
•Major depressive disorders
•Obsessive compulsive disorder
•Pervasive developmental disorder or autism
There are no annual visit limits for these “parity” conditions.
Can I get weekly therapy from Kaiser?
If weekly visits are determined to be medically necessary, they are covered.
I’ve heard that Kaiser has a short-term therapy model. Does Kaiser offer long-term therapy?
There is no limitation on the length of medically necessary therapy. Ongoing therapy is covered as long as it’s determined to be medically necessary.
– A GRIEVANCE VERSUS A COMPLAINT –
What is the difference between a grievance and a complaint?
Kaiser provides the following definitions for these terms:
Complaint: Within the grievance process, an expression of dissatisfaction.
Grievance: Within the grievance process, any expression of dissatisfaction for which the member seeks referral, provision of or reimbursement for services or supplies, or other financial restitution.
– FILING A GRIEVANCE WITHIN KAISER –
How do I file a grievance with Kaiser?
There are several ways to file a grievance but the three primary methods are: Online, by phone, and in-person.
Filing a grievance online: Go to kp.org. You will have the option to submit a complaint (i.e., grievance) after clicking on the “Member Services” tab. You do not have to be signed into the Kaiser website to submit a complaint.
The below slideshow provides a step-by-step overview of how to submit an online complaint (Click on each slide to progress through the slideshow. There are eight slides in all):
Filing a grievance by phone: Call Kaiser Member Services at 1-800-464-4000 to file a grievance over the phone.
Filing a grievance in-person: You can visit a Member Services Representative at any Kaiser facility that has a Member Services Department and file a grievance.
All members are able to file a verbal grievance. However, this method is not recommended because it produces a less robust “paper” trail (as compared to filing an online grievance).
How long will it take for my grievance to be acknowledged and subsequently decided?
Within five calendar days of receiving a grievance, Kaiser is required to send out a “grievance acknowledgement.” If your grievance relates to an urgent matter, Kaiser is required to provide acknowledgment within 24 hours. [Section 1368(a)(1), Rule 1300.68(b)(1) and 1300.68(b)(4)]
Grievance decisions: If your problem is urgent, Kaiser must give you a decision within 72 hours. If your problem is not urgent, Kaiser must give you a decision within 30 days.
What about if I am a Medicare member?
For Kaiser Medicare members, the grievance process is administered by the Center for Medicare & Medicaid Services (CMS) via the Center for Health Disputes Resolution (CHDR). Note that Independent Medical Review decisions are binding regardless of whether they are reviewed by the DMHC or CMS.
Can I file a grievance on behalf of my son/daughter/family member?
Yes. If the Kaiser member is a minor or is mentally incompetent, a grievance can be submitted on the member’s behalf by a parent, guardian, conservator or other relative of the patient.
In order to file a grievance on behalf of someone else, an authorization form must be completed. These forms are available by calling Kaiser Member Services at 1-800-464-4000. These forms are also available at Kaiser facilities with a Member Services Department. Make sure to include this authorization form when filing a grievance on behalf of someone else.
You may also, as a Kaiser member, appoint an authorized representative in writing by including your representative’s name, address, and telephone contact information with your grievance.
English isn’t my first language. Can I get help and assistance when filing a grievance?
Yes. According to Kaiser, members with limited English proficiency or with a visual or other communicative impairment should receive assistance including, but not limited to, interpreters, telephone relay systems and other devices that aid individuals to communicate.
– FILING A COMPLAINT WITH THE STATE OF CALIFORNIA –
What are the steps required to file a complaint with the state?
Depending on your health insurance policy, you will need to file the complaint with either the California Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI). The majority of Kaiser members have plans that are regulated by the DMHC (it is the DMHC that regulates HMOs). A smaller number of Kaiser’s plans (such as PPO plans or high deductible plans) are regulated by the CDI. You can file a complaint either online, by fax or U.S. postal mail. For urgent complaints, you should call in your complaint using the appropriate phone number listed below:
To request an Independent Medical Review by the Department of Managed Health Care you can submit an online request at http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.aspx The DMHC’s mailing address is:
California Department of Managed Health Care
980 Ninth St., Suite 500
Sacramento, CA 95814
To request an Independent Medical Review by the California Department of Insurance you can submit an online request at https://cdiapps.insurance.ca.gov/CP/create-complaint-page/. Alternatively, you can submit a request via mail to:
California Department of Insurance
Consumer Communications Bureau
300 S. Spring Street, South Tower
Los Angeles, CA 90013
Does it cost anything to file a complaint with the state?
No. Filing a complaint is free and, in fact, Kaiser is responsible for the cost of Independent Medical Reviews.
Where can I get more information about how to file a complaint with the state?
You can get additional information from both the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) at each of their respective websites:
DMHC – http://www.dmhc.ca.gov/FileaComplaint.aspx
CDI – https://www.insurance.ca.gov/01-consumers/110-health/50-h-rfa/index.cfm (If this page is unresponsive you can also directly download a PDF version of the CDI health insurance complaint form here and a PDF version of the CDI application for Independent Medical Review here.)
How can I file a complaint with the Federal Government?
If you are enrolled in a Kaiser Medicare plan, the Center for Medicare & Medicaid Services (CMS) is responsible for ensuring that your plan adheres to CMS guidelines and standards. As a federal agency, the Center for Medicaid and Medicare Services (CMS) is responsible for overseeing Kaiser’s Medicare plans and for protecting the rights of Medicare patients. You can get more information on the CMS website.
What else can I do if I am dissatisfied with Kaiser’s quality of care?
Depending on your health insurance policy, and where you are geographically located, you may have additional options. Regardless, you can always seek out the services of an attorney and/or reach out to journalists and other media. For information about arbitration with Kaiser go to: www.oia-kaiserarb.com.