The Department of Managed Health Care (DMHC) is a regulatory body governing

managed health care The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("ma ...

plans, sometimes referred to as

Health Maintenance Organization In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded healt ...

s (HMOs) in

California California is a U.S. state, state in the Western United States, located along the West Coast of the United States, Pacific Coast. With nearly 39.2million residents across a total area of approximately , it is the List of states and territori ...

. The DMHC was created as the first state department in the country solely dedicated to regulating managed health care plans and assisting consumers to resolve disputes with their health plans. The DMHC Help Center educates consumers about their health care rights, resolves consumer complaints, helps consumers navigate and understand their coverage and assists consumers in getting timely access to appropriate health care services. The DMHC Help Center provides direct assistance in all languages to health care consumers through the Department’s website, www.HealthHelp.ca.gov, and a toll-free phone number, 1-888-466-2219. Mary Watanabe is currently the director of the DMHC. The DMHC is part of the California Health and Human Services Agency. It was established in 2000 and is responsible for enforcing the Knox-Keene Health Care Service Plan Act of 1975, and other related laws and regulations.

Dual health insurance regulation

The DMHC regulates the majority of state-regulated health care coverage in California including 96% of commercial and government health plan enrollment. However, not all health plans operating in California are under the jurisdiction of the DMHC; for example, some

preferred provider organization In U.S. health insurance, a preferred provider organization (PPO), sometimes referred to as a participating provider organization or preferred provider option, is a managed care organization of medical doctors, hospitals, and other health care ...

s are regulated by the

California Department of Insurance The California Department of Insurance (CDI), established in 1868, is the agency charged with overseeing insurance regulations, enforcing statutes mandating consumer protections, educating consumers, and fostering the stability of insurance marke ...

(CDI). Two state-based health insurance regulators is unusual in the United States, and has led to various additional work to synchronize laws. This dual regulation arose due for historical reasons, and when the DMHC was created in 2000, the California legislature requested a report on merging the health insurer responsibilities with the CDI. In 2001, J. Clark Kelso, who served as acting

California Insurance Commissioner The California insurance commissioner has been an elected executive office position in California since 1991. Prior to that time, the insurance commissioner was appointed by the governor. The officeholder is in charge of the California Departm ...

in 2000, produced a report outlining costs and benefits of agency consolidation. In addition, the federal government regulates health insurance for members of the military, and "self-insured" or ERISA plans, offered by some large employers are under the jurisdiction of the

U.S. Department of Labor The United States Department of Labor (DOL) is one of the United States federal executive departments, executive departments of the federal government of the United States, U.S. federal government. It is responsible for the administration of fede ...

Knox-Keene licenses

In 2020, 87 full-service health plans licensed by the DMHC provided health care services to more than 27.7 million Californians. This included more than 14 million commercial enrollees and approximately 13.6 million government enrollees. In addition to full-service health plans, the DMHC oversees 45 specialized health plans including chiropractic, dental, vision, behavioral health (psychological) and pharmacy.

History

The agency was created in July 2000, in the wake of widespread dissatisfaction with

managed care The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("man ...

across the country and in response to concerns that the prior regulator, the

California Department of Corporations The California Department of Corporations (DOC) was a department within the former California Business, Transportation and Housing Agency in California. The chief officer of the Department was the Commissioner of Corporations. Effective July 1, 20 ...

, lacked medical and consumer protection expertise. At the time of its creation, California was the largest market for

health maintenance organization In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded healt ...

s (HMOs) in the United States. After it was created,

Kaiser Permanente Kaiser Permanente (; KP), commonly known simply as Kaiser, is an American integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield. Kaiser P ...

challenged its authority in court, but did not succeed.

References

External links

*
The Department of Managed Health Care
in the

California Code of Regulations The California Code of Regulations (CCR, Cal. Code Regs.) is the codification of the general and permanent rules and regulations (sometimes called administrative law) announced in the ''California Regulatory Notice Register'' by California state ...

Healthcare in California Managed care Medical and health organizations based in California State agencies of California {{US-health-org-stub

Dual health insurance regulation

Knox-Keene licenses

History

See also

References

External links