Emergency Services Insurance Coverage
What is an Emergency?
Where to Find Help
However, If you do have insurance that covers emergency care, California law requires your insurer to pay the same benefit at any hospital providing your emergency care, even if that hospital is not in your insurer’s hospital network. Two agencies govern California Health Plans and Health insurance companies, The California Department of Managed Health Care and The California Department of Insurance. If your company is listed with either of these sites they are obligated to follow these guidelines. To check the California Department of Managed Health Care, to see a list of companies regulated by the Department of Managed Care.
If your insurance company is not listed under the site above click here. This page will enable you to complete a search for your insurer’s name.
Emergencies and Urgent Care
What if it's an emergency and the nearest hospital is not in my HMO's network?
What about ambulance service?
What if my HMO refuses to pay for my emergency care?
How to File a Complaint with Your HMO
- Ask your HMO Member Services to send you a complaint form.
- Your HMO must take action within 30 days after it receives your complaint.
- If your problem is urgent, ask for an Expedited Review. Your HMO must take action within 3 days.
- If your HMO still won’t help or doesn’t reply within the time limit, call the HMO Help Center at 1-888-HMO-2219.
How to File a Complaint with the HMO Help Center
- Unless your problem is urgent, you usually need to file a complaint with your HMO first.
- If your HMO doesn’t take action within 30 days or you still need help, you can file a complaint with the HMO Help Center
To file a complaint, call HMO Help Center (1-888-HMO-2219). To see a complaint form visit: www.hmohelp.ca.gov
Request an Independent Review
You and your HMO may disagree about the care you need. Your HMO may say that the treatment you’ve asked for is not necessary for you health or is experimental. Or you may have gotten emergency care that your HMO won’t pay for.
If these things happen, you can ask for an Independent Medical Review, or IMR. The State of California hires an independent organization to conduct these reviews. This organization has doctors who review the cases. The doctors are experts on your condition, but they are not part of your HMO. And they do not get any money from your HMO. To request an Independent Medical Review (IMR), call the HMO Help Center.
Where to Find Help
Office of the Patient Advocate (OPA)
Information on California’s HMOs
(Health Insurance Counseling & Advocacy Program)
Information, counseling and advocacy for Medicare Members
HMO Help Center
Information and assistance for California HMO members