Prior to appealing to the board and accorded an
opportunity for a fair hearing pursuant to Government Code section
22848, an
employee or annuitant must complete the requirements in subsections (b) and
(c), if applicable.
(a) As used in
this section and Government Code section
22848:
(1) "Administrative hearing" means the fair
hearing described in Government Code section
22848.
(2) "Administrative review" means the process
by which an employee or annuitant appeals to the board as permitted under
Government Code section
22848.
(3) "Complaint" means the same as
"grievance."
(4) "Coverage" means a
health benefit provided by a plan to employees and annuitants and their family
members and described in the plan's evidence of coverage.
(5) "Dissatisfied with any action or failure
to act" means a complaint or grievance an employee or annuitant may have
regarding his or her coverage or the coverage of his or her family
members.
(6) "Evidence of coverage"
means a booklet provided by a plan to employees and annuitants and their family
members describing their coverage and in effect for the period when an employee
or annuitant has a complaint or grievance.
(7) "Grievance" means a written or oral
expression of dissatisfaction regarding coverage and shall include a complaint,
dispute, request for reconsideration or appeal made by an employee or
annuitant. Where it is not possible to distinguish between a grievance and an
inquiry, it shall be considered a grievance.
(b) Exhaustion of complaint or grievance
process.
An employee or annuitant who is dissatisfied with any
action or failure to act in connection with his or her coverage or the coverage
of his or her family members must file a complaint or grievance and participate
in and exhaust the complaint or grievance process, including all levels of
appeal, provided by the plan in which he, she or any family member is
enrolled.
(c) Exhaustion of
other appeals processes.
If the employee or annuitant is dissatisfied with the
decision from the plan's complaint or grievance process as described in
subsection (b), the employee or annuitant may request an administrative review
as described in subsection (d) unless the employee or annuitant's complaint or
grievance is eligible for one of the appeals processes listed in paragraphs (1)
through (3) of this subsection. The plan's evidence of coverage will provide
information about eligibility for the appeals processes listed in paragraphs
(1) through (3) of this subsection. If the employee or annuitant's complaint or
grievance is eligible for one of the appeals processes listed in paragraphs (1)
through (3) of this subsection, the employee or annuitant must participate in
and exhaust that appeals process before requesting an administrative
review.
(1) The Department of Managed
Health Care's complaint system.
(2)
The Department of Managed Health Care's independent medical review
system.
(3) The external review
process administered by a plan in accordance with the Patient Protection and
Affordable Care Act (
Pub. L.
No. 111 -148).
(d) Request for administrative review.
If an employee or annuitant is dissatisfied with the
decision from the appeals processes outlined in subsection (b) or subsection
(c), he or she may request an administrative review of the decision. Only
requests that involve an issue regarding coverage are eligible for an
administrative review. The employee or annuitant must request an administrative
review and receive a decision from the unit charged with the processing and
oversight of health appeals before the employee or annuitant may request an
administrative hearing. An employee or annuitant may not request an
administrative review if he or she decides to resolve a complaint or grievance
through arbitration or by filing a civil action in a court of competent
jurisdiction as may be provided for in the plan's evidence of coverage.
Complaints or grievances alleging medical malpractice, quality of care or
quality of services provided by a plan are not eligible for administrative
review.
(1) A request for
administrative review must be filed with the unit charged with the processing
and oversight of health appeals within thirty (30) days of the date of a
decision from an appeals process described in subsection (b) or (c). Upon
satisfactory showing of good cause, CalPERS may grant additional time to submit
a request for an administrative review, not to exceed thirty (30) days. Good
cause includes, but is not limited to, inability to file timely for causes
beyond the employee or annuitant's control, and acts of nature. The request for
administrative review shall be in writing, state the grounds on which it is
requested, the relief that is sought and include all supporting evidence.
Supporting evidence includes, but is not limited to, copies of medical records,
statements of health care providers, and copies of medical bills submitted or
paid by the employee or annuitant.
(2) The unit charged with the processing and
oversight of health appeals shall acknowledge the request for administrative
review in writing within 15 days of receipt of the request. The unit charged
with the processing and oversight of health appeals shall review the request
and may request additional documentation. If the employee or annuitant does not
provide the requested additional documentation within the timeframe specified
by the unit charged with the processing and oversight of health appeals,
CalPERS may terminate the administrative review. Written notification of the
administrative review decision shall be mailed to the employee or annuitant
within 60 days of receipt of all pertinent information.
(e) Request for administrative hearing.
If an employee or annuitant is dissatisfied with the
administrative review decision, he or she may request an administrative
hearing.
(1) An employee or annuitant
must request an administrative hearing in writing within 30 days of the date of
the administrative review decision. The date of the administrative review
decision will be indicated on the written notification the unit charged with
the processing and oversight of health appeals is required to send to the
employee or annuitant pursuant to subsection(d)(2). Upon satisfactory showing
of good cause, CalPERS may grant additional time to file a request for an
administrative hearing, not to exceed thirty (30) days. Good cause includes,
but is not limited to, inability to file timely for causes beyond the employee
or annuitant's control, and acts of nature.
(2) The request for an administrative hearing
must set forth the facts and the law upon which the request is based. The
request should include any additional arguments and evidence favorable to an
employee or annuitant's case not previously submitted for administrative
review. An employee or annuitant may, but is not required to, be represented by
an attorney.
(3) If the request for
an administrative hearing is granted, it will be conducted in accordance with
the Administrative Procedure Act (Title 2, Division 3, Part 1 (commencing with
Section
11500) of the Government Code).
After taking testimony and receiving evidence, an administrative law judge will
issue a proposed decision and this decision will be presented to the board. If
the board adopts the proposed decision as its own decision at an open meeting,
this decision will be provided in writing to the employee or annuitant within
two weeks of the board's open meeting where the decision was adopted.
(4) An employee or annuitant who is
dissatisfied with the board's decision as described in paragraph (3) of this
subsection may petition the board for reconsideration or may appeal to the
Superior Court. An employee or annuitant may not pursue civil legal remedies
until after exhausting administrative review and an administrative
hearing.
(f) This section
shall apply to employees and annuitants enrolled in a supplemental plan if
their dissatisfaction with any action or failure to act in connection with
their coverage or the coverage of their family members involves a health
benefit provided by the plan that is not a health benefit covered by
Medicare.
(g) The requirements
specified in subsections (b) and (c) shall not apply to an employee or
annuitant who is dissatisfied with any action or failure to act in connection
with his or her eligibility for coverage or the eligibility for coverage of his
or her family members.
Notes
Cal. Code Regs. Tit. 2, §
599.518
1. New
section filed 11-3-2014; operative 1-1-2015 (Register 2014, No.
45).
2. Amendment of subsections (d)(1) and (e)(1) filed 2-27-2020;
operative 4-1-2020 (Register 2020, No. 9).
3. Governor Newsom issued
Executive Order N-40-20 (2019 CA EO 40-20), dated March 30, 2020, which
extended certain deadlines relating to enrollment in health benefits plans, due
to the COVID-19 pandemic.
4. Editorial correction of restoring
inadvertently omitted subsection (e)(2) (Register 2022, No.
17).
Note: Authority cited: Sections
22794 and
22796,
Government Code. Reference: Sections
22796 and
22848,
Government Code.
1. New section filed
11-3-2014; operative 1-1-2015 (Register 2014, No. 45).
2. Amendment
of subsections (d)(1) and (e)(1) filed 2-27-2020; operative
4/1/2020
(Register
2020, No. 9).