While You Are in AIM

Health Plan’s Dispute Resolution Process

If you are unhappy with something your health plan did (or did not do), you must resolve your problems with the plan according to its policies and procedures. The procedures are listed in the Evidence of Coverage (EOC) or Certificate of Insurance (COI) booklet. You will receive these booklets from the health plan. You may review these documents prior to selecting a health plan. Call the plan directly and ask for a copy.

If you are unable to resolve your dispute with the plan, and your insurance plan is licensed by the state, contact the state government agency, Department of Managed Health Care or Department of Insurance which licenses the insurance plan. The number is listed in the EOC or COI booklet.

What is Binding Arbitration?

Binding Arbitration is an agreement between some insurance plans and subscribers to have health care disputes reviewed by a neutral person. If you choose an insurance plan with arbitration, you give up the right to a jury or court trial to resolve disputes you may have with your insurance plan. The neutral person makes a decision after reviewing and hearing all the facts from both parties. Both parties agree to accept the decision.

Which plans require their members to use Binding Arbitration to resolve disputes?

• Blue Cross EPO and HMO: Yes (includes medical malpractice)
• Contra Costa Health Plan: No
• Health Net: Yes (includes medical malpractice)
• Kaiser Permanente: Yes (includes medical malpractice)
• Molina Healthcare of California: No
• Santa Barbara Prenatal Plus 2: Yes (includes medical malpractice)
• Ventura County Health Care Plan: Yes (includes medical malpractice)

The Managed Risk Medical Insurance Board (MRMIB) Benefits Appeal Process

You should first attempt to resolve disputes with the plan according to its established policies and procedures. If you are dissatisfied with the resolution of your grievance you can appeal to the California Managed Risk Medical Insurance Board (MRMIB).

The appeal must be submitted to MRMIB in writing within sixty (60) calendar days following the Plan’s decision. The appeal must include the following:

• A copy of any decision being appealed or a written statement of the action or failure to act being appealed;
• A statement specifically describing the issue you
  are disputing;
• A statement of the resolution you are requesting; and
• Any other relevant information you would like
  to include.

Appeals that do not include the above information will be returned. You may resubmit the complete appeal within the sixty (60) calendar days from the plan’s denial or within twenty (20) calendar days of the receipt of the returned appeal, whichever is later. Mail or FAX your appeal to:

Executive Director
Managed Risk Medical Insurance Board
P.O. Box 2769
Sacramento, CA 95812-2769
Phone: (916) 324-4695
FAX: (916) 327-9661

AIM Program Privacy Notification

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

When you apply for the AIM Program, the information you provide in the application is reviewed by a private contractor. The private contractor is hired by the State of California to assist in the administration of the AIM Program. The contractor uses your information to determine whether you are eligible for AIM. The contractor and the State will use your information for administration and evaluation of the program and for necessary purposes authorized by law.

If you are determined eligible for AIM, the contractor will then send your information to the health insurance plan and provider that you select, so you can begin to receive health insurance coverage under that plan.

Once your baby is born, your health plan and provider may send to the State information regarding your baby and the health care you and your baby received. This information will include what is required under State law for your baby’s birth certificate, such as your baby’s name, sex, date of birth, weight, and your pregnancy history. In addition, the State will also receive summary information on treatment you and your baby received while being covered by AIM. This information includes the number of doctor visits you received before and after delivery, and the number of immunizations provided to your baby.

Uses and disclosures that are not part of the operations of the Program will only be made with your written authorization. This authorization may later be revoked at your written request.

Your rights regarding how your personal information is used
You have the right to request the AIM Program to restrict the use of your personal information. The Program may not agree to restrictions if it would interfere with its normal operations and administration. You also have the right to obtain a copy, or request to change the personal information you provided to the AIM Program as long as the Program retains such information. You have the right to obtain an explanation of how your personal information was disclosed, other than the use of your information by the AIM Program to carry out the operations of the Program.

AIM may revise the privacy practices described here. The Program will notify its subscribers in updated Program handbooks or through direct mailed notices prior to such revisions becoming effective. You may complain to the AIM Program if you believe your privacy rights have been violated by contacting:

Privacy Officer
AIM Program
Managed Risk Medical Insurance Board
P.O. Box 2769
Sacramento, CA 95812-2769
(916) 324-4695

New subscribers will receive a copy of the Notice of Privacy Practices with their enrollment confirmation.