In managed care, generally the cases fall into two categories: enrollment-disenrollment issues and issues concerning denial of medical treatment. Who is responsible for writing the position statement, the CDHS Managed Care Division or the managed care plan?

If the issue is an enrollment-disenrollment issue, the CDHS Managed Care Division is responsible for the position statement unless the county is one of the six County Operated Health System (COHS) counties. If the issue involves a medical determination such as denial of a wheelchair, the managed care plan is responsible for the position statement.

In the six COHS counties, (Napa, Orange, San Mateo, Santa Barbara, Santa Cruz and Solano) there is only the one plan operating in the county. In those counties, the plan is responsible for the position statement for both enrollment-disenrollment issues and for denial of medical treatment or services.

If a judge does not receive a position statement on any managed care issue in any county, the judge may call Lupe Martinez at (916) 657-2694 (CALNET 437-2694) or Augie Maravilla at (916) 657-0861 (CALNET 437-0861).

In a case involving a COHS county, the judge may call the individual COHS county contact if the judge is unable to reach one of the managed care contacts. (It is unlikely that it will be necessary to make such a call since a COHS representative generally appears at the hearing.) The following is a list of COHS contacts:

The individual plan that took the disputed action should be identified as the party in a hearing decision. In the case of an enrollment-disenrollment issue, the party is the CDHS Health Care Options provider.