Member Discrimination Grievance Procedure

1. RELATED POLICIES:
2. CGA-003, Medi-Cal Member Grievance System
3. CGA004 Healthy Kids Member grievance System
4. MP PR 200, PHC Provider Contracts

1. IMPACTED DEPTS:
2. All Departments.

1. DEFINITIONS:a.Complaint is a member's oral or written expression of dissatisfaction with PHC and/or a provider.
   b.Discrimination:unequal treatment of persons, for a reason which has nothing to do with legal rights or ability. To distinguish, single out, or make a distinction.
   c.Grievance: is the process by which a PHC member complaints and appeals are addressed andresolved.
   d.Lead Grievance Coordinator: is the senior grievance staff member responsible for summarizing, analyzing, investigatingand issue acknowledgements and resolutions to member complaints and appeals and also represents PHC during state hearings.
   e.Member is the Medi-Cal eligible individual receiving health care through PHC to whom reference will be made as "members" in all protocols.
   f.Provider is an organization such as a hospital, residential treatment center or rehabilitation facility.

1. ATTACHMENTS:
2. Appendix C, Part 92, Section 1557 of the Affordable Care Act

1. PURPOSE:

It is the policy of Partnership HealthPlan of California (PHC) not to discriminate on the basis of race, creed, religion, ancestry, marital status, sexual orientation, or physical or mental handicap, color, national origin, sex, age or disabilityin accordance with Title VI of theCivil Rights Act of 1964, 42 USC Sections 2000d and 18116, rules andregulations promulgated pursuant thereto, or as otherwiseprovided by law or regulations. PHC adopts this internal member discrimination grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. § 18116) (herein Section 1557) and its implementing regulations at 45 C.F.R. pt. 92, issued by the U.S. Department of Health and Human Services.

Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities. Title VI of theCivil Rights Act of 1964, 42 USC Sections 2000d prohibits discriminations on the grounds of race, color,creed, religion, ancestry, age, sex, national origin, maritalstatus, sexual orientation, or physical or mental handicapinclude, but not limited to, the following:

1) Denying any Member any Covered Services oravailability of a facility, except where medically indicated;

2) Providing to a Member any Covered Service which isdifferent, or is provided in a different manner or at adifferent time from that provided to other Membersexcept where medically indicated;

3) Subjecting a Member to segregation or separatetreatment in any manner related to the receipt of anyCovered Service;

4) Restricting a Member in anyway in the enjoyment of anyadvantage or privilege enjoyed by others receiving anyCovered Service, treating a Member or EligibleBeneficiary differently from others in determiningwhether he or she satisfies any admission, Enrollment,quota,eligibility, membership, or other requirement orcondition which individuals must meet in order to beprovided any Covered Service;

5) The assignment of times or places for the provision ofservices on the basis of the race, color, national origin,creed, ancestry, religion, language, age, gender, maritalstatus, sexual orientation, health status, or disability ofthe participants to be served.

6) For the purposes of this section, physical handicapincludes the carrying of a gene which may, undersome circumstances, be associated with disability inthat person's offspring, but which causes no adverseeffects on the carrier. Such genes will include, butare not limited to, Tay-Sachs trait, sickle cell trait,thalassemia trait, and X-linked hemophilia.

7) For purposes of this section, discrimination related to health status means PHC shall not discriminate among eligible individualson the basis of their health status requirements or

requirements for health care services during enrollment, reenrollmentor disenrollment. PHC will not terminate the enrollment of an eligible individual based on an adversechange in the Member’s health.

1. POLICY / PROCEDURE:

1. Any complaint regarding discrimination shall be handled as a grievance.
2. The Lead Grievance Coordinator (LGC) shall be designated as the Section 1557 Coordinator. The LGC is designated to coordinate the efforts of PHC to comply with Section 1557 and Department of Health Care Contract 08-85215 A19, Exhibit E, Attachment 2 – Program Terms and Conditions, Section 29.
3. Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex, age or disability may file a grievance under this procedure. It is against the law for PHC to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance.
4.Grievances must be submitted to the Section 1557 Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discriminatory action.
5. A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.
6.The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 1557 Coordinator will maintain the files and records of PHC relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.
7. PHC will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings. The Section 1557 Coordinator will be responsible for such arrangements.
8.The Section 1557 Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.
9. The person filing the grievance may appeal the decision of the Section 1557 Coordinator by writing to the (Administrator/Chief Executive Officer/Board of Directors/etc.) within 15 days of receiving the Section 1557 Coordinator’s decision. The (Administrator/Chief Executive Officer/Board of Directors/etc.) shall issue a written decision in response to the appeal no later than 30 days after its filing.
10. The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights.
11. The following notice shall be provided to Members:
A person can file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal, which is available at: or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Complaint forms are available at: Such complaints must be filed within 180 days of the date of the alleged discrimination. PHC will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings. The Section 1557 Coordinator will be responsible for such arrangements.
Dated: [TO BE INSERTED.] Sylvia M. Burwell, Secretary.
12. The PHC Section 1557 Coordinator will forward to DHCS for review and appropriate action, copies of all grievances allegingdiscrimination against Members or Eligible Beneficiaries
because of race, color, national origin, creed, ancestry,religion, language, age, gender, marital status, sexualorientation, health status, or disability.

1. REFERENCES:
2. Appendix C, Part 92, Section 1557 of the Affordable Care Act
3. Section 14029.91 of the Welfare and Institutions Code;
4. Title VI of the Civil Rights Act of 1964 (Title VI);
5. 42 U.S.C. 2000d et seq. (race, color, national origin);
6. Title IX of the Education Amendments of 1972 (Title IX);
7. 20 U.S.C. 1681 et seq. (sex), the Age Discrimination Act of 1975 (Age Act)
8. 42 U.S.C. 6101 et seq. (age), or Section 504 of the Rehabilitation Act of 1973;
9. (Section 504), 29 U.S.C. 794 (disability)
10. DHCS Contract 08-85215, Amendment 19, Attachment 2

1. DISTRIBUTION:
2. PHC Employee Manual
3. PHC4Me
4. Sharepoint
5. Directors

1. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
   Lead Coordinator, Grievance and Appeals Department

1. REVISION DATES:

N/A

PREVIOUSLY APPLIED TO:

N/A

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