BILL NUMBER: AB 51	INTRODUCED
	BILL TEXT


INTRODUCED BY   Assembly Member Dymally

                        DECEMBER 4, 2006

   An act to amend Section 1368.02 of the Health and Safety Code,
relating to health care service plans.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 51, as introduced, Dymally. Gallegos-Rosenthal Patient Advocate
Program.
   Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care. The
Gallegos-Rosenthal Patient Advocate Program within the department
represents the interests of enrollees of health care service plans,
and one of its functions is to create a quality of care report card
on health care service plans.
   This bill would require the program to include information in the
report card on the quality of care and access provided by health care
service plans under Medicare Part D, the federal program for
prescription drug reimbursement coverage.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1368.02 of the Health and Safety Code is
amended to read:
   1368.02.  (a)  The director shall establish and maintain a
toll-free telephone number for the purpose of receiving complaints
regarding health care service plans regulated by the director.
   (b)  Every health care service plan shall publish the department's
toll-free telephone number, the department's TDD line for the
hearing and speech impaired, the plan's telephone number, and the
department's Internet address, on every plan contract, on every
evidence of coverage, on copies of plan grievance procedures, on plan
complaint forms, and on all written notices to enrollees required
under the grievance process of the plan, including any written
communications to an enrollee that offer the enrollee the opportunity
to participate in the grievance process of the plan and on all
written responses to grievances. The department's telephone number,
the department's TDD line, the plan's telephone number, and the
department's Internet address shall be displayed by the plan in each
of these documents in 12-point boldface type in the following regular
type statement:

   "The California Department of Managed Health Care is responsible
for regulating health care service plans. If you have a grievance
against your health plan, you should first telephone your health plan
at (insert health plan's telephone number) and use your health plan'
s grievance process before contacting the department. Utilizing this
grievance procedure does not prohibit any potential legal rights or
remedies that may be available to you. If you need help with a
grievance involving an emergency, a grievance that has not been
satisfactorily resolved by your health plan, or a grievance that has
remained unresolved for more than 30 days, you may call the
department for assistance. You may also be eligible for an
Independent Medical Review (IMR). If you are eligible for IMR, the
IMR process will provide an impartial review of medical decisions
made by a health plan related to the medical necessity of a proposed
service or treatment, coverage decisions for treatments that are
experimental or investigational in nature and payment disputes for
emergency or urgent medical services. The department also has a
toll-free telephone number (1-888-HMO-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The department'
s Internet Web site http://www.hmohelp.ca.gov has complaint forms,
IMR application forms and instructions online."

   (c)  (1)  There is within the department an Office of Patient
Advocate, which shall be known and may be cited as the
Gallegos-Rosenthal Patient Advocate Program, to represent the
interests of enrollees served by health care service plans regulated
by the department. The goal of the office shall be to help enrollees
secure health care services to which they are entitled under the laws
administered by the department.
   (2)  The office shall be headed by a patient advocate recommended
to the Governor by the Secretary of the Business, Transportation and
Housing Agency. The patient advocate shall be appointed by and serve
at the pleasure of the Governor.
   (3)  The duties of the office shall be determined by the
secretary, in consultation with the director, and shall include, but
not be limited to:
   (A)  Developing educational and informational guides for consumers
describing enrollee rights and responsibilities, and informing
enrollees on effective ways to exercise their rights to secure health
care services. The guides shall be easy to read and understand,
available in English and other languages, and shall be made available
to the public by the department, including access on the department'
s Internet Web site and through public outreach and educational
programs.
   (B)  Compiling an annual publication, to be made available on the
department's Internet Web site, of a quality of care report card,
including, but not limited to, health care service plans.  The
report card shall include information on quality of care and access
provided by plans under Medicare Part D (Pub. L. No. 108-173). 
   (C)  Rendering advice and assistance to enrollees regarding
procedures, rights, and responsibilities related to the use of health
care service plan grievance systems, the department's system for
reviewing unresolved grievances, and the independent review process.
   (D)  Making referrals within the department regarding studies,
investigations, audits, or enforcement that may be appropriate to
protect the interests of enrollees.
   (E)  Coordinating and working with other government and
nongovernment patient assistance programs and health care
ombudsperson programs.
   (4)  The director, in consultation with the patient advocate,
shall provide for the assignment of personnel to the office. The
department may employ or contract with experts when necessary to
carry out functions of the office. The annual budget for the office
shall be separately identified in the annual budget request of the
department.
   (5)  The office shall have access to department records including,
but not limited to, information related to health care service plan
audits, surveys, and enrollee grievances. The department shall assist
the office in compelling the production and disclosure of any
information the office deems necessary to perform its duties, from
entities regulated by the department, if the information is
determined by the department's legal counsel to be subject, under
existing law, to production or disclosure to the department.
   (6)  The patient advocate shall annually issue a public report on
the activities of the office, and shall appear before the appropriate
policy and fiscal committees of the Senate and Assembly, if
requested, to report and make recommendations on the activities of
the office.