BILL NUMBER: AB 2787	AMENDED
	BILL TEXT

	AMENDED IN SENATE  JULY 15, 2010
	AMENDED IN SENATE  JUNE 22, 2010
	AMENDED IN SENATE  MAY 27, 2010
	AMENDED IN ASSEMBLY  MAY 10, 2010

INTRODUCED BY   Assembly Member Monning
   (Principal coauthor: Senator Alquist)

                        MARCH 9, 2010

   An act  to add Section 1374.18 to, and  to add
Division 115 (commencing with Section 136000) to  , 
the Health and Safety Code, relating to health care coverage, and
making an appropriation therefor.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 2787, as amended, Monning. Office of the California Health
Ombudsman.
   Existing law, the federal Patient Protection and Affordable Care
Act, requires the United States Secretary of Health and Human
Services to award grants to states to enable them to establish,
expand, or provide support for offices of health insurance consumer
assistance or health insurance ombudsman programs and imposes
specified eligibility requirements on states in order to receive
those grants.
   This bill would establish the Office of the California Health
Ombudsman in state government, to be governed by a chief executive
officer known as the California Health Ombudsman who would be
appointed  in an unspecified manner   by the
Governor, subject to confirmation by the Senate  . The bill
would require the ombudsman to, among other things, educate consumers
on their rights and responsibilities with respect to health care
coverage, assist consumers with enrollment in health care coverage,
and resolve problems with obtaining specified premium tax credits.
The bill would also require the ombudsman to operate a specified
hotline and Internet Web site and would require that the telephone
number and Web site be included on every membership card and evidence
of coverage issued to Medi-Cal beneficiaries and to individuals with
coverage under health care service plans or health insurers  ,
as specified  . The bill would require the ombudsman to apply to
the United States Secretary of Health and Human Services for a grant
to implement these requirements and would create the California
Health Ombudsman Trust Fund as a continuously appropriated fund in
the State Treasury for purposes of the act. The bill would also
impose  fees   an annual fee  on health
care service plans and health insurers for purposes of funding these
provisions, as specified.
   Vote: majority. Appropriation: yes. Fiscal committee: yes.
State-mandated local program: no.


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

  SECTION 1.  Division 115 (commencing with Section 136000) is added
to the Health and Safety Code, to read:

      DIVISION 115.  OFFICE OF THE CALIFORNIA HEALTH OMBUDSMAN


   136000.  (a) There is hereby created in state government an
independent office of health care coverage consumer assistance called
the Office of the California Health Ombudsman. The office shall
operate in compliance with the criteria established by the United
States Secretary of Health and Human Services and shall be under the
direction of a chief executive officer who shall be known as the
California Health Ombudsman. The ombudsman shall be appointed by
 ____   the Governor, subject to confirmation by
the Senate  .
   (b) The ombudsman shall, in coordination with the Department of
Managed Health Care, the Department of Insurance, the State
Department of Health Care Services, the Managed Risk Medical
Insurance Board, the Exchange, as defined in subdivision (j), and
consumer assistance organizations, receive and respond to inquiries,
complaints, and requests for assistance concerning health care
coverage with respect to requirements under federal and state law.
   (c) The ombudsman shall do all of the following with respect to
all health care coverage available in California, including coverage
available through public programs and coverage available through
health care service plans under Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code and health insurers
under Part 2 (commencing with Section 10110) of Division 2 of the
Insurance Code:
   (1) Assist with the filing of complaints and appeals, including
appeals with the internal appeal or grievance process of the health
care service plan, health insurer, or group health plan involved, and
providing information about any external appeal process.
   (2) Collect, track, quantify, and analyze problems and inquiries
encountered by consumers with respect to health care coverage,
including, but not limited to, the complaints reported to the
ombudsman under subdivision (h). The ombudsman shall publicly report
its analysis of these problems and inquiries at least annually on the
Internet Web site of the office. The ombudsman shall track, analyze,
and publicly report on complaints reported to the ombudsman under
subdivision (h) according to the nature and resolution of the
complaints and the health status, age, race, ethnicity, language,
geographic region, and gender of the complainants in order to
identify the most common types of problems and the problems faced by
particular populations. In addition, the ombudsman shall track,
analyze, and report on those complaints by health insurer or health
care service plan and by the type of health care coverage program,
including the timeliness of resolution of the complaints, and shall
take into account the number of individuals enrolled in each health
insurer or health care service plan and in each health care coverage
program.
   (3) Educate consumers on their rights and responsibilities with
respect to health care coverage and provide this information in plain
language.
   (4) Assist consumers with enrollment in health care coverage by
providing information, referral, and assistance.
   (5) Resolve problems with obtaining premium tax credits under
Section 36B of the Internal Revenue Code.
   (6) Provide the assistance and education described in this
subdivision to consumers with limited English language proficiency in
their primary language.
   (d) (1) In order to assist consumers in navigating and resolving
problems with health care coverage and programs, the ombudsman shall
do both of the following:
   (A) Operate a HealthHelp hotline that is available 24 hours a day,
seven days a week.
   (B) Operate a HealthHelp Internet Web site, other social media,
and up-to-date communication systems.
   (2) The telephone number and Internet Web site for the HealthHelp
hotline described in paragraph (1) shall be included on every
membership card and evidence of coverage issued to the following:
   (A) An individual insured under a policy of health insurance
regulated under the Insurance Code.  A health insurer shall
reissue membership cards that were issued to insureds prior to
January 1, 2011, in order to comply with this paragraph. 
   (B) An individual enrolled in a health care service plan contract
regulated under Chapter 2.2 (commencing with Section 1340) of
Division 2.  A plan shall reissue membership cards that were
issued to enrollees prior to January 1, 2011, in order to comply with
this paragraph. 
   (C) A beneficiary of the Medi-Cal program.  Except with
respect to Medi-Cal managed care plans subject to subparagraph (B),
this requirement shall only apply to membership cards issued to
beneficiaries on or after January   1, 2011. 
   (e) In order to carry out the duties described in subdivision (c),
the ombudsman shall utilize a network of local community-based
non-profit consumer assistance programs with experience in the
following areas:
   (1) Assisting consumers in navigating the local health care
system.
   (2) Enrolling consumers in health care coverage.
   (3) Resolving consumer problems associated with health care
access.
   (4) Serving consumers with special needs, including, but not
limited to, consumers with limited English language proficiency,
low-income consumers, consumers with disabilities, and consumers with
multiple health conditions.
   (5) Collecting and reporting data on the types of health care
coverage problems consumers face.
   (f) The ombudsman shall collect and report data to the United
States Secretary of Health and Human Services on the types of
problems and inquiries encountered by consumers.
   (g) The ombudsman shall develop protocols and procedures for the
resolution of consumer complaints and the establishment of
responsibility or referral as appropriate with regard to the
following agencies:
   (1) The federal Department of Labor with respect to employee
welfare benefit plans regulated under ERISA to enable the ombudsman
to provide accurate information and referrals to consumers covered
under those plans.
   (2) The Centers for Medicare and Medicaid Services to enable the
ombudsman to give accurate information and referrals for consumers
covered under the Medicare Program.
   (3) The Department of Managed Health Care regarding consumers
enrolled in coverage under health care service plans regulated under
Chapter 2.2 (commencing with Section 1340) of Division 2. The
ombudsman shall also directly assist these consumers.
   (4) The Department of Insurance regarding consumers with policies
of health insurance regulated under the Insurance Code. The ombudsman
shall also directly assist these consumers.
   (5) The State Department of Health Care Services regarding
consumers enrolled in the Medi-Cal Program. The ombudsman shall also
directly assist these consumers.
   (6) The Managed Risk Medical Insurance Board regarding consumers
enrolled in the Healthy Families Program (Part 6.2 (commencing with
Section 12693) of Division 2 of the Insurance Code), the Access for
Infants and Mothers Program (Part 6.3 (commencing with Section 12695)
of Division 2 of the Insurance Code), the California Major Risk
Medical Insurance Program (Part 6.5 (commencing with Section 12700)
of Division 2 of the Insurance Code), and the federal temporary high
risk pool established under Section 1101 of the federal Patient
Protection and Affordable Care Act (Public Law 111-148). The
ombudsman shall also directly assist these consumers.
   (7) The Exchange regarding consumers enrolled in coverage pursuant
to the Exchange. The ombudsman shall also directly assist these
consumers.
   (h) The Department of Managed Health Care, the Department of
Insurance, the State Department of Health Care Services, the Managed
Risk Medical Insurance Board, the State Department of Public Health,
and the Exchange shall report data and other information to the
ombudsman regarding consumer complaints submitted to those agencies,
including the nature of the complaints, the resolution of the
complaints and the timeliness thereof, and the health status, age,
race, ethnicity, language, geographic region, and gender of the
complainants. This information shall be reported according to the
particular health insurer or health care service plan involved.
   (i) (1) The ombudsman shall apply to the United States Secretary
of Health and Human Services for a grant under Section 2793 of the
federal Public Health Service Act, as added by Section 1002 of the
federal Patient Protection and Affordable Care Act (Public Law
111-148), to implement the requirements of this section. 
   (2) The office and the services provided by local consumer
assistance programs under subdivision (e) shall be also be funded out
of licensure fees on health care service plans, consistent with
Section 1356, and out of fees on health insurers by assessing a per
policy assessment. The fees shall be set by the Director of the
Department of Managed Health Care or the Insurance Commissioner, as
applicable, in consultation with the ombudsman. The fees shall be
allocated based on the number of covered lives and shall be the same
per covered life regardless of the regulator.  
   (3) 
    (2)  To the extent permitted by federal law, the
ombudsman may seek federal financial participation for assisting
beneficiaries of the Medi-Cal program. 
   (j) For fiscal years 2010-11 to 2014-15, inclusive, each health
care service plan, including a specialized health care service plan,
and each health insurer shall be assessed an annual fee in an amount
determined through regulation that shall be proportionate to the
number of covered lives regulated by the Department of Managed Health
Care and the Department of Insurance. The amount of the fee shall be
determined by the Department of Managed Health Care and the
Department of Insurance in consultation with the ombudsman and shall
be limited to the amount necessary to fund the actual and necessary
expenses of the office and its work in implementing this division.
 
   (k) The fee on plans and insurers described in subdivision (j)
shall be assessed by the Department of Managed Health Care and the
Department of Insurance, respectively, in coordination with the
ombudsman.  
   (1) Health care service plans shall be notified of the fee on or
before June 15 of each year. That notice shall be included with the
annual assessment notice issued pursuant to Section 1356. The fee
imposed under this section is separate and independent of the
assessments imposed under Section 1356.  
   (2) Health insurers shall be notified of the fee in accordance
with the notice sent for the annual assessment or quarterly premium
tax revenues.  
   (3) The fee shall be paid on an annual basis no later than August
1 of each year. The Department of Managed Health Care and the
Department of Insurance shall forward the assessments to the
Controller for deposit in the California Health Ombudsman Trust Fund
immediately following their receipt.  
   (j) 
    (l)  For purposes of this section, the following
definitions shall apply:
   (1) "Exchange" means the American Health Benefit Exchange
established in California under Section 1311 of the federal Patient
Protection and Affordable Care Act (Public Law 111-148).
   (2) "Group health plan" has the same meaning set forth in Section
2791 of the federal Public Health Service Act (42 U.S.C. 300gg-91).

   (3) "Health care service plan" or "specialized health care service
plan" has the same meaning as that set forth in subdivision (f) of
Section 1345.  
   (4) "Health insurance" has the same meaning as that set forth in
Section 106 of the Insurance Code.  
   (5) "Health insurer" means an insurer that issues policies of
health insurance. 
   136020.  (a) The California Health Ombudsman Trust Fund is hereby
created in the State Treasury for the purpose of this division.
Notwithstanding Section 13340 of the Government Code, all moneys in
the fund shall be continuously appropriated without regard to fiscal
year for the purposes of this division. Any moneys in the fund that
are unexpended or unencumbered at the end of the fiscal year may be
carried forward to the next succeeding fiscal year.
   (b) The ombudsman shall establish and maintain a prudent reserve
in the fund.
   (c) Notwithstanding Section 16305.7 of the Government Code, all
interest earned on moneys that have been deposited in the fund shall
be retained in the fund and used for purposes consistent with this
division.