BILL NUMBER: AB 922 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MARCH 29, 2011
INTRODUCED BY Assembly Member Monning
FEBRUARY 18, 2011
An act to amend Section 1368.02 of, and to add Division 115
(commencing with Section 136000) to, the Health and Safety Code,
relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 922, as amended, Monning. Office of Health Consumer Assistance.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the regulation of health care service plans by the
Department of Managed Health Care. Existing law provides for the
regulation of health insurers by the Department of Insurance.
Existing law creates within the Department of Managed Health Care an
Office of Patient Advocate to assist enrollees with regard to health
care coverage.
This bill would eliminate the Office of Patient Advocate and would
instead create an Office of Health Consumer Assistance. The bill
would impose specified duties and responsibilities on the Office of
Health Consumer Assistance with regard to providing outreach and
education about health care coverage to consumers. The bill would
authorize the office to contract with community organizations to
provide those services and would require the office
to adopt certain standards and procedures regarding those
organizations . The bill would require specified state agencies
to report to the office regarding consumer complaints submitted to
those agencies by individuals with complaints about their health care
coverage. The bill would establish the California Health Consumer
Assistance Trust Fund for those purposes and would make moneys
deposited into that fund available for purposes of administering the
program, subject to appropriation by the Legislature. The bill would
authorize the office to apply to the federal government for moneys to
fund the office and would transfer moneys used to support the Office
of Patient Advocate to the fund.
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."
SEC. 2. Division 115 (commencing with Section 136000) is added to
the Health and Safety Code, to read:
DIVISION 115. Office of Health Consumer Assistance
136000. (a) There is hereby created in state government an
independent office of health coverage consumer assistance called the
Office of Health Consumer Assistance. The office shall be under the
direction of a chief executive officer who shall be known as the
Director of the Office of Health Consumer Assistance. The director
shall be appointed by the Governor, subject to confirmation by the
Senate.
(b) The Office of Health Consumer Assistance shall receive and
respond to all telephonic and in-person inquiries, complaints, and
requests for assistance from individuals concerning all health care
coverage available in California, including coverage available
through the Medi-Cal program, the Exchange, the Healthy Families
Program (Part 6.2 (commencing with Section 12693) of Division 2 of
the Insurance Code), or any other county or state public health
program, or individual or group coverage available through health
care service plans under Chapter 2.2 (commencing with Section 1340)
of Division 2 or health insurers under Part 2 (commencing with
Section 10110) of Division 2 of the Insurance Code.
(c) The office shall do all of the following:
(1) Develop educational and informational guides for consumers
describing their rights and responsibilities and informing consumers
on effective ways to exercise their rights to secure health care
services. The guides shall be easy to read and understand, shall be
available in English and threshold languages, and shall be made
available to the public by the office, including on the office's
Internet Web site and through public outreach and educational
programs.
(2) Compile data and prepare an annual publication, to be made
available on the office's Internet Web site, that provides a quality
of care report card, including, but not limited to, health care
service plans and health insurers.
(1)
(3) Provide outreach and education about health care
coverage options including, but not limited to, information regarding
the cost of coverage and education about how to navigate the health
care arena, including what health services a plan or insurer
offers or provides, how to select a plan or insurer
, and how to find a doctor or other health care provider.
(2)
(4) Educate consumers on their rights and
responsibilities with respect to health care coverage.
(3)
(5) Advise and assist consumers regarding eligibility
for health care coverage, including enrollment in, retention in, and
transitions between, health care coverage programs by providing
information, referral, and direct application assistance for all
types of payors, including public programs such as Medi-Cal, Healthy
Families, Medicare, private individual coverage, employer-sponsored
coverage, ERISA plans, charity care, unsubsidized Exchange coverage,
and Exchange coverage with tax subsidies or tax credits .
(4)
(6) Advise and assist consumers with problems related
to health care services, including care and service problems and
claims or payment problems. Explain how to resolve these problems and
provide direct assistance, if needed.
(5)
(7) Advise and assist consumers with the filing of
complaints and appeals, including appeals of coverage denials with
the health care coverage program denying eligibility, and appeals
with the internal appeal or grievance process of the health care
service plan, health insurer, or group health plan involved, and
provide information about any external appeal process.
(6)
(8) Advise and assist consumers with resolving problems
with obtaining premium tax credits under Section 36B of the Internal
Revenue Code.
(7)
(9) Provide the assistance and education described in
this subdivision to consumers with limited English language
proficiency in their primary oral and written language,
using an appropriate literacy level for written material
languages, and provide written materials in threshold languages
using an appropriate literacy level , and in a culturally
competent manner.
(d) The Office of Health Consumer Assistance may contract with
community-based consumer assistance organizations to assist in
any or all of the requirements of subdivisions (b) and (c).
(e) (1) The Office of Health Consumer Assistance shall 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 network of health consumer
assistance organizations and the agencies under subdivision
(m) (n) . The Office of Health Consumer
Assistance shall publicly report its analysis of these problems and
inquiries at least quarterly on its Internet Web site.
(2) The Office of Health Consumer Assistance shall track, analyze,
and publicly report on complaints reported to the Office of Health
Consumer Assistance under subdivision (m) (n)
according to the nature and resolution of the complaints and,
including, but not limited to, the health status, age, race,
ethnicity, language, geographic region, gender, or sexual orientation
of the complainants in order to identify the most common types of
problems and the problems faced by particular populations, including
any health disparity population.
(3) The Office of Health Consumer Assistance shall track, analyze,
and report on those complaints by health insurer or health care
service plan , by race, ethnicity, and language preference,
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 by each health insurer or
health care service plan and in each health care coverage program.
(f) In order to assist consumers in navigating and resolving
problems with health care coverage and programs, the Office of Health
Consumer Assistance shall do the following:
(1) Operate a HealthHelp toll-free telephone hotline that can
route callers to the consumer assistance program in their area and
provide interpreters for LEP
limited-English-proficient (LEP) callers.
(2) Operate a HealthHelp Internet Web site, other social media,
and up-to-date communication systems to give information regarding
the consumer assistance programs.
(g) The Office of Health Consumer Assistance and any local
community-based nonprofit consumer assistance programs that they
contract with shall have as their primary mission assistance of
health care consumers. Contracting consumer assistance programs shall
have experience in the following areas:
(1) Assisting consumers in navigating the local health care
system.
(2) Advising consumers regarding their health care coverage
options and helping enroll consumers in and retaining health care
coverage.
(3) Resolving consumer problems Assisting
consumers with problems in accessing health care services.
(4) Serving consumers with special needs, including, but not
limited to, consumers with limited-English language proficiency,
consumers requiring culturally competent services, low-income
consumers, consumers with disabilities, consumers with low literacy
rates, and consumers with multiple health conditions.
(5) Collecting and reporting data on the categories of populations
listed in subdivision (e), including subgroup categories of race,
ethnicity, language preference, and types of health care
coverage problems consumers face.
(h) Consumer assistance programs that contract with the Office of
Health Consumer Assistance to provide direct consumer assistance
shall qualify as navigators pursuant to paragraph (1) of subdivision
(l) of Section 100502 of the Government Code.
(i) The Office of Health Consumer Assistance shall collect and
report data to the United States Secretary of Health and Human
Services on the categories of populations listed in subdivision (e),
including subgroup categories of race, and types of problems and
inquiries encountered by consumers.
(j) The Office of Health Consumer Assistance shall develop
protocols and procedures and training modules for consumer assistance
programs.
(j) The Office of Health Consumer Assistance shall develop
protocols, procedures, and training modules for organizations with
which it contracts. The office shall implement and oversee a training
program for organizations with which it contracts with continuing
education components.
(k) The Office of Health Consumer Assistance shall adopt standards
for organizations with which it contracts regarding confidentiality
and conduct. The office shall have the power to revoke the contract
of any organization that violates these standards and shall include a
clause reserving that power in every contract entered into with such
an organization.
(k)
(l) The Office of Health Consumer Assistance may
contract with consumer assistance programs to develop a series of
appropriate literacy level and culturally and linguistically
appropriate educational materials in all threshold languages for
consumers regarding health care coverage options and how to resolve
problems. These materials shall be made available to all consumer
assistance programs and on the Internet Web site of the Office of
Health Consumer Assistance.
(l)
(m) The Office of Health Consumer Assistance 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 regarding employee welfare
benefit plans regulated under ERISA.
(2) The Centers for Medicare and Medicaid Services regarding the
Medicare Program.
(3) The Department of Managed Health Care regarding coverage
under health care service plans regulated under Chapter 2.2
(commencing with Section 1340) of Division 2.
(4) The Department of Insurance regarding policies of health
insurance regulated under the Insurance Code.
(5) The State Department of Health Care Services regarding the
Medi-Cal program.
(6) The Managed Risk Medical Insurance Board regarding 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 Part 6.6 (commencing with Section 12739.5) of
Division 2 of the Insurance Code.
(7) The Exchange regarding coverage through the Exchange.
(m)
(n) 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 Office of Health Consumer Assistance
regarding consumer complaints submitted to those agencies, including
the nature of the complaints, the resolution of the complaints, and
the timeliness of the resolution, and further including, but not
limited to, the health status, age, race, ethnicity, language,
geographic region, gender, or sexual orientation of the complainants.
This information shall be reported according to the particular
health insurer or health care service plan involved.
(n)
(o) (1) The Office of Health Consumer Assistance 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).
(2) To the extent permitted by federal law, the Office of Health
Consumer Assistance may seek federal financial participation for
assisting beneficiaries of the Medi-Cal program.
(3) To the extent permitted by federal law, the Office of Health
Consumer Assistance may seek federal funding through the federal
Children's Health Insurance Program Reauthorization Act outreach
grants.
(o)
(p) For purposes of this section, the following
definitions shall apply:
(1) "Exchange" means the California Health Benefit Exchange
established pursuant to Title 22 (commencing with Section 100500) of
the Government Code.
(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 set forth in
Section 106 of the Insurance Code.
(5) "Health insurer" means an insurer that issues policies of
health insurance.
(6) For purposes of this section, "threshold languages" are
languages spoken by at least 20,000 or more
limited-English-proficient (LEP) health consumers residing in
California.
136020. (a) The California Health Consumer Assistance Trust Fund
is hereby created in the State Treasury, and, upon appropriation by
the Legislature, moneys in the fund shall be made available for the
purpose 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 Office of Health Consumer Assistance 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.
136030. Funds allocated to support the Office of the Patient
Advocate shall be transferred to the California Health Consumer
Assistance Trust Fund.