BILL NUMBER: AB 922 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MAY 27, 2011
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. Patient Advocate.
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 , which is headed by a patient advocate
recommended to the Governor by the Business, Transportation and
Housing Agency. The Office of Patient Advocate is responsible for,
among other things, developing educational and informational guides
for consumers, compiling an annual publication of a quality of care
report card, and rendering advice and assistance to enrollees. The
annual budget of the Office of Patient Advocate is separately
identified in the annual budget request of the department
.
This bill would eliminate transfer
the Office of Patient Advocate and would instead create an
Office of Health Consumer Assistance from the
Department of Managed Health Care to instead operate as an
independent state entity, and delete the requirement that the patient
advocate be recommended to the Governor by the Business,
Transportation and Housin g Agency . The bill would
impose specified add additional duties
and responsibilities on to the existing
duties of the Office of Health Consumer Assistance
Patient Advocate 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 provide that funding for the actual and
necessary expenses of the office shall be provided, subject to
appropriation by the Legislature, from transfers of moneys from the
Managed Care Fund and the Insurance Fund, to be based on the number
of covered lives in the state that are covered by plans or insurers,
as determined by the Department of Managed Health Care and the
Department of Insurance, in proportion to the total number of covered
lives in the state. The bill would establish the
California Health Consumer Assistance Office of
Patient Advocate 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 also 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 and require the office to
request from the federal government specified grant moneys .
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.
(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.
SEC. 2. Division 115 (commencing with Section
136000) is added to the Health and Safety Code
, to read:
DIVISION 115. Office of Patient Advocate
136000. (a) (1) There is hereby transferred from the Department
of Managed Health Care the Office of Patient Advocate to operate as
an independent entity within state government, 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 of Managed Health Care, insureds
covered by health insurers regulated by the Department of Insurance,
and individuals who receive or are eligible for other health care
coverage in California, including coverage available through the
Medi-Cal program, the California Health Benefit Exchange, the Healthy
Families Program, or any other county or state health care program.
The goal of the office shall be to help those enrollees, insureds,
and individuals to secure health care coverage to which they are
entitled under the law.
(2) The office shall be headed by a patient advocate appointed by
the Governor. The patient advocate shall serve at the pleasure of the
Governor.
(b) The duties of the office shall include, but not be limited to,
all of the following:
(1) Developing educational and informational guides for consumers
describing their rights and responsibilities, and informing them on
effective ways to exercise their rights to secure health care
coverage. The guides shall be easy to read and understand and shall
be made available in English and other threshold languages, using an
appropriate literacy level, and in a culturally competent manner. The
informational guides shall be made available to the public by the
office, including being made accessible on the office's Internet Web
site and through public outreach and educational programs.
(2) Compiling an annual publication, to be made available on the
office's Internet Web site, of a quality of care report card,
including, but not limited to, health care service plans.
(3) Rendering advice and assistance to consumers regarding the
filing of complaints, grievances, and appeals, including appeals of
denials of care 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, group health
plan, or other county or state health care program involved, and
provide information about any external appeal process.
(4) Rendering advice and assistance to consumers with problems
related to health care services, including care and service problems
and claims or payment problems. Explaining how to resolve these
problems and providing direct assistance, if needed.
(5) Advising consumers on problems related to mental health parity
and coverage for substance abuse treatment, consistent with existing
state and federal law.
(6) Making referrals to the appropriate state agency regarding
studies, investigations, audits, or enforcement that may be
appropriate to protect the interests of consumers.
(7) Coordinating and working with other government and
nongovernment patient assistance programs and health care
ombudsperson programs.
(8) The office shall employ necessary staff. The office may employ
or contract with experts when necessary to carry out the functions
of the office. The patient advocate shall make an annual budget
request for the office which shall be identified in the annual budget
act.
(9) The office shall have access to records of the Department of
Managed Health Care and the Department of Insurance, including, but
not limited to, information related to health care service plan or
health insurer audits, surveys, and enrollee or insured grievances.
(10) 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.
(c) The office shall also do all of the following:
(1) 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.
(2) Provide outreach and education about health care coverage
options, including, but not limited to:
(A) Information regarding applying for coverage; the cost of
coverage; renewal in, and transitions between, health coverage
programs; and education about how to navigate the health care arena,
including what health care 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.
(B) Information and referral for all types of payers, including
public programs such as Medi-Cal, Healthy Families, and Medicare;
private coverage, including employer-sponsored coverage, self-insured
plans, unsubsidized Exchange coverage, and Exchange coverage with
tax subsidies or tax credits; and other sources of care, such as
county services, community clinics, discounted hospital care, or
charity care.
(3) Educate consumers on their rights and responsibilities with
respect to health care coverage.
(4) Advise and assist consumers with resolving problems with
obtaining premium tax credits under Section 36B of the Internal
Revenue Code.
(d) The office may contract with community-based consumer
assistance organizations to assist in any or all of the duties of
subdivisions (b) and (c).
(e) (1) The office 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 (n). The office shall publicly
report its analysis of these problems and inquiries at least
quarterly on its Internet Web site.
(2) The office shall track, analyze, and publicly report on
complaints reported to the office under subdivision (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, gender identity, gender expression, 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 shall track, analyze, and report on those
complaints by all of the following:
(A) Health insurer or health care service plan.
(B) Health status, age, race, ethnicity, language preference,
geographic region, gender, gender identity, gender expression, and
sexual orientation.
(C) The type of health care coverage program.
(D) The timeliness of resolution of complaints.
(4) In analyzing and reporting complaints, the office 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 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 limited-English-proficient 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 and any local community-based nonprofit consumer
assistance programs with which the office contracts shall include in
their mission assistance of, and duty to, 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 consumers enroll in and retain health care
coverage.
(3) 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, including
behavioral health.
(5) Collecting and reporting data on the categories of populations
listed in subdivision (e), including subgroup categories of race,
ethnicity, language preference, gender, gender identity, gender
expression, and sexual orientation, and types of health care coverage
problems consumers face.
(h) Consumer assistance programs that contract with the office 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 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 shall develop protocols, procedures, and training
modules for organizations with which it contracts. The office shall
implement and oversee a training program with continuing education
components for organizations with which it contracts.
(k) The office 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.
(l) The office 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.
(m) The office 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 Health Insurance Counseling and Advocacy Program as
provided in Section 9541 of the Welfare and Institutions Code and, as
appropriate, the federal 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 (Part
6.6 (commencing with Section 12739.5) of Division 2 of the Insurance
Code).
(7) The Exchange regarding coverage through the Exchange.
(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 regarding consumer complaints submitted to those agencies,
including, but not limited to, the nature of the complaints, the
resolution of the complaints, the timeliness of the resolution, and
the health status, age, race, ethnicity, language, geographic region,
and gender or sexual orientation of the complainants, in a format
and manner to be specified by the office. This information shall be
reported according to the particular health insurer or health care
service plan involved.
(o) For purposes of this section, the following definitions shall
apply:
(1) "Consumer" or "individual" includes the individual or his or
her parent, guardian, conservator, or authorized representative.
(2) "Exchange" means the California Health Benefit Exchange
established pursuant to Title 22 (commencing with Section 100500) of
the Government Code.
(3) "Group health plan" has the same meaning set forth in Section
2791 of the federal Public Health Service Act (42 U.S.C. Sec.
300gg-91).
(4) "Health care" includes behavioral health, including both
mental health and substance abuse treatment.
(5) "Health care service plan" has the same meaning as that set
forth in subdivision (f) of Section 1345. Health care service plan
includes "specialized health care service plans," including
behavioral health plans.
(6) "Health insurance" has the same meaning as set forth in
Section 106 of the Insurance Code.
(7) "Health insurer" means an insurer that issues policies of
health insurance.
(8) "Office" means the Office of Patient Advocate.
(9) "Threshold languages" are languages spoken by at least 20,000
or more limited-English-proficient health consumers residing in
California.
136020. (a) The Office of Patient Advocate 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 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. (a) In addition to the moneys received pursuant to
subdivision (d), funding for the actual and necessary expenses of the
office in implementing this division shall be provided, subject to
appropriation by the Legislature, from transfers of moneys from the
Managed Care Fund and the Insurance Fund.
(b) The share of funding from the Managed Care Fund shall be based
on the number of covered lives in the state that are covered under
plans regulated by the Department of Managed Health Care, including
covered lives under Medi-Cal managed care and the Healthy Families
Program, as determined by the Department of Managed Health Care, in
proportion to the total number of all covered lives in the state.
(c) The share of funding to be provided from the Insurance Fund
shall be based on the number of covered lives in the state that are
covered under health insurance policies and benefit plans regulated
by the Department of Insurance, including covered lives under
Medicare supplement plans, as determined by the Department of
Insurance, in proportion to the total number of all covered lives in
the state.
(d) In addition to moneys received pursuant to subdivision (a),
the office may receive funding as follows:
(1) The office may apply to the United States Secretary of Health
and Human Services for federal grants.
(2) The office 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).
(3) To the extent permitted by federal law, the office may seek
federal financial participation for assisting beneficiaries of the
Medi-Cal program.
(e) All moneys received by the Office of Patient Advocate shall be
deposited into the fund specified in Section 136020.
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.
(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.
(4) Educate consumers on their rights and responsibilities with
respect to health care coverage.
(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.
(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.
(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.
(8) Advise and assist consumers with resolving problems with
obtaining premium tax credits under Section 36B of the Internal
Revenue Code.
(9) Provide the assistance and education described in this
subdivision to consumers with limited English language proficiency in
their primary oral 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 (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 (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 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) 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, 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.
(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.
(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.
(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.
(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.
(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.