BILL NUMBER: AB 922 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 20, 2011
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 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 transfer the Office of Patient Advocate 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 Housing Agency. The bill would add additional
duties and responsibilities to the existing duties of the Office of
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
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 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 Web site 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 Web site 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 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) (1) The duties of the office shall
include, but not be limited to, all of the following:
(1)
(A) 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)
(B) 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)
(C) 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.
(D) Providing direct assistance to consumers, if necessary,
including assistance in filing complaints, grievances, or appeals
with the appropriate regulator or public program.
(4)
(E) 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 ,
including assistance in filing complaints, grievances, or appeals
with the appropriate regulator or public program .
(5)
(F) Advising consumers on problems related to mental
health parity and coverage for substance abuse treatment, consistent
with existing state and federal law , including assistance in
filing complaints, grievances, or appeals with the appropriate
regulator or public program .
(6)
(G) Making referrals to the appropriate state agency
regarding studies, investigations, audits, or enforcement that may be
appropriate to protect the interests of consumers.
(7)
(H) Coordinating and working with other government and
nongovernment patient assistance programs and health care
ombudsperson programs.
(8)
(2) 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)
(3) 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)
(4) 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 , electronic,
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 number
that can route callers to the proper regulating body or
public program for their question, their health plan, or 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 gender, gender
identity, gender expression, 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.