BILL NUMBER: AB 922 ENROLLED
BILL TEXT
PASSED THE SENATE SEPTEMBER 7, 2011
PASSED THE ASSEMBLY SEPTEMBER 8, 2011
AMENDED IN SENATE SEPTEMBER 2, 2011
AMENDED IN SENATE AUGUST 31, 2011
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 13975 of the Government Code, and to amend
Sections 1341 and 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, 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. The California Health and Human
Services Agency consists of, among others, the State Department of
Health Care Services, the State Department of Mental Health, the
State Department of Public Health, and the State Department of Social
Services.
This bill would transfer the Department of Managed Health Care
and, effective July 1, 2012, the Office of Patient Advocate to the
California Health and Human Services Agency. The bill would delete
the requirement that the patient advocate be recommended to the
Governor by the Business, Transportation and Housing Agency. The
bill, effective January 1, 2013, 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, effective January 1, 2013,
would authorize the office to contract with community organizations,
subject to specified requirements, to provide certain services and
would also require the office to adopt certain standards and
procedures regarding those organizations. The bill, effective January
1, 2013, 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 authorize the office to request from the federal
government specified grant moneys.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 13975 of the Government Code is amended to
read:
13975. The Business and Transportation Agency in state government
is hereby renamed the Business, Transportation and Housing Agency.
The agency consists of the State Department of Alcoholic Beverage
Control, the Department of the California Highway Patrol, the
Department of Corporations, the Department of Housing and Community
Development, the Department of Motor Vehicles, the Department of Real
Estate, the Department of Transportation, the Department of
Financial Institutions, and the Board of Pilot Commissioners for the
Bays of San Francisco, San Pablo, and Suisun. The California Housing
Finance Agency is also located within the Business, Transportation
and Housing Agency, as specified in Division 31 (commencing with
Section 50000) of the Health and Safety Code.
SEC. 2. Section 1341 of the Health and Safety Code is amended to
read:
1341. (a) There is in state government, in the California Health
and Human Services Agency, a Department of Managed Health Care that
has charge of the execution of the laws of this state relating to
health care service plans and the health care service plan business
including, but not limited to, those laws directing the department to
ensure that health care service plans provide enrollees with access
to quality health care services and protect and promote the interests
of enrollees.
(b) The chief officer of the Department of Managed Health Care is
the Director of the Department of Managed Health Care. The director
shall be appointed by the Governor and shall hold office at the
pleasure of the Governor. The director shall receive an annual salary
as fixed in the Government Code. Within 15 days from the time of the
director's appointment, the director shall take and subscribe to the
constitutional oath of office and file it in the office of the
Secretary of State.
(c) The director shall be responsible for the performance of all
duties, the exercise of all powers and jurisdiction, and the
assumption and discharge of all responsibilities vested by law in the
department. The director has and may exercise all powers necessary
or convenient for the administration and enforcement of, among other
laws, the laws described in subdivision (a).
SEC. 3. 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. 4. 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) Effective July 1, 2012, there is hereby
transferred from the Department of Managed Health Care the Office of
Patient Advocate to be established within the California Health and
Human Services Agency, to provide assistance to, and advocate on
behalf of, individuals 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 individuals secure the health
care services to which they are entitled or for which they are
eligible under the law. Notwithstanding any provision of this
division, each regulator and health coverage program shall retain its
respective authority, including its authority to resolve complaints,
grievances, and appeals.
(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.
(3) The provisions of this division affecting insureds covered by
health insurers regulated by the Department of Insurance and
individuals who receive or are eligible for 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 shall commence on January 1, 2013, except that for the
period July 1, 2012, to January 1, 2013, the office shall continue
with any duties, responsibilities, or activities of the office
authorized as of July 1, 2011, shall continue to be authorized.
(b) (1) The duties of the office shall include, but not be limited
to, all of the following:
(A) Developing, in consultation with the Managed Risk Medical
Insurance Board, the State Department of Health Care Services, the
California Health Benefit Exchange, the Department of Managed Health
Care, and the Department of Insurance, 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.
(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.
(C) Rendering assistance to consumers regarding procedures,
rights, and responsibilities related to the filing of complaints,
grievances, and appeals, including appeals of coverage denials and
information about any external appeal process.
(D) Making referrals to the appropriate state agency regarding
studies, investigations, audits, or enforcement that may be
appropriate to protect the interests of consumers.
(E) Coordinating and working with other government and
nongovernment patient assistance programs and health care
ombudsperson programs.
(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.
(3) Until January 1, 2013, the office shall have access to records
of the Department of Managed Health Care, including, but not limited
to, information related to health care service plan or health
insurer audits, surveys, and enrollee or insured grievances.
(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.
(5) The office shall adopt standards for the organizations with
which it contracts pursuant to this section to ensure compliance with
the privacy and confidentiality laws of this state, including, but
not limited to, the Information Practices Act of 1977 (Chapter 1
(commencing with Section 1798) of Division 3 of the Civil Code). The
office shall conduct privacy trainings as necessary, and regularly
verify that the organizations have measures in place to ensure
compliance with this provision.
(c) In enacting this act, the Legislature recognizes that, because
of the enactment of federal health care reform on March 23, 2010,
and the implementation of various provisions by January 1, 2014, it
is appropriate to transfer the Office of Patient Advocate and to
confer new responsibilities on the Office of Patient Advocate,
including assisting consumers in obtaining health care coverage and
obtaining health care through health coverage that is regulated by
multiple regulators, both state and federal. The new responsibilities
include assisting consumers in navigating both public and private
health care coverage and assisting consumers in determining which
regulator regulates the health care coverage of a particular
consumer. In order to assist in implementing federal health care
reform in California, commencing January 1, 2013, the office, in
addition to the duties set forth in subdivision (b), shall also do
all of the following:
(1) Receive and respond to all inquiries, complaints, and requests
for assistance from individuals concerning health care coverage
available in California.
(2) Provide, and assist in the provision of, outreach and
education about health care coverage options as set forth in
subparagraph (A) of paragraph (1) of subdivision (b), including, but
not limited to:
(A) Information regarding applying for coverage; the cost of
coverage; and renewal in, and transitions between, health coverage
programs.
(B) Information and assistance regarding public programs, such as
Medi-Cal, Healthy Families, and Medicare; private coverage, including
employer-sponsored coverage, Exchange coverage, and other sources of
care if the consumer is not eligible for coverage, such as county
services, community clinics, discounted hospital care, or charity
care.
(3) Coordinate with other state and federal agencies engaged in
outreach and education regarding the implementation of federal health
care reform.
(4) Render assistance to, and advocate on behalf of, consumers
with problems related to health care services, including care and
service problems and claims or payment problems.
(5) Refer consumers to the appropriate regulator of their health
coverage programs for filing complaints, grievances, or claims, or
for payment problems.
(d) (1) Commencing January 1, 2013, the office shall track and
analyze data on problems and complaints by, and questions from,
consumers about health care coverage for the purpose of providing
public information about problems faced and information needed by
consumers in obtaining coverage and care. The data collected shall
include demographic data, source of coverage, regulator, and
resolution of complaints, including timeliness of resolution.
(2) The Department of Managed Health Care, the Department of
Health Care Services, the Department of Insurance, the Managed Risk
Medical Insurance Board, the California Health Benefit Exchange, and
other public coverage programs shall provide to the office data in
the aggregate concerning consumer complaints and grievances. For the
purpose of publicly reporting information about the problems faced by
consumers in obtaining care and coverage, the office shall analyze
data on consumer complaints and grievances resolved by these
agencies, including demographic data, source of coverage, insurer or
plan, resolution of complaints and other information intended to
improve health care and coverage for consumers. The office shall
develop and provide comprehensive and timely data and analysis based
on the information provided by other agencies.
(3) The office shall collect and report data to the United States
Secretary of Health and Human Services on complaints and consumer
assistance as required to comply with requirements of the federal
Patient Protection and Affordable Care Act (Public Law 111-148).
(e) Commencing in January 1, 2013, in order to assist consumers in
understanding the impact of federal health care reform as well as
navigating and resolving questions and problems with health care
coverage and programs, the office shall ensure that either the office
or a state agency contracting with the office shall do the
following:
(1) Operate a 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.
(2) Operate a Internet Web site, other social media, and
up-to-date communication systems to give information regarding the
consumer assistance programs.
(f) (1) The office may contract with community-based consumer
assistance organizations to assist in any or all of the duties of
subdivision (c) in accordance with Section 19130 of the Government
Code or provide grants to community-based consumer assistance
organizations for portions of these purposes.
(2) Commencing on January 1, 2013, any local community-based
nonprofit consumer assistance program with which the office contracts
shall include in its mission the assistance of, and duty to, health
care consumers. Contracting consumer assistance programs shall have
experience in the following areas:
(A) Assisting consumers in navigating the local health care
system.
(B) Advising consumers regarding their health care coverage
options and helping consumers enroll in and retain health care
coverage.
(C) Assisting consumers with problems in accessing health care
services.
(D) 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.
(E) Collecting and reporting data, including demographic data,
source of coverage, regulator, and resolution of complaints,
including timeliness of resolution.
(3) Commencing on January 1, 2013, the office shall develop
protocols, procedures, and training modules for organizations with
which it contracts.
(4) Commencing on January 1, 2013, the office shall adopt
standards for organizations with which it contracts regarding
confidentiality and conduct.
(5) Commencing on January 1, 2013, 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.
(g) (1) Commencing on January 1, 2013, the office shall develop
protocols and procedures for assisting in the resolution of consumer
complaints, including both of the following:
(1) A procedure for referral of complaints and grievances to the
appropriate regulator or health coverage program for resolution by
the relevant regulator or public program.
(2) A protocol or procedure for reporting to the appropriate
regulator and health coverage program regarding complaints and
grievances relevant to that agency that the office received and was
able to resolve without further action or referral.
(h) 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) "Health care" includes behavioral health, including both
mental health and substance abuse treatment.
(4) "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.
(5) "Health coverage program" includes the Medi-Cal program,
Healthy Families Program, tax subsidies and premium credits under the
Exchange, the Basic Health Program, if enacted, county health
coverage programs, and the Access for Infants and Mothers Program.
(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" shall have the same meaning as for
Medi-Cal managed care.
136020. (a) Effective July 1, 2012, 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) Effective July 1, 2012, 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. For the 2012-13 budget year, the apportionment shall be
effective for the period from January 1, 2013, to July 1, 2013,
consistent with paragraph (1) of subdivision (a) of Section 136000.
(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 may 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.