Senate Bill No. 1159

Introduced by Senator Hernandez

February 18, 2016

An act to amend Section 136000 of the Health and Safety Code, relating to health care.

LEGISLATIVE COUNSEL’S DIGEST

SB 1159, as introduced, Hernandez. Health Care: Office of Patient Advocate.

Existing law establishes the Office of Patient Advocate within the California Health and Human Services Agency, to provide assistance to, and advocate on behalf of, health care consumers. The duties of the office, include, among other things, compiling an annual publication, to be made available on the office’s Internet Web site, of specified information relating to certain publicly operated consumer assistance centers.

This bill would require the office to log, and include in the annual publication, a call center’s record of answering calls within 30 seconds, the number of abandoned calls, and the number of busy messages sent to consumers.

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 136000 of the Health and Safety Code
is amended to read:

136000.  

(a) (1) The Office of Patient Advocate is hereby
established within the California Health and Human Services
Agency, to provide assistance to, and advocate on behalf of, health
care consumers. The goal of the office shall be to coordinate
amongst, provide assistance to, and collect data from, all of the
state agency consumer assistance or patient assistance programs
and call centers, to better enable health care consumers to access
the health care services to which they are eligible under the law,
including, but not limited to, commercial and Exchange coverage,
Medi-Cal, Medicare, and federal veterans health benefits.
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.

(b) (1) The duties of the office shall include, but not be limited
to, all of the following:

(A) Coordinate and work in consultation with state agency and
local, nongovernment health care consumer or patient assistance
programs and health care ombudsperson programs.

(B) Produce a baseline review and annual report to be made
publically available on the office’s Internet Web site by July 1,
2015, and annually thereafter, of health care consumer or patient
assistance help centers, call centers, ombudsperson, or other
assistance centers operated by the Department of Managed Health
Care, the Department of Health Care Services, the Department of
Insurance, and the Exchange, that includes, at a minimum, all of
the following:

(i) The types of calls received and the number of calls.

(ii) The call center’s role with regard to each type of call,
question, complaint, or grievance.

(iii) The call center’s protocol for responding to requests for
assistance from health care consumers, including any performance
standards.

(iv) The protocol for referring or transferring calls outside the
jurisdiction of the call center.

(v) The call center’s methodology of tracking calls, complaints,
grievances, or inquiries.

begin insert

(vi) The call center’s record of answering calls within 30
seconds, the number of abandoned calls, and the number of busy
messages sent to consumers.

end insert

(C) (i) Collect, 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, type of problem or issue or
comparable types of problems or issues, and resolution of
complaints, including timeliness of resolution. Notwithstanding
Section 10231.5 of the Government Code, the office shall submit
a report by July 1, 2015, and annually thereafter to the Legislature.
The report shall be submitted in compliance with Section 9795 of
the Government Code. The format may be modified annually as
needed based upon comments from the Legislature and
stakeholders.

(ii) For the purpose of publically reporting information as
required in subparagraph (B) and this subparagraph about the
problems faced by consumers in obtaining care and coverage, the
office shall analyze data on consumer complaints and grievances
resolved by the agencies listed in subdivision (c), including
demographic data, source of coverage, insurer or plan, resolution
of complaints, and other information intended to improve health
care and coverage for consumers.

(D) Make recommendations, in consultation with stakeholders,
for improvement or standardization of the health consumer
assistance functions, referral process, and data collection and
analysis.

(E) Develop model protocols, in consultation with consumer
assistance call centers and stakeholders, that may be used by call
centers for responding to and referring calls that are outside the
jurisdiction of the call center, program, or regulator.

(F) Compile an annual publication, to be made publically
available on the office’s Internet Web site, of a quality of care
report card, including, but not limited, to health care service plans,
preferred provider organizations, and medical groups.

(G) Make referrals to the appropriate state agency, whether
further or additional actions may be appropriate, to protect the
interests of consumers or patients.

(H) Assist in the development of educational and informational
guides for consumers and patients describing their rights and
responsibilities and informing them on effective ways to exercise
their rights to secure and access health care coverage, produced
by the Department of Managed Health Care, the Department of
Health Care Services, the Exchange, and the California Department
of Insurance, and to endeavor to make those materials easy to read
and understand and available in all threshold languages, using an
appropriate literacy level and in a culturally competent manner.

(I) Coordinate with other state and federal agencies engaged in
outreach and education regarding the implementation of federal
health care reform, and to assist in these duties, may provide or
assist in the provision of grants to community-based consumer
assistance organizations for these purposes.

(J) If appropriate, refer consumers to the appropriate regulator
of their health coverage programs for filing complaints or
grievances.

(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 that shall be identified in the annual
Budget Act.

(3) 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.

(4) 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 Title 1.8 of Part 4 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) The Department of Managed Health Care, the Department
of Health Care Services, the Department of Insurance, the
Exchange, and any other public health coverage programs shall
provide to the office data concerning call centers to meet the
reporting requirements in subparagraph (B) of paragraph (1) of
subdivision (b) and consumer complaints and grievances to meet
the reporting requirements in clause (i) of subparagraph (C) of
paragraph (1) of subdivision (b).

(d) For purposes of this section, the following definitions 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 services provided by any of the health
care coverage programs.

(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” has the same meaning as for
Medi-Cal managed care.