BILL NUMBER: AB 2787 AMENDED
BILL TEXT
AMENDED IN SENATE MAY 27, 2010
AMENDED IN ASSEMBLY MAY 10, 2010
INTRODUCED BY Assembly Member Monning
( Principal coauthor: Senator
Alquist )
MARCH 9, 2010
An act to amend Section 14132.27 of the Welfare and
Institutions Code, relating to Medi-Cal. An act
relating to health care coverage, and making an appropriation
therefor.
LEGISLATIVE COUNSEL'S DIGEST
AB 2787, as amended, Monning. Medi-Cal: Disease
Management Waiver. Office of the California Health
Ombudsman.
Existing law, the federal Patient Protection and Affordable Care
Act, requires the United States Secretary of Health and Human
Services to award grants to states to enable them to establish,
expand, or provide support for offices of health insurance consumer
assistance or health insurance ombudsman programs and imposes
specified eligibility requirements on states in order to receive
those grants.
This bill would establish the Office of the California Health
Ombudsman in state government, to be governed by a chief executive
officer known as the California Health Ombudsman who would be
appointed in an unspecified manner. The bill would require the
ombudsman to, among other things, educate consumers on their rights
and responsibilities with respect to health care coverage, assist
consumers with enrollment in health care coverage, and resolve
problems with obtaining specified premium tax credits. The bill would
require the ombudsman to apply to the United States Secretary of
Health and Human Services for a grant to implement these requirements
and would create the California Health Ombudsman Trust Fund as a
continuously appropriated fund in the State Treasury for purposes of
the act.
Existing law establishes the Medi-Cal program, administered by the
State Department of Health Care Services, under which basic health
care services are provided to qualified low-income persons. Existing
law requires the department to apply for a waiver of federal law to
test the efficacy of providing a disease management benefit, as
described, to specified beneficiaries under the Medi-Cal program.
Existing law requires the department to submit an evaluation of the
effectiveness of the waiver to the appropriate policy and fiscal
committees of the Legislature on or before January 1, 2008.
This bill would, instead, require the department to submit this
evaluation on or before July 1, 2011, and would also require the
department to include recommendations for modifications that should
be made prior to a statewide implementation of the waiver.
Vote: majority. Appropriation: no yes
. Fiscal committee: yes. State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. (a) There is hereby created in state
government an independent office of health care coverage consumer
assistance called the Office of the California Health Ombudsman. The
office shall operate in compliance with the criteria established by
the United States Secretary of Health and Human Services and shall be
under the direction of a chief executive officer who shall be known
as the California Health Ombudsman. The ombudsman shall be appointed
by ____.
(b) The ombudsman shall, in coordination with the Department of
Managed Health Care, the Department of Insurance, and consumer
assistance organizations, receive and respond to inquiries and
complaints concerning health care coverage with respect to
requirements under federal and state law.
(c) The ombudsman shall do all of the following with respect to
all health care coverage available in California, including coverage
available through public programs and coverage available through
health care service plans under Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code and health insurers
under Part 2 (commencing with Section 10110) of Division 2 of the
Insurance Code:
(1) Assist with the filing of complaints and appeals, including
appeals with the internal appeal or grievance process of the health
care service plan, health insurer, or group health plan involved, and
providing information about any external appeal process.
(2) Collect, track, and quantify problems and inquiries
encountered by consumers with respect to health care coverage.
(3) Educate consumers on their rights and responsibilities with
respect to health care coverage.
(4) Assist consumers with enrollment in health care coverage by
providing information, referral, and assistance.
(5) Resolve problems with obtaining premium tax credits under
Section 36B of the Internal Revenue Code.
(d) In order to carry out the duties described in subdivision (c),
the ombudsman shall utilize a network of local community-based
non-profit consumer assistance programs with experience in the
following areas:
(1) Assisting consumers in navigating the local health care
system.
(2) Enrolling consumers in health care coverage.
(3) Resolving consumer problems associated with health care
access.
(4) Serving consumers with special needs, including, but not
limited to, consumers with limited English language proficiency,
low-income consumers, consumers with disabilities, and consumers with
multiple health conditions.
(5) Collecting and reporting data on the types of health care
coverage problems consumers face.
(e) The ombudsman shall collect and report data to the United
States Secretary of Health and Human Services on the types of
problems and inquiries encountered by consumers.
(f) The ombudsman 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), to implement the requirements of this section.
(g) For purposes of this section, "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).
SEC. 2. (a) The California Health Ombudsman Trust
Fund is hereby created in the State Treasury for the purpose of this
act. Notwithstanding Section 13340 of the Government Code, all moneys
in the fund shall be continuously appropriated without regard to
fiscal year for the purposes of this act. 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 ombudsman 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
act.
SECTION 1. Section 14132.27 of the Welfare and
Institutions Code is amended to read:
14132.27. (a) (1) The department shall apply for a waiver of
federal law pursuant to Section 1396n of Title 42 of the United
States Code to test the efficacy of providing a disease management
benefit to beneficiaries under the Medi-Cal program. A disease
management benefit shall include, but not be limited to, the use of
evidence-based practice guidelines, supporting adherence to care
plans, and providing patient education, monitoring, and healthy
lifestyle changes.
(2) The waiver developed pursuant to this section shall be known
as the Disease Management Waiver. The department shall submit any
necessary waiver applications or modifications to the Medicaid State
Plan to the federal Centers for Medicare and Medicaid Services to
implement the Disease Management Waiver, and shall implement the
waiver only to the extent federal financial participation is
available.
(b) The Disease Management Waiver shall be designed to provide
eligible individuals with a range of services that enable them to
remain in the least restrictive and most homelike environment while
receiving the medical care necessary to protect their health and
well-being. Services provided pursuant to this waiver program shall
include only those not otherwise available under the state plan, and
may include, but are not limited to, medication management,
coordination with a primary care provider, use of evidence-based
practice guidelines, supporting adherence to a plan of care, patient
education, communication and collaboration among providers, and
process and outcome measures. Coverage for those services shall be
limited by the terms, conditions, and duration of the federal waiver.
(c) Eligibility for the Disease Management Waiver shall be limited
to those persons who are eligible for the Medi-Cal program as aged,
blind, and disabled persons or those persons over 21 years of age who
are not enrolled in a Medi-Cal managed care plan, or eligible for
the federal Medicare program, and who are determined by the
department to be at risk of, or diagnosed with, select chronic
diseases, including, but not limited to, advanced atherosclerotic
disease syndromes, congestive heart failure, and diabetes.
Eligibility shall be based on the individual's medical diagnosis and
prognosis, and other criteria, as specified in the waiver.
(d) The Disease Management Waiver shall test the effectiveness of
providing a Medi-Cal disease management benefit. The department shall
evaluate the effectiveness of the Disease Management Waiver.
(1) The evaluation shall include, but not be limited to,
participant satisfaction, health and safety, the quality of life of
the participant receiving the disease management benefit, and
demonstration of the cost neutrality of the Disease Management Waiver
as specified in federal guidelines.
(2) The evaluation shall estimate the projected savings, if any,
in the budgets of state and local governments if the Disease
Management Waiver was expanded statewide.
(3) (A) The evaluation shall be submitted to the appropriate
policy and fiscal committees of the Legislature on or before July 1,
2011, and shall include recommendations for modifications that should
be made prior to a statewide implementation of the Disease
Management Waiver.
(B) The requirement for submitting the evaluation imposed under
this paragraph is inoperative on July 1, 2015, pursuant to Section
10231.5 of the Government Code.
(C) The evaluation to be submitted pursuant to this paragraph
shall be submitted in compliance with Section 9795 of the Government
Code.
(e) The department shall limit the number of participants in the
Disease Management Waiver during the initial three years of its
operation to a number that will be statistically significant for
purposes of the waiver evaluation and that meets any requirements of
the federal government, including a request to waive statewide
implementation requirements for the waiver during the initial years
of evaluation.
(f) In undertaking this Disease Management Waiver, the director
may enter into contracts for the purpose of directly providing
Disease Management Waiver services.
(g) The department shall seek all federal waivers necessary to
allow for federal financial participation under this section.
(h) The Disease Management Waiver shall be developed and
implemented only to the extent that funds are appropriated or
otherwise available for that purpose.
(i) The department shall not implement this section if any of the
following apply:
(1) The department's application for federal funds under the
Disease Management Waiver is not accepted.
(2) Federal funding for the waiver ceases to be available.