BILL NUMBER: AB 2787 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 22, 2010
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 add Section 1374.18 to, and to add Division 115
(commencing with Section 136000) to, the Health and Safety Code,
relating to health care coverage, and making an appropriation
therefor.
LEGISLATIVE COUNSEL'S DIGEST
AB 2787, as amended, Monning. 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 also require the ombudsman to operate a specified hotline and
Internet Web site and would require that the telephone number and Web
site be included on every membership card and evidence of coverage
issued to Medi-Cal beneficiaries and to individuals with coverage
under health care service plans or health insurers. 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. The bill would also impose fees on health
care service plans and health insurers for purposes of funding these
provisions, as specified.
Vote: majority. Appropriation: yes. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. There is hereby created in state
government
SECTION 1. Division 115 (commencing with Sec
tion 136000) is added to the Health and Safety Code
, to read:
DIVISION 115. OFFICE OF THE CALIFORNIA HEALTH
OMBUDSMAN
136000. (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, the State
Department of Health Care Services, the Managed Risk Medical
Insurance Board, the Exchange, as defined in subdivision (j),
and consumer assistance organizations, receive and respond to
inquiries and complaints , complaints, and
requests for assistance 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 quantify,
and analyze problems and inquiries encountered by consumers
with respect to health care coverage.
coverage, including, but not limited to, the complaints reported to
the ombudsman under subdivision (h). The ombudsman shall publicly
report its analysis of these problems and inquiries at least annually
on the Internet Web site of the office. The ombudsman
shall track, analyze, and publicly report on complaints reported to
the ombudsman under subdivision (h) according to the nature and
resolution of the complaints and the health status, age, race,
ethnicity, lan guage, geographic region, and gender of the
complainants in order to identify the most common types of problems
and the problems faced by particular populations. In addition, the
ombudsman shall track, analyze, and report on those complaints by
health insurer or health care service plan 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 in each health insurer or health care service plan and in
each health care coverage program.
(3) Educate consumers on their rights and responsibilities with
respect to health care coverage and provide this information in
plain language .
(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.
(6) Provide the assistance and education described in this
subdivision to consumers with limited English language proficiency in
their primary language.
(d) (1) In order to assist consumers in navigating and resolving
problems with health care coverage and programs, the ombudsman shall
do both of the following:
(A) Operate a HealthHelp hotline that is available 24 hours a day,
seven days a week.
(B) Operate a HealthHelp Internet Web site, other social media,
and up-to-date communication systems.
(2) The telephone number and Internet Web site for the HealthHelp
hotline described in paragraph (1) shall be included on every
membership card and evidence of coverage issued to the following:
(A) An individual insured under a policy of health insurance
regulated under the Insurance Code.
(B) An individual enrolled in a health care service plan contract
regulated under Chapter 2.2 (commencing with Section 1340) of
Division 2.
(C) A beneficiary of the Medi-Cal program.
(d)
(e) 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)
(f) 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.
(g) The ombudsman 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 with respect to employee
welfare benefit plans regulated under ERISA to enable the ombudsman
to provide accurate information and referrals to consumers covered
under those plans.
(2) The Centers for Medicare and Medicaid Services to enable the
ombudsman to give accurate information and referrals for consumers
covered under the Medicare Program.
(3) The Department of Managed Health Care regarding consumers
enrolled in coverage under health care service plans regulated under
Chapter 2.2 (commencing with Section 1340) of Division 2. The
ombudsman shall also directly assist these consumers.
(4) The Department of Insurance regarding consumers with policies
of health insurance regulated under the Insurance Code. The ombudsman
shall also directly assist these consumers.
(5) The State Department of Health Care Services regarding
consumers enrolled in the Medi-Cal Program. The ombudsman shall also
directly assist these consumers.
(6) The Managed Risk Medical Insurance Board regarding consumers
enrolled in 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 Section 1101 of the federal Patient
Protection and Affordable Care Act (Public Law 111-148). The
ombudsman shall also directly assist these consumers.
(7) The Exchange regarding consumers enrolled in coverage pursuant
to the Exchange. The ombudsman shall also directly assist these
consumers.
(h) 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
ombudsman regarding consumer complaints submitted to those agencies,
including the nature of the complaints, the resolution of the
complaints and the timeliness thereof, and the health status, age,
race, ethnicity, language, geographic region, and gender of the
complainants. This information shall be reported according to the
particular health insurer or health care service plan involved.
(f)
(i) (1) 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.
(2) The office and the services provided by local consumer
assistance programs under subdivision (e) shall be also be funded out
of licensure fees on health care service plans, consistent with
Section 1356, and out of fees on health insurers by assessing a per
policy assessment. The fees shall be set by the Director of the
Department of Managed Health Care or the Insurance Commissioner, as
applicable, in consultation with the ombudsman. The fees shall be
allocated based on the number of covered lives and shall be the same
per covered life regardless of the regulator.
(3) To the extent permitted by federal law, the ombudsman may seek
federal financial participation for assisting beneficiaries of the
Medi-Cal program.
(g) For purposes of this section, "group health plan" has the
(j) For purposes of this section, the following definitions shall
apply:
(1) "Exchange" means the American Health Benefit Exchange
established in California under Section 1311 of the federal Patient
Protection and Affordable Care Act (Public Law 111-148).
(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).
SEC. 2.
136020. (a) The California Health Ombudsman Trust Fund
is hereby created in the State Treasury for the purpose of this
act division . 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 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 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 division .