BILL NUMBER: AB 922 INTRODUCED
BILL TEXT
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 introduced, Monning. Office of Health Consumer
Assistance.
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.
This bill would eliminate the Office of Patient Advocate and would
instead create an Office of Health Consumer Assistance. The bill
would impose specified duties and responsibilities on the Office of
Health Consumer Assistance 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. 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 establish the California
Health Consumer Assistance 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 authorize the office to apply to the
federal government for moneys to fund the office and would transfer
moneys used to support the Office of Patient Advocate to the fund.
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 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
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."
(c) (1) There is within the department an Office of Patient
Advocate, 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. The goal of the office shall be to help enrollees
secure health care services to which they are entitled under the laws
administered by the department.
(2) The office shall be headed by a patient advocate recommended
to the Governor by the Secretary of the Business, Transportation and
Housing Agency. The patient advocate shall be appointed by and serve
at the pleasure of the Governor.
(3) The duties of the office shall be determined by the
secretary, in consultation with the director, and shall include, but
not be limited to:
(A) Developing educational and informational guides for consumers
describing enrollee rights and responsibilities, and informing
enrollees on effective ways to exercise their rights to secure health
care services. The guides shall be easy to read and understand,
available in English and other languages, and shall be made available
to the public by the department, including access on the department'
s Internet Web site and through public outreach and educational
programs.
(B) Compiling an annual publication, to be made available on the
department's Internet Web site, of a quality of care report card,
including, but not limited to, health care service plans.
(C) Rendering advice and assistance to enrollees regarding
procedures, rights, and responsibilities related to the use of health
care service plan grievance systems, the department's system for
reviewing unresolved grievances, and the independent review process.
(D) Making referrals within the department regarding studies,
investigations, audits, or enforcement that may be appropriate to
protect the interests of enrollees.
(E) Coordinating and working with other government and
nongovernment patient assistance programs and health care
ombudsperson programs.
(4) The director, in consultation with the patient advocate,
shall provide for the assignment of personnel to the office. The
department may employ or contract with experts when necessary to
carry out functions of the office. The annual budget for the office
shall be separately identified in the annual budget request of the
department.
(5) The office shall have access to department records including,
but not limited to, information related to health care service plan
audits, surveys, and enrollee grievances. The department shall assist
the office in compelling the production and disclosure of any
information the office deems necessary to perform its duties, from
entities regulated by the department, if the information is
determined by the department's legal counsel to be subject, under
existing law, to production or disclosure to the department.
(6) 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.
SEC. 2. Division 115 (commencing with Section 136000) is added to
the Health and Safety Code, to read:
DIVISION 115. Office of Health Consumer Assistance
136000. (a) There is hereby created in state government an
independent office of health coverage consumer assistance called the
Office of Health Consumer Assistance. The office shall be under the
direction of a chief executive officer who shall be known as the
Director of the Office of Health Consumer Assistance. The director
shall be appointed by the Governor, subject to confirmation by the
Senate.
(b) The Office of Health Consumer Assistance shall receive and
respond to all telephonic and in-person inquiries, complaints, and
requests for assistance from individuals concerning all health care
coverage available in California, including coverage available
through the Medi-Cal program, the Exchange, the Healthy Families
Program (Part 6.2 (commencing with Section 12693) of Division 2 of
the Insurance Code), or any other county or state public health
program, or individual or group coverage available through health
care service plans under Chapter 2.2 (commencing with Section 1340)
of Division 2 or health insurers under Part 2 (commencing with
Section 10110) of Division 2 of the Insurance Code.
(c) The office shall do all of the following:
(1) Provide outreach and education about health care coverage
options including, but not limited to, information regarding the cost
of coverage and education about how to navigate the health care
arena, including what health services a plan offers or provides, how
to select a plan, and how to find a doctor or other health care
provider.
(2) Educate consumers on their rights and responsibilities with
respect to health care coverage.
(3) Advise and assist consumers regarding eligibility for health
care coverage, including enrollment in, retention in, and transitions
between, health care coverage programs by providing information,
referral, and direct application assistance.
(4) Advise and assist consumers with problems related to health
care services, including care and service problems and claims or
payment problems. Explain how to resolve these problems and provide
direct assistance, if needed.
(5) Advise and assist consumers with the filing of complaints and
appeals, including appeals of coverage denials 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, or group health plan involved, and provide information about
any external appeal process.
(6) Advise and assist consumers with resolving problems with
obtaining premium tax credits under Section 36B of the Internal
Revenue Code.
(7) Provide the assistance and education described in this
subdivision to consumers with limited English language proficiency in
their primary oral and written language, using an appropriate
literacy level for written material, and in a culturally competent
manner.
(d) The Office of Health Consumer Assistance may contract with
community-based consumer assistance organizations to assist in the
requirements of subdivisions (b) and (c).
(e) (1) The Office of Health Consumer Assistance 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 (m). The
Office of Health Consumer Assistance shall publicly report its
analysis of these problems and inquiries at least quarterly on its
Internet Web site.
(2) The Office of Health Consumer Assistance shall track, analyze,
and publicly report on complaints reported to the Office of Health
Consumer Assistance under subdivision (m) 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, 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 of Health Consumer Assistance 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 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 of Health
Consumer Assistance shall do the following:
(1) Operate a HealthHelp toll-free telephone hotline that can
route callers to the consumer assistance program in their area and
provide interpreters for LEP 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 of Health Consumer Assistance and any local
community-based nonprofit consumer assistance programs that they
contract with shall have as their primary mission assistance of
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 enroll consumers in and retaining health care
coverage.
(3) Resolving consumer problems 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.
(5) Collecting and reporting data on the categories of populations
listed in subdivision (e), including subgroup categories of race,
and types of health care coverage problems consumers face.
(h) Consumer assistance programs that contract with the Office of
Health Consumer Assistance 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 of Health Consumer Assistance 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 of Health Consumer Assistance shall develop
protocols and procedures and training modules for consumer assistance
programs.
(k) The Office of Health Consumer Assistance 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 of Health
Consumer Assistance.
(l) The Office of Health Consumer Assistance 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 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
established under Part 6.6 (commencing with Section 12739.5) of
Division 2 of the Insurance Code.
(7) The Exchange regarding coverage through the Exchange.
(m) 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 of Health Consumer Assistance regarding consumer complaints
submitted to those agencies, including the nature of the complaints,
the resolution of the complaints, and the timeliness of the
resolution, and further including, but not limited to, the health
status, age, race, ethnicity, language, geographic region, gender, or
sexual orientation of the complainants. This information shall be
reported according to the particular health insurer or health care
service plan involved.
(n) (1) The Office of Health Consumer Assistance 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).
(2) To the extent permitted by federal law, the Office of Health
Consumer Assistance may seek federal financial participation for
assisting beneficiaries of the Medi-Cal program.
(3) To the extent permitted by federal law, the Office of Health
Consumer Assistance may seek federal funding through the federal
Children's Health Insurance Program Reauthorization Act outreach
grants.
(o) For purposes of this section, the following definitions shall
apply:
(1) "Exchange" means the California Health Benefit Exchange
established pursuant to Title 22 (commencing with Section 100500) of
the Government Code.
(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).
(3) "Health care service plan" or "specialized health care service
plan" has the same meaning as that set forth in subdivision (f) of
Section 1345.
(4) "Health insurance" has the same meaning as set forth in
Section 106 of the Insurance Code.
(5) "Health insurer" means an insurer that issues policies of
health insurance.
136020. (a) The California Health Consumer Assistance 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 of Health Consumer Assistance 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. Funds allocated to support the Office of the Patient
Advocate shall be transferred to the California Health Consumer
Assistance Trust Fund.