BILL NUMBER: AB 922 AMENDED
BILL TEXT
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 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 amended, 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 Office of Patient Advocate from the
Department of Managed Health Care to instead operate as an
independent state entity , and the
California Health and Human Services A gency. 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 those 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 require the office to request from the
federal government specified grant moneys.
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 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. 2. 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) There is hereby transferred from the Department
of Managed Health Care the Office of Patient Advocate to
operate as an independent entity within state government, which shall
be known and may be cited as the Gallegos-Rosenthal Patient Advocate
Program, to be established within the California
Health and Human Services Agency, to represent the interests of
enrollees 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 enrollees, insureds, and
individuals to secure health care coverage to which they are entitled
under the law. Notwithstanding any provision of this division,
each regulator and public program shall retain its respective
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) Developing 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 advice and assistance to consumers regarding the
filing of complaints, grievances, and appeals, including appeals of
denials of care 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, group health
plan, or other county or state health care program involved, and
provide information about any external appeal process.
(D) Providing direct assistance to consumers, if necessary,
including assistance in filing complaints, grievances, or appeals
with the appropriate regulator or public program.
(E)
(D) Rendering advice and assistance to consumers with
problems related to health care services, including care and service
problems and claims or payment problems. Explaining how to
resolve these problems and providing direct assistance, if needed,
including assistance in filing complaints, grievances, or appeals
with the appropriate regulator or public program.
(F) Advising consumers on problems related to mental health parity
and coverage for substance abuse treatment, consistent with existing
state and federal law, including assistance in filing complaints,
grievances, or appeals with the appropriate regulator or public
program.
(G)
(E) Making referrals to the appropriate state agency
regarding studies, investigations, audits, or enforcement that may be
appropriate to protect the interests of consumers.
(H)
(F) 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) The office shall have access to records of the Department of
Managed Health Care and the Department of Insurance, 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.
(c) The Commencing on January 1, 2013, the
office shall also do all of the following:
(1) Receive and respond to all telephonic, electronic,
and in-person inquiries, complaints, and requests for
assistance from individuals concerning all health care coverage
available in California.
(2) Provide outreach and education about health care coverage
options, including, but not limited to:
(A) Information regarding applying for coverage; the cost of
coverage; renewal in, and transitions between, health coverage
programs; and education about how to navigate the health care arena,
including what health care services a plan or insurer offers or
provides, how to select a plan or insurer, and how to find a doctor
or other health care provider.
(B) Information and referral for all types of payers, including
public programs such as Medi-Cal, Healthy Families, and Medicare;
private coverage, including employer-sponsored coverage, self-insured
plans, unsubsidized Exchange coverage, and Exchange coverage with
tax subsidies or tax credits; and other sources of care, such as
county services, community clinics, discounted hospital care, or
charity care.
(3) Educate consumers on their rights and responsibilities with
respect to health care coverage.
(4) Advise and assist consumers with resolving problems with
obtaining premium tax credits under Section 36B of the Internal
Revenue Code.
(5) Provide explanations to consumers on resolving problems
related to health care services, and, if necessary, provide direct
assistance to consumers in filing complaints, grievances, or appeals
with the appropriate regulator or public program.
(6) Advising consumers on problems related to mental health parity
and coverage for substance abuse treatment, consistent with existing
state and federal law, including assistance in filing complaints,
grievances, or appeals with the appropriate regulator or public
program.
(d) The Commencing on January
1, 2013, the office may contract with community-based consumer
assistance organizations to assist in any or all of the duties of
subdivisions (b) and (c) in accordance with Section 19130 of the
Government Code .
(e) (1) The Commencing on January 1, 2013,
the office 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 (n) (m)
. The office shall publicly report its analysis of these
problems and inquiries at least quarterly on its Internet Web site.
(2) The office shall track, analyze, and publicly report on
complaints reported to the office under subdivision (n)
(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, gender identity, gender
expression, or sexual orientation and gender 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 shall track, analyze, and report on those
complaints by all of the following:
(A) Health insurer or health care service plan.
(B) Health status, age Age , race,
ethnicity, language preference, geographic region, gender,
gender identity, gender expression, and sexual orientation
and gender .
(C) The type of health care coverage program and its
respective regulator .
(D) The timeliness of resolution of complaints.
(4) In analyzing and reporting complaints, the office 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 Commencing on January 1, 2013, in
order to assist consumers in navigating and resolving problems
with health care coverage and programs, the office shall do the
following:
(1) Operate a HealthHelp 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 and provide interpreters for
limited-English-proficient 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 Commencing on January 1, 2013, the
office and any local community-based nonprofit consumer
assistance programs with which the office contracts shall include in
their mission assistance of, and duty to, 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 consumers enroll in and retain health care
coverage.
(3) Assisting consumers with problems in 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, including
behavioral health.
(5) Collecting and reporting data on the categories of populations
listed in subdivision (e), including subgroup categories of race,
ethnicity, language preference, gender, gender identity,
gender expression, and sexual orientation, and types of
health care coverage problems consumers face.
(h) Consumer assistance programs that contract with the office 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
(h) Commencing on January 1, 2013, the
office 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
(i) Commencing on January 1, 2013, the
office shall develop protocols, procedures, and training
modules for organizations with which it contracts. The office shall
implement and oversee a training program with continuing education
components for organizations with which it contracts.
(k) The
(j) Commencing on January 1, 2013, the
office shall adopt standards for organizations with which it
contracts regarding confidentiality and conduct. The office shall
have the power to revoke the contract of any organization that
violates these standards and shall include a clause reserving that
power in every contract entered into with such an organization.
(l) The
(k) 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. These materials shall be made available to
all consumer assistance programs and on the Internet Web site of the
office.
(m) The
(l) (1)
Commencing on January 1, 2013, the office 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)
(A) The federal Department of Labor regarding employee
welfare benefit plans regulated under ERISA.
(2)
(B) The Health Insurance Counseling and Advocacy
Program as provided in Section 9541 of the Welfare and Institutions
Code and, as appropriate, the federal Centers for Medicare and
Medicaid Services regarding the Medicare Program.
(3)
(C) 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)
(D) The Department of Insurance regarding policies of
health insurance regulated under the Insurance Code.
(5)
(E) The State Department of Health Care Services
regarding the Medi-Cal program.
(6)
(F) 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 (Part 6.6 (commencing with Section 12739.5) of Division 2
of the Insurance Code).
(7)
(G) The Exchange regarding coverage through the
Exchange.
(2) The protocols and procedures shall include all of the
following:
(A) A procedure for the referral of complaints and grievances to
the appropriate regulator or public program for resolution by the
relevant regulator or public program.
(B) A process for reporting to the appropriate regulator and
public program those complaints and grievances that were received and
resolved without filing a complaint or grievance with the regulator
or public program.
(n) The
(m) Commencing on January 1, 2013, the
Department of Managed Health Care, the Department of Insurance,
the State Department of Health Care Services, the Managed Risk
Medical Insurance Board, and the Exchange shall report only
data and other information in its possession to the
office regarding consumer complaints submitted to those agencies,
including, but not limited to, the nature of the complaints, the
resolution of the complaints, the timeliness of the resolution, and
the health status, age, race, ethnicity, language,
geographic region, gender, gender identity, gender
expression, or sexual orientation and gender of
the complainants, in a format and manner to be specified by the
office. This information shall be reported according to the
particular health insurer or health care service plan involved.
This information shall also be reported according to the source of
coverage, including employer-based coverage, individual coverage, or
specific public program coverage, including Medicare, Medi-Cal, the
Exchange, or other publicly funded coverage.
(o)
(n) 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) "Group health plan" has the same meaning as set
forth in Section 2791 of the federal Public Health Service Act (42
U.S.C. Sec. 300gg-91).
(4) "Health care" includes behavioral health, including both
mental health and substance abuse treatment.
(5) "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.
(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" are languages spoken by at
least 20,000 or more limited-English-proficient health consumers
residing in California. shall mean Medi-Cal threshold
languages.
136020. (a) 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) 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.
(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 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).
(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.