BILL ANALYSIS �
AB 922
Page 1
Date of Hearing: April 5, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 922 (Monning) - As Amended: March 29, 2011
SUBJECT : Office of Health Consumer Assistance.
SUMMARY : Creates an independent office of health coverage
consumer assistance, called the Office of Health Consumer
Assistance (OHCA), in state government. Specifically, this
bill :
Office of Health Consumer Assistance Duties
1)Creates an independent OHCA in state government, under the
direction of a chief executive officer known as the Director
of the OHCA, who is appointed by the Governor and confirmed by
the Senate. Requires OHCA to:
a) Receive and respond to all telephone and in-person
inquiries, complaints, and requests for assistance from
individuals concerning all health care coverage available
in California, including Medi-Cal, the California Health
Benefits Exchange (the Exchange), the Healthy Families
Program (HFP), or any other county or state public health
program, or individual or group coverage available through
health care service plans or health insurers;
b) Develop educational and informational guides for
consumers describing their rights and responsibilities, and
informing consumers on effective ways to exercise their
rights to secure health care services. Requires the guides
to be easy to read and understand, available in English and
"threshold" languages, and be made available to the public,
including through the OHCA Website and public outreach and
educational programs. Defines "threshold languages" to be
languages spoken by at least 20,000 or more limited English
proficient (LEP) health consumers residing in California;
c) Compile an annual publication, to be made available on
the OHCA Website, of a quality of care report card,
including, but not limited to, health care service plans
and insurers;
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d) 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 or insurer offers or provides, how to
select a plan or insurer, and how to find a doctor or other
health care provider;
e) Educate consumers on their rights and responsibilities
with respect to health care coverage;
f) 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 for all types of payors, including public
programs such as Medi-Cal, HFP, Medicare, private
individual coverage, employer-sponsored coverage, Employee
Retirement Income Security Act (ERISA) plans, charity care,
unsubsidized Exchange coverage, and Exchange coverage with
tax subsidies and/or tax credits;
g) 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;
h) 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 plan, health insurer, or
group health plan involved, and provide information about
any external appeal process; and,
i) Advise and assist consumers to resolve problems with
obtaining federal premium tax credits.
2)Requires OHCA to provide the assistance and education above to
consumers with LEP in their primary oral language, written
materials in threshold languages using an appropriate literacy
level, and in a culturally competent manner.
3)Permits OHCA to contract with community-based consumer
assistance organizations to assist in some or all of the
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above.
4)Requires OHCA, in order to assist consumers in navigating and
resolving problems with health care coverage and programs, to:
a) 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; and,
b) Operate a HealthHelp Internet Website, other social
media, and up-to-date communication systems to give
information regarding the consumer assistance programs.
5)Requires OHCA to develop protocols and procedures for the
resolution of consumer complaints and the establishment of
responsibility or referral, as appropriate, to the federal
Department of Labor (DOL) regarding employee welfare benefit
plans regulated under ERISA, the Centers for Medicare and
Medicaid Services regarding the Medicare Program, the
Department of Managed Health Care (DMHC) regarding health plan
coverage, the Department of Insurance (CDI) regarding health
insurance policies, the State Department of Health Care
Services (DHCS) regarding the Medi-Cal program, the Managed
Risk Medical Insurance Board (MRMIB) regarding HFP, the Access
for Infants and Mothers Program, the California Major Risk
Medical Insurance Program Federal Temporary High Risk Pool,
and the Exchange.
Data Collection and Reporting
6)Requires OHCA to 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. Requires OHCA to
publicly report its analysis of these problems and inquiries
at least quarterly on its Website.
7)Requires OHCA to track, analyze, and publicly report on
complaints it receives 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
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disparity population.
8)Requires OHCA to track, analyze, and report on those
complaints by health insurer or health plan, by race/ethnicity
and language preference, and by the type of health care
coverage program, including the timeliness of resolution of
the complaints, and to take into account the number of
individuals enrolled by each health insurer or health care
service plan and in each health care coverage program.
9)Requires OHCA to collect and report data to the United States
Secretary of Health and Human Services (HHS) on the categories
of populations in 6) above, including subgroup categories of
race/ethnicity, and types of problems and inquiries
encountered by consumers.
10)Requires DMHC, CDI, DHCS, MRMIB, the Department of Public
Health, and the Exchange to report data and other information
to the OHCA 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.
Requires this information to be reported according to the
particular health insurer or health care service plan
involved.
Contracting Consumer Assistance Programs
11)Requires OHCA and any local community-based nonprofit
consumer assistance programs that they contract with to have
as their primary mission the assistance of health care
consumers. Requires contracting consumer assistance programs
to have experience in:
a) Assisting consumers in navigating the local health care
system;
b) Advising consumers regarding their health care coverage
options and helping enroll consumers in and retaining
health care coverage;
c) Assisting consumers with problems in accessing health
care services;
d) Serving consumers with special needs, including, but not
limited to, consumers with LEP, consumers requiring
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culturally competent services, low-income consumers,
consumers with disabilities, consumers with low literacy
rates, and consumers with multiple health conditions; and,
e) Collecting and reporting data on the categories of
populations listed in subdivision (e), including subgroup
categories of race/ethnicity, language preference, and
types of health care coverage problems consumers face.
12)Requires consumer assistance programs that contract with OHCA
to provide direct consumer assistance to qualify as
"navigators" under the Exchange, as specified.
13)Requires OHCA to develop protocols, procedures, and training
modules for organizations with whom it contracts and to
implement and oversee a training program for contracted
organizations with continuing education components. Requires
OHCA to adopt standards for contracted organizations regarding
confidentiality and conduct. Gives OHCA the power to revoke
the contract of organizations that violate these standards, as
specified.
14)Permits OHCA to 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. Requires these
materials to be made available to all consumer assistance
programs and on the OHCA Website.
Funding
15)Requires OHCA to apply to HHS for a grant, as specified.
Permits OHCA, to the extent permitted by federal law, to seek
federal funding for assisting beneficiaries of the Medi-Cal
Program and for outreach grants through Children's Health
Insurance Program Reauthorization Act.
16)Creates the California Health Consumer Assistance Trust Fund
in the State Treasury, and requires moneys in the fund to be
made available for the purpose of this bill upon appropriation
by the Legislature.
17)Repeals existing law which establishes the Office of Patient
Advocate (OPA). Requires funds allocated to support the OPA
to be transferred to the California Health Consumer Assistance
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Trust Fund.
EXISTING STATE LAW :
1)Requires DMHC to establish and maintain a toll-free telephone
number for the purpose of receiving complaints regarding
health plans regulated by DMHC. Establishes OPA within DMHC
to represent the interests of enrollees served by health plans
regulated by DMHC, and establishes as the goal of OPA to help
enrollees secure health care services to which they are
entitled under the laws administered by DMHC.
2)Requires the Insurance Commissioner to establish a program to
investigate complaints, respond to inquiries, and to bring
enforcement actions. Requires the program to include, but not
be limited to, a toll-free telephone number dedicated to the
handling of complaints and inquiries, public service
announcements to inform consumers of the toll-free telephone
number, and information as to how to register a complaint or
make an inquiry to the CDI, and make available a simple,
standardized complaint form designed to assure that complaints
will be properly registered and tracked.
3)Permits DHCS, for purposes of the Medi-Cal Program, on a
regional pilot project basis and to the extent authorized by
law, to enter into contracts with one or more nonprofit
organizations to perform the functions of the DHCS' Office of
the Ombudsman.
EXISTING FEDERAL LAW :
1)The Patient Protection and Affordable Care Act (PPACA)
requires the HHS Secretary to award grants to states to enable
states (or the exchanges operating in such states) to
establish, expand, or provide support for offices of health
insurance consumer assistance or health insurance ombudsman
programs.
2)Establishes criteria for states to meet in order to receive a
federal PPACA grant, and requires the ombudsman to perform
certain activities, including assisting with the filing of
complaints and appeals of health plans, educating consumers on
their rights and responsibilities, assisting consumers with
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enrollment in a health plan, and resolving problems in
obtaining premium tax credits made available by PPACA. As a
condition of receiving a federal ombudsman grant, an office of
health insurance consumer assistance or ombudsman program is
required to collect and report data to the Secretary of HHS on
the types of problems and inquiries encountered by consumers.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill
establishes the OHCA in state government to position California to
receive federal monies made available by PPACA for the purpose of
establishing and operating such an office. The author states
California currently has a fragmented system for consumer
assistance with health care coverage complaints. The author
states that there are currently eight governmental entities and
several private, non-profit entities that provide a number of
services to assist persons with public and private health care
coverage. These services include advice on coverage options,
education about how to navigate the system, assistance with
complaints and grievances, and assistance in choosing a health
plan and finding a provider. These entities also respond to
complaints about, among other things, eligibility, coverage of
services, and timely access to health care providers. The author
argues it is imperative that Californians be provided with a
single source of correct and current information on PPACA, and
that the OHCA will also provide for much needed, clear and
understandable consumer information and assistance by expanding
and strengthening current programs operating at the local level
that will be consistent with the federal requirements for
independence and consumer orientation.
2)PPACA . On March 23, 2010, President Obama signed PPACA; Public
Law (P. L.) 111-148, as amended by the Health Care and Education
Reconciliation Act of 2010; P. L. 111-152. It is estimated that
4.7 million California children and adults who were uninsured
during some part of 2009 will be eligible for health coverage
under PPACA. Among its many provisions, PPACA appropriated $30
million in the first fiscal year funding for states to establish
health insurance ombudsman programs. To be eligible to receive a
grant, states were required to designate an independent office of
health insurance consumer assistance that either directly, or in
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coordination with state health insurance regulators and consumer
assistance organizations, receives and responds to inquiries and
complaints concerning health insurance coverage regarding federal
and state health insurance requirements. States receiving grants
under PPACA are required to comply with federal criteria
established by the HHS Secretary.
DMHC, in partnership with the OPA, was awarded $3.4 million
to:
a) Develop and promote a coordinated consumer-friendly
Website and corresponding toll-free number that consumers
can call with questions about health care coverage, and to
receive assistance with the filing of complaints and
appeals;
b) Conduct a statewide media campaign, in partnership with
consumer organizations, to educate consumers about their
rights and responsibilities and to provide assistance with
enrollment in group health plans or health insurance
coverage. DMHC has sought approval to redirect the funds
for the media campaign to community-based organizations to
provide one-on-one assistance to consumers; and,
c) Evaluate the effectiveness of the initiatives, and
collect, track, and quantify consumer problems and
inquiries for reporting to state and federal policymakers.
1)CURRENT SYSTEM OF CONSUMER ASSISTANCE . California currently
has a fragmented system for consumer assistance with health
care coverage complaints. There are eight governmental
entities and several private, non-profit entities that provide
a number of services for assistance with public and private
health care coverage:
Government Entities
- HMO HelpLine
- Medi-Cal Managed Care (MCMC) Ombudsman
- CDI Consumer Hotline (all types of insurance issues, not
just health insurance)
- DOL, Employee Benefits Security Administration (EBSA)
- 1-800-Medicare
- County welfare offices
- OPA
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- California Health Benefits Exchange (forthcoming)
Nonprofit Entities
- Health Consumer Alliance (HCA)
- Health Insurance Counseling and Advocacy Program (HICAP)
- Certified Application Assistors (CAAs)
These services include advice on coverage options, education
about how to navigate the system, assistance with complaints
and grievances, assistance in choosing a health plan, and
finding a provider. These entities also respond to complaints
about, among other things, eligibility, coverage of services,
and timely access to providers. While these entities exist to
help consumers and purchasers of their specific services,
implementation of the PPACA will lead to millions of more
Californians enrolled in coverage, including expansions of
public programs. Consumers will also have expanded choices of
coverage and different options to use, should they lose a
source of job-based coverage, have a child, divorce, or have
an increase in income. All of these changes will affect
consumers' eligibility for health coverage, making it all the
more necessary to establish one entity to help them with their
health coverage. The charts below illustrate how fragmented
service provision is:
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| | | | | | | |
--------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------
| Government Entities |
-----------------------------------------------------------------
|--------------+--------------+--------------+--------------+--------------+--------------+--------------|
|HMO HelpLine | HMOs | HMOs | HMOs | HMOs | HMOs | HMOs |
|--------------+--------------+--------------+--------------+--------------+--------------+--------------|
|MCMC Ombuds | | | Medi-Cal HMO | Medi-Cal HMO | Medi-Cal HMO | Medi-Cal HMO |
|--------------+--------------+--------------+--------------+--------------+--------------+--------------|
|CDI | | | | | PPOs | PPOs |
|--------------+--------------+--------------+--------------+--------------+--------------+--------------|
|DOL, EBSA | | | | | ERISAs | |
|--------------+--------------+--------------+--------------+--------------+--------------+--------------|
|1-800-Medicare| Medicare | | | Medicare | Medicare | Medicare |
| | | | | | | |
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|--------------+--------------+--------------+--------------+--------------+--------------+--------------|
|County |County Health |County Health | |County Health | | |
|Offices | & Medi-Cal | | | & Medi-Cal | | |
--------------------------------------------------------------------------------------------------------
|OPA | | | HMOs | | | |
|--------------+--------------+--------------+--------------+--------------+--------------+--------------|
|Exchange | Exchange | | Exchange | Exchange | | |
--------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------
| Non-Profits |
-----------------------------------------------------------------
--------------------------------------------------------------------------------------------------------
|HCA | All | All | All | All | All | All |
|--------------+--------------+--------------+--------------+--------------+--------------+--------------|
|HICAPs | Medicare | Medicare | Medicare | Medicare | Medicare | Medicare |
--------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
| | | | | | | | |
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------
| Government Entities |
-------------------------------------------------------------------
|------------+------------+------------+------------+------------+------------+------------+------------|
|HMO | Medi-Cal | HMOs | HMOs | HMOs | HMOs | | |
|HelpLine | HMO | | | | | | |
|------------+------------+------------+------------+------------+------------+------------+------------|
|MCMC Ombuds | Medi-Cal | | | | | | |
| | HMO | | | | | | |
|------------+------------+------------+------------+------------+------------+------------+------------|
|CDI | | | | PPOs | PPOs | | |
|------------+------------+------------+------------+------------+------------+------------+------------|
|DOL, EBSA | | | | ERISAs | | | |
|------------+------------+------------+------------+------------+------------+------------+------------|
|1-800-Medica| Medicare | | | | Medigap| Medicare | |
|re | | | | | | | |
-------------------------------------------------------------------------------------------------------
|County | Medi-Cal | | | | | | County |
|Offices | | | | | | | Health |
|------------+------------+------------+------------+------------+------------+------------+------------|
|OPA | HMOs | HMOs | HMOs | HMOs | HMOs | | |
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------
| Non-Profits |
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-------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
|HCA | All | All | All | All | All | All | All |
|------------+------------+------------+------------+------------+------------+------------+------------|
|HICAPs | | | |Coordination| Medigap | Medicare | |
| | | | | | | | |
-------------------------------------------------------------------------------------------------------
1)COMMUNITY-BASED ORGANIZATIONS . There are a number of
community-based organizations in California that provide
assistance to health care consumers. The HCA helps low-income
Californians in 13 counties get the health care they need.
Each health consumer center runs a hotline to assist consumers
by telephone and provides in-person visits as well as
outstationed services in hospitals, courts, or farm fields.
Consumers can also email an office for assistance. The HCA
helps consumers regardless of their type of coverage: from
Medi-Cal and HFP to employer-based coverage (both insured and
self-insured) and individual coverage, from the uninsured to
consumers with multiple types of coverage. The HCA programs
provide a range of types of services including advice and
referrals to the consumer, assisting with communication
between the consumer and a health care entity by conducting a
conference call or calling on behalf of the consumer and
clarifying coverage, plan or provider policies; and providing
direct representation in health plan appeals, administrative
fair hearings and other adjudications. The HCA collects data
about the types of problems faced by the thousands of health
care consumers they help each year. Based on this data, the
HCA can identify systemic problems faced by consumers.
HICAP provides free and objective information and counseling
about Medicare. Volunteer counselors help Medicare
beneficiaries understand their rights and health care options.
HICAP also offers free educational presentations to groups of
Medicare beneficiaries, their families and/or providers on a
variety of Medicare and other health insurance related topics.
CAAs are placed in community settings to help families
complete and submit the joint HFP/Medi-Cal application. These
community-based entities play a crucial role in providing
information to thousands of Californians (primarily
low-income, many with LEP) about health coverage options and
helping them to get enrolled and properly use their insurance
coverage. CAAs are trained and certified by MRMIB to help
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Californians understand their coverage options and enroll in
health coverage. CAAs are frequently bilingual and come from
the communities they serve. CAAs can be employed by Federally
Qualified Health Centers, Rural Health Centers, regional
nonprofit organizations, and schools, among others. Throughout
California, these entities have developed strong and trusting
relationships within their communities and are valued by
families needing information about health coverage.
2)PREVIOUS LEGISLATION . AB 2787 (Monning) of 2010 would have
established the Office of the California Health Ombudsman,
governed by a chief executive officer known as the California
Health Ombudsman, and would have required the Ombudsman to
educate consumers on their health care coverage rights and
responsibilities, assist consumers with enrollment in health
care coverage, and resolve problems with obtaining federal
premium tax credits. AB 2787 was held on suspense in the
Senate Appropriations Committee.
3)support . This bill is supported by consumer and children's
health groups. Western Center on Law & Poverty (WCLP), a
cosponsor of this bill, writes that California's uninsured
population has different needs than those who are consistently
covered. This includes people who primarily speak a language
other than English, those who have never navigated a health
insurance plan, and those who have perhaps never consistently
seen a health care provider. For all those reasons, WCLP
states that Californians need a centralized hub to connect to
when dealing with questions or problems with their coverage.
WCLP asserts that the OHCA created under this bill will fill
this void by providing information on coverage options,
education about how to navigate the system, assistance with
complaints and grievances, and assistance in choosing a health
plan and finding a provider. WCLP further states that OHCA
will also respond to complaints regarding eligibility,
coverage of services, and timely access to providers and that
this model, which incorporates all kinds of health coverage,
does not currently exist at the state level.
Health Access California writes that the enactment of federal
health reform means that virtually every Californian will have
access to quality, affordable health care. Existing programs,
including the HMOHelp line has done much of what is
contemplated in this bill, but not all. Health Access
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contends that these programs have filled the void created by
the failures of CDI, the Medi-Cal Program, and MRMIB to have
effective consumer assistance systems, but that this bill will
create a OHCA that will serve as the first line of triage for
consumer complaints while leaving with the respective
regulators and sources of coverage the responsibility for
resolving the complaints and grievances within their
jurisdiction. Health Access California states that this bill
connects state government with the federal government agencies
responsible for resolving complaints, such as the DOL for
ERISA plans and Medicare for Medicare coverage. Finally,
Health Access California asserts that this bill envisions
robust response to grievances and complaints about the health
care system.
4)OPPOSITION . The California Right to Life Committee (CRLC),
Inc. writes that this is advancing the federal Patient
Protection and Affordable Care Act when presently there are
serious challenges to its constitutionality; and that it would
be better public policy not to depend on federal tax dollars
under these circumstances. CRLC contends that this bill "is
another attempt to promote family planning and abortion
services to low-income persons and non-English speaking
populations"
5)POLICY COMMENT . This bill does not currently include
sufficient specificity regarding funding for the OHCA. The
author intends that funding will come from three major
sources: federal monies made available through PPACA; existing
state funds that are used for existing functions that OHCA
will assume; and, a fee on health plans and insurers to pay
for services provided to persons covered by HMOs and insurers.
To clarify the drafting of the funding provisions of this
bill, the author intends to add language generally modeled on
the fee provisions used in existing law (except for the $2
million annual cap) to fund the California Health Benefits
Review Program, which is administered by the University of
California and which reviews health benefit mandate
legislation. The new provisions would apply to both insurers
and health plans for services provided to persons covered by
insurers and HMOs.
REGISTERED SUPPORT / OPPOSITION :
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Support
Health Access California (cosponsor)
Western Center on Law and Poverty (cosponsor)
American Federation of State, County and Municipal Employees,
AFL-CIO
California Association of Marriage and Family Therapists
California Children's Health Initiatives
California Immigrant Policy Center
California Pan-Ethnic Health Network
Children NOW
Children's Defense Fund-California
Children's Partnership
Consumers Union
Maternal and Child Health Access
Neighborhood Legal Services of Los Angeles County
PICO California
The 100% Campaign
Unitarian Universalist Legislative Ministry Action Network, CA
Youth Law Center
Opposition
California Right to Life Committee, Inc.
Analysis Prepared by : Melanie Moreno / HEALTH / (916)
319-2097