BILL ANALYSIS �
Senate Appropriations Committee Fiscal Summary
Senator Christine Kehoe, Chair
AB 922 (Monning)
Hearing Date: 8/25/2011 Amended: 6/20/2011
Consultant: Katie Johnson Policy Vote: Health 6-2
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BILL SUMMARY: AB 922 would transfer the Office of the Patient
Advocate (OPA) from the Department of Managed Health Care (DMHC)
and would establish the office as an independent entity. The
bill would state that the goal of OPA would be to help enrollees
of health plans, insureds, and individuals secure health care
coverage to which they are entitled under the law.
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Fiscal Impact (in thousands)
Major Provisions 2011-12 2012-13 2013-14 Fund
OPA expansion unknown, potentially in the
hundredsSpecial*
and shift of thousands of dollars
OPA additional duties and likely in the millions of
dollars annually Special*
ongoing administration commencing January 1, 2013
DMHC data reporting $0 about $250 $500
Special**
CDI data reporting $0 $1,100 $550
Special***
DHCS, MRMIB, and unknown, potentially significant
General/****
Exchange data reportingcommencing January 1, 2013 Federal/
Special
*Office of the Patient Advocate Trust Fund
**Managed Care Fund
***Insurance Fund
****MRMIB costs shared 35 percent General Fund, 65 percent
federal funds; Medi-Cal costs shared 50 percent General Fund, 50
percent federal funds Exchange costs paid from the California
Health Trust Fund; to the extent federal financial participation
AB 922 (Monning)
Page 1
is available.
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STAFF COMMENTS: SUSPENSE FILE. AS PROPOSED TO BE AMENDED.
AB 922 would transfer the Office of the Patient Advocate (OPA)
from the Department of Managed Health Care (DMHC) and would
establish the office as an independent entity. This bill would
continue and augment OPA's charge to represent the interests of
enrollees served by health care service plans (health plans),
insureds, and individuals who are eligible for other health care
coverage including coverage available through the Medi-Cal
program, the California Health Benefit Exchange (Exchange), the
Healthy Families Program (Healthy Families), and any other
county or state health care program.
Existing law establishes OPA within DMHC to represent the
interests of enrollees served by health care service plans
regulated by the department with the goal of the office to be to
help enrollees secure health care services to which they are
entitled under the law. The existing OPA is charged with:
1) Developing educational and informational guides for
enrollees on their rights to secure health care services;
2) Compiling an annual publication of a quality of care
report card;
3) Rendering advice and assistance to enrollees regarding
procedures, rights, and responsibilities related to the use
of health plan grievance systems, the department's
grievance system, and the independent review process;
4) Making referrals within the department regarding
studies, investigations, audits, or enforcement that would
protect the interests of enrollees;
5) Coordinating and working with other government and
nongovernmental patient assistance and ombudsman programs;
DMHC provides personnel to the office and is permitted to employ
or contract with experts when necessary. Its budget requests are
required to be separate from DMHC's. The office has access to
DMHC records including information related to health plan
audits, surveys, and enrollee grievances.
This bill would revise and recast OPA's current duties as the
following:
AB 922 (Monning)
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1) Render advice and assistance to consumers regarding the
filing of complaints, grievances, and appeals including
appeals with the denial of care with the health care
program denying eligibility, and the internal appeal system
of the health plan, health insurer, group health plan, or
other county or state health care program involved;
2) Provide direct assistance to consumers, including filing
complaints with the appropriate regulator or public
program;
3) Render advice and assistance to consumers with problems
related to health care services, including care and service
problems and claims or payment problems;
4) Advise 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 or appeals with the
appropriate regulator or public program;
5) Make referrals to appropriate state agencies regarding
studies that would be appropriate to protect the interests
of consumers.
OPA would employ staff, contract with experts when necessary,
and would make an annual budget request for office resources.
OPA would have access to records of DMHC and the California
Department of Insurance (CDI) including information related to
health plan or health insurer audits, surveys, and enrollee or
insured grievances. Contracted agencies would be required to
have specified experience in consumer assistance and would be
required to qualify as navigators for the Exchange. OPA would be
required to develop protocols, procedures, and training modules
for organizations with which it contracts and to oversee a
continuing education training program.
OPA would also be required to do 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:
a. Information regarding applying for coverage,
the cost of coverage, renewal in, and transitions
between, health coverage programs, education on how to
navigate the health care arena such as how to select a
AB 922 (Monning)
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plan or insurer or a doctor;
b. Information and referral for all types of
payers, including public programs such as Medi-Cal,
Healthy Families Program (Healthy Families), and
Medicare, private coverage, including Exchange
coverage, and other sources of care such as county
services, community clinics, and discounted hospital
or charity care;
c. Educate consumers on their rights and
responsibilities with respect to health care coverage;
d. Advise and assist consumers with resolving
problems with obtaining premium tax credits.
OPA would be required to collect, track, quantify, and analyze
problems and inquiries encountered by consumers, such as
complaints. OPA would be required to develop protocols and
procedures for the resolution of consumer complaints and the
establishment of responsibility or referral with regards to the
appropriate regulator or payer.
In order to assist consumers in navigating and resolving
problems with health care coverage, OPA would be required to
operate:
1) a HealthHelp toll-free hotline number that would be able
to route callers to the proper regulating body, public
program, health plan, or consumer assistance program and to
provide interpreters for limited-English-proficient
callers;
2) a HealthHelp Internet Web site, other social media, and
up-to-date communication systems.
DMHC, CDI, the Department of Health Care Services (DHCS), the
Managed Risk Medical Insurance Board (MRMIB), and the Exchange
would be required to report specified data and other consumer
complaint information to OPA.
Fiscal Impact
This bill would establish the Office of Patient Advocate Trust
Fund (OPA Trust Fund). Moneys in the OPA Trust Fund would be
available upon appropriation by the Legislature and would
consist of transfers from the Managed Care Fund and Insurance
Fund in an amount necessary to cover the actual and necessary
expenses of OPA. Funds in the Managed Care Fund and in the
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Insurance Fund are administrative fee revenues assessed by DMHC
and CDI to cover the regulators' administrative expenses.
The shares of the transfer amounts that would come from the
Managed Care Fund and the Insurance Fund would be based on the
number of covered lives in the state that are covered under
health plans and health insurers regulated by the respective
regulators. Additionally, this bill would permit OPA to apply to
the United States Secretary of Health and Human Services for
federal grant funds and would require the office to apply for
consumer assistance grants established 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) (ACA).
The cost to implement and maintain OPA pursuant to this bill
would likely be in the millions of dollars annually to support a
patient advocate, to be appointed by the Governor, staff to
complete the duties enumerated above, including answering phone
calls, providing direct consumer assistance with complaints,
grievances, and appeals, and collecting and analyzing data. By
way of comparison, the DMHC Help Center currently employs 97
staff with a budget of $16.7 million in FY 2010-2011. Since OPA
would be serving at least as many individuals as the DMHC Help
Center, although in a somewhat different capacity, it would be
reasonable to assume a similar magnitude of annual expenditure.
All Californians would be able to be serviced by OPA pursuant to
this bill. According to the California Health Benefits Review
Program (CHBRP), DMHC and CDI regulate health plans and insurers
that provide coverage for about 19 million and 3 million
Californians respectively; these numbers include Medi-Cal
managed care plans, Healthy Families, the Access for Infants and
Mothers Program, and the Major Risk Medical Insurance Program's
covered lives.
Currently, DMHC funds OPA with $2.4 million. Additionally,
consumer assistance funds were made specifically available in
the ACA. To date, DMHC has received $4.16 million in consumer
assistance program grants from the federal government; however,
it is not anticipated that DMHC would receive additional or
ongoing consumer assistance funds. It is unclear whether OPA
would be able to access such funds. Finally, OPA could
potentially seek federal financial participation to the extent
that OPA serves Medi-Cal beneficiaries. Medi-Cal administrative
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costs are funded 50 percent federal funds and 50 percent
non-federal funds.
There would be cost pressure on DMHC and CDI to increase the
assessments on health plans and health insurers in order to
backfill the gap in the Managed Care Fund and Insurance Fund
made by the transfers of funds to the OPA Trust Fund in the same
amount as the cost to administer OPA.
Additionally, DMHC, CDI, MRMIB, DHCS, and the Exchange would
likely incur costs in the hundreds of thousands of dollars to
comply with the data collection provisions of this bill to the
extent they are required to obtain and process data that they do
not currently collect. Exchange expenditures would be paid from
the California Health Trust Fund, federal, and subscriber funds;
MRMIB costs would be paid by a variety of funds consisting
mostly of federal funds and state tobacco tax revenues, but its
largest program by far is Healthy Families, in which costs are
shared 65 percent federal funds and 35 percent General Fund;
DHCS administrative costs would likely be 50 percent federal
funds and 50 percent General Fund, to the extent federal
financial participation is available for this purpose.
This bill is similar to AB 2787 (Monning, 2010) which would have
established the Office of the California health Ombudsman and
would have required the Ombudsman to educate consumers on their
health care coverage rights and responsibilities, and assist
consumers with enrollment in health care coverage. AB 2787 was
held on the Senate Appropriations Committee Suspense File.
AS PROPOSED TO BE AMENDED. The author's proposed amendments
would:
1) Place OPA under the jurisdiction of the California
Health and Human Services Agency (CHHS);
2) Clarify that, with respect to the resolution of
complaints, grievances and appeals, each regulator and
public program would retain its authority to resolve
complaints, grievances, and appeals;
3) Permit OPA to contract with community-based consumer
assistance organizations in accordance with Government Code
Section 19130;
4) Delete the requirement for OPA to track, analyze, and
publicly report the health status, gender identity, gender
expression, or sexual orientation of the complainants;
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5) Require that OPA track analyze and report on complaints
by the respective regulator;
6) Remove the provision that would automatically qualify as
Exchange navigators the consumer assistance programs that
contract with OPA to provide direct consumer assistance;
7) Require OPA to include in its protocols and procedures
for the resolution of consumer complaints the following:
a. A procedure for referral of complaints and
grievances to the appropriate regulator or public
program for resolution through their normal processes;
b. A protocol and procedures for reporting to the
appropriate regulator and public program regarding
complaints and grievances relevant to that program
that OPA received and was able to resolve without
forwarding it to the regulator or program;
8) Remove the requirement for CDI, DMHC, DHCS, MRMIB, and
the Exchange to report the health status of an individual
to OPA;
9) Require the data reported to OPA by CDI, DMHC, DHCS,
MRMIB, and the Exchange to also be reported according to
the source of coverage, including employer-based coverage,
individual coverage, or specific public program including
Medicare, Medi-Cal, the Exchange or other publicly funded
coverage;
10) Define "threshold languages" as the Medi-Cal threshold
languages;
All provisions except moving the OPA statute under CHHS and the
establishment of the Fund would commence January 1, 2013. The
OPA expansion to insureds, Medi-Cal beneficiaries, and others
would increase the number of people served by OPA and could
increase costs by the hundreds of thousands of dollars
commencing January 1, 2012. Costs would increase into the
millions of dollars commencing January 1, 2013, when OPA's
existing duties would be augmented significantly.