BILL ANALYSIS �
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|SENATE RULES COMMITTEE | AB 922|
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THIRD READING
Bill No: AB 922
Author: Monning (D)
Amended: 8/31/11 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 6-2, 6/29/11
AYES: Hernandez, Alquist, Blakeslee, De Le�n, DeSaulnier,
Wolk
NOES: Strickland, Anderson
NO VOTE RECORDED: Rubio
SENATE APPROPRIATIONS COMMITTEE : 6-3, 8/25/11
AYES: Kehoe, Alquist, Lieu, Pavley, Price, Steinberg
NOES: Walters, Emmerson, Runner
ASSEMBLY FLOOR : 51-27, 6/2/11 - See last page for vote
SUBJECT : Office of Patient Advocate
SOURCE : Health Access California
Western Center on Law and Poverty
DIGEST : This bill transfers the Office of the Patient
Advocate (OPA) from the Department of Managed Health Care
(DMHC) to operate as an agency within the Health and Human
Services Agency, and states that the goal of OPA is to
represent the interests of enrollees served by health care
service plans regulated by DMHC, insureds covered by health
insurers regulated by the Department of Insurance, and
individuals who receive or are eligible for other health
CONTINUED
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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.
ANALYSIS :
Existing federal law:
1. Requires, under the Patient Protection and Affordable
Care Act (PPACA) (Public Law 111-148), as amended by the
Health Care Education and Reconciliation Act of 2010
(Public Law 111-152), each state, by January 1, 2014, to
establish an American Health Benefit Exchange that makes
qualified health insurance products available to
qualified individuals and qualified employers. If a
state does not establish an Exchange, the federal
government administers the Exchange.
2. Requires the federal Secretary of Health and Human
Services Agency (HHS) 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.
3. Establishes criteria for states to meet in order to
receive a consumer assistance grant under the PPACA, and
requires the ombudsman to perform certain activities,
including assisting with the filing of complaints and
appeals, educating consumers on their rights and
responsibilities, assisting consumers with enrollment,
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.
Existing state law:
1. Provides for the regulation of health plans by DMHC
under the Knox-Keene Health Care Service Plan Act of
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1975, and for the regulation of health insurers by the
CDI, under provisions of the Insurance Code
(collectively referred to as regulators).
2. Requires DMHC to establish and maintain a toll-free
telephone number for the purpose of receiving complaints
regarding health plans regulated by DMHC.
3. Establishes the 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.
4. Requires OPA to compile an annual publication, to be
made available on DMHC's Web site, of a quality-of-care
report card, including, but not limited to, health
plans.
5. Requires the Insurance Commissioner to establish a
program to investigate complaints, respond to inquiries,
and to bring enforcement actions regarding health
insurers.
6. 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, information as to how to register a
complaint or make an inquiry to the Department of
Insurance (CDI), and a simple, standardized complaint
form designed to assure that complaints will be properly
registered and tracked.
7. Establishes the Medi-Cal program, which is administered
by the Department of Health Care Services (DHCS), under
which qualified low-income individuals receive health
care services.
8. Authorizes DHCS, for purposes of the Medi-Cal Program,
on a regional pilot project basis, 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.
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9. Establishes and specifies the duties and authority the
California Health Benefit Exchange (Exchange) within
state government in a manner that is consistent with
PPACA.
10.Establishes the Managed Care Fund and the Insurance
Fund, for the purposes of funding the regulatory
activities of DMHC and CDI, respectively.
This bill:
1. Transfers the OPA from DMHC, and establishes it as an
independent entity within state government.
2. Requires existing OPA duties to also apply to health
insurers regulated by CDI and their insureds (in
addition to DMHC-regulated health plans).
3. Requires the OPA to be headed by a patient advocate who
is appointed by the Governor and who serves at the
pleasure of the Governor.
4. Specifies that the duties of the OPA include, but are
not limited to:
A. Developing educational and informational guides
for consumers describing their rights and
responsibilities, and informing them of effective
ways to exercise their rights to secure health
coverage, as specified.
B. Compiling an annual publication, to be made
available on the OPA's Web site, containing a quality
of care report card, as specified.
C. Rendering advice and direct assistance to
consumers regarding:
(1) Filing of complaints, grievances, and
appeals, including appeals of denials of care, as
specified, with the appropriate regulator or
public program.
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(2) Problems related to health care services,
including care and service problems, and claims or
payment problems, as specified.
D. Advising consumers on problems related to mental
health parity and coverage for substance abuse
treatment, consistent with state and federal law, as
specified.
E. Making referrals to the appropriate state agency
regarding studies, investigations, audits, or
enforcement that may be appropriate to protect the
interests of consumers.
F. Coordinating and working with other government and
nongovernment patient assistance programs and health
care ombudsman programs.
5. Requires the OPA to employ necessary staff, and
authorizes OPA to employ or contract with experts when
necessary to carry out the functions of the office.
6. Requires the patient advocate to make annual budget
requests for the OPA, which shall be identified in the
annual budget act.
7. Requires the OPA to have access to records of DMHC and
CDI, as specified.
8. Requires the OPA to annually issue a public report on
the activities of the office, and to appear before the
appropriate legislative policy and fiscal committees, if
requested, to report and make recommendations on the
activities of the office.
9. Directs the OPA to also do all of the following:
A. 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 carrier
offers or provides, how to select a plan or insurer,
and how to find a doctor or other health care
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provider.
B. Advise and assist consumers regarding eligibility
for coverage, including enrollment in, retention in,
and transitions between, 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.
C. Advise and assist consumers to resolve problems
with obtaining federal premium tax credits.
D. Operate a HealthHelp toll-free telephone hotline
that can route callers to the proper regulator,
public program, carrier, or consumer assistance
program in their area and provide interpreters for
limited English proficiency callers.
E. Operate a HealthHelp Web site, other social media,
and up-to-date communication systems to provide
public information regarding consumer assistance
programs.
10.Requires the OPA to collect, track, quantify, analyze,
and publicly report on problems, inquiries, and
complaints encountered by consumers, including, but not
limited to, the complaints reported to health consumer
assistance organizations and agencies, according to the
nature and resolution of the complaints and, including,
but not limited to, information by carrier, type of
coverage program, timeliness of resolution, health
status, age, race, ethnicity, language, geographic
region, or 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, as specified.
11.Requires the OPA to publicly report its analyses of
these problems and inquiries at least quarterly on its
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website and to collect and report data to the United
States Secretary of HHS on the categories of
populations, as specified.
12.Requires the OPA, in analyzing and reporting complaints,
to take into account the number of individuals enrolled
by each carrier and in each coverage program.
13.Permits the OPA to contract with community-based
consumer assistance organizations to assist in any or
all of its duties, as specified.
14.Requires these programs to have, as their primary
mission, the assistance of health care consumers, and
other specified experience.
15.Requires these programs to qualify as "navigators" under
the Exchange, as specified.
16.Requires the OPA to develop protocols, procedures, and
training modules and to implement and oversee a training
program for contracted organizations with continuing
education components.
17.Requires the OPA to adopt standards for contracted
organizations regarding confidentiality and conduct.
18.Authorizes the OPA to revoke the contract of
organizations that violate these standards, as
specified.
19.Authorizes the OPA 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.
20.Requires these materials to be made available to all
consumer assistance programs and on the OPA Web site.
21.Requires the OPA to develop protocols and procedures for
the resolution of consumer complaints and the
establishment of responsibility or referral, as
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appropriate, to the appropriate public program or
regulator.
22.Requires this information to be reported according to
the particular carrier involved.
23.Creates the OPA Trust Fund in the State Treasury, and
upon appropriation by the Legislature, requires moneys
in the fund to be made available for implementing the
provisions of this bill.
24.Directs the OPA to establish and maintain a prudent
reserve.
25.Requires funding for the actual and necessary expenses
of the OPA to be provided, subject to appropriation by
the Legislature, from the Managed Care Fund and the
Insurance Fund, as specified.
26.Requires the OPA to apply to HHS for a grant, as
specified. Permits OPA to apply for other federal
grants, and to the extent permitted by federal law, to
seek federal funding for assisting beneficiaries of the
Medi-Cal Program.
27.Places OPA under the jurisdiction of the HHS.
28.Clarifies 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.
29.Permits OPA to contract with community-based consumer
assistance organizations in accordance with Government
Code Section 19130.
30.Requires that OPA track analyze and report on complaints
by the respective regulator.
31.Requires 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
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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.
32.Requires 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.
33.Defines "threshold languages" as the Medi-Cal threshold
languages.
Background
Patient assistance provisions in federal health reform . On
March 23, 2010, President Obama signed the PPACA. 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 the PPACA. Among other
provisions, the new law makes statutory changes affecting
the regulation of and payment for certain types of private
health insurance. The law also significantly expands
health care coverage to currently uninsured individuals
through public program expansions, a mandate to purchase
coverage, a temporary high-risk pool program, and by
requiring guaranteed issue of coverage. It is anticipated
that millions of currently uninsured persons in California
will obtain coverage under the provisions of PPACA.
PPACA also contains provisions to provide funding for
states to establish health insurance consumer assistance
programs. In order to be eligible to receive a grant,
states are required to designate an independent office of
health insurance consumer assistance that, directly or in
coordination with state health insurance regulators and
consumer assistance organizations, receives and responds to
inquiries and complaints concerning federal and state
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health insurance requirements. DMHC, in partnership with
the OPA, has been awarded $3.4 million to:
1. 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.
2. Conduct a statewide media campaign to educate consumers
about their rights and responsibilities, and to provide
assistance with enrollment in group health plans or
health insurance coverage.
3. Evaluate the effectiveness of the initiatives, and track
and quantify consumer problems and inquiries, for
reporting to state and federal policymakers.
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 eligibility, making it all the more necessary to
establish one entity to help them with their health
coverage.
California's current system of consumer assistance .
California currently has a fragmented system for consumer
assistance with health care coverage complaints. Entities
that provide services for assistance with public and
private health care coverage include:
1. Government Entities : HMO HelpLine, Medi-Cal Managed
Care Ombudsman, CDI Consumer Hotline (applies to all
types of insurance) Department of Labor, the Employee
Benefits Security Administration, 1-800-Medicare, county
welfare offices, the OPA, and the Exchange
(forthcoming).
2. Nonprofit Entities : Health Consumer Alliance, Health
Insurance Counseling and Advocacy Program, and Certified
Application Assistors.
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These services include advice on coverage options,
education about how to navigate the system, assistance with
complaints and grievances, and assistance in choosing a
carrier and finding a provider. These entities also
respond to complaints about, among other things,
eligibility, coverage of services, and timely access to
providers.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: No
SUPPORT : (Verified 8/31/11)
Health Access California (co-source)
Western Center on Law and Poverty (co-source)
100% Campaign
American Federation of State, County and Municipal
Employees, AFL-CIO
Asian Pacific American Legal Center
California Association of Marriage and Family Therapists
California Children's Health Initiatives
California Chiropractic Association
California Coalition for Mental Health
California Coverage & Health Initiatives
California Family Resource Association
California Immigrant Policy Center
California Optometric Association
California Pan-Ethnic Health Network
California Rural Legal Assistance Foundation
Children NOW
Children's Defense Fund-California
Children's Health Initiatives of Greater Los Angeles
Children's Partnership
Congress of California Seniors
Consumers Union
First 5 Association of California
Having Our Say
Health Consumer Center
Inland Empire United Way
Maternal and Child Health Access
Mental Health Association in California
National Alliance on Mental Illness California
National Association of Social Workers - California Chapter
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National Health Law Program
Neighborhood Legal Services of Los Angeles County
PICO California
Santa Clara Board of Supervisors
SEIU California
Unitarian Universalist Legislative Ministry Action Network,
California
United Way of California
Youth Law Center
OPPOSITION : (Verified 8/31/11)
Association of California Life and Health Insurance
Companies
California Association of Health Plans
California Right to Life Committee, Inc.
ARGUMENTS IN SUPPORT : Health Access California (HAC), a
co-sponsor of this bill, writes that enactment of federal
health reform means that virtually every Californian will
have access to quality, affordable health care. Existing
programs, including the HMOHelp Line, have done much of
what is contemplated in this bill, but not all. HAC
contends a state-level ombudsman who serves as the first
line of triage for consumer complaints, while leaving the
respective regulators and sources of coverage the
responsibility for resolving specific complaints and
grievances, is necessary. HAC asserts that this bill will
result in a robust response to grievances and complaints
about the health care system.
Western Center on Law and Poverty (WCLP), also a
co-sponsor, writes that uninsured persons have 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 never consistently seen a health
care provider. For all those reasons, WCLP states that
Californians need a centralized hub when dealing with
questions or problems with their coverage. WCLP argues
that this bill leverages existing consumer assistance
programs by allowing OPA to contract with community based
organizations that already provide consumer assistance
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services, many of which are experts in public programs,
while ensuring that the most qualified organizations can
assist consumers in community-based settings in a
linguistically and culturally appropriate manner. WCLP
asserts that this "hub-and-spokes" approach has been
effective in states like New York, which allows one
nonprofit organization to coordinate with other community
organizations to assist health consumers.
Consumers Union argues that this bill positions California
to maximize federal funds for ombudsman and consumer
navigation services, which is critically important to have
in place well in advance of the mandate for individual
coverage that takes effect in 2014. The American
Federation of State, County and Municipal Employees states
that this bill would greatly facilitate California's
ability to comply and cope with federal health reform, and
that the state cannot offer its residents adequate
assistance in this matter currently.
ARGUMENTS IN OPPOSITION : The California Association of
Health Plans (CAHP) opposes this bill on the grounds that
California already has consumer advocacy programs under
each regulator that are funded by the industry through
assessments and taxes that cost the industry and its
consumers millions of dollars. CAHP states that this new
entity does not provide any order to the myriad of
assistance programs currently available to consumers, and
instead adds a new layer of government bureaucracy designed
largely to forward calls back to the regulator. CAHP
supports consolidation of existing consumer related
functions, and argues that consolidation could lead to more
uniformity and clarity for consumers.
The Association of California Life and Health Insurance
Companies (ACLHIC) concurs with CAHP, and argues that this
bill has the potential to increase the cost of health care
by increasing the fees imposed on carriers. ACLHIC points
out that the industry currently funds consumer assistance
programs at DMHC, OPA and CDI, and existing law requires
carriers to include their respective regulator's consumer
complaint number on claims forms, as well as other written
notices that go out to enrollees and insureds. ACLHIC also
asserts that there is no real evidence supporting the
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concept of adding an additional independent office for
consumer assistance.
ASSEMBLY FLOOR : 51-27, 6/2/11
AYES: Alejo, Allen, Ammiano, Atkins, Beall, Block,
Blumenfield, Bonilla, Bradford, Brownley, Buchanan,
Butler, Charles Calderon, Campos, Carter, Cedillo,
Chesbro, Davis, Dickinson, Eng, Feuer, Fong, Fuentes,
Furutani, Galgiani, Gatto, Gordon, Hayashi, Roger
Hern�ndez, Hill, Huber, Hueso, Huffman, Lara, Bonnie
Lowenthal, Ma, Mendoza, Mitchell, Monning, Pan, Perea, V.
Manuel P�rez, Portantino, Skinner, Solorio, Swanson,
Torres, Wieckowski, Williams, Yamada, John A. P�rez
NOES: Achadjian, Bill Berryhill, Conway, Cook, Donnelly,
Fletcher, Beth Gaines, Garrick, Grove, Hagman, Halderman,
Harkey, Jeffries, Jones, Knight, Logue, Mansoor, Miller,
Morrell, Nestande, Nielsen, Norby, Olsen, Silva, Smyth,
Valadao, Wagner
NO VOTE RECORDED: Gorell, Hall
CTW:mw 8/31/11 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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