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Division 115. Office Of Patient Advocate of California Health And Safety Code >> Division 115.
(a) (1) The Office of Patient Advocate is hereby
established within the California Health and Human Services Agency,
to provide assistance to, and advocate on behalf of, health care
consumers. The goal of the office shall be to coordinate amongst,
provide assistance to, and collect data from, all of the state agency
consumer assistance or patient assistance programs and call centers,
to better enable health care consumers to access the health care
services to which they are eligible under the law, including, but not
limited to, commercial and Exchange coverage, Medi-Cal, Medicare,
and federal veterans health benefits. Notwithstanding any provision
of this division, each regulator and health coverage program shall
retain its respective authority, including its 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) Coordinate and work in consultation with state agency and local, nongovernment health care consumer or patient assistance programs and health care ombudsperson programs.
(B) Produce a baseline review and annual report to be made publically available on the office's Internet Web site by July 1, 2015, and annually thereafter, of health care consumer or patient assistance help centers, call centers, ombudsperson, or other assistance centers operated by the Department of Managed Health Care, the State Department of Health Care Services, the Department of Insurance, and the Exchange, that includes, at a minimum, all of the following:
(i) The types of calls received and the number of calls.
(ii) The call center's role with regard to each type of call, question, complaint, or grievance.
(iii) The call center's protocol for responding to requests for assistance from health care consumers, including any performance standards.
(iv) The protocol for referring or transferring calls outside the jurisdiction of the call center.
(v) The call center's methodology of tracking calls, complaints, grievances, or inquiries.
(C) (i) Collect, track, and analyze data on problems and complaints by, and questions from, consumers about health care coverage for the purpose of providing public information about problems faced and information needed by consumers in obtaining coverage and care. The data collected shall include demographic data, source of coverage, regulator, type of problem or issue or comparable types of problems or issues, and resolution of complaints, including timeliness of resolution. Notwithstanding Section 10231.5 of the Government Code, the office shall submit a report by July 1, 2015, and annually thereafter to the Legislature. The report shall be submitted in compliance with Section 9795 of the Government Code. The format may be modified annually as needed based upon comments from the Legislature and stakeholders.
(ii) For the purpose of publically reporting information as required in subparagraph (B) and this subparagraph about the problems faced by consumers in obtaining care and coverage, the office shall analyze data on consumer complaints and grievances resolved by the agencies listed in subdivision (c), including demographic data, source of coverage, insurer or plan, resolution of complaints, and other information intended to improve health care and coverage for consumers.
(D) Make recommendations, in consultation with stakeholders, for improvement or standardization of the health consumer assistance functions, referral process, and data collection and analysis.
(E) Develop model protocols, in consultation with consumer assistance call centers and stakeholders, that may be used by call centers for responding to and referring calls that are outside the jurisdiction of the call center, program, or regulator.
(F) Compile an annual publication, to be made publically available on the office's Internet Web site, of a quality of care report card, including, but not limited, to health care service plans, preferred provider organizations, and medical groups.
(G) Make referrals to the appropriate state agency, whether further or additional actions may be appropriate, to protect the interests of consumers or patients.
(H) Assist in the development of educational and informational guides for consumers and patients describing their rights and responsibilities and informing them on effective ways to exercise their rights to secure and access health care coverage, produced by the Department of Managed Health Care, the State Department of Health Care Services, the Exchange, and the Department of Insurance, and to endeavor to make those materials easy to read and understand and available in all threshold languages, using an appropriate literacy level and in a culturally competent manner.
(I) Coordinate with other state and federal agencies engaged in outreach and education regarding the implementation of federal health care reform, and to assist in these duties, may provide or assist in the provision of grants to community-based consumer assistance organizations for these purposes.
(J) If appropriate, refer consumers to the appropriate regulator of their health coverage programs for filing complaints or grievances.
(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 that shall be identified in the annual Budget Act.
(3) 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.
(4) The office shall adopt standards for the organizations with which it contracts pursuant to this section to ensure compliance with the privacy and confidentiality laws of this state, including, but not limited to, the Information Practices Act of 1977 (Chapter 1 (commencing with Section 1798) of Title 1.8 of Part 4 of Division 3 of the Civil Code). The office shall conduct privacy trainings as necessary, and regularly verify that the organizations have measures in place to ensure compliance with this provision.
(c) The Department of Managed Health Care, the State Department of Health Care Services, the Department of Insurance, the Exchange, and any other public health coverage programs shall provide to the office data concerning call centers to meet the reporting requirements in subparagraph (B) of paragraph (1) of subdivision (b) and consumer complaints and grievances to meet the reporting requirements in clause (i) of subparagraph (C) of paragraph (1) of subdivision (b).
(d) For purposes of this section, the following definitions 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) "Health care" includes services provided by any of the health care coverage programs.
(4) "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.
(5) "Health coverage program" includes the Medi-Cal program, Healthy Families Program, tax subsidies and premium credits under the Exchange, the Basic Health Program, if enacted, county health coverage programs, and the Access for Infants and Mothers Program.
(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" has the same meaning as for Medi-Cal managed care.
(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) Coordinate and work in consultation with state agency and local, nongovernment health care consumer or patient assistance programs and health care ombudsperson programs.
(B) Produce a baseline review and annual report to be made publically available on the office's Internet Web site by July 1, 2015, and annually thereafter, of health care consumer or patient assistance help centers, call centers, ombudsperson, or other assistance centers operated by the Department of Managed Health Care, the State Department of Health Care Services, the Department of Insurance, and the Exchange, that includes, at a minimum, all of the following:
(i) The types of calls received and the number of calls.
(ii) The call center's role with regard to each type of call, question, complaint, or grievance.
(iii) The call center's protocol for responding to requests for assistance from health care consumers, including any performance standards.
(iv) The protocol for referring or transferring calls outside the jurisdiction of the call center.
(v) The call center's methodology of tracking calls, complaints, grievances, or inquiries.
(C) (i) Collect, track, and analyze data on problems and complaints by, and questions from, consumers about health care coverage for the purpose of providing public information about problems faced and information needed by consumers in obtaining coverage and care. The data collected shall include demographic data, source of coverage, regulator, type of problem or issue or comparable types of problems or issues, and resolution of complaints, including timeliness of resolution. Notwithstanding Section 10231.5 of the Government Code, the office shall submit a report by July 1, 2015, and annually thereafter to the Legislature. The report shall be submitted in compliance with Section 9795 of the Government Code. The format may be modified annually as needed based upon comments from the Legislature and stakeholders.
(ii) For the purpose of publically reporting information as required in subparagraph (B) and this subparagraph about the problems faced by consumers in obtaining care and coverage, the office shall analyze data on consumer complaints and grievances resolved by the agencies listed in subdivision (c), including demographic data, source of coverage, insurer or plan, resolution of complaints, and other information intended to improve health care and coverage for consumers.
(D) Make recommendations, in consultation with stakeholders, for improvement or standardization of the health consumer assistance functions, referral process, and data collection and analysis.
(E) Develop model protocols, in consultation with consumer assistance call centers and stakeholders, that may be used by call centers for responding to and referring calls that are outside the jurisdiction of the call center, program, or regulator.
(F) Compile an annual publication, to be made publically available on the office's Internet Web site, of a quality of care report card, including, but not limited, to health care service plans, preferred provider organizations, and medical groups.
(G) Make referrals to the appropriate state agency, whether further or additional actions may be appropriate, to protect the interests of consumers or patients.
(H) Assist in the development of educational and informational guides for consumers and patients describing their rights and responsibilities and informing them on effective ways to exercise their rights to secure and access health care coverage, produced by the Department of Managed Health Care, the State Department of Health Care Services, the Exchange, and the Department of Insurance, and to endeavor to make those materials easy to read and understand and available in all threshold languages, using an appropriate literacy level and in a culturally competent manner.
(I) Coordinate with other state and federal agencies engaged in outreach and education regarding the implementation of federal health care reform, and to assist in these duties, may provide or assist in the provision of grants to community-based consumer assistance organizations for these purposes.
(J) If appropriate, refer consumers to the appropriate regulator of their health coverage programs for filing complaints or grievances.
(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 that shall be identified in the annual Budget Act.
(3) 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.
(4) The office shall adopt standards for the organizations with which it contracts pursuant to this section to ensure compliance with the privacy and confidentiality laws of this state, including, but not limited to, the Information Practices Act of 1977 (Chapter 1 (commencing with Section 1798) of Title 1.8 of Part 4 of Division 3 of the Civil Code). The office shall conduct privacy trainings as necessary, and regularly verify that the organizations have measures in place to ensure compliance with this provision.
(c) The Department of Managed Health Care, the State Department of Health Care Services, the Department of Insurance, the Exchange, and any other public health coverage programs shall provide to the office data concerning call centers to meet the reporting requirements in subparagraph (B) of paragraph (1) of subdivision (b) and consumer complaints and grievances to meet the reporting requirements in clause (i) of subparagraph (C) of paragraph (1) of subdivision (b).
(d) For purposes of this section, the following definitions 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) "Health care" includes services provided by any of the health care coverage programs.
(4) "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.
(5) "Health coverage program" includes the Medi-Cal program, Healthy Families Program, tax subsidies and premium credits under the Exchange, the Basic Health Program, if enacted, county health coverage programs, and the Access for Infants and Mothers Program.
(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" has the same meaning as for Medi-Cal managed care.
(a) Effective July 1, 2012, 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.
(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.
(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, 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 may seek private grant funding from foundations or other sources.
(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.
(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, 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 may seek private grant funding from foundations or other sources.
(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.
