BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 513
A
AUTHOR: De Leon
B
AMENDED: May 5, 2009
HEARING DATE: July 15, 2009
5
CONSULTANT:
1
Park/
3
SUBJECT
Health care coverage: breast-feeding
SUMMARY
Requires health plans and those health insurers that
provide maternity benefits to cover the rental of breast
pumps and lactation consultation with an international
board certified lactation consultant (IBCLC).
CHANGES TO EXISTING LAW
Existing law:
Existing law provides for the regulation of health plans by
the Department of Managed Health Care (DMHC) and health
insurers by the California Department of Insurance (CDI).
Existing law requires full-service health plans licensed by
DMHC to cover all medically necessary basic health care
services, including physician services; hospital inpatient
and outpatient services; diagnostic services; preventive
and routine care; emergency and urgent care services;
medically appropriate home health services; and,
rehabilitation therapy. There is no requirement for health
insurers subject to regulation by CDI to cover medically
necessary basic services or any specific minimum basic
Continued---
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benefits.
Existing law and regulations require health plans to
provide all medically necessary basic health care services,
including maternity services necessary to prevent serious
deterioration of the health of the enrollee or the
enrollee's fetus, and preventive health care services,
specifically including prenatal care.
Existing law defines health plans that cover only certain
kinds of care, such as dental and vision care plans,
behavioral or mental health plans, and chiropractic plans,
as specialized plans. Existing law defines a policy of
health insurance for covered benefits in a single
specialized area of health care, including dental-only,
vision-only, and behavioral health-only policies, as a
specialized health insurance policy.
This bill:
This bill would require every health plan contract and
every health insurance policy that provides maternity
benefits that is issued, amended, renewed, or delivered on
or after January 1, 2010, to provide coverage for the
rental of breast pumps and lactation consultation (LC) with
an IBCLC.
This bill would exempt specialized health plan contracts
and policies, and other policies, as specified. The bill
would make various legislative findings and declarations
relating to the benefits of LC and breast-feeding.
FISCAL IMPACT
According to the Assembly Appropriations Committee, based
on findings of the California Health Benefits Review
Program (CHBRP), this bill will result in increased annual
costs of $178,000 (60 percent General Fund) to the
California Public Employees' Retirement System, and annual
increased premium costs across the private insurance market
of $3 million.
BACKGROUND AND DISCUSSION
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The author points out that breast-feeding has been well
established as a low-cost, low-tech preventive intervention
with far-reaching benefits for mothers and babies and
significant cost savings. The author notes that exclusive
breast-feeding for three months has been shown to reduce
health care costs for infants in the first year of life
alone by up to $475, compared to non-breast-fed infants.
The author cites a U.S. Department of Agriculture estimate
that indicates a minimum of $3.6 billion in medical
expenses annually would be saved if the number of children
breastfed for six months were to increase by fifty percent.
The author points out that exclusive breast-feeding for six
months, with continued breast-feeding for at least the
first year, is recommended by all of the major health
organizations.
The author notes that the WIC program provides lactation
support, but cannot provide support for all that is
requested by mothers using WIC. The author states that
mothers not on WIC, with HMO coverage, usually do not have
this support in their benefits.
IBCLCs
According to the International Board of Lactation
Consultant Examiners, IBCLCs are health care professionals
who specialize in the clinical management of breast-feeding
and have demonstrated their competence to practice by
passing an internationally recognized criterion-reference
examination. IBCLCs provide skilled breast-feeding
assistance to mothers and children, work as part of a
health care team to prevent and solve breast-feeding
problems, and encourage a social environment that supports
breast-feeding families. IBCLCs work in a variety of
settings including hospitals, neonatal intensive care units
and special care nurseries, lactation clinics, maternal and
child health services, and in private practice. There are
approximately 1,097 IBCLCs in California.
California Health Benefits Review Program
Pursuant to AB 1996 (Thomson), Chapter 795, Statutes of
2002, and SB 1704 (Kuehl), Chapter 684, Statutes of 2006,
which asks the University of California to assess
legislation proposing a mandated benefit or service, or the
repeal of a mandated benefit or service, the California
STAFF ANALYSIS OF ASSEMBLY BILL 513 (De Leon) Page
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Health Benefits Review Program (CHBRP) prepared a written
analysis of the public health, medical, and economic
impacts of this measure. The following are highlights from
the analysis:
CHBRP notes that only two market segments may exclude
maternity benefits: CDI-regulated small group policies
and CDI-regulated individual market policies. Earlier
CHBRP reports indicate that 100 percent of persons with
coverage from large and small group policies regulated by
CDI have coverage, as do 22 percent of persons with
coverage through CDI-regulated individual market
policies; therefore, only a portion of the CDI-regulated
individual market would not be subject to this mandate.
(AB 98 (De La Torre) of 2009, if enacted, would change
this and subject all individual market policies to this
mandate.)
CHBRP also notes that breast pumps are medical devices
regulated by the federal Food and Drug Administration.
CHBRP also notes that its survey of health plans and
policies indicates that current coverage of outpatient LC
may be limited in scope, i.e., LC can be restricted to
the inpatient setting, and coverage for breast pump
rental can be restricted, unless there are medical
complications on the part of the mother or child.
Importantly, CHBRP notes that, should AB 513 become law,
the required scope of coverage would be expected to
expand for DMHC-regulated plans but not for CDI-regulated
policies. DMHC-regulated plans would likely be required
to consider outpatient lactation consultation delivered
by an IBCLC and breast pump rentals for any nursing
mother as within the scope of covered services. For some
plans, this would be an expansion of current scope. The
expansion would be based on DMHC's consideration of
medical necessity criteria for provision of mandated
benefits. To establish medical necessity, DMHC considers
current clinical guidelines and standards of care.
Current clinical guidelines, as noted in the Medical
Effectiveness section, recommend lactation consultation
and breast pump use in order to promote the health
benefits associated with breast-feeding. In contrast, CDI
does not consider current clinical guidelines, and so the
bill would not be likely to require an expansion of scope
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among policies that currently cover these services.
[Emphasis added.]
CHBRP notes that six government agencies and professional
societies recommend that health professionals provide
education and support to encourage mothers to initiate
and continue breast-feeding. Three organizations
recommend that breast pumps be available to all women who
are separated from their infants for long periods of
time, including mothers returning to work, as well as
those who have sick or preterm infants.
Medical Effectiveness . CHBRP was unable to identify any
studies that compared the effectiveness of LC provided by
IBCLCs to the effectiveness of LC provided by other
health professionals, such as nurses or midwives.
According to CHBRP, all studies with regard to LC
compared extra LC provided by a professional lactation
consultant, i.e., on a one-to-one basis, to standard
breast-feeding care, i.e., care typically provided by a
hospital or outpatient setting. CHBRP found that the
evidence of the effectiveness of extra LC on cessation of
any breast-feeding is ambiguous. The preponderance of
evidence found no effect of extra LC on the cessation of
exclusive breast-feeding before four to six weeks after
delivery. CHBRP also reported that there is clear and
convincing evidence that extra LC does not affect
cessation of exclusive breast-feeding up to six months
post delivery.
With regard to breast pumps, CHBRP indicated that
literature on breast pumps is limited in terms of number
of studies and the populations studied. However, CHBRP
states that findings from a single study suggest that for
low-income women returning to work who had immediate or
delayed access to renting a breast pump, the odds of not
using formula at six months were three to five times as
large as the odds for women who did not rent a breast
pump. CHBRP noted that evidence regarding the relative
impact of simultaneous versus sequential pumping with an
electric pump on the volume of milk expressed is
ambiguous. Lastly, CHBRP reported that one study found
no effect of electric or manual pumping on breast-feeding
rates at six months.
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Utilization, Cost, and Coverage Impacts . According to
CHBRP, about 20.5 million people are enrolled in
privately and publicly funded health plans and policies
subject to this mandate, of which 416,000 are delivering
women who would be directly impacted by the services
included in this bill. Among the estimated 416,000
delivering women with coverage subject to this bill,
about 103,000 would gain coverage for outpatient LC
provided after discharge from the hospital, and
approximately 27,000 would gain coverage for breast pump
rental. CHBRP estimates that of the 416,000 delivering
women who would be the anticipated users of the services
covered by this bill, 44 percent currently consult with
IBCLCs during delivery admission, 6 percent consult with
IBCLCs in an outpatient practice, and 6.2 percent rent
breast pumps.
According to CHBRP, there would be no change in
utilization rates as a result of this bill for LC during
delivery admission, outpatient LC, or breast pump rental,
because LC during delivery admission is already fully
covered for 96.2 percent of enrollees; and, while more
than 50 percent of women utilizing outpatient LC must
currently pay for it themselves, CHBRP assumes demand is
currently fully met because the service is usually
accessed only once or twice, so the financial exposure is
limited. With regard to breast pump rental, CHBRP
assumes that due to the low cost ($10 per week) of
rental, demand is met at the current 6.2 percent
utilization level. CHBRP notes that, among lower-income
women, for whom the price of outpatient LC may be a
barrier to use, the service is currently fully covered by
Medi-Cal. (CHBRP estimates the per-visit cost for
outpatient lactation consultation at $95.)
Total annual expenditures as a result of this bill are
estimated to increase by $607,000. This bill is
estimated to increase premiums by about $4.1 million.
Total premiums for private employers are estimated to
increase by 0.006 percent, or $2.8 million. Total
employer premium expenditures for CalPERS are estimated
to increase by $178,000, or $0.02 per member, per month.
Premiums paid by employees in group insurance, including
CalPERS, would increase by 0.006 percent, or $756,000.
Total premiums for those with individually purchased
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insurance are estimated to increase by $323,000 or $0.03
per member, per month in the DMHC regulated market, and
no per member, per month increase in the CDI-regulated
market. State expenditures for Medi-Cal and those for
Healthy Families are estimated to remain unchanged, as
CHBRP staff indicates these programs already provide
these benefits under the more generous clinical
guidelines for medical necessity.
Public Health Impact . CHBRP states that the overall
consensus from the medical community is that
breast-feeding has substantial health benefits to both
infants and mothers. However, this bill is not expected
to generate health benefits associated with
breast-feeding, since CHBRP indicates this bill is not
expected to result in an increase in utilization of LC or
use of electric breast pumps. CHBRP does note that this
bill is expected to reduce out-of-pocket costs for the
current 6,000 users of outpatient LC and 2,000 users of
electric breast pumps. Furthermore, CHBRP states that
since this bill is not expected to result in an increase
in LC or use of electric breast pumps, it is not expected
to decrease racial health disparities, decrease the
economic burden associated with health conditions that
could be prevented by increased breast-feeding, or result
in long-term health benefits.
Breast-feeding guidelines
Current guidelines issued by the U.S. Department of Health
and Human Services, the U.S. Preventive Services Task
Force, the Academy of Breast-feeding Medicine, the American
Academy of Family Physicians, the American Academy of
Pediatrics, and the American College of Obstetrics and
Gynecology each recommend breast-feeding because it is
associated with numerous health benefits for children and
their mothers. Four of these professional groups recommend
that infants should consume breast milk exclusively for the
first six months of life. Health benefits for breast-fed
babies include fewer ear, respiratory, and urinary tract
infections and lower incidences of obesity, type 1 and 2
diabetes, childhood leukemia, and sudden infant death
syndrome. Breast-feeding mothers with a history of
lactation have reduced risks of type 2 diabetes and breast
and ovarian cancer. All six sets of national guidelines
recommend that health providers provide education and
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support to encourage mothers to initiate and continue
breast-feeding.
Related legislation
AB 98 (De La Torre) would require every individual or group
health insurance policy, as specified, to cover maternity
services, as defined. Pending in the Senate Health
Committee.
Arguments in support
The sponsor of this bill, the California WIC Association,
notes in support that 87 percent of California mothers
initiate breast-feeding in the hospital and this bill will
ensure that, in the early days and weeks after birth,
mothers will receive the help they need to solve normal and
expected problems so they can continue breast-feeding,
exclusively, without the need for formula.
Supporters, representing health providers, public health
groups, working women, and breast-feeding advocacy groups,
assert that mothers should have access to the support and
tools they need to ensure that breast-feeding is
successful. The California Nurses Association states that
this bill promotes the use of breast milk which produces
healthier babies, provides new mothers the support services
they need to be even better mothers, and reduces health
care costs. Beach Cities Health Districts writes that the
benefits of prevention starts with newborns. LA Best
Babies Network notes that the federal Healthy People 2010
goal is to increase the proportion of mothers who
breast-feed their babies in the early postpartum period to
75 percent and at six months to 50 percent.
The California Commission on the Status of Women points out
that, when women who work full-time have access to breast
pumps, they are able to return to work while continuing to
breast-feed and are shown to take less time off work since
their children get sick less often due to the
immune-enhancing benefits of breast milk. The California
Center for Public Health Advocacy believes breast-feeding
is a cost effective prevention strategy to ensure newborns
are healthy and also regards breast-feeding as an important
obesity prevention strategy.
The California Medical Association writes in support that
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breast-feeding is the best form of nutrition for infants,
and this bill will make LC more accessible for new mothers
and facilitate the first step of the breast-feeding
process. The American College of Obstetricians and
Gynecologists adds that the minimal costs associated with
these services should be more than offset by the reduction
of medical conditions in the future needing medical
treatment. The California Women's Law Center cites a
two-year study by CIGNA, which found that a lactation
support program for its employees resulted in an annual
savings to the company of $240,000 in health expenses, 62
percent fewer prescriptions, and $60,000 savings from
reduced absenteeism rates.
Arguments in opposition
Health plans, health insurers, and business groups
generally object to all benefit mandates because, while
they sympathize with the intent to meet a need, mandates
increase the already high cost of care for everyone and
hinder a carrier's ability to offer a wider range of
affordable products, which together may lead individuals
and employers to drop coverage.
Anthem Blue Cross states that California currently requires
insurers to cover 29 benefits and 14 provider types, which
it asserts make premiums in the range of 22 percent to 53
percent higher than they would be for products that do not
comply with the mandates. The California Association of
Health Plans writes that it is opposed to all benefit
mandates impacting health plans regulated by the DMHC.
Health Net contends that it already provides coverage for
breast pumps as part of durable medical equipment coverage
when there is a demonstrated medical necessity, and opposes
this bill because it requires coverage of pumps when they
are not needed for medical reasons but to assist the mother
in expressing milk on a schedule that is suitable for her.
Health Net also notes that most enrollees receive LC,
primarily from nurses, during delivery admission, and it is
not aware of any evidence that challenges the competence of
nurses to provide this assistance to new mothers. Health
Net highlights that the CHBRP report calls into doubt the
effectiveness of extra lactation consultation on
breast-feeding rates.
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PRIOR ACTIONS
Assembly Floor: 50-28
Assembly Appropriations:12-5
Assembly Health: 12-3
COMMENTS
1.IBCLCs.
The bill requires coverage for lactation consultation
with an IBCLC, which is a certification that is not
recognized in California law. Other health care coverage
mandates typically require covered services to be
provided by a licensed provider or other recognized
provider type, or under the supervision of a licensed
provider operating within his or her scope of practice.
2.Rental of breast pumps.
Staff recommends an amendment to clarify what type of
breast pumps are covered under this mandate. The language
is contained in the mockup below.
3.Parallel application of the benefit.
According to CHBRP's analysis, DMHC and CDI indicate that
they would apply differing medical necessity standards to
this coverage benefit. DMHC indicates it would apply
current clinical guidelines, which suggest medical
necessity upon more liberal terms, while CDI indicates
individual insurers may require a medical complication in
either infant or mother in order to meet medical
necessity. The author may wish to consider whether health
plans and health insurers should apply this benefit more
uniformly, regardless of the regulatory jurisdiction
under which the contract or policy falls.
4.Technical amendment.
Staff recommends striking references to interpretation of
current law, as it is unnecessary. The language is
contained in the mockup below.
SEC. 2. Section 1367.625 is added to the Health and
Safety Code, to read:
1367.625. (a) Every health care service plan contract,
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except a specialized health care service plan contract,
that provides maternity coverage, and that is issued,
amended, renewed, or delivered on or after January 1,
2010, shall provide coverage for lactation consultation
with an international board certified lactation
consultant (IBCLC) and for the rental of breast pumps.
(b) For the purposes of this section, breast pump means
an FDA-approved reusable breast pump that is considered
to be durable medical equipment, and meets state or
federal quality standards for durable medical equipment.
Nothing in this section shall be construed to mean that a
health care service plan is not required to provide
breast-feeding support benefits, including, but not
limited to, lactation consultation and breast pumps, to
women and children enrolled in any of the following:
(1) The Medi-Cal, Healthy Families, or Access to Infants
and Mothers programs when the health care service plan
participates in, or has a contract with, any of those
programs.
(2) Private health care coverage where breast-feeding
support benefits are included as part of maternity or
other benefits provided by a health care service plan
pursuant to a contract in effect before January 1, 2010.
(c) This section shall not apply to specialized health
care service plans, Medicare supplement, short-term
limited duration health insurance, CHAMPUS-supplement
insurance, TRI-CARE supplement, or to hospital indemnity,
accident-only, or specified disease plans.
SEC. 3. Section 10123.875 is added to the Insurance Code,
to read:
10123.875. (a) Every policy of health insurance that
provides maternity coverage, and that is issued, amended,
renewed, or delivered on or after January 1, 2010, shall
provide coverage for lactation consultation with an
international board certified lactation consultant
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(IBCLC) and for the rental of breast pumps.
(b) For the purposes of this section, breast pump means
an FDA-approved reusable breast pump that is considered
to be durable medical equipment, and meets state or
federal quality standards for durable medical equipment.
Nothing in this section shall be construed to mean that
the Medi-Cal fee-for-service program or a private insurer
is not required to provide breast-feeding support
benefits, including, but not limited to, lactation
consultation and breast pumps, to women and children
enrolled in any of the following:
(1) Medi-Cal fee-for-service.
(2) Private health insurance where breast-feeding support
benefits are included as part of maternity or other
benefits provided by the insurer pursuant to a policy in
effect before January 1, 2010.
(c) This section shall not apply to specialized health
insurance, Medicare supplement, short-term limited
duration health insurance, CHAMPUS-supplement insurance,
TRI-CARE supplement, or to hospital indemnity,
accident-only, or specified disease plans.
POSITIONS
Support: California WIC Association (sponsor)
American Academy of Pediatrics, Chapter 3, District
IX
American College of Obstetricians and Gynecologists,
District IX/ CA
American Federation of State, County and Municipal
Employees, AFL-CIO
Beach Cities Health District
Birth Education Services
Breastfeeding Task Force of Greater Los Angeles
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California Breastfeeding Coalition
California Center for Public Health Advocacy
California Commission on the Status of Women
California Communities United Institute
California Food Policy Advocates
California Medical Association
California Nurses Association
California Women's Law Center
Consumer Action
First 5 Fresno County
First 5 LA
Inland Empire Breastfeeding Coalition
Kaweah Delta Medical Center
LA Best Babies Network
Los Angeles County, Department of Public Health
Monterey County WIC Program
National Association of Working Women
Planned Parenthood Affiliates of California
Prevention Institute
The Pump Connection
San Diego County Breastfeeding Coalition
San Francisco Breastfeeding Promotion Coalition
Santa Cruz County Breastfeeding Coalition
United Nurses Associations of California/Union of
Health Care Professionals
Several individuals
Oppose: Association of California Life and Health
Insurance Companies
Anthem Blue Cross
California Association of Health Plans
California Chamber of Commerce
Department of Finance
Department of Managed Health Care
Health Net
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