BILL NUMBER: SB 630	AMENDED
	BILL TEXT

	AMENDED IN SENATE  JUNE 1, 2009
	AMENDED IN SENATE  MAY 20, 2009

INTRODUCED BY   Senator Steinberg
   (Coauthor: Senator Alquist)

                        FEBRUARY 27, 2009

   An act to amend Section 1367.63 of the Health and Safety Code, and
to amend Section 10123.88 of the Insurance Code, relating to health
care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   SB 630, as amended, Steinberg. Health care coverage:  cleft
palate  reconstructive surgery: dental and orthodontic services.

   Existing law provides for the licensure and regulation of health
care service plans by the Department of Managed Health Care. Existing
law provides for the regulation of health insurers by the Department
of Insurance. A willful violation of the provisions governing health
care service plans is a crime. Existing law requires health care
service plan contracts and health insurance policies to cover
reconstructive surgery, as defined.
   This bill would provide that the requirement to cover
reconstructive surgery includes dental or orthodontic services that
are medically necessary to provide or complete  the 
reconstructive surgery  for cleft palate procedures  ,
except as specified. Because a willful violation of the provision by
a health care service plan would be a crime, the bill would impose a
state-mandated local program.
   The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1367.63 of the Health and Safety Code is
amended to read:
   1367.63.  (a) Every health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, renewed, or delivered in this state on or after July 1,
1999, shall cover reconstructive surgery, as defined in 
paragraph (1) of  subdivision (c), that is necessary to achieve
the purposes specified in  paragraph (1) or (2) 
 subparagraph (A) or (B) of paragraph (1)  of subdivision
(c). Nothing in this section shall be construed to require a plan to
provide coverage for cosmetic surgery, as defined in subdivision (d).

   (b) No individual, other than a licensed physician competent to
evaluate the specific clinical issues involved in the care requested,
may deny initial requests for authorization of coverage for
treatment pursuant to this section. For a treatment authorization
request submitted by a podiatrist or an oral and maxillofacial
surgeon, the request may be reviewed by a similarly licensed
individual, competent to evaluate the specific clinical issues
involved in the care requested.
   (c) (1) "Reconstructive surgery" means surgery performed to
correct or repair abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma, infection,
tumors, or disease to do either of the following:
   (A) To improve function.
   (B) To create a normal appearance, to the extent possible.
   (2) No plan contract shall exclude coverage for dental or
orthodontic services that are medically necessary to provide or
complete  the  reconstructive surgery 
required by this section.   for cleft palate procedures.

    (3) For purposes of this section, "cleft palate" means a
condition that may include cleft palate, cleft lip, or related
craniofacial anomalies. 
   (d) "Cosmetic surgery" means surgery that is performed to alter or
reshape normal structures of the body in order to improve
appearance.
   (e) In interpreting the definition of reconstructive surgery, a
health care service plan may utilize prior authorization and
utilization review that may include, but need not be limited to, any
of the following:
   (1) Denial of the proposed surgery if there is another more
appropriate surgical procedure that will be approved for the
enrollee.
   (2) Denial of the proposed surgery or surgeries if the procedure
or procedures, in accordance with the standard of care as practiced
by physicians specializing in reconstructive surgery, offer only a
minimal improvement in the appearance of the enrollee.
   (3) Denial of payment for procedures performed without prior
authorization.
   (4) For services provided under the Medi-Cal program (Chapter 7
(commencing with Section 14000) of Part 3 of Division 9 of the
Welfare and Institutions Code), denial of the proposed surgery if the
procedure offers only a minimal improvement in the appearance of the
enrollee, as may be defined in any regulations that may be
promulgated by the State Department of Health Care Services.
   (f)  This   As   applied to
procedures described in paragraph (2) of subdivision (c) only, this
 section shall not apply to Medi-Cal managed care plans that
contract with the State Department of Health Care Services pursuant
to Chapter 7 (commencing with Section 14000) of, Chapter 8
(commencing with Section 14200) of, or Chapter 8.75 (commencing with
Section 14590) of, Part 3 of Division 9 of the Welfare and
Institutions Code, where such contracts do not provide coverage for
California Children's Services (CCS) or dental services.
  SEC. 2.  Section 10123.88 of the Insurance Code is amended to read:

   10123.88.  (a) Every policy of health insurance covering hospital,
medical, or surgical expenses that is issued, amended, renewed, or
delivered in this state on or after July 1, 1999, shall cover
reconstructive surgery, as defined in  paragraph (1) of 
subdivision (c), that is necessary to achieve the purposes specified
in  paragraph (1) or (2)   subparagraph (A) or
(B) of paragraph (1)  of subdivision (c). Nothing in this
section shall be construed to require a policy to provide coverage
for cosmetic surgery, as defined in subdivision (d). This section
shall only apply to health benefit plans, as defined in subdivision
(a) of Section 10198.6, except that for accident only, specified
disease, or hospital indemnity insurance, coverage for benefits under
this section shall apply to the extent that the benefits are covered
under the general terms and conditions that apply to all other
benefits under the policy. Nothing in this section shall be construed
as imposing a new benefit mandate on accident only, specified
disease, or hospital indemnity insurance.
   (b) No individual, other than a licensed physician competent to
evaluate the specific clinical issues involved in the care requested,
may deny initial requests for authorization of coverage for
treatment pursuant to this section. For a treatment authorization
request submitted by a podiatrist or an oral and maxillofacial
surgeon, the request may be reviewed by a similarly licensed
individual, competent to evaluate the specific clinical issues
involved in the care requested.
   (c) (1) "Reconstructive surgery" means surgery performed to
correct or repair abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma, infection,
tumors, or disease to do either of the following:
   (A) To improve function.
   (B) To create a normal appearance, to the extent possible.
   (2) No policy shall exclude coverage for dental or orthodontic
services that are medically necessary to provide or complete 
the  reconstructive surgery  required by this
section.   for cleft palate procedures. 
    (3) For purposes of this section, "cleft palate" means a
condition that may include cleft palate, cleft lip, or related
craniofacial anomalies. 
   (d) Nothing in this section shall be construed to require an
insurer to provide coverage for cosmetic surgery. "Cosmetic surgery"
means surgery that is performed to alter or reshape normal structures
of the body in order to improve the patient's appearance.
   (e) In interpreting the definition of reconstructive surgery, an
insurer may utilize prior authorization and utilization review that
may include, but need not be limited to, any of the following:
   (1) Denial of the proposed surgery if there is another more
appropriate surgical procedure that will be approved for the
enrollee.
   (2) Denial of the proposed surgery or surgeries if the procedure
or procedures, in accordance with the standard of care as practiced
by physicians specializing in reconstructive surgery, offer only a
minimal improvement in the appearance of the enrollee.
   (3) Denial of payment for procedures performed without prior
authorization.
  SEC. 3.  It is the intent of the Legislature to clarify and confirm
that any   medically necessary  dental or
orthodontic services  , when medically necessary 
 performed  to provide or complete reconstructive surgery
 , are  for cleft palate procedures are examples
of  services that are already required by the statutory
provisions amended by this act.
  SEC. 4.  No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.