BILL NUMBER: SB 630 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY SEPTEMBER 4, 2009
AMENDED IN ASSEMBLY AUGUST 31, 2009
AMENDED IN ASSEMBLY JUNE 22, 2009
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 define reconstructive surgery , as of July 1,
2010, to include medically necessary dental or orthodontic
services that are an integral part of reconstructive surgery for
cleft palate procedures, except as specified. Because a willful
violation of this 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 subdivision
(c), that is necessary to achieve the purposes specified in
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) "Reconstructive surgery" includes
(2) As of July 1, 2010, "reconstructive
surgery" shall include medically necessary dental or
orthodontic services that are an integral part of reconstructive
surgery, as defined in paragraph (1), for cleft palate procedures.
(3) For purposes of this section, "cleft palate" means a condition
that may include cleft palate, cleft lip, or other craniofacial
anomalies associated with cleft palate.
(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) As applied to services 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 subdivision (c), that is
necessary to achieve the purposes specified in 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) "Reconstructive surgery" includes
(2) As of July 1, 2010, "reconstructive
surgery" shall include medically necessary dental or
orthodontic services that are an integral part of reconstructive
surgery, as defined in paragraph (1), for cleft palate procedures.
(3) For purposes of this section, "cleft palate" means a condition
that may include cleft palate, cleft lip, or other craniofacial
anomalies associated with cleft palate.
(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 medically necessary dental or orthodontic
services performed to provide or complete reconstructive surgery for
cleft palate procedures are examples of services that are already
required by the statutory provisions amended by this act.
It is not the intent of the Legislature to narrow the existing
requirement to provide reconstructive surgery or to otherwise limit
or prevent coverage for dental or orthodontic services that are a
necessary and integral part of reconstructive surgery to address
other medical conditions pursuant to current law. Further, it is not
the intent of the Legislature to extend the requirement to provide
coverage to dental or orthodontic services that are not medically
necessary and are not related to medical conditions that require
reconstructive surgery.
SEC. 4. SEC. 3. 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.