BILL NUMBER: SB 255	INTRODUCED
	BILL TEXT


INTRODUCED BY   Senator Pavley

                        FEBRUARY 10, 2011

   An act to amend Section 1367.635 of the Health and Safety Code,
and to amend Section 10123.86 of the Insurance Code, relating to
health care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   SB 255, as introduced, Pavley. Health care coverage: breast
cancer.
   Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care, and makes a willful
violation of its provisions a crime. Existing law provides for the
regulation of health insurers by the Department of Insurance.
Existing law requires every health care service plan contract and
health insurance policy that provides coverage for mastectomies and
lymph node dissections to allow the length of any hospital stay to be
determined by the attending physician and surgeon in consultation
with the patient, to cover prosthetic devices or reconstructive
surgery, and to cover all complications from a mastectomy. Existing
law defines mastectomy for those purposes as the removal of all or
part of the breast for medically necessary reasons, as determined by
a licensed physician and surgeon.
   This bill would revise and recast the definition of mastectomy and
would specify that the partial removal of a breast includes, but is
not limited to, lumpectomy, which includes surgical removal of the
tumor with clear margins. The bill would require the consultation
regarding the length of any hospital stay to be conducted
postsurgery.
   Because a willful violation of these provisions by a health care
service plan is 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.  The Legislature finds and declares all of the
following:
   (a) The National Cancer Institute estimates that a woman born
today in the United States has a one in eight chance of developing
breast cancer during her lifetime.
   (b) According to the American Cancer Society, excluding cancers of
the skin, breast cancer is the most frequently diagnosed cancer in
women.
   (c) According to the American Cancer Society, an estimated 40,480
women and 450 men died from breast cancer in 2008.
   (d) Nationwide, in 2008, an estimated 182,460 new cases of
invasive breast cancer were diagnosed in women, and an estimated
1,990 invasive breast cancer cases were diagnosed in men. In
addition, an estimated 67,770 new cases of in situ breast cancer
occurred in women in 2008, and, of these, approximately 85 percent
were ductal carcinoma in situ.
   (e) According to the American Cancer Society, most breast cancer
patients undergo some type of surgical treatment, which may involve
breast-conserving surgeries, such as lumpectomy (surgical removal of
the tumor with clear margins) or mastectomy (surgical removal of the
breast) with removal of some of the axillary (underarm) lymph nodes.
   (f) Currently, 20 states mandate minimum in-patient coverage after
a patient undergoes a mastectomy, including California.
   (g) Breast cancer patients have reported adverse outcomes,
including infection, and inadequately controlled pain resulting from
premature hospital discharge following breast cancer surgery.
  SEC. 2.  Section 1367.635 of the Health and Safety Code is amended
to read:
   1367.635.  (a) Every health care service plan contract that is
issued, amended, renewed, or delivered on or after January 1, 1999,
that provides coverage for surgical procedures known as mastectomies
and lymph node dissections, shall do all of the following:
   (1) Allow the length of a hospital stay associated with those
procedures to be determined by the attending physician and surgeon in
consultation with the patient,  postsurgery,  consistent
with sound clinical principles and processes. No health care service
plan shall require a treating physician and surgeon to receive prior
approval from the plan in determining the length of hospital stay
following those procedures.
   (2) Cover prosthetic devices or reconstructive surgery, including
devices or surgery to restore and achieve symmetry for the patient
incident to the mastectomy. Coverage for prosthetic devices and
reconstructive surgery shall be subject to the deductible and
coinsurance conditions applicable to other benefits.
   (3) Cover all complications from a mastectomy, including
lymphedema.
   (b) As used in this section, all of the following definitions
apply:
   (1) "Coverage for prosthetic devices or reconstructive surgery"
means any initial and subsequent reconstructive surgeries or
prosthetic devices, and followup care deemed necessary by the
attending physician and surgeon.
   (2) "Prosthetic devices" means and includes the provision of
initial and subsequent prosthetic devices pursuant to an order of the
patient's physician and surgeon.
   (3) "Mastectomy"  shall have the same meaning as in
Section 1367.6   means the removal of all or part of the
breast for medically necessary reasons, as determined by a licensed
physician and surgeon. Partial removal of a breast includes, but is
not limited to, lumpectomy, which includes surgical removal of the
tumor with clear margins  .
   (4) "To restore and achieve symmetry" means that, in addition to
coverage of prosthetic devices and reconstructive surgery for the
diseased breast on which the mastectomy was performed, prosthetic
devices and reconstructive surgery for a healthy breast is also
covered if, in the opinion of the attending physician and surgeon,
this surgery is necessary to achieve normal symmetrical appearance.
   (c) No individual, other than a licensed physician and surgeon
competent to evaluate the specific clinical issues involved in the
care requested, may deny requests for authorization of health care
services pursuant to this section.
   (d) No health care service plan shall do any of the following in
providing the coverage described in subdivision (a):
   (1) Reduce or limit the reimbursement of the attending provider
for providing care to an individual enrollee or subscriber in
accordance with the coverage requirements.
   (2) Provide monetary or other incentives to an attending provider
to induce the provider to provide care to an individual enrollee or
subscriber in a manner inconsistent with the coverage requirements.
   (3) Provide monetary payments or rebates to an individual enrollee
or subscriber to encourage acceptance of less than the coverage
requirements.
   (e) On or after July 1, 1999, every health care service plan shall
include notice of the coverage required by this section in the plan'
s evidence of coverage.
   (f) Nothing in this section shall be construed to limit
retrospective utilization review and quality assurance activities by
the plan.
  SEC. 3.  Section 10123.86 of the Insurance Code is amended to read:

   10123.86.  (a) Every policy of disability insurance covering
hospital, surgical, or medical expenses that is issued, amended,
renewed, or delivered on or after January 1, 1999, that provides
coverage for surgical procedures known as mastectomies and lymph node
dissections, shall do all of the following:
   (1) Allow the length of a hospital stay associated with those
procedures to be determined by the attending physician and surgeon in
consultation with the patient,  postsurgery,  consistent
with sound clinical principles and processes. No disability insurer
shall require a treating physician and surgeon to receive prior
approval in determining the length of hospital stay following those
procedures.
   (2) Cover prosthetic devices or reconstructive surgery, including
devices or surgery to restore and achieve symmetry for the patient
incident to the mastectomy. Coverage for prosthetic devices and
reconstructive surgery shall be subject to the deductible and
coinsurance conditions applicable to other benefits.
   (3) Cover all complications from a mastectomy, including
lymphedema.
   (b) As used in this section, all of the following definitions
apply:
   (1) "Coverage for prosthetic devices or reconstructive surgery"
means any initial and subsequent reconstructive surgeries or
prosthetic devices, and followup care deemed necessary by the
attending physician and surgeon.
   (2) "Prosthetic devices" means and includes the provision of
initial and subsequent prosthetic devices pursuant to an order of the
patient's physician and surgeon.
   (3) "Mastectomy"  shall have the same meaning as in
Section 10123.8   means the removal of all or part of
the breast for medically necessary reasons, as determined by a
licensed physician and surgeon. Partial removal of a breast includes,
but is not limited to, lumpectomy, which includes surgical removal
of the tumor with clear   margins  .
   (4) "To restore and achieve symmetry" means that, in addition to
coverage of prosthetic devices and reconstructive surgery for the
diseased breast on which the mastectomy was performed, prosthetic
devices and reconstructive surgery for a healthy breast is also
covered if, in the opinion of the attending physician and surgeon,
this surgery is necessary to achieve normal symmetrical appearance.
   (c) No individual, other than a licensed physician and surgeon
competent to evaluate the specific clinical issues involved in the
care requested, may deny requests for authorization of health care
services pursuant to this section.
   (d) No insurer shall do any of the following in providing the
coverage described in subdivision (a):
   (1) Reduce or limit the reimbursement of the attending provider
for providing care to an insured in accordance with the coverage
requirements.
   (2) Provide monetary or other incentives to an attending provider
to induce the provider to provide care to an insured in a manner
inconsistent with the coverage requirements.
   (3) Provide monetary payments or rebates to an insured to
encourage acceptance of less than the coverage requirements.
   (e) On or after July 1, 1999, every insurer shall include notice
of the coverage required by this section in the insurer's evidence of
coverage or certificate of insurance.
   (f) Nothing in this section shall be construed to limit
retrospective utilization review and quality assurance activities by
the insurer.
   (g) 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.
  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.