BILL NUMBER: SB 255	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  AUGUST 6, 2012
	AMENDED IN SENATE  APRIL 25, 2011

INTRODUCED BY   Senator Pavley
    (   Coauthor:   Senator   Evans
  ) 
    (   Coauthors:   Assembly Members 
 Atkins,   Bonnie Lowenthal,   and Mitchell
  ) 

                        FEBRUARY 10, 2011

   An act to amend Sections 1367.6 and 1367.635 of the Health and
Safety Code, and to amend Sections 10123.8 and 10123.86 of the
Insurance Code, relating to health care coverage.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 255, as amended, 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 to provide coverage for screening for,
diagnosis of, and treatment for, breast cancer, including coverage
for prosthetic devices or reconstructive surgery to restore and
achieve symmetry for the patient incident to a mastectomy. 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
  inpatient  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 1367.6 of the Health and Safety Code is amended to
read:
   1367.6.  (a) Every health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, delivered, or renewed on or after January 1, 2000, shall
provide coverage for screening for, diagnosis of, and treatment for,
breast cancer.
   (b) No health care service plan contract shall deny enrollment or
coverage to an individual solely due to a family history of breast
cancer, or who has had one or more diagnostic procedures for breast
disease but has not developed or been diagnosed with breast cancer.
   (c) Every health care service plan contract shall cover screening
and diagnosis of breast cancer, consistent with generally accepted
medical practice and scientific evidence, upon the referral of the
enrollee's participating physician.
   (d) Treatment for breast cancer under this section shall include
coverage for prosthetic devices or reconstructive surgery to restore
and achieve symmetry for the patient incident to a mastectomy.
Coverage for prosthetic devices and reconstructive surgery shall be
subject to the copayment, or deductible and coinsurance conditions,
that are applicable to the mastectomy and all other terms and
conditions applicable to other benefits.
   (e) As used in this section, "mastectomy" 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.
   (f) As used in this section, "prosthetic devices" means the
provision of initial and subsequent devices pursuant to an order of
the patient's physician and surgeon.
  SEC. 3.  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" 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. 4.  Section 10123.8 of the Insurance Code is amended to read:
   10123.8.  (a) Every policy of disability insurance that provides
coverage for hospital, medical, or surgical expenses, that is issued,
amended, delivered, or renewed on or after January 1, 2000, shall
provide coverage for screening for, diagnosis of, and treatment for,
breast cancer.
   (b) No policy of disability insurance that provides coverage for
hospital, medical, or surgical expenses shall deny enrollment or
coverage to an individual solely due to a family history of breast
cancer, or who has had one or more diagnostic procedures for breast
disease but has not developed or been diagnosed with breast cancer.
   (c) Every policy of disability insurance shall cover screening and
diagnosis of breast cancer, consistent with generally accepted
medical practice and scientific evidence, upon the referral of the
insured's participating physician.
   (d) Treatment for breast cancer under this section shall include
coverage for prosthetic devices or reconstructive surgery to restore
and achieve symmetry for the patient incident to a mastectomy.
Coverage for prosthetic devices and reconstructive surgery shall be
subject to the deductible and coinsurance conditions applied to the
mastectomy and all other terms and conditions applicable to other
benefits.
   (e) As used in this section, "mastectomy" 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.
   (f) As used in this section, "prosthetic devices" means the
provision of initial and subsequent devices pursuant to an order of
the patient's physician and surgeon.
   (g) For purposes of this section, disability insurance does not
include accident only, credit, disability income, specified disease
and hospital confinement indemnity, coverage of Medicare services
pursuant to contracts with the United States government, Medicare
supplement, long-term care insurance, dental, vision, coverage issued
as a supplement to liability insurance, insurance arising out of a
workers' compensation or similar law, automobile medical payment
insurance, or insurance under which benefits are payable with or
without regard to fault and that is statutorily required to be
contained in any liability insurance policy or equivalent
self-insurance.
  SEC. 5.  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" 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. 6.    Nothing in this act shall be construed to
establish a new mandated   benefit. The purpose of this act
is to clarify that the existing definition of the term "mastectomy"
also includes lumpectomy. 
   SEC. 6.   SEC. 7.   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.