BILL ANALYSIS Ó
SB 255
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Date of Hearing: August 8, 2012
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Felipe Fuentes, Chair
SB 255 (Pavley) - As Amended: August 6, 2011
Policy Committee: HealthVote:17-1
Urgency: No State Mandated Local Program:
Yes Reimbursable: No
SUMMARY
This bill clarifies and further specifies a current-law mandate
related to health care coverage of breast cancer treatment.
Specifically, this bill:
1)Clarifies, for purposes of defining mastectomy, that partial
removal of a breast includes but is not limited to lumpectomy,
which includes surgical removal of the tumor with clear
margins.
2)Requires the determination of length of a hospital stay
following a mastectomy or lymph node dissection, which current
law requires a physician to make in consultation with a
patient, to be made post-surgery.
3)Specifies that its purpose is to clarify that the existing
definition of mastectomy includes lumpectomy, and that it
shall not be construed as establishing a new mandated benefit.
FISCAL EFFECT
Negligible state fiscal effect.
COMMENTS
1)Rationale . The author indicates this bill clarifies existing
law by specifying lumpectomy is a medical term for partial
removal of the breast. This bill is intended to clarify that
health plans and policies must follow safe minimum standards
for medically necessary hospital stays, prosthetics and
surgery complications for all breast cancer surgeries - both
mastectomies and lumpectomies.
SB 255
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2)Background . Current law allows the length of hospital stay for
patients who have mastectomies and lymph node dissections to
be determined by the physician and the patient, for purposes
of health insurance coverage. Mastectomy is in law defined as
removal of the entire or partial removal of the breast. While
the original law intended to include lumpectomies by
describing the surgical procedure in law, it did not include
the term lumpectomy. The author believes this has led to
confusion with respect to when coverage is required under
existing law.
3)Essential Health Benefits . The practical impact of this bill
should be fairly limited as it simply clarifies an existing
mandate and does not mandate any new benefits.
The federal Patient Protection and Affordable Care Act of 2010
(ACA) imposes a number of reforms on the health insurance
marketplace, including requiring most plans and policies to
cover a minimum set of essential health benefits (EHBs)
beginning in 2014. The ACA also requires states to offset any
costs associated with state-specific coverage mandates that
exceed the set of EHBs. Preliminary federal guidance suggests
the state will be allowed to define a set of EHBs by reference
to an existing California health plan. Assuming final federal
guidance aligns with this preliminary guidance, this method of
defining EHBs will allow the state to avoid any costs
associated with state-specific mandates until at least 2016.
Regardless of California's choice of a benchmark plan,
medically necessary hospitalization is required to be covered
under EHBs under federal law. However, the existing
mastectomy-related state benefit mandate this bill clarifies
is more specific than what is required under federal law. It
is unknown whether, after 2016, the federal government may
ascribe any costs to such existing mandates. Any potential
future costs would be related to the existing mandate this
bill seeks to clarify, not to this bill.
4)Related Legislation . SB 951 (Hernández) and AB 1453 (Monning)
define California's EHB package as those benefits included in
a specific Kaiser Permanente Health Plan small-group plan. SB
951 is pending in this committee, and AB 1453 is pending in
Senate Appropriations Committee.
SB 255
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Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081