BILL ANALYSIS Ó
SB 255
Page 1
SENATE THIRD READING
SB 255 (Pavley)
As Amended August 6, 2012
Majority vote
SENATE VOTE :27-6
HEALTH 17-1 APPROPRIATIONS 16-0
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|Ayes:|Monning, Logue, Ammiano, |Ayes:|Fuentes, Harkey, |
| |Atkins, Bonilla, Eng, | |Blumenfield, Bradford, |
| |Garrick, Gordon, Hayashi, | |Charles Calderon, Campos, |
| |Roger Hernández, | |Davis, Gatto, Hall, Hill, |
| |Bonnie Lowenthal, | |Lara, Mitchell, Nielsen, |
| |Mitchell, Nestande, V. | |Norby, Solorio, Wagner |
| |Manuel Pérez, Silva, | | |
| |Smyth, Williams | | |
| | | | |
|-----+--------------------------+-----+--------------------------|
|Nays:|Mansoor | | |
| | | | |
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SUMMARY : 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 to be made
post-surgery, which current law requires a physician to make
in consultation with a patient.
3)Specifies that the purpose of this measure is to clarify that
existing definition of mastectomy includes lumpectomy, and
prohibits language in this bill from being construed as
establishing a new mandated benefit.
EXISTING FEDERAL LAW :
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1)Defines, under the Patient Protection and Affordable Care Act
(Public Law 111-148), as amended by the Health Care Education
and Reconciliation Act of 2010 (Public Law 111-152), a list of
essential health benefits which health care service plans
(health plans) and individual or group health insurers
(insurers) must provide beginning in 2014.
2)Provides protections to patients who choose to have breast
reconstruction in connection with a mastectomy under the
Women's Health and Cancer Rights Act of 1998. Requires health
plans and insurers that provide mastectomy coverage benefits
to cover reconstruction of the breast removal, surgery and
reconstruction of the other breast to achieve symmetry, any
external breast prostheses needed before or during the
reconstruction; and, any physical complications at all stages
of mastectomy, including lymphedema.
EXISTING STATE LAW :
1)Provides for the regulation of health plans by the Department
of Managed Health Care and insurers by the California
Department of Insurance.
2)Requires every health 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 incidental to a mastectomy.
3)Requires every health plan and health insurance policy that
provides coverage for mastectomies and lymph node dissections
to allow the length of stay to be determined by the attending
physician and surgeon in consultation with the patient, cover
prosthetic devices or reconstructive surgery; and, cover all
complications from a mastectomy, as specified. Prohibits a
health plan or insurer from requiring a treating physician and
surgeon to receive prior approval in determining length of
hospital stay following those procedures.
4)Defines mastectomy as the removal of all or part of the breast
for medically necessary reasons, as determined by a licensed
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physician and surgeon.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, this bill would have negligible state fiscal effect.
COMMENTS : According to the author, this bill updates medical
terminology and clarifies that the original hospital safeguards
placed in law 14 years ago apply to both mastectomies and
lumpectomies. The author maintains that the law was intended to
cover both types of surgeries by using the definition "removal
of all or part of the breast" and this bill simply updates the
law with the medical name for removing "part of the breast" with
lumpectomy. The author asserts that current law provides that
patients who undergo mastectomies and lymph node dissections,
are entitled to a hospital stay determined by the physician and
patient. Patients are also entitled to coverage for
prosthetics, reconstruction, and surgery to address
complications, if medically necessary. However, according to
the author, the law is unclear about whether these services
apply to breast conservation surgeries, like partial
mastectomies and lumpectomies. The author maintains that while
most lumpectomy patients will not need a longer hospital stay,
some patients undergoing these surgeries may experience
unexpected complications, have no support at home and may
require a longer stay to manage pain, bleeding drains and the
risk of an infection - just like some patients undergoing
mastectomies. Patients may require different lengths of stay to
recuperate based on their health, age and other factors. The
author argues that this clarification is necessary so that
doctors, patients and payers are clear about appropriate
treatment when it is medically necessary for all breast cancer
surgeries.
Mastectomy is performed under general anesthesia. Most women
treated with mastectomy are hospitalized for at least one night
following surgery. The entire affected breast plus some lymph
nodes are removed. (The lymph nodes are removed to determine
whether the cancer has spread to them.) Women who have a
mastectomy may choose to have breast reconstruction at the same
time or at a later date.
Lumpectomy is performed under either local or general anesthesia
and is typically provided on an outpatient basis in a hospital
or outpatient surgical center. The area of the breast in which
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the tumor is located plus a border of healthy tissue around the
tumor are removed. A second incision is often made under the
arm to remove some lymph nodes. The border of healthy tissue
around the tumor is referred to as the surgical margin. If the
surgical margin is not free of cancer, a second surgery is
performed to obtain cancer-free margins.
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097
FN: 0004719