Amended in Senate September 4, 2013

Amended in Senate August 20, 2013

Amended in Senate July 2, 2013

Amended in Senate June 19, 2013

Amended in Senate June 17, 2013

California Legislature—2013–14 Regular Session

Assembly Bill No. 219

Introduced by Assembly Member Perea

(Coauthors: Assembly Members Olsen, Wieckowski, and Williams)

(Coauthor: Senator Wright)

February 4, 2013

An act to add begin insert and repeal end insert Section 1367.656 begin delete to end delete begin insert of end insert the Health and Safety Code, and to add begin insert and repeal end insert Section 10123.206 begin delete to end delete begin insert of end insert the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

AB 219, as amended, Perea. Health care coverage: cancer treatment.

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 the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide coverage for all generally medically accepted cancer screening tests and requires those contracts and policies to also provide coverage for the treatment of breast cancer. Existing law imposes various requirements on contracts and policies that cover prescription drug benefits.

This bill would prohibit begin delete a end delete begin insert an individual or group end insert health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2015, that provides coverage for prescribed, orally administered anticancer medications begin delete from requiring an enrollee or insured to pay a total cost-sharing amount of more than $100 per filled prescription. The bill would provide that, with respect to a high deductible health plan, as defined, this provision applies only if the plan deductible has been satisfied. end delete begin insert used to kill or slow the growth of cancerous cells from requiring an enrollee or insured to pay, notwithstanding any deductible, a total amount of copayments and coinsurance that exceeds $200 for an individual prescription of up to a 30-day supply of a prescribed orally administered anticancer medication. The bill would provide that for a health care service plan contract or health insurance policy that meets a specified federal definition of a high deductible health plan, this prohibition shall only apply once the enrollee’s or insured’s deductible has been satisfied for the year. The bill would authorize a health care service plan or health insurer, on January 1, 2016, and on January 1 of each year thereafter, to increase the $200 limit by the percentage increase in the Consumer Price Index for that year. The bill would repeal these provisions on January 1, 2019. end insert

Because a willful violation of the bill’s requirements relative to health care service plans 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:

begin insert

begin insert SECTION 1. end insert   

end insert begin insert

(a) The Legislature finds and declares that the
majority of prescriptions for oral anticancer medications are filled
by cancer patients at reasonable cost due to effective health plan
or health insurance coverage of the product or the low retail price
of the drug.

end insert begin insert

(b) It is the intent of the Legislature to help cancer patients who
do not have access to the most appropriate treatment for their
cancer because the terms of their health care service plan contract
or health insurance policy do not make the covered treatment
affordable.

end insert begin insert

(c) It is further the intent of the Legislature to set a maximum
total copayment and coinsurance amount that health care service
plans and health insurers can require patients to pay for a 30-day
supply of oral anticancer medication. The Legislature does not
intend health care service plans or health insurers to interpret that
maximum to be a target or desirable patient cost.

end insert

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 1367.656 is added to the end insert begin insert Health and Safety
Code end insert begin insert , to read: end insert

begin insert

begin insert 1367.656. end insert   

(a) Notwithstanding any other law, an individual
or group health care service plan contract issued, amended, or
renewed on or after January 1, 2015, that provides coverage for
prescribed, orally administered anticancer medications used to
kill or slow the growth of cancerous cells shall comply with all of
the following:

(1) Notwithstanding any deductible, the total amount of
copayments and coinsurance an enrollee is required to pay shall
not exceed two hundred dollars ($200) for an individual
prescription of up to a 30-day supply of a prescribed orally
administered anticancer medication covered by the contract.

(2) For a health care service plan contract that meets the
definition of a “high deductible health plan” set forth in Section
223(c)(2) of Title 26 of the United States Code, paragraph (1)
shall only apply once an enrollee’s deductible has been satisfied
for the year.

(3) Paragraph (1) shall not apply to any coverage under a health
care service plan contract for the Medicare Program pursuant to
Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395
et seq.).

(4) On January 1, 2016, and on January 1 of each year
thereafter, health care service plans may adjust the two hundred
dollar ($200) limit described in paragraph (1). The adjustment
shall not exceed the percentage increase in the Consumer Price
Index for that year.

(5) A prescription for an orally administered anticancer
medication shall be provided consistent with the appropriate
standard of care for that medication.

(b) This section shall remain in effect only until January 1, 2019,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2019, deletes or extends that date.

end insert

begin insert

begin insert SEC. 3. end insert   

end insert

begin insert Section 10123.206 is added to the end insert begin insert Insurance Code end insert begin insert , to
read: end insert

begin insert

begin insert 10123.206. end insert   

(a) Notwithstanding any other law, an individual
or group health insurance policy issued, amended, or renewed on
or after January 1, 2015, that provides coverage for prescribed,
orally administered anticancer medications used to kill or slow
the growth of cancerous cells shall comply with all of the following:

(1) Notwithstanding any deductible, the total amount of
copayments and coinsurance an insured is required to pay shall
not exceed two hundred dollars ($200) for an individual
prescription of up to a 30-day supply of a prescribed orally
administered anticancer medication covered by the policy.

(2) For a health insurance policy that meets the definition of a
“high deductible health plan” set forth in Section 223(c)(2) of
Title 26 of the United States Code, paragraph (1) shall only apply
once an insured’s deductible has been satisfied for the year.

(3) Paragraph (1) shall not apply to any coverage under a health
insurance policy for the Medicare Program pursuant to Title XVIII
of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.).

(4) On January 1, 2016, and on January 1 of each year
thereafter, health insurers may adjust the two hundred dollar
($200) limit described in paragraph (1). The adjustment shall not
exceed the percentage increase in the Consumer Price Index for
that year.

(5) A prescription for an orally administered anticancer
medication shall be provided consistent with the appropriate
standard of care for that medication.

(b) This section shall remain in effect only until January 1, 2019,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2019, deletes or extends that date.

end insert

begin insert

begin insert SEC. 4. end insert   

end insert begin insert

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.

end insert

begin delete

SECTION 1.  

Section 1367.656 is added to the Health and
Safety Code, to read:

1367.656.  

(a) Notwithstanding any other law, a health care
service plan contract issued, amended, or renewed on or after
January 1, 2015, that provides coverage for prescribed, orally
administered anticancer medications shall not require an enrollee
to pay a total cost-sharing amount of more than one hundred dollars
($100) per filled prescription.

(b) The cost-sharing limit in this section shall not apply to a
health care service plan contract if the plan is a high deductible
health plan, as defined in Section 223 of Title 26 of the United
States Code, and the plan deductible has not been satisfied.

end delete

begin delete

SEC. 2.  

Section 10123.206 is added to the Insurance Code, to
read:

10123.206.  

(a) Notwithstanding any other law, a health
insurance policy issued, amended, or renewed on or after January
1, 2015, that provides coverage for prescribed, orally administered
anticancer medications shall not require an insured to pay a total
cost-sharing amount of more than one hundred dollars ($100) per
filled prescription.

(b) The cost-sharing limit in this section shall not apply to a
health insurance policy if the policy is a high deductible health
plan, as defined in Section 223 of Title 26 of the United States
Code, and the policy deductible has not been satisfied.

end delete

begin delete

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.

end delete