BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 912
AUTHOR: Quirk-Silva
INTRODUCED: February 22, 2013
HEARING DATE: June 26, 2013
CONSULTANT: Robinson-Taylor
SUBJECT : Health care coverage: fertility preservation.
SUMMARY : Requires every group or individual health care service
plan contract and health insurance policy that is issued,
amended, or renewed, on and after January 1, 2014, to provide
coverage for medically necessary expenses for standard fertility
preservation services when a necessary medical treatment may
cause iatrogenic infertility to an enrollee or insured.
Existing federal law
1.Establishes the Affordable Care Act (ACA) to make, among other
provisions, statutory changes affecting the regulation of, and
payment for, certain types of private health insurance and
includes coverage for prescription drugs in the categories of
10 essential health benefits (EHBs) that all qualified health
plans must cover.
Existing state law:
1.Establishes the Knox-Keene Health Care Service Plan Act of
1975 to regulate and license health plans and specialized
health plans by the Department of Managed Health Care (DMHC)
and provides for the regulation of health insurers by the
California Department of Insurance (CDI).
2.Requires health plan contracts and health insurance policies
to offer group coverage for the treatment of infertility, as
defined.
3.Establishes as California's EHBs the Kaiser Small Group Health
Maintenance Organization plan along with the following 10 ACA
mandated benefits:
a. Ambulatory patient services;
b. Emergency services;
c. Hospitalization;
d. Maternity and newborn care;
e. Mental health and substance use disorder services,
Continued---
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including behavioral health treatment;
f. Prescription drugs;
g. Rehabilitative and habilitative services and devices;
h. Laboratory services;
i. Preventive and wellness services and chronic disease
management; and,
j. Pediatric services, including oral and vision care.
FISCAL EFFECT : According to the Assembly Appropriations
Committee analysis, this bill will result in the following
costs:
1. Approximately $69,000 to CalPERS for additional
premiums.
2. Unknown costs, potentially greater than $100,000, to
Covered California, to the extent the fertility treatment
preservation services exceed the EHBs requirement under the
ACA.
PRIOR VOTES :
Assembly Health: 13- 6
Assembly Appropriations:12- 5
Assembly Floor: 52- 26
COMMENTS :
1.Author's statement. AB 912 ensures that patients with severe
diseases don't have to make the wrenching choice between
receiving life-saving medical help and starting a family. In
the United States, there are approximately 140,000 persons 45
and under who are diagnosed with cancer each year. A
diagnosis of cancer or other disease may bring with it an
unexpected consequence: the potential loss of fertility.
Chemotherapy and radiation may stop the cancer and save lives,
but there is a risk of reproductive damage that partially
depends on the age and sex of the patient, as well as the type
and duration of treatment. Treatments that preserve fertility
in men and women can often be performed before therapy starts,
and utilized after the patient is given a clean bill of
health. However, the cost to preserve fertility is not a
covered option for the majority of cancer patients, even
though fertility loss occurs as a direct consequence of their
treatment. This bill will provide sperm, embryo and egg
preservation insurance coverage for patients undergoing
treatments known to compromise fertility. This is a sensible,
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humane, and cost-effective solution to a foreseeable harm from
medically necessary treatment.
2.Iatrogenic infertility. Iatrogenic infertility is medically
induced infertility caused by a medical intervention used to
treat a primary disease or condition. According to the
California Health Benefits Review Program (CHBRP), iatrogenic
infertility is typically caused by cancer treatments, such as
radiation and chemotherapy or surgical removal of reproductive
organs. Less frequently, fertility is compromised by
treatments for autoimmune disorders such as systemic lupus,
rheumatoid arthritis, or Crohn's disease. Patients at risk
for iatrogenic infertility differ from patients being treated
for infertility in that they need to undergo fertility
preservation services before they undergo treatments that may
put them at risk for becoming infertile. For example, a
patient undergoing treatment for cancer would need to freeze
his sperm prior to starting treatment for his cancer. While
at the time of the procedure, his fertility may be intact, if
he does not take part in fertility preserving treatment, his
future ability to father a child may be at risk.
3.Fertility preservation. A patient may have coverage for
infertility treatment but may not have coverage for fertility
preservation treatment. Current California law mandates
health plans and health insurers to offer group purchasers the
option of buying coverage of infertility treatment (except in
vitro fertilization) but they are not required to cover the
service. Even if patients have coverage for infertility
treatment and do not have coverage for fertility preservation
treatment, they would be ineligible for coverage of those
treatments because they do not meet the definition of being
infertile prior to undergoing cancer treatment.
Fertility preservation services fall into three general
categories encompassing seven standard procedures: 1)
cryopreservation (freezing reproductive tissue) includes sperm
cryopreservation, oocyte cryopreservation, and embryo
cryopreservation; 2) harm reduction includes ovarian
transposition (oophoropexy), ovarian shielding during
radiation therapy, and testicular shielding during radiation
therapy; and 3) conservative surgery (cancer therapy modified
to preserve reproductive tissue) including the two most common
procedures, trachelectomy (i.e., surgical removal of the
cervix) and conservative surgery for ovarian cancer.
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4.EHBs. Effective 2014, the ACA requires non-grandfathered
small-group and individual market health insurance, including
those qualified health plans (QHPs) that will be sold in
Covered California, to cover 10 specified categories of EHBs.
The federal Department of Health and Human Services has
allowed each state to define its own EHBs for 2014 and 2015 by
selecting one of a set of specified benchmark plan options.
SBX1 2 (Hernandez), Chapter 2, Statutes of 2013-14, first
extraordinary session, and ABX1 2 (Pan), Chapter 1, Statutes
of 2013-14, first extraordinary session selected the Kaiser
Foundation Health Plan Small Group Health Maintenance
Organization 30 Plan (Kaiser HMO 30 plan) as its benchmark
plan. According to CHBRP, the ACA allows a state to "require
that a qualified health plan offered in an exchange to offer
benefits in addition to the EHBs." If the state does so, the
state must make payments to defray the cost of those
additionally mandated benefits.
According to CHBRP, coverage for medically necessary fertility
preservation services are not a covered benefit in the Kaiser
HMO 30 plan, and thus are not included in the EHB benchmark
benefit package. According to CHBRP, this triggers the
requirement that the state defray the costs of coverage for
enrollees in QHPs in Covered California.
5.CHBRP. CHBRP was created in response to AB 1996 (Thomson),
Chapter 795, Statutes of 2002, which requests the University
of California assess legislation proposing a mandated benefit
or service, and prepare a written analysis with relevant data
on the public health, medical, and economic impact of proposed
health plan and health insurance benefit mandate legislation.
In its review of this bill, CHBRP focuses on fertility
preservation among cancer patients because approximately 90
percent of iatrogenic infertility is caused by cancer
treatment. Among CHBRP's findings are the following:
a. Medical Effectiveness. According to CHBRP,
fertility preservation services for patients at risk for
iatrogenic fertility vary by age and gender of the
patient, the patient's marital status, cultural and
religious beliefs, and the type of treatment the patient
is undergoing. CHBRP's medical effectiveness review
focused on the three major categories of fertility
preservation services available to male and female
patients undergoing cancer treatments that could
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compromise their fertility. One involves freezing
reproductive material (sperm, eggs, embryos, testicular
tissue, or ovarian tissue) prior to treatment. A second
type uses specific methods to try to reduce the harms of
cancer treatment on fertility (ovarian transposition,
gonadal shielding during radiation, and gonadal
suppression with hormone therapies). The third is to
pick the cancer treatment with the lowest likelihood of
causing infertility, such as selection of a more
conservative surgery, to minimize the amount of
reproductive tissue lost. CHBRP provides the following
standard fertility preservation services and its
conclusions regarding their overall medical
effectiveness:
i. Sperm cryopreservation is the collection
and freezing of sperm. This is the standard
fertility preservation service offered to males at
risk for iatrogenic infertility. There is a
preponderance of evidence that sperm
cryopreservation with sperm collected through
ejaculate is an effective method of fertility
preservation.
ii. Embryo cryopreservation involves
harvesting eggs followed by in vitro fertilization
and freezing of resulting embryos for later
implantation. Embryo cryopreservation is the
standard fertility preservation service available
for females. There is a preponderance of evidence
that embryo cryopreservation is an effective method
of fertility preservation.
iii. Oocyte (egg) cryopreservation, the
collection and freezing of eggs, is an effective
method of fertility preservation and is the standard
offered to females at risk for iatrogenic
infertility who do not have a male partner or who do
not want to use donor sperm.
iv. Trachelectomy is the treatment for
cervical cancer where the cervix is surgically
removed while the uterus is preserved and ovarian
cancer surgery where the uterus with one ovary can
be preserved are effective methods of conservative
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gynecologic surgeries for fertility preservations.
v. Ovarian transposition, also called
oophoropexy, is a surgical repositioning of ovaries
to another location in the body away from the
radiation field. There is insufficient evidence to
conclude that ovarian transposition is an effective
method of fertility preservation.
vi. During cancer treatment with radiation
therapy, special shields can be placed over the
gonads (ovaries in females and testicles in males)
to reduce the dose of radiation delivered to these
reproductive organs. There is insufficient evidence
that testicular shielding is an effective method of
fertility preservation in males. There is also
insufficient evidence that ovarian shielding during
radiation therapy is an effective method of
fertility preservation in females. Despite this, it
stands to reason that patients undergoing pelvic
radiation where there is a high risk of damage to
the reproductive organs may want to consider gonadal
shielding to protect their fertility.
b. Utilization, Cost, and Coverage Impacts.
California's existing mandate as it relates to fertility
treatment is a mandate to offer, and it applies for most
group insurance coverage. As such, some enrollees have
coverage for fertility treatment, and some enrollees
already have coverage for fertility preservation which is
the subject of this bill. According to CHBRP, 19.4
million enrollees are in DMHC-regulated plans and
CDI-regulated policies that are subject to this bill.
CHBRP reports that approximately 8.3 percent of the 19.4
million enrollees currently have coverage for fertility
preservation services. Under this bill, 100 percent of
enrollees would be covered. CHBRP also states that no
publicly funded DMHC-regulated plans currently include
coverage for fertility preservation services, but if
enacted, California Public Employees' Retirement System
HMOs would be subject to this bill.
CHBRP's population analysis was restricted to those of
reproductive age (ages 14-40 for females and ages 12-50
for males). CHBRP estimates that currently in a one year
period, 1,051 male enrollees use sperm cryopreservation
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(with 947 paying for the uncovered benefit directly) and
72 female enrollees use embryo or oocyte cryopreservation
(with 56 paying for the uncovered benefit directly).
CHBRP reports that if this bill in enacted, utilization
for male enrollees will increase by 19 percent (or 198
males) and for female enrollees by 175 percent (or 126
females). In total a 29 percent increase in the use of
fertility preservation services.
According to CHBRP, the per-unit costs for fertility
preservation vary depending on whether the procurement
and storage services are for men or for women. Both face
initial charges for the procurement procedure, along with
annual fees for storage. CHBRP estimated that the
average per unit cost for the initial procedure of sperm
cryopreservation is $400. Embryo procurement is a
surgical procedure and requires a month of prescription
drug treatment prior to the actual procedure itself.
Taken together, the average cost of the procurement
surgery and the fertility drugs is approximately $14,700
for embryo cryopreservation. The annual storage costs
beyond 2014 are estimated to be $100 for sperm and $300
for embryos and oocytes.
According to CHBRP, increases in per member per month
premiums for newly mandated benefit coverage vary
slightly by market segment but are estimated to range
from 0.0017 percent to 0.031 percent. CHBRP reports that
the net health expenditures are projected to increase by
$2.1 million due to an $2.9 million increase in premiums
plus a 0.3 million increase in enrollee out-of-pocket
expenses for newly covered benefits, partially offset by
a net reduction in enrollee out-of-pocket expenditures
for uncovered benefits ($1.1 million).
c. Public Health Impact. CHBRP reports that the loss
of fertility can negatively impact the quality of life
for cancer survivors of reproductive age and as a result
of this bill, it is expected that the quality of life
could improve for some of the 7,650 cancer patients at
risk for iatrogenic infertility each year who would gain
coverage. According to CHBRP it is estimated this bill
would reduce the net financial burden by almost $750,000
across enrollees who would have paid for previously
uncovered services. According to CHBRP, there is a great
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disparity in the degree to which males and females face
direct expenses and associated financial burden in paying
for fertility preservation services. As previously
stated, sperm cryopreservation for males is estimated to
cost $400 while embryo cryopreservation for females is
estimated to cost $14,700 and $11,200 for oocyte
cryopreservation. This bill, according to CHBRP, is
expected to decrease the disparity in the financial
burden of expenses related to fertility preservation
services borne by females. CHBRP did not find any
disparities in the use of fertility preservation
treatments by race/ethnicity. CHBRP determined that
although cancer is a substantial cause of iatrogenic
infertility, premature mortality, and economic loss in
California, this bill is not expected to result in a
reduction in premature death or associated economic loss.
And lastly, according to CHBRP, this bill is expected to
increase utilization of sperm cryopreservation and embryo
cryopreservation services and annual long-term benefits
could include an estimated five additional males and four
additional female cancer patients having a biological
child each year as a result of this bill.
6.Related legislation. AB 460 (Ammiano) requires coverage for
the treatment of infertility to be offered and provided
without discrimination on the basis of age, ancestry, color,
disability, domestic partner status, gender, gender
expression, gender identity, genetic information, marital
status, national origin, race, religion, sex, or sexual
orientation.
7.Prior legislation.
a. AB 428 (Portantino) of 2011, was substantially
similar to this bill. AB 428 was held in Assembly
Appropriations on suspense.
b. AB 2356 (Skinner), Chapter 699, Statutes of 2012,
authorizes a recipient of sperm donated by a sexually
intimate partner (SIP) of the recipient for reproductive
use to waive a second or repeat testing of that donor if
the recipient is informed of the donor testing
requirements, as specified, and signs a written waiver.
Defines SIP to include a known or designated donor to
whose sperm the recipient has previously been exposed in
a nonmedical setting in an attempt to conceive. Excludes
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physicians and surgeons from liability and disciplinary
action, as specified.
c. AB 1586 (Koretz), Chapter 421, Statutes of 2005,
defines the term "sex" to include, but not be limited to,
a person's gender, as specified, under existing law that
prohibits health plans and insurers from specified
discriminatory acts.
8.Support. The American Society For Reproductive Medicine and
the Society for Reproductive Technology (SART), sponsors of
this legislation, and the American Congress of Obstetricians
and Gynecologists (ACOG) write in support that with advances
in medical treatment, many diseases once thought to be fatal
or chronic can now be treated and cured but the very treatment
that could give a person a good chance for a long life, could
also deprive them the potential of biological children. ACOG
maintains that surveys and anecdotal information from treating
physicians suggest that patients, if not able to obtain
fertility preservation services, choose less effective medical
care in an attempt to preserve fertility. Supporters argue
that to choose therapy to try to balance these needs instead
of being able to focus on the most effective cure means these
patients could have worse outcomes, resulting in more
expensive treatment. Planned Parenthood writes that they
believe that the costs of enacting this measure will be
modest, due to the relatively small number of people in their
reproductive years who will need this care especially when
spreading the cost among all insured persons.
9. Opposition. The California Chamber of Commerce and America's
Health Insurance Plans both write in opposition that, while
well intentioned, this bill would further exacerbate the
problem of rising health care costs. The opposition maintains
that this bill cannot be viewed in isolation. With the state
already required to meet requirements designated by the ACA,
the opposition believes California should focus its attention
on meeting the EHBs required by the ACA rather than adding
additional mandated benefits. These mandates, according to the
opposition, have already reduced flexibility in benefit
design, increased health care costs and premium rates, leading
to reduced employers' and individuals' choice of benefit
packages from health insurers and HMOs. The opposition asserts
that benefit mandates that do not promote evidence-based
medicine may lead to lower quality of care, over-utilization,
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and high costs for possible non-effective treatments.
SUPPORT AND OPPOSITION :
Support: American Society for Reproductive Medicine
(co-sponsor)
American Congress of Obstetricians and Gynecologists,
District IX
Association of Northern California Oncologists
American Cancer Society Cancer Action Network
California Affiliates of Susan G. Komen Race for the
Cure
California Chronic Care Coalition
Cancer Legal Resource Center
CHOC Children's
National Center for Lesbian Rights
Oncofertility Consortium
Planned Parenthood
Resolve
Southern California Institute for Reproductive
Sciences
Oppose: America's Health Insurance Plans
California Association of Health Plans
California Association of Health Underwriters
California Chamber of Commerce
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