BILL ANALYSIS �
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THIRD READING
Bill No: AB 912
Author: Quirk-Silva (D), et al.
Amended: 9/3/13 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 7-2, 6/26/13
AYES: Hernandez, Beall, De Le�n, DeSaulnier, Monning, Pavley,
Wolk
NOES: Anderson, Nielsen
SENATE APPROPRIATIONS COMMITTEE : 5-2, 8/30/13
AYES: De Le�n, Hill, Lara, Steinberg, Padilla
NOES: Walters, Gaines
ASSEMBLY FLOOR : 52-26, 5/29/13 - See last page for vote
SUBJECT : Health care coverage: fertility preservation
SOURCE : American Society for Reproductive Medicine
Fertile Action
DIGEST : This bill requires every large group 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, as defined, when a necessary
medical treatment may cause iatrogenic infertility to an
enrollee or insured. Also authorizes the Department of Managed
Health Care (DMHC) and the Department of Insurance (CDI) to
adopt regulations to implement the provisions of this bill.
CONTINUED
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ANALYSIS : Existing federal law 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 (QHPs) 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 DMHC and provides for the regulation of
health insurers by 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,
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.
This bill:
1. Requires every large group health care service plan that is
issued, amended, or renewed on and after January 1, 2014,
that provides hospital, medical, or surgical coverage to
include coverage for medically necessary expenses for
standard fertility preservation services when a necessary
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medical treatment may directly or indirectly cause iatrogenic
infertility to an enrollee.
2. Requires every health insurer that issues, amends, or renews
a policy on and after January 1, 2014, that covers hospital,
medical, or surgical expenses on a large group basis to
include coverage for medically necessary expenses for
standard fertility preservation services when a necessary
medical treatment may directly or indirectly cause iatrogenic
infertility to an insured.
3. Defines the following terms:
A. "Standard fertility preservation services" means
procedures consistent with established medical practices
and professional guidelines published by the American
Society for Reproductive Medicine, the American Society of
Clinical Oncology, or other reputable professional medical
organizations.
B. "May directly or indirectly cause" means treatment
with a likely side effect of infertility as established by
the American Society for Reproductive Medicine, the
American Society of Clinical Oncology, or other reputable
professional organizations.
4. Authorizes DMHC and CDI to adopt regulations to implement the
provisions of this bill.
Background
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
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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.
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.
EHBs . Effective 2014, the ACA requires non-grandfathered
small-group and individual market health insurance, including
those 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. SB 2X1 (Hernandez, Chapter 2, Statutes
of 2013-14, 1st Extraordinary Session), and AB 2X1 (Pan, Chapter
1, Statutes of 2013-14, 1st 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
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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.
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% of
iatrogenic infertility is caused by cancer treatment. Among
CHBRP's findings are the following:
1. 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 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.
2. 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
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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%
of the 19.4 million enrollees currently have coverage for
fertility preservation services. Under this bill, 100% of
enrollees will 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 (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% (or 198 males) and for female enrollees
by 175% (or 126 females). In total, a 29% increase in the
use of fertility preservation services.
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% to
0.031%. 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).
3. 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 reduces the net financial
burden by almost $750,000 across enrollees who would have
paid for previously uncovered services. According to CHBRP,
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there is a great 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.
Prior Legislation
AB 428 (Portantino, 2011) was substantially similar to this
bill. The bill was held in Assembly Appropriations Committee on
suspense.
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
physicians and surgeons from liability and disciplinary action,
as specified.
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.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
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Local: Yes
According to the Senate Appropriations Committee:
Increased health care costs to the California Public
Employees' Retirement System of about $70,000 per year
(various funds) based on an analysis by the CHBRP. However,
CalPERS indicates that their costs from this bill could be
higher, depending on the demand for fertility preservation
services related to infertility caused by medications and
procedures other than those used to treat cancer.
No anticipated costs to the Medi-Cal program. Under the
law, Medi-Cal managed care plans are not considered "large
group" plans and thus are not impacted by this benefit
mandate.
No anticipated costs to the state to pay for the cost of
subsidizing benefits in the California Health Benefit
Exchange (Exchange).
One-time costs of about $20,000 for the review of plan
filings by the DMHC (Managed Care Fund).
Ongoing costs of about $10,000 per year for review of
insurance policy filings by the CDI (Insurance Fund).
Because the benefit mandate in this bill is limited to the large
group market and does not impact the small group or individual
markets, this bill does not expand the state's essential health
benefits. Therefore, this bill will not require health insurers
or health plans selling policies in the Exchange to provide this
benefit and there will be no state obligation to subsidize such
a benefit.
SUPPORT : (Verified 9/3/13)
American Society for Reproductive Medicine (co-source)
Fertile Action (co-source)
American Cancer Society Cancer Action Network
American Congress of Obstetricians and Gynecologists, District
IX
Association of Northern California Oncologists
California Affiliates of Susan G. Komen
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California Chronic Care Coalition
California Cryobank
California National Organization for Women
Cancer Legal Resource Center, Disability Rights Legal Center
Equality California
Hyundai Cancer Institute at Children's Hospital of Orange County
Children's Hospital
Medical Oncology Association of Southern California
National Center for Lesbian Rights
Oncofertility Consortium
Planned Parenthood Affiliates of California
RESOLVE: The National Infertility Association
Southern California Institute for Reproductive Sciences
OPPOSITION : (Verified 9/3/13)
America's Health Insurance Plans
California Association of Health Plans
California Association of Health Underwriters
California Chamber of Commerce
ARGUMENTS IN SUPPORT : The American Society for Reproductive
Medicine and the Society for Reproductive Technology, sponsors
of this bill, and the American Congress of Obstetricians and
Gynecologists (ACOG) state 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.
ARGUMENTS IN OPPOSITION : The California Chamber of Commerce
and America's Health Insurance Plans state that, while well
intentioned, this bill further exacerbates the problem of rising
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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, and high costs for possible
non-effective treatments.
ASSEMBLY FLOOR : 52-26, 5/29/13
AYES: Alejo, Ammiano, Atkins, Bloom, Blumenfield, Bocanegra,
Bonilla, Bonta, Bradford, Brown, Buchanan, Ian Calderon,
Campos, Chau, Chesbro, Cooley, Daly, Dickinson, Eggman, Fong,
Fox, Frazier, Garcia, Gatto, Gomez, Gonzalez, Gordon, Gray,
Hall, Roger Hern�ndez, Jones-Sawyer, Levine, Lowenthal,
Medina, Mitchell, Mullin, Muratsuchi, Nazarian, Pan, Perea, V.
Manuel P�rez, Quirk, Quirk-Silva, Rendon, Salas, Skinner,
Stone, Ting, Weber, Wieckowski, Yamada, John A. P�rez
NOES: Achadjian, Allen, Bigelow, Ch�vez, Conway, Dahle,
Donnelly, Beth Gaines, Gorell, Grove, Hagman, Harkey, Jones,
Linder, Logue, Maienschein, Mansoor, Melendez, Morrell,
Nestande, Olsen, Patterson, Wagner, Waldron, Wilk, Williams
NO VOTE RECORDED: Holden, Vacancy
JL:k 9/3/13 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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