BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                    AB 1763


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          Date of Hearing:  May 4, 2016


                        ASSEMBLY COMMITTEE ON APPROPRIATIONS


                               Lorena Gonzalez, Chair


          AB  
          1763 (Gipson) - As Introduced February 3, 2016


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          Urgency:  No  State Mandated Local Program:  YesReimbursable:   
          No


          SUMMARY:


          This bill requires health plans and insurers to cover, without  
          cost-sharing, certain colorectal cancer screening procedures,  
          under specified conditions. Specifically, this bill:


          1)Mirrors federal requirements requiring coverage without  
            cost-sharing for colorectal cancer screening and laboratory  








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            exams assigned either a grade of A or B by the United States  
            Preventive Services Task Force (USPSTF) for persons of average  
            risk. 


          2)Requires coverage for additional colorectal cancer screening  
            examinations and laboratory tests as recommended by a health  
            care provider, if a person is at high risk of colorectal  
            cancer as determined by a health care provider. 


          3)Specifies for an enrollee 50 years of age or older that  
            colonoscopy, including the removal of polyps, is covered  
            without cost-sharing when the colonoscopy is either: (1) a  
            screening procedure not occasioned by a recent positive test  
            or procedure, or (2) scheduled because of a positive result on  
            a test or a procedure, other than colonoscopy, that has been  
            assigned either a grade of A or B by the USPSTF.


          FISCAL EFFECT:


          1)According to the California Health Benefits Review Program  
            (CHBRP): 
             a)   No costs to Medi-Cal (GF/federal) and $1.3 million to  
               CalPERS for increased premiums. 



             b)   Increased employer-funded premium costs in the private  
               insurance market of approximately $17.3 million.



             c)   Increased premium expenditures by employees and  
               individuals purchasing insurance of $26.5 million, and  
               decreased out-of-pocket expenses of $35.4 million.   









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          2)Minor costs to the California Department of Insurance  
            (Insurance Fund) and the Department of Managed Health Care  
            (Managed Care Fund) to verify plans and insurers comply with  
            this requirement.
          


          COMMENTS:





          1)Purpose. According to the author, this bill will remove cost  
            barriers to colonoscopies for adults over 50 years of age,  
            helping to catch cases of colorectal cancer earlier and  
            improving survival.  


          2)Background. Colon cancer is cancer of the large intestine  
            (colon), the lower part of the digestive system.  Rectal  
            cancer is cancer of the last several inches of the colon.   
            Together, they're often referred to as colorectal cancer.   
            Most cases begin as small, noncancerous clumps of cells called  
            adenomatous polyps, which may produce few, if any, symptoms.   
            Over time some of these polyps become cancerous. For this  
            reason, doctors recommend regular screening tests to help  
            prevent colorectal cancer by identifying and removing polyps  
            before they become cancerous.


          3)Current requirements. The federal Affordable Care Act requires  
            coverage of certain preventive services that meet evidentiary  
            standards without cost-sharing.  Specifically, services given  
            an "A" or "B" grade by the USPSTF, a federally designated body  
            that reviews clinical evidence, are covered with no  
            cost-sharing.  The USPSTF recommends screening for colorectal  








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            cancer using fecal occult blood testing, sigmoidoscopy, or  
            colonoscopy in adults, beginning at age 50 years and  
            continuing until age 75 years. This is given an "A" grade for  
            this age group, meaning the USPSTF recommends the service and  
            there is high certainty that the net benefit is substantial.   
            They note the risks and benefits of these screening methods  
            vary.  The most recent recommendations were published in 2008,  
            and they are in the final stages of being updated this year.   
            There is no "A" or "B" grade recommendation for screening in  
            individuals older than 75, neither in the current  
            recommendation nor the new draft recommendation. 


            Colonoscopy, sigmoidoscopy, and blood tests are recommended  
            screening modalities.  A colonoscopy is recommended every 10  
            years beginning at age 50. It is the most comprehensive test  
            and removes any offending polyps during the test.  Fecal  
            occult blood testing, another recommended screening modality,  
            is performed annually. Blood testing may lead to greater  
            compliance with recommended screening than colonoscopy, which  
            is more invasive.  A positive blood test can, however, provide  
            an indication for a follow-up colonoscopy. 


            This bill is intended to address a situation where a follow-up  
            colonoscopy is considered "diagnostic" and subject to a  
            patient share of cost, versus a preventive screening which is  
            covered with no share of cost.  A colonoscopy following a  
            positive blood test is recommended.  However, the blood test  
            is considered a highly sensitive test for colon cancer,  
            meaning the follow-up colonoscopy may be considered a  
            diagnostic test and therefore could, depending on the  
            specifications of coverage and how a provider bills for it, be  
            subject to cost-sharing.  This bill also allows providers wide  
            discretion to recommend other tests for individuals at high  
            risk, and requires the tests be covered with no cost-sharing.


          4)CHBRP findings. CHBRP assumed an additional 2,500 screenings  








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            would occur as a result of this bill's requirements, but CHBRP  
            projects no measurable public health impact at the population  
            level due to the small number of additional enrollees who  
            would avail themselves of screening.  CHBRP states it is  
            reasonable to assume that this reduction in financial burden  
            would promote greater adherence to physician-recommended  
            screenings on a long-term basis among this small set of people  
            impacted.  


          5)Essential Health Benefits (EHBs). Federal law requires the  
            state to defray additional costs caused by any state mandates  
            that exceed a set of federally defined EHBs.  CHBRP states his  
            bill impacts the terms and conditions of coverage for  
            screenings and tests, but does not change coverage itself and  
            thus does not exceed EHBs.  Plans and insurers question this  
            finding, as noted in their opposition, below. 


          6)Support. This bill is sponsored by the American Cancer Society  
            Cancer Acton Network and the California Colorectal Cancer  
            Coalition, and it is supported by a number of other groups.   
            Supporters indicate this bill will increase screening and  
            survival as well as reduce racial, ethnic, and socioeconomic  
            disparities by removing financial barriers to screening. 


          7)Opposition.  Health plans and insurers oppose this bill,  
            citing increased costs and the potential to exceed EHBs.  Blue  
            Shield of California (BSC) argues that new USPSTF screening  
            recommendations expected later in 2016 are likely to be  
            different than current ones, making this bill premature.  BSC  
            is also concerned with this bill's requirement to cover, at no  
            share of cost, a broad array of additional screenings and  
            tests recommended by a physician if a person is considered  
            "high risk."  


          8)Staff Comments.  This bill shifts costs of recommended  








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            screening tests fully to insurance coverage, reducing  
            out-of-pocket expenses for colonoscopy and, for high-risk  
            individuals, other tests as recommended.  There is some  
            survival benefit of an additional number of people getting  
            tests because of the reduction in share of costs.  For  
            follow-up colonoscopies, this is generally beneficial and  
            recommended testing and would likely benefit people who have  
            higher cost-sharing and who would be more likely to skip the  
            test if they had to pay out of pocket for it.  Less is known  
            about a net benefit of the additional screening tests for  
            high-risk individuals, since that provision is broad, subject  
            to interpretation by the provider, and not based on a finding  
            from a nationally recognized entity.  Health plans also  
            believe this could exceed EHBs, resulting in a state fiscal  
            impact to defray costs. It is unclear whether this bill  
            exceeds EHBs, as it is unclear which cancer screening tests  
            for people of high risk for cancer would be denied coverage  
            under current law.


          Analysis Prepared by:Lisa Murawski / APPR. / (916)  
          319-2081