BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1763
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|AUTHOR: |Gipson |
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|VERSION: |May 31, 2016 |
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|HEARING DATE: |June 22, 2016 | | |
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|CONSULTANT: |Teri Boughton |
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SUBJECT : Health care coverage: colorectal cancer: screening
and testing
SUMMARY : Requires health plan and health insurance coverage without
cost sharing for specified colorectal cancer screening
examinations and laboratory tests for individuals at average
risk, and requires coverage for additional colorectal cancer
screening examinations without cost-sharing for individuals at
high risk, as specified. Prohibits the imposition of cost
sharing on colonoscopies, including the removal of polyps, for
an enrollee who is between 50 and 75 years of age and has
received a positive test, as specified.
Existing federal law:
1)Requires, pursuant to the Affordable Care Act (ACA), coverage
of the following ten essential health benefits (EHBs) and
places limits on cost sharing:
a) Ambulatory patient services;
b) Emergency services;
c) Hospitalizations;
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.
2)Requires, pursuant to Section 2713 of the Public Health
AB 1763 (Gipson) Page 2 of ?
Services Act (PHSA) as added by the ACA the preventive
services without cost sharing (such as copayment, coinsurance,
or deductible), as soon as 12 months after a recommendation
appears in any of following sources:
a) A and B rated recommendations of the United States
Preventive Services Task Force (USPSTF);
b) Immunizations recommended by the Advisory Committee
on Immunization Practices of the Centers for Disease
Control and Prevention;
c) For infants, children, and adolescents,
evidence-informed preventive care and screenings provided
for in the comprehensive guidelines supported by the
Health Resources and Services Administration (HRSA); and,
d) For women, preventive care and screenings provided
for in comprehensive guidelines supported by HRSA.
3)States, pursuant to federal regulation, that nothing in 2)
above requires a plan or insurer that has a network of
providers to provide benefits for the items or services
described in 2) above that are delivered by an out-of-network
provider; or precludes a plan or insurer that has a network of
providers from imposing cost-sharing requirements for the
items or services described in 2) above that are delivered by
an out-of-network provider.
Existing law:
1)Requires health plans to be regulated by the Department of
Managed Health Care (DMHC) and health insurers to be regulated
by the California Department of Insurance (CDI).
2)Mandates ten federally required EHBs, state mandated benefits
and benefits covered under the Kaiser Small Group health plan,
which is California's EHB benchmark plan for non-grandfathered
individual and small group health plan contracts and insurance
policies, required under the ACA.
3)Requires, to the extent required by federal law, a group or
individual health care service plan contract or health
insurance policy issued, amended, renewed, or delivered on or
after September 23, 2010, to comply with Section 2713 of the
PHSA as added by the ACA, and any rules or regulations issued
under that section.
4)Mandates coverage for all generally accepted cancer screening
AB 1763 (Gipson) Page 3 of ?
tests, subject to all terms and conditions that apply, and
screening for breast cancer, cervical cancer, mammography, and
prostate cancer. Requires coverage for breast cancer diagnosis
and treatment. Establishes requirements for mastectomies and
lymph node dissections. Limits copayments on orally
administered anticancer medications, as specified, until
January 1, 2019. Mandates coverage for routine patient care
costs related to clinical trials for an enrollee or insured
diagnosed with cancer, as specified.
This bill:
1)Requires every health plan contract and health insurance
policy, except a specialized health plan contract or health
insurance policy, that is issued, amended, or renewed on or
after January 1, 2018, to provide coverage without any cost
sharing for all colorectal cancer screening examinations and
laboratory tests assigned either a grade of A or a grade of B
by the USPSTF for individuals at average risk. Requires if an
enrollee is at high risk for colorectal cancer, the plan or
insurer to include additional colorectal cancer screening
examinations as listed by the USPSTF as recommended screening
strategy and at least at the frequency established pursuant to
regulations issued by the federal Centers for Medicare and
Medicaid Services (CMS) for the Medicare program.
2)Prohibits, for an enrollee who is between 50 and 75 years of
age, a health plan contract or insurance policy from imposing
cost sharing on colonoscopies, including the removal of
polyps, when either of the following applies:
a) The colonoscopy is a screening procedure not
occasioned by a recent positive test or procedure; or,
b) The colonoscopy has been scheduled because of
a positive result on a test or procedure, other than a
colonoscopy, assigned either a grade of A or a grade
of B by the USPSTF.
FISCAL EFFECT: According to the Assembly Appropriations
Committee, this bill has been narrowed since the California
Health Benefits Review Program (CHBRP) reviewed its provisions.
CHBRP found the following costs associated with a more expansive
version of this bill:
AB 1763 (Gipson) Page 4 of ?
a) No costs to Medi-Cal (General Fund/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;
and,
c) Increased premium expenditures by employees and
individuals purchasing insurance of $26.5 million, and
decreased out-of-pocket expenses of $35.4 million.
Though a revised CHBRP review is not available at this time,
the narrower bill is likely to result in a lower cost impact
than noted above.
Minor costs to CDI (Insurance Fund) and DMHC (Managed Care Fund)
to verify plans and insurers comply with this requirement.
PRIOR
VOTES :
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|Assembly Floor: | 65 - 4 |
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|Assembly Appropriations Committee: | 14 - 3 |
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|Assembly Health Committee: | 14 - 0 |
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COMMENTS :
1)Author's statement. According to the author, stool blood
tests are an important colorectal cancer screening option.
Availability is better than for colonoscopy, the cost is
lower, and they offer the opportunity to increase the overall
screening rate which would reduce incidence and mortality.
Some individuals, including those from low income communities
and communities of color may not have initial access to
screening colonoscopy. Some prefer a stool blood test because
the procedure is simpler, there is lower risk of complications
and it is less invasive. Screening with stool blood tests has
been shown to decrease incidence and mortality in randomized
controlled trials, and years of life saved are essentially the
same as with colonoscopy screening. However, the benefits of
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stool blood tests as a strategy to reach more Californians,
especially in communities with lower access to colonoscopy
services are not realized when there is a cost to patients. A
co-pay or cost-sharing can be a barrier, preventing some
individuals with positive stool blood tests from getting a
follow up colonoscopy to complete the colorectal cancer
screening process, defeating the purpose of screening. A
policy that removes the cost to patients will make stool blood
tests a more viable screening option and will reduce costs to
payers.
2)ACA Preventive services mandate. The ACA requires coverage
for and elimination of cost-sharing on certain recommended
preventive health services, for policies renewing on or after
September 23, 2010, based on guidelines from the USPSTF.
There are 15 covered preventive services for adults which
include one-time screening for abdominal aortic aneurysm,
screening and counseling for alcohol misuse, aspirin, blood
pressure screening, cholesterol screening, depression
screening, screening for Type 2 Diabetes, diet counseling, HIV
screening, immunizations, obesity screening and counseling,
prevention counseling for sexually transmitted infection,
screening and cessation interventions for tobacco use, and
colorectal cancer screening for adults over 50.
3)Colorectal cancer screening. According to the National Cancer
Institute, colorectal cancer is a disease in which malignant
(cancer) cells form in the tissues of the colon or the rectum.
Colorectal cancer is the second leading cause of death from
cancer in the United States. For the vast majority of adults,
the most important risk factor for colorectal cancer is older
age. Most cases of colorectal cancer occur among adults older
than 50 years; the median age at diagnosis is 68 years. A
positive family history (excluding known inherited familial
syndromes) is thought to be linked to about 20% of cases of
colorectal cancer. About 3% to 10% of the population has a
first-degree relative with colorectal cancer. Male sex and
black race are also associated with higher colorectal cancer
incidence and mortality. Black adults have the highest
incidence and mortality rates compared with other
racial/ethnic subgroups. The final USPSTF recommendation for
colorectal cancer screening recommends screening with one of
several approved methodologies for colorectal cancer starting
at age 50 years and continuing until age 75 years. The
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decision to screen for colorectal cancer in adults aged 76 to
85 years should be an individual one, taking into account the
patient's overall health and prior screening history. The
screening modalities and intervals are fecal occult blood test
(FOBT), which has received an A or B recommendation from the
USPSTF and Fecal immunochemical test (FIT), which is
recommended in the 2016 draft updated guidelines. Both tests
are suggested annually to detect cancer. A flexible
sigmoidoscopy is recommended every five years to detect polyps
and cancer and has received an A or B recommendation from the
USPSTF. A colonoscopy is recommended every 10 years to detect
polyps and cancer and has received an A or B recommendation.
It is also recommended that a colonoscopy should be performed
if test results are positive.
4)Medicare recommendations. Medicare Part B (Medical Insurance)
covers several types of colorectal cancer screening tests to
help find precancerous growths or find cancer early, when
treatment is most effective. Regarding cost-sharing, Medicare
recommends patients find out how much the specific test, item,
or service will cost, and indicates that the specific amount
owed may depend on several things, like other insurance, how
much the doctor charges, whether the doctor accepts
assignment, the type of facility, and the location. The doctor
or other health care provider may recommend services more
often than Medicare covers. Or, they may recommend services
that Medicare does not cover. If this happens, the patient may
have to pay some or all of the costs. For colonoscopies,
Medicare covers this test once every 24 months if the patient
is at high-risk for colorectal cancer. If the patient is not
at high-risk for colorectal cancer, Medicare covers this test
once every 120 months, or 48 months after a previous flexible
sigmoidoscopy.
5)CHBRP analysis. AB 1996 (Thomson, Chapter 795, Statutes of
2002), requests the University of California assess
legislation proposing a mandated benefit or service and
prepare a written analysis with relevant data on the medical,
economic, and public health impacts of proposed health plan
and health insurance benefit mandate legislation. CHBRP was
created in response to AB 1996, and reviewed an earlier
version of this bill and issued an updated letter based on the
April 27, 2016 version of this bill. Key findings include:
AB 1763 (Gipson) Page 7 of ?
a) Coverage impacts and enrollees covered. Californians
with state-regulated coverage impacted by this bill would
increase from 13.8 million to 14.7 million. It is
estimated that the percentage of enrollees 50 and older
with coverage for colorectal cancer screening services
without cost sharing would increase from 78% to 100%.
b) Essential health benefits. CHBRP indicates that this
bill impacts the terms and conditions of coverage for
colorectal cancer screenings and tests, but does not
change coverage itself, and therefore does not exceed
EHBs.
c) Medical effectiveness. There is a preponderance of
evidence that USPSTF-recommended colorectal cancer
screening modalities are medically effective for the
detection and prevention of colorectal cancer screenings
among average and high-risk individuals. For
average-risk individuals, evidence exists suggesting a
small but positive impact of insurance coverage for
colorectal cancer screening and utilization (Cokkinides,
2011), and that low socioeconomic status individuals may
benefit from the elimination of barriers to screening
utilization (Fedewa, 2015a).
d) Utilization. CHBRP assumes that the overall
utilization of colorectal cancer screening and lab tests
is going to increase by 0.4% (2,499 users), which is
mainly due to the increase in use among enrollees aged 50
and older after the removal of cost-sharing requirements.
e) Impact on expenditures. CHBRP estimates that this
bill would increase total net annual expenditures by
$9.86 million or 0.006% for enrollees with DMHC-regulated
plans and CDI-regulated policies. This is due to a $26.61
million increase in total health insurance premiums paid
by employers and enrollees for newly covered benefits,
partially offset by a decrease in enrollee expenditures
for previously non-covered benefits ($35.37 million).
f) Public health. CHBRP projects no measurable public
health impact on the diagnosis or prevention of
colorectal cancer at the population level due to the
small number of enrollees who would avail themselves of
the additional screening.
6)Support. The American Cancer Society Action Network writes
that colorectal cancer is the second leading cause of cancer
deaths in the United States but is the most preventable with
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screening and early detection. Timely and appropriate
screening can decrease colorectal cancer incidence and
mortality by 30% to 60%. High-sensitivity FOBT tests are
effective, non-invasive, easily accessible and safe screening
tests that are more cost efficient than colonoscopies.
However, a positive test result requires that a follow-up
colonoscopy be provided. Multiple studies have shown that
individuals are less likely to seek additional health
services, including preventive screenings, when they are
required to pay out-of-pocket. Additionally, research has
shown that limiting colorectal cancer screening choices to
only colonoscopy can result in a lower colorectal cancer
screening completion rate compared to providing a choice
between colonoscopy and a stool-based test, particularly among
racial and ethnic minorities.
The California Colorectal Cancer Coalition (C4) writes that
many health insurers apply cost-sharing to colonoscopies that
follow a positive stool blood test because they consider it a
diagnostic procedure rather than a screening test. Patient
cost can be more than $300 when a polyp or abnormal growth is
removed during the screening colonoscopy. This charge is
generally received unexpectedly after having a screening and
can act as a disincentive for future screening for colon
cancer. Finding an adenomatous polyp during a screening
colonoscopy can be found in at least 50% of good quality
colonoscopy exams. This bill would eliminate this unexpected
cost, and remove the financial disincentives, which prevent
people from getting their colon cancer screening.
7)Opposition. America's Health Insurance Plans write that this
bill creates a new mandate for health plans and insurers to
cover costly services for diagnostic purposes without
cost-sharing, which threatens the efforts of all health care
stakeholders to provide consumers with meaningful health care
choices and affordable coverage options. This bill will
increase annual expenditures by $5.63 million for enrollees
with DMHC-regulated plans and CDI-regulated policies. The
state should be looking for ways to bring down health care
costs for consumers, not drive them up. Extending the
elimination of cost-sharing to diagnostic care in this
instance creates a slippery slope to eliminating cost-sharing
for other similar types of diagnostic care. As currently
amended, this bill fails to follow the federal standard by not
recognizing the value of in-network benefits - and would
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result in increased costs in premiums if cost-sharing on
out-of-network benefits was not permitted. A recent study
conducted by AHIP found that in California average billed
charge for colonoscopies and biopsies was 252.7% of the
Medicare rate. Requiring plans to cover such services and pay
full billed charges would allow those providers to set charges
at any level that they wish.
8)Policy Comment. A tenet of closed network managed care is a
requirement that enrollees use network providers for
non-emergency services. This bill is silent on the extent to
which this coverage without cost-sharing applies only when the
tests or services are provided by in-network providers. The
committee may wish to request an amendment to clarify this
issue.
9)Suggested Amendment. Add subdivision (c) Nothing in this
section requires a plan or insurer that has a network of
providers to provide benefits for items or services described
in this section that are delivered by an out-of-network
provider; or precludes a plan or insurer that has a network of
providers from imposing cost-sharing requirements for the
items or services described in this section that are delivered
by an out-of-network provider.
SUPPORT AND OPPOSITION:
Support: California Colorectal Cancer Coalition (sponsor)
American Cancer Society Cancer Action Network
(sponsor)
California Colorectal Cancer Coalition (cosponsor)
American College of Gastroenterology
American College of Surgeons
American Gastroenterology Association
American Society for Gastrointestinal Endoscopy
Bayer
California Academy of Physician Assistants
California Black Health Network
California Chapters of the American College of
Physicians
California Immigrant Policy Center
California Life Sciences Association
California Primary Care Association
Fresno Center for New Americans
Fresno Interdenominational Refugee Ministries
Health Officers Association of California
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Southeast Asia Resource Action Center
Several Individuals
Oppose: America's Health Insurance Plans
Blue Shield of California (prior version)
California Chamber of Commerce (prior version)
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