BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1954
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|AUTHOR: |Burke |
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|VERSION: |June 13, 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: reproductive health care
services
SUMMARY : Establishes the Direct Access to Reproductive Health Care Act,
which prohibits health plans and health insurers from requiring
an enrollee to receive a referral prior to receiving coverage or
services for reproductive and sexual health care.
Existing law:
1)Establishes the Department of Managed Health Care (DMHC),
which regulates health care service plans (health plans), and
the California Department of Insurance (CDI), which regulates
insurers.
2)Requires a health plan contract, or group or individual
disability insurance policy, except as specified, that is
issued, amended, renewed, or delivered on or after January 1,
2016, to provide coverage for all of the following services
and contraceptive methods for women:
a) All United States Food and Drug Administration
(FDA)-approved contraceptive drugs, devices, and other
products for women, including all FDA-approved
contraceptive drugs, devices, and products available over
the counter, as prescribed by the enrollee's provider;
b) Voluntary sterilization procedures;
c) Patient education and counseling on contraception;
and,
d) Follow-up services related to the drugs, devices,
products, and procedures, including, but not limited to,
management of side effects, counseling for continued
adherence, and device insertion and removal.
AB 1954 (Burke) Page 2 of ?
1)Prohibits a health plan or insurer from imposing a deductible,
coinsurance, copayment, or any other cost-sharing requirement
on the coverage provided pursuant to 2) above. Prohibits
cost-sharing from being imposed on any Medi-Cal beneficiary.
2)Exempts, if the FDA has approved one or more therapeutic
equivalents of a contraceptive drug, device, or product, a
health plan or insurer from covering all therapeutically
equivalent versions as long as at least one is covered without
cost sharing.
3)Requires, if a covered therapeutic equivalent of a drug,
device, or product is not available, or is deemed medically
inadvisable by the enrollee's provider, a health plan or
insurer to provide coverage, subject to a plan's utilization
management procedures, for the prescribed contraceptive drug,
device, or product without cost sharing.
4)Prohibits a health plan or insurer from imposing any
restrictions or delays on the coverage described in 2), except
as specified.
5)Requires every health plan contract, as specified, to allow an
enrollee the option to seek obstetrical and gynecological
physician services directly from a participating obstetrician
and gynecologist (OB-GYN) or directly from a participating
family practice physician and surgeon designated by the plan
as providing those services.
6)Permits a health plan or insurer to establish reasonable
provisions governing utilization protocols and the use of
OB-GYN, or family practice physicians and surgeons
participating in the plan network, medical group, or
independent practice association, consistent with the law,
those customarily applied to other physicians and surgeons,
such as primary care physicians and surgeons, to whom the
enrollee has direct access, and not more restrictive for the
provision of obstetrical and gynecological physician services.
Prohibits an enrollee from being required to obtain prior
approval from another physician, another provider, or the
health plan prior to obtaining direct access to obstetrical
and gynecological physician services. Permits the plan to
establish reasonable requirements for the participating OB-GYN
or family practice physician and surgeon to communicate with
AB 1954 (Burke) Page 3 of ?
the enrollee's primary care physician and surgeon regarding
the enrollee's condition, treatment, and any need for
follow-up care.
This bill:
1)Requires every health plan contract or health insurance policy
issued, amended, renewed, or delivered on or after January 1,
2017, to be prohibited from requiring an enrollee to receive a
referral prior to receiving coverage or services for
reproductive and sexual health care.
2)Defines "reproductive and sexual health care services" as all
reproductive and sexual health services described in existing
law related to minor consent for HIV testing, pregnancy
prevention, sexual transmitted disease (STD) treatment and
medical treatment after rape and sexual assault, as specified.
Indicates that this bill applies whether or not the patient
is a minor.
3)Permits a health plan or health insurer to establish
reasonable provisions governing utilization protocols for
obtaining reproductive and sexual health care services from
health care providers participating in, or contracting with,
the plan network, medical group, or independent practice
association, provided that these provisions are consistent
with the intent of this bill and those customarily applied to
other health care providers, such as primary care physicians
and surgeons, to whom the enrollee has direct access, and not
more restrictive for the provision of reproductive and sexual
health care services.
4)Prohibits an enrollee or insured from being required to obtain
prior approval from another physician, another provider, the
health plan or health insurer prior to obtaining direct access
to reproductive and sexual health care services. Permits a
plan or insurer to establish provisions governing
communication with the enrollee's primary care physician and
surgeon regarding the enrollee's or insured's condition,
treatment, and any need for follow-up care.
5)Prohibits a health plan or health insurer subject to this bill
from imposing utilization protocols related to contraceptive
drugs, supplies, and devices, as specified.
6)Exempts specialized health plans, specialized health
AB 1954 (Burke) Page 4 of ?
insurance, health plans governed by Medi-Cal, Medicare
supplement insurance, short-term limited duration health
insurance, CHAMPUS supplement insurance, or TRI-CARE
supplement insurance, or to hospital indemnity, accident-only,
and specified disease insurance.
7)States legislative intent that there are wide variances in
health benefit plans regarding referral requirements for
reproductive and sexual health care services, and women across
the state are obtaining these vital services from other
licensed provider types, including family practice physicians,
nurse practitioners, physician assistants, and certified
nurse-midwives; and this bill is intended to increase timely,
equal, and direct access to time-sensitive and comprehensive
reproductive and sexual health care services.
FISCAL
EFFECT : According to the Assembly Appropriations Committee,
costs in the range of $50,000 per year to DMHC and minor costs
to CDI for ensuring and enforcing compliance. While this bill
could slightly increase utilization of reproductive and sexual
health care in the private health care market, it does not
appear to result in a noticeable premium impact. Although
access to some of these services without a referral varies by
plan, the services are covered under current law.
PRIOR
VOTES :
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|Assembly Floor: |53 - 23 |
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|Assembly Appropriations Committee: |15 - 5 |
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|Assembly Health Committee: |14 - 4 |
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COMMENTS :
1)Author's statement. According to the author, for many women,
reproductive health care is primary care. Nearly
three-quarters of women of reproductive age in the nation
receive at least one sexual or reproductive health service
each year. While we've taken some steps to improve access to
care, including the allowance through the Affordable Care Act
which enables women to access OB-GYN care without a referral,
AB 1954 (Burke) Page 5 of ?
there is still more to be done to ensure that Californians
have timely access to the care they need without unnecessary
barriers. AB 1954 eliminates the patchwork of referral
policies for in-network providers for enrollees seeking
reproductive and sexual health care services. By removing the
unnecessary administrative burdens that cause delays in care,
this bill levels the playing field across plans, creating more
equitable access to care for all enrollees.
2)Use and access to services. The California Health Benefits
Review Program (CHBRP) reviewed an earlier version of AB 1954
which mandated coverage for out-of-network reproductive and
sexual health care. CHBRP resulted from the passage of AB 1996
(Thomson, Chapter 795, Statutes of 2002), which requests the
University of California to 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. Although the CHBRP analysis is not
entirely relevant based on the current version of AB 1954, the
CHBRP report provides some helpful background information.
For example, according to CHBRB, it is estimated that among
the insured population in California aged 12 and older, 21%
get tested for an STD each year. Access to timely screening
and treatment for STDs and HIV testing is critical to
preventing further spread of these diseases and limiting the
health impacts of infected individuals. Timely access to care
has been cited by patients of specialized STD testing and
reproductive health clinics as a major reason for seeking
services there instead of at their usual places of care, even
among those patients who have health insurance (Hoover et al.,
2015). Unmet need for prevention and treatment of pregnancy
services among the insured population may be underestimated
due to their use of specialized publicly-funded family
planning clinics.
3)Related legislation. SB 999 (Pavley), authorizes a pharmacist
to dispense a 12-month supply of FDA-approved,
self-administered hormonal contraceptives and requires health
plans and insurers to cover the cost. SB 999 is pending in
Assembly Business and Professions Committee.
4)Prior legislation. SB 1053 (Mitchell, Chapter 576, Statutes
of 2014), required health plans and insurers to provide
coverage for all FDA-approved contraceptive drugs, devices,
AB 1954 (Burke) Page 6 of ?
and products.
AB 12 (Davis, Chapter 22, Statutes of 1998), requires health
plans to allow enrollees to seek obstetrical and gynecological
physician services directly from either an OB-GYN or a family
practice physician.
AB 2493 (Speier, Chapter 759, Statutes of 1994), and AB 396
(Speier, Chapter 353, Statutes of 1995), require health plans
to include OB-GYNs as primary care physicians, provided they
meet the plan's eligibility criteria for all specialists
seeking primary care physician status.
5)Support. The California Family Health Council writes that
nearly three-quarters of women of reproductive age in the
nation receive at least one sexual or reproductive health
service each year. Commercial health plans operating in
California currently widely vary in terms of referral
policies. Variances in these policies have created a
patchwork of coverage and access to time
sensitive-reproductive health services. NARAL Pro-Choice
California indicates that requiring referrals also triggers
potential confidentiality concerns that lead to further delays
in obtaining care. ACT for Women writes that this bill would
remove unnecessary administrative burdens that cause delays in
care, and level the playing field to create greater, more
equitable access to sexual and reproductive health care
services by allowing access without referrals. The American
Congress of Obstetricians and Gynecologists District IX writes
that this bill builds on the Affordable Care Act by allowing
patients in commercial health plans to obtain family planning
and sexual health services without referrals from other
providers including advanced practice clinicians, like nurse
practitioners and certified nurse midwives.
6)Opposition. The California Catholic Conference, Inc.,
believes this bill reduces the standard of care for women and
girls because it would bypass the referral process in our
health care system. AB 1954 would not be in the best interest
of women, nonetheless young girls who are generally much less
informed about their own reproductive and sexual health care.
The California Right to Life Committee, INC, finds this bill
to be detrimental to women's and children's health,
irresponsible spending of health care dollars and an actual
barrier to betterment of lives in general.
AB 1954 (Burke) Page 7 of ?
7)Policy Comment. A question has been raised about whether or
not it is appropriate to apply this bill's provisions to
preferred provider organizations (PPOs), which generally do
not require referrals for health care services. However,
existing law related to direct access to OB-GYNs has been
applied to PPOs, and since it has been practice to establish
parallel provisions for both regulators it is reasonable to
continue to do so. It is unclear if there are ever occasions
under which PPOs might not allow direct access to providers.
Without the PPO provisions in this bill there would not be a
prohibition on insurers requiring a referral for these
reproductive and sexual health care services. Therefore, the
committee may wish to maintain those provisions in this bill.
8)Amendments. It is recommended that these amendments should be
made in both sections of this bill.
a) In order to make the provisions of this bill
consistent with existing law the author may wish to amend
this bill to add "reasonable" in the last sentence in
subdivision (c) as follows:
A health care service plan may establish reasonable
provisions governing communication with the enrollee's
primary care physician and surgeon regarding the
enrollee's condition, treatment, and any need for
follow-up care.
b) Subdivision (d) should be amended as follows:
A health care service plan subject to this section
shall not impose utilization protocols related to
contraceptive drugs, supplies, and devices beyond the
provisions outlined in Section 1367.25 of this code or
Section 14132 of the Welfare and Institutions Code.
SUPPORT AND OPPOSITION :
Support: California Family Health Council (cosponsor)
California Latinas for Reproductive Justice
(cosponsor)
NARAL Pro-Choice California (cosponsor)
ACT for Women
American Congress of Obstetricians and Gynecologists
District IX
Anti-Defamation League (prior version)
Bayer (prior version)
Black Women for Wellness
AB 1954 (Burke) Page 8 of ?
California Academy of Family Physicians
California Health+Advocates
California National Organization for Women
California Primary Care Association (prior version)
Community Clinic Association of Los Angeles County
Community Clinic Consortium (prior version)
Forward Together (prior version)
HIVE (prior version)
Latino Coalition for a Healthy California
Law Students for Reproductive Justice
Los Angeles LGBT Center
Maternal and Child Health Access (prior version)
NARAL Pro-Choice California
National Association of Social Workers (prior version)
National Health Law Program
Nevada County Citizens for Choice (prior version)
Northeast Valley Health Corporation
Physicians for Reproductive Health
Planned Parenthood Affiliates of California
Secular Coalition for California
URGE: Unite for Reproductive & Gender Equity
Women's Community Clinic
Women's Health Specialists of California
Oppose: America's Health Insurance Plan (prior version)
California Catholic Conference
California Right to Life Committee, INC
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