BILL ANALYSIS Ó
SB 999
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Date of Hearing: June 28, 2016
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Rudy Salas, Chair
SB 999(Pavley) - As Amended June 20, 2016
SENATE VOTE: 29-6
NOTE: This bill is double-referred, having been previously heard
by the Assembly Committee on Health on June 14, 2016 and
approved on a 13-0 vote.
SUBJECT: Health insurance: contraceptives: annual supply
SUMMARY: Authorizes a pharmacist to dispense a 12-month supply
of United States Food and Drug Administration (FDA)-approved,
self-administered hormonal contraceptives and requires insurance
to cover the cost.
EXISTING LAW:
1)Establishes the Department of Managed Care (DMHC) to regulate
health plans under the Knox-Keene Health Care Service Plan Act
of 1975 and the Department of Insurance (CDI) to regulate
health insurers under the Insurance Code. (Health and Safety
Code §§ 1340, et seq.)
2)Establishes the Medi-Cal program, which is administered by the
State Department of Health Care Services (DHCS), under which
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qualified low-income persons receive health care benefits and,
in part, governed and funded by federal Medicaid program
provisions. (Welfare and Institutions Code §§ 14000, et seq.)
3)Establishes the Board of Pharmacy (BOP) to regulate the
practice of pharmacy, including the licensure of pharmacists.
(Business and Professions Code (BPC) §§ 4000, et seq.)
4)Requires a health plan contract, or a group or individual
policy of disability insurance, except for a specialized
health plan contract or a specialized health insurance policy,
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: (Insurance Code
(INS) § 10123.196(b)(1))
a) All 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 or insured'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
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adherence, and device insertion and removal.
5)Prohibits a health plan or disability insurer from imposing a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided pursuant to contraceptive
coverage, except in the case of a grandfathered health plan.
Prohibits cost sharing from being imposed on any Medi-Cal
beneficiary. (INS § 10123.196(b)(2))
6)Permits a religious employer to request a health plan contract
or disability insurance policy without coverage for
FDA-approved contraceptive methods that are contrary to the
religious employer's religious tenets, and requires a health
plan contract or disability insurance policy to be provided
without coverage for contraceptive methods, if requested.
(INS § 10123.196(e))
7)Establishes as California's essential health benefits (EHBs)
as the Kaiser Small Group HMO plan, along with the following
10 federally mandated benefits under the Patient Protection
and Affordable Care Act (ACA), as well as other existing state
mandated benefits: (INS § 10112.27)
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;
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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.
8)Permits a pharmacist to dispense no more than a 90-day supply
of a dangerous drug other than a controlled substance pursuant
to a valid prescription that specifies an initial quantity of
less than a 90-day supply followed by periodic refills of that
amount, if specified requirements are satisfied, such as the
patient has completed an initial 30-day supply of the
dangerous drug. Prohibits a pharmacist from dispensing a
greater supply of a dangerous drug if the prescriber
personally indicates, either orally or in his or her own
handwriting, "No change to quantity," or words of similar
meaning. (BPC § 4064.5)
9)Permits a pharmacist to furnish self-administered hormonal
contraceptives in accordance with standardized procedures or
protocols developed and approved by both the BOP and the
Medical Board of California in consultation with the American
Congress of Obstetricians and Gynecologists (ACOG), the
California Pharmacists Association, and other appropriate
entities. (BPC § 4052.3)
10) Requires the standardized procedure or protocol in 9)
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above to require that the patient use a self-screening tool
that will identify patient risk factors for use of
self-administered hormonal contraceptives, based on the
current United States Medical Eligibility Criteria for
Contraceptive Use developed by the federal Centers for Disease
Control and Prevention (CDC), and that the pharmacist refer
the patient to the patient's primary care provider or, if the
patient does not have a primary care provider, to nearby
clinics, upon furnishing a self-administered hormonal
contraceptive, or if it is determined that use of a
self-administered hormonal contraceptive is not recommended.
(BPC § 4052.3(a)(1))
11) Requires the pharmacist to provide the patient a
standardized fact sheet that includes, but is not limited to,
the indications and contraindications for use of the drug, the
appropriate method for using the drug, the need for medical
follow-up, and other appropriate information, developed, as
specified. (BPC § 4052.3(c))
THIS BILL:
1)Requires health care service plan (health plan) contracts and
health insurance policies, issued, amended, renewed, or
delivered on or after January 1, 2017, to provide coverage for
up to a 12-month supply of FDA-approved contraceptives when
dispensed at one time for an enrollee by a provider,
pharmacist, or at a location licensed or otherwise authorized
to dispense drugs or supplies.
2)Prohibits construing this bill to require contraceptive
coverage by an out-of-network provider, pharmacy, or location
licensed or otherwise authorized to dispense drugs or
supplies, except as otherwise authorized by state or federal
law or by the health plan's policies regarding out-of-network
coverage.
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3)Prohibits construing this bill to require a provider to
prescribe, furnish, or dispense 12 months of contraceptives at
one time.
4)Provides that a pharmacist furnishing self-administered
hormonal contraction pursuant to the BOP protocols may
dispense, at the patient's request, up to a 12-month supply at
one time.
FISCAL EFFECT: According to the Senate Committee on
Appropriations, this bill will result in:
1)Minor costs to review information from health insurers by the
[CDI].
2)No significant costs are anticipated to review health plan
information by the [DMHC].
3)No significant costs or savings are projected for the Medi-Cal
program. According to an analysis of the bill by the
California Health Benefits Review Program, utilization of
hormonal contraceptives by Medi-Cal enrollees is not expected
to increase significantly. This is because Medi-Cal already
covers up to a 12-month supply of oral contraceptives and
utilization of the other covered forms of contraception is
very low. Therefore, there is no significant increase in
utilization anticipated nor is there an anticipated reduction
in health care services related to unintended pregnancy.
4)Annual premium savings to the CalPERS system of about $2
million per year, due to reduced health care costs associated
with unintended pregnancies. About half of those savings
would accrue to the state General Fund and special funds and
half would accrue to local governments.
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5)No state costs to subsidize coverage through Covered
California are anticipated. Under federal law, the costs of
any state-imposed benefit mandate that exceeds the essential
health benefits included in the state's benchmark plan is a
state responsibility. In other words, if the state imposes a
new benefit mandate on health plans or health insurers that
sell coverage through Covered California, the state is
obligated to pay for the cost to subsidize that benefit
mandate for enrollees receiving federal subsidies. Because the
bill does not impose a new benefit mandate, but only changes
the terms of an existing mandate to cover contraceptives, the
bill does not expand the state's essential health benefits.
COMMENTS:
Purpose. This bill is sponsored by Planned Parenthood
Affiliates of California , the California Family Health Council ,
and NARAL, Pro-Choice America . According to the author, "SB 999
addresses a leading barrier to obtaining consistent access to
contraception by changing the timing of contraception
dispensing. Under current law, health insurance companies and
plans must limit their coverage of birth control to a one-or-
three- month supply. This practice can lead to unwanted gaps in
use and increase unintended pregnancies. Inconsistent supplies
of birth control are problematic for many women who have
unpredictable work hours, difficulty accessing transportation,
or other barriers preventing them from accessing a provider,
pharmacy or clinic, in a timely manner. By allowing women to
receive up to a 12 month supply of birth control at one time,
women can better control their birth control use. The CA Health
Benefits Review Panel estimates that under the bill, costs to
employers and consumers would be reduced by over $42 million
annually, with 15,000 fewer unintended pregnancies, and 7000
fewer abortions each year. The report cited that the program
found no difference in medical health risks in 3, 6, or 12 month
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dispensation. Given that California has a continued access to
care crisis, a provider shortage and high rates of unintended
pregnancy, California must continue to find inventive ways to
remove barriers to providing consistent contraception."
Background. Methods of Birth Control. Contraceptives
prescribed by a healthcare provider are in hormonal or
non-hormonal forms. Hormonal contraceptives are made up of
female sex hormones: estrogen or progestin (a synthetic form of
progesterone). The most popular hormonal contraceptive is the
combination pill, or oral contraceptive. Other hormonal
contraceptives include injected progestins, subdermal implants
that release progestins, transdermal patch, and vaginal rings.
Non-hormonal methods include use of an intrauterine device,
cervical cap, diaphragm, and contraceptive sponge.
Pharmacists' Procedures and Protocols for Furnishing Hormonal
Contraceptives. Section 4052.3(a)(1) of the BPC authorizes a
pharmacist to furnish self-administered hormonal contraceptives
in accordance with a protocol approved by the BOP and the MBC.
The purpose of the protocol is to ensure timely access to
self-administered hormonal contraception medication and that the
patient receives adequate information to successfully comply
with therapy.
When a patient requests self-administered hormonal
contraception, the pharmacist measures and record the patient's
seated blood pressure, if combined hormonal contraceptives are
requested or recommended. The pharmacist also ensures that the
patient is appropriately trained in the administration of the
requested or recommended contraceptive medication, and has the
patient complete an annual self-screening tool that will
identify patient risk factors for use of self-administered
hormonal contraceptives, based on the current United States
Medical Eligibility Criteria (USMEC) for Contraceptive Use
developed by the federal Centers for Disease Control and
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Prevention.
Health Insurance Plans. Under current law, health insurance
companies and plans must limit their coverage of birth control
to a one or three month supply. This practice can lead to
unwanted gaps in birth control use and an increased incidence of
unintended pregnancies. According to the author, inconsistent
supplies of birth control are particularly problematic for many
women who have unpredictable work hours, difficulty accessing
transportation, or other barriers preventing them from accessing
a provider, pharmacy, or clinic, in a timely manner.
Studies and Reports of the Impact of Annual Dispensing of
Hormonal Contraceptives. In 2013, the CDC recommended that
women be provided with a year's supply of self-administered
hormonal contraceptives. In January of 2015, the ACOG issued
guidelines that recommend that payment and practice policies
support annual dispensing of contraceptives.
According to a study from the University of California San
Francisco (UCSF), women who received a full year's worth of
pills at one time were 30 percent less likely to have an
unintended pregnancy than women who received either a one-month
or three-month supply of pills. California's Family Pact
Program for low-income women has successfully provided annual
dispensing of contraception the last two decades. In addition,
as of February 5, 2016, the DHCS is now requiring all Medi-Cal
managed care plans to pay for 12 month dispensing.
On March 28, 2016, the California Health Benefits Review Program
(CHBRP) released its analysis of SB 999. The report cited,
"there is a preponderance of evidence that annual dispensing
leads to a reduction in unintended pregnancy and related
outcomes." It estimated that costs to employers and consumers
would be reduced by over $42 million annually, and estimated
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that as a result of the bill, there would be 15,000 fewer
unintended pregnancies, and 7000 fewer abortions each year. In
addition, the report cited that the program found no difference
in medical health risks in three, six, or twelve month
dispensation.
Other States. This past year, both Oregon and the District of
Columbia enacted new laws requiring the annual dispensing of
contraception. Similar legislation is being considered in
Colorado Washington, Wisconsin, New York, and Hawaii.
REGISTERED SUPPORT:
Alameda County Board of Supervisors
American Congress of Obstetricians and Gynecologists
California Academy of Family Physicians
California Pan Ethnic Health Network
City Council of West Hollywood
Having Our Say
Health Access
March of Dimes California
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Planned Parenthood Affiliates of California
Planned Parenthood Pasadena and San Gabriel Valley
Planned Parenthood LA County
Planned Parenthood San Bernardino
Planned Parenthood Ventura
Planned Parenthood San Luis Obispo
Planned Parenthood Mar Monte
Planned Parenthood Northern California Action Fund
Planned Parenthood Community Action Fund of Orange and San
Bernardino
Santa Clara County Democratic Activists for Women Now
REGISTERED OPPOSITION:
Association of California Life and Health Insurance Companies
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Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /
(916) 319-3301