BILL ANALYSIS Ó
SB 999
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Date of Hearing: June 14, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
SB
999 (Pavley) - As Amended April 18, 2016
SENATE VOTE: 29-6
SUBJECT: Health insurance: contraceptives: annual supply.
SUMMARY: Requires coverage for up to a 12-month supply of Food
and Drug Administration (FDA) approved, self-administered
hormonal contraceptives (contraceptives) and permits pharmacists
to dispense these contraceptives consistent with existing
protocols and upon a patient's request. Specifically, 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
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supplies, except as otherwise authorized by state or federal
law or by the health plan's policies regarding out-of-network
coverage.
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 Board of Pharmacy (BOP)
protocols may dispense, at the patient's request, up to a
12-month supply at one time.
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.
2)Establishes the Medi-Cal program, which is administered by the
State Department of Health Care Services (DHCS), under which
qualified low-income persons receive health care benefits and,
in part, governed and funded by federal Medicaid program
provisions.
3)Establishes the BOP to regulate the practice of pharmacy,
including the licensure of pharmacists.
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
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services and contraceptive methods for women:
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
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.
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.
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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:
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.
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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.
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.
10) Requires the standardized procedure or protocol in 9)
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.
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
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follow-up, and other appropriate information, developed, as
specified.
FISCAL EFFECT: According to the Senate Appropriations
Committee:
1)Minor costs to review information from health insurers by the
CDI (Insurance Fund).
2)No significant costs are anticipated to review health plan
information by the DMHC (Managed Care Fund).
3)No significant costs or savings are projected for the Medi-Cal
program (General Fund (GF) and federal funds). According to
an analysis of the bill by the California Health Benefits
Review Program (CHBRP), 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 California Public Employees'
Retirement System of about $2 million per year, due to reduced
health care costs associated with unintended pregnancies (GF,
special funds, local funds). About half of those savings
would accrue to the GF and special funds and half would accrue
to local governments.
5)No state costs to subsidize coverage through Covered
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California are anticipated. Under federal law, the costs of
any state-imposed benefit mandate that exceeds the EHBs
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, this bill does
not expand the state's EHBs.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, California has
required insurance coverage for FDA-approved contraception
since 1998, but many hurdles remain. Under current law,
health insurance companies and plans must limit 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. The author
cites a University of California (UC) San Francisco study that
found that women who received a full year's worth of birth
control pills at one time were 30% less likely to have an
unintended pregnancy than women who received a one or three
month supply. The author states that there is growing
momentum nationwide to provide annual dispensing. For
example, in 2013, the CDC recommended that women be provided
with a year's supply of self-administered hormonal
contraceptives. Also, in January 2015, ACOG issued guidelines
that recommended that payment and practice policies support
annual dispensing of contraceptives.
Additionally, the author notes that the language in this bill
requires health plans to cover up to a 12-month supply of
contraception and what is ultimately dispensed is the product
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of a conversation between the patient and the provider. This
bill mandates that insurers cover instances when providers
conclude that dispensing 12 months at one time is in the best
interests of the patient. Finally, the author notes other
states enacting similar laws, including Oregon, and cites to
the Oregon Health Plan and the Oregon Contraception Care
Program which found that it was rare for annual dispensing to
result in an oversupply of contraception.
2)BACKGROUND.
a) CHBRP analysis. AB 1996 (Thomson), Chapter 795,
Statutes of 2002, requests UC 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. CHBRP
was created in response to AB 1996. SB 125 (Hernandez),
Chapter 9, Statutes of 2015, added an impact assessment on
EHBs, and legislation that impacts health insurance benefit
designs, cost sharing, premiums, and other health insurance
topics. CHBRP states in its analysis of this bill the
following:
i) Enrollees covered. CHBRP estimates that in 2016,
25.2 million Californians have state-regulated coverage
that would be subject to this bill.
ii) Impact on expenditures. CHBRP estimates that total
net annual expenditures would decrease by $42.8 million
or 0.03% for enrollees with DMHC-regulated plans and
CDI-regulated policies. This represents the anticipated
savings in 2017 due to the avoidance of unintended
pregnancies (leading to reduced delivery, miscarriage,
and abortion costs) and the reduced number of office
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visits in the first year postmandate. The decrease in
total expenditures is due to a $24 million decrease in
total health insurance premiums paid by employers and
enrollees, along with a decrease in enrollee
out-of-pocket expenditures ($18.7 million), for an
overall net decrease of $42.8 million.
iii) EHBs. This bill does not constitute a new benefit
but rather, alters the terms and conditions (i.e., supply
dispensed) of an existing benefit (coverage for
self-administered hormonal contraceptives). This bill
does not exceed the EHBs.
iv) Medical effectiveness. There is a preponderance of
evidence to indicate that dispensing oral contraceptives
in larger quantities leads to a reduction in unintended
pregnancy and related outcomes. However, fewer studies
examine the effect of the amount of dispensed supply of
self-administered hormonal contraceptives, the primary
impact of this bill. There is a preponderance of
evidence from studies with moderate research designs that
conclude that dispensing oral contraceptives in larger
quantities leads to a reduction in unintended pregnancy
and related outcomes. There was no known literature on
the impact of dispensing patterns for vaginal ring and
contraceptive patch. Two studies were conducted
examining data on women receiving oral contraceptive
pills through the California Family PACT (Planning,
Access, Care and Treatment) Program to compare pregnancy
rates between women given a 12-month supply to those
given a one or three month supply (Foster et al., 2011;
Foster et al., 2006b). The results indicated that women
who were given a 12-month supply had reduced rates of
unintended pregnancy (1.2% of women who received a
12-month supply and 3.3% of women who received a three
month supply) (Foster et al., 2011). There was an
associated 30% decrease in the odds of having an
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unintended pregnancy, as well as a 46% decrease in the
odds of an abortion when dispensing a 12-month supply
compared to dispensing 1- or 3 month supplies (Foster et
al., 2011).
i) Benefit coverage. CHBRP estimates that coverage for
an annual supply of self-administered hormonal
contraceptives (including oral contraceptive pill, patch,
and ring) would increase from 0% to 100% of enrollees of
DMHC-regulated plans and CDI-regulated policies.
ii) Utilization. Postmandate, CHBRP estimates that the
number of active self-administered hormonal contraceptive
prescriptions will remain the same, but more women will
receive a 12-month supply at once and office visits are
expected to decrease.
iii) Public Health. As a result of SB 999, CHBRP
estimates a decrease in unintended pregnancies of 15,000
(which includes 6,000 fewer live births, 2,000 fewer
miscarriages, and 7,000 fewer abortions). Obtaining a
12-month supply of self-administered hormonal
contraceptives at one time reduces the potential for
delays in refills between cycles. Consistent, continuous
contraceptive use helps to prevent any extension of the
usual hormone-free interval; extension of this interval
results in an increased possibility of unintended
pregnancy. CHBRP estimates that among the 744,000
enrollees using self-administered hormonal
contraceptives, 280,000 enrollees will shift to using a
12-month prescription postmandate (resulting in 285,000
total enrollees using a 12-month supply). Among the
285,000 enrollees using a 12-month prescription for
self-administered hormonal contraceptives, CHBRP
estimates that this bill will result in 15,000 averted
unintended pregnancies. Based on estimates by Kost
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(2015) that 45% of unintended pregnancies in California
end in abortion and 13% result in miscarriage, CHBRP
estimates that 7,000 abortions and 2,000 miscarriages
would be averted due to decreases in unintended
pregnancies resulting from SB 999.
iv) Long-term impacts. CHBRP projects that SB 999 would
result in a decrease in the rate of unintended
pregnancies and abortions over the long term, resulting
in a corresponding decrease in the risk of maternal
mortality, adverse child health outcomes, behavioral
problems in children, and negative psychological outcomes
associated with unintended pregnancies for both mothers
and children. Avoiding unintended pregnancies also helps
women to delay childbearing and pursue additional
education, spend additional time in their careers, and
have increased earning power over the long term.
a) California Family Planning Program. Family PACT is a
reproductive health program for clinical family planning
services. Family PACT provides comprehensive family
planning services to women and men including all
FDA-approved forms of contraception, emergency
contraception, pregnancy testing with counseling,
preconception counseling, male and female sterilization,
limited infertility services, sexually transmitted
infection testing and treatment, cancer screening, and HIV
screening. Individual client reproductive health education
and counseling is an ongoing component of all services.
Family PACT clients are female and male residents of
California with a family income at or below 200% of the
federal poverty level with no other source of family
planning coverage. Clients are individuals with a medical
necessity for family planning services who do not have
Medi-Cal and do not have access to health insurance.
Medi-Cal clients with an unmet share of cost may also be
eligible. Eligibility determination and enrollment are
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conducted at the provider's office with point of service
activation of a client membership card.
b) Medi-Cal requirements. According to a recently revised
All Plan Letter (APL) issued by DHCS, effective May 1,
2016, Medi-Cal managed care plans (MCPs) must pay for up to
13 cycles of oral contraceptives, up to 12 patches in a 90
day period, and up to four vaginal rings in a 90 day period
if such quantity is dispensed in an onsite clinic and
billed by a qualified family planning provider, including
out-of-plan providers. A qualified provider is a provider
who is licensed to furnish family planning services within
their scope of practice, is an enrolled Medi-Cal provider,
and is willing to furnish family planning services to an
enrollee, as specified in regulation. A physician,
physician assistant (under the supervision of a physician),
certified nurse midwife, and nurse practitioner are
authorized to dispense medications. Pursuant to current
state law, if these contraceptives are dispensed by a
registered nurse (RN), the RN must have completed required
training, and the contraceptives must be billed with
Evaluation and Management procedure codes, as specified.
The APL also states that under federal law, a primary care
case management system, a health maintenance organization,
or a similar entity shall not restrict the choice of the
qualified person from whom the individual may receive such
services under 1396d(a)(4)(C) of Title 42. Therefore MCP
beneficiaries must be allowed freedom of choice of family
planning providers, and may receive such services from any
qualified family planning provider, including out-of-plan
providers, without prior authorization.
c) Other states. Currently, only Oregon and the District
of Columbia have laws in effect that are similar to this
bill. In 2015, Oregon became the first state in the
country to require that private insurers cover a 12-month
supply of contraceptives, including oral contraceptives,
the patch, and the ring dispensed at one time. Following
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Oregon, the District of Columbia passed similar
legislation. At the time of CHBRP's publication of its
analysis, several other states have considered such
legislation, including Alaska, New York, Rhode Island,
Washington, and Wisconsin. Additionally, some state
Medicaid programs and state family planning programs for
low-income residents already require a 12-month supply of
contraceptives to be dispensed at one time, including the
Oregon Contraceptive Care program.
3)SUPPORT. Planned Parenthood Affiliates of California (PPAC)
states that consistency is essential for birth control to be
effective. Additionally, for many women, particularly those
who live in low income rural areas, receiving only a short
supply of contraception can impede their ability to use birth
control on a consistent basis. PPAC states that studies show
that dispensing a 12-month supply of birth control at one time
reduces a woman's odds of having an unintended pregnancy by
30%.
4)OPPOSE UNLESS AMENDED. The Association of California Life and
Health Insurance Companies (ACLHIC) and California Association
of Health Plans (CAHP) are concerned with the potential for
pharmaceutical waste, and are therefore requesting this bill
be amended to allow an insurer to request that a patient be
stabilized on the medication prior to the 12-month supply
being filled. Additionally, ACLHIC and CAHP are requesting
that the implementation date be extended to January 1, 2018,
to allow health plans and insurers the necessary time to
integrate this new process into their systems and update their
policies to reflect the change in their products.
5)OPPOSITION. The California Right to Life Committee, Inc.
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states that they oppose any measure that expands access to
abortifacients (drugs causing abortions).
6)DOUBLE-REFFERAL. This bill was heard in the Senate Business,
Professions and Economic Development Committee on April 4,
2016 and was approved with a vote of 7-2. This bill will also
be heard in the Assembly Business and Professions Committee.
7)RELATED LEGISLATION. AB 1954 (Burke) creates the Direct
Access to Reproductive Health Care Act which prohibits health
plans or health insurance policies from requiring an enrollee
or insured to receive a referral before receiving coverage of
services for reproductive or sexual health care. AB 1954 is
currently pending in the Senate.
8)PREVIOUS LEGISLATION.
a) SB 1053 (Mitchell), Chapter 576, Statutes of 2014,
requires a health plan contract or health insurance policy
issued, amended, or renewed on or after January 1, 2016, to
provide coverage for women for all prescribed and
FDA-approved female contraceptive drugs, devices, and
products, as well as voluntary sterilization procedures,
contraceptive education and counseling, and related
follow-up services. Prohibits a nongrandfathered plan
contract or health insurance policy from imposing any
cost-sharing requirements or other restrictions or delays
with respect to this coverage, as specified.
b) SB 493 (Hernandez), Chapter, 469, Statutes of 2013,
authorizes advanced practice pharmacists to perform other
functions, including, among other things, furnishing
self-administered hormonal contraceptives, nicotine
replacement products, and prescription medications not
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requiring a diagnosis that are recommended for
international travelers, as specified.
REGISTERED SUPPORT / OPPOSITION:
Support
California Family Health Council (co-sponsor)
NARAL Pro-Choice California (co- sponsor)
Planned Parenthood Affiliates of California (co-sponsor)
Alameda County Board of Supervisors
American Civil Liberties Union of California
American Congress of Obstetricians and Gynecologists, District
IX California
American Medical Women's Association
Asian Law Alliance
Bayer Corporation
Black Women for Wellness
California Academy of Family Physicians
California Academy of Physician Assistants
California Medical Association
California Pan-Ethnic Health Network
California Primary Care Association
California Religious Coalition for Reproductive Choice
California Women's Law Center
Citizens for Choice
Community Action Fund of Planned Parenthood of Orange and San
Bernardino Counties
Community Clinic Association of Los Angeles County
El Proyecto del Barrio, Inc.
Forward Together
Having Our Say Coalition
Health Access California
Jewish Family Service of Los Angeles
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Kaiser Permanente
Local Health Plans of California
March of Dimes Foundation in California
National Association of Social Workers, California Chapter
Northeast Valley Health Corporation
Physicians for Reproductive Health
Planned Parenthood Action Fund of Santa Barbara, Bentura, & San
Luis Obispo Counties
Planned Parenthood Action Fund of the Pacific Southwest
Planned Parenthood Advocacy Project Los Angeles County
Planned Parenthood Advocates Pasadena and San Gabriel Valley
Planned Parenthood Affiliates of California
Planned Parenthood Mar Monte
Planned Parenthood Northern California Action Fund
Secular Coalition for California
Opposition
America's Health Insurance Plans
Association of California Life and Health Insurance Companies
California Association of Health Plans
California Catholic Conference, Inc.
California Right to Life Committee
Analysis Prepared by:Kristene Mapile / HEALTH / (916)
319-2097
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