BILL NUMBER: SB 5	ENROLLED
	BILL TEXT

	PASSED THE SENATE   SEPTEMBER 9, 1999
	PASSED THE ASSEMBLY   SEPTEMBER 8, 1999
	AMENDED IN ASSEMBLY   JUNE 29, 1999
	AMENDED IN ASSEMBLY   JUNE 14, 1999
	AMENDED IN SENATE   APRIL 28, 1999
	AMENDED IN SENATE   MARCH 9, 1999

INTRODUCED BY   Senator Rainey

                        DECEMBER 7, 1998

   An act to amend Section 1367.65 of, and to repeal and add Section
1367.6 of, the Health and Safety Code, and to amend Section 10123.81
of, and to repeal and add Section 10123.8 of, the Insurance Code,
relating to health.



	LEGISLATIVE COUNSEL'S DIGEST


   SB 5, Rainey.  Health care benefits:  breast cancer services.
   Existing law provides for the licensure and regulation of health
care service plans administered by the Commissioner of Corporations.
Existing law provides for the licensure and regulation of disability
insurers that cover hospital, medical, or surgical expenses by the
Insurance Commissioner. Existing law provides that a willful
violation of the law regulating health care service plans is
punishable as either a felony or a misdemeanor.
   Under existing law, every health care service plan contract and
every group policy of disability insurance or self-insured employee
welfare benefit plan that provides for the surgical procedure known
as a mastectomy, that is issued, amended, delivered, or renewed in
this state on or after July 1, 1980, is required to include coverage
for prosthetic devices or reconstructive surgery, subject to
specified conditions.
   This bill would, instead, require health care service plan
contracts, except specialized health care plan contracts, and certain
policies of disability insurance providing coverage for hospital,
medical, or surgical expenses, that are issued, amended, delivered,
or renewed on or after January 1, 2000, to provide coverage for
screening for, diagnosis of, and treatment for, breast cancer.  The
bill would prohibit the denial of enrollment or coverage solely due
to a family history of breast cancer, or because of one or more
diagnostic procedures for breast disease where breast cancer has not
developed or been diagnosed.  The bill would require coverage of
screening and diagnosis of breast cancer consistent with generally
accepted medical and scientific evidence upon the referral of an
enrollee's or insured's participating physician.
   Existing law provides that every individual or group health care
service plan contract, individual or group policy of disability
insurance, and self-insured employee welfare benefit plan that is
issued, amended, or renewed after January 1, 1991, and that includes
coverage for mastectomy and prosthetic devices and reconstructive
surgery incident to mastectomy, shall be deemed to provide coverage
for mammography for screening or diagnosis purposes upon referral by
a participating nurse practitioner, participating certified nurse
midwife, or participating physician.
   This bill would, instead, provide that a health care service plan
contract, except a specialized health care service plan contract,
that is issued, amended, delivered, or renewed on or after January 1,
2000, shall be deemed to provide coverage for mammography for
screening or diagnostic purposes upon referral by a participating
nurse practitioner, participating certified nurse midwife, or
participating physician, providing care to the patient and operating
within the scope of practice provided under existing law.  This bill
would enact similar provisions applicable to every individual or
group policy of disability insurance and self-insured employee
welfare benefit plan.
   Because a willful violation of the bill's provisions applicable to
health care service plans would be a crime, this bill would impose a
state-mandated local program by imposing a new crime.
  The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:


  SECTION 1.  Section 1367.6 of the Health and Safety Code is
repealed.
  SEC. 2.  Section 1367.6 is added to the Health and Safety Code, to
read:
   1367.6.  (a) Every health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, delivered, or renewed on or after January 1, 2000, shall
provide coverage for screening for, diagnosis of, and treatment for,
breast cancer.
   (b) No health care service plan contract shall deny enrollment or
coverage to an individual solely due to a family history of breast
cancer, or who has had one or more diagnostic procedures for breast
disease but has not developed or been diagnosed with breast cancer.
   (c) Every health care service plan contract shall cover screening
and diagnosis of breast cancer, consistent with generally accepted
medical practice and scientific evidence, upon the referral of the
enrollee's participating physician.
   (d) Treatment for breast cancer under this section shall include
coverage for prosthetic devices or reconstructive surgery to restore
and achieve symmetry for the patient incident to a mastectomy.
Coverage for prosthetic devices and reconstructive surgery shall be
subject to the copayment, or deductible and coinsurance conditions,
that are applicable to the mastectomy and all other terms and
conditions applicable to other benefits.
   (e) As used in this section, "mastectomy" means the removal of all
or part of the breast for medically necessary reasons, as determined
by a licensed physician and surgeon.
   (f) As used in this section, "prosthetic devices" means the
provision of initial and subsequent devices pursuant to an order of
the patient's physician and surgeon.
  SEC. 3.  Section 1367.65 of the Health and Safety Code is amended
to read:
   1367.65.  (a) On or after January 1, 2000, every health care
service plan contract, except a specialized health care service plan
contract, that is issued, amended, delivered, or renewed shall be
deemed to provide coverage for mammography for screening or
diagnostic purposes upon referral by a participating nurse
practitioner, participating certified nurse midwife, or participating
physician, providing care to the patient and operating within the
scope of practice provided under existing law.
   (b) Nothing in this section shall be construed to prevent
application of copayment or deductible provisions in a plan, nor
shall this section be construed to require that a plan be extended to
cover any other procedures under an individual or a group health
care service plan contract.  Nothing in this section shall be
construed to authorize a plan enrollee to receive the services
required to be covered by this section if those services are
furnished by a nonparticipating provider, unless the plan enrollee is
referred to that provider by a participating physician, nurse
practitioner, or certified nurse midwife providing care.
  SEC. 4.  Section 10123.8 of the Insurance Code is repealed.
  SEC. 5.  Section 10123.8 is added to the Insurance Code, to read:
   10123.8.  (a) Every policy of disability insurance that provides
coverage for hospital, medical, or surgical expenses, that is issued,
amended, delivered, or renewed on or after January 1, 2000, shall
provide coverage for screening for, diagnosis of, and treatment for,
breast cancer.
   (b) No policy of disability insurance that provides coverage for
hospital, medical, or surgical expenses shall deny enrollment or
coverage to an individual solely due to a family history of breast
cancer, or who has had one or more diagnostic procedures for breast
disease but has not developed or been diagnosed with breast cancer.
   (c) Every policy of disability insurance shall cover screening and
diagnosis of breast cancer, consistent with generally accepted
medical practice and scientific evidence, upon the referral of the
insured's participating physician.
   (d) Treatment for breast cancer under this section shall include
coverage for prosthetic devices or reconstructive surgery to restore
and achieve symmetry for the patient incident to a mastectomy.
Coverage for prosthetic devices and reconstructive surgery shall be
subject to the deductible and coinsurance conditions applied to the
mastectomy and all other terms and conditions applicable to other
benefits.
   (e) As used in this section, "mastectomy" means the removal of all
or part of the breast for medically necessary reasons, as determined
by a licensed physician and surgeon.
   (f) As used in this section, "prosthetic devices" means the
provision of initial and subsequent devices pursuant to an order of
the patient's physician and surgeon.
   (g) For purposes of this section, disability insurance does not
include accident only, credit, disability income, specified disease
and hospital confinement indemnity, coverage of Medicare services
pursuant to contracts with the United States government, Medicare
supplement, long-term care insurance, dental, vision, coverage issued
as a supplement to liability insurance, insurance arising out of a
workers' compensation or similar law, automobile medical payment
insurance, or insurance under which benefits are payable with or
without regard to fault and that is statutorily required to be
contained in any liability insurance policy or equivalent
self-insurance.
  SEC. 6.  Section 10123.81 of the Insurance Code is amended to read:

   10123.81.  On or after January 1, 2000, every individual or group
policy of disability insurance or self-insured employee welfare
benefit plan that is issued, amended, or renewed, shall be deemed to
provide coverage for at least the following, upon the referral of a
nurse practitioner, certified nurse midwife, or physician, providing
care to the patient and operating within the scope of practice
provided under existing law for breast cancer screening or diagnostic
purposes:
   (a) A baseline mammogram for women age 35 to 39, inclusive.
   (b) A mammogram for women age 40 to 49, inclusive, every two years
or more frequently based on the women's physician's recommendation.

   (c) A mammogram every year for women age 50 and over.
   Nothing in this section shall be construed to require an
individual or group policy to cover the surgical procedure known as
mastectomy or to prevent application of deductible or copayment
provisions contained in the policy or plan, nor shall this section be
construed to require that coverage under an individual or group
policy be extended to any other procedures.
   Nothing in this section shall be construed to authorize an insured
or plan member to receive the coverage required by this section if
that coverage is furnished by a nonparticipating provider, unless the
insured or plan member is referred to that provider by a
participating physician, nurse practitioner, or certified nurse
midwife providing care.
  SEC. 7.  No reimbursement is required by this act pursuant to
Section 6 of Article XIIIB of the California Constitution because the
only costs that may be incurred by a local agency or school district
will be incurred because this act creates a new crime or infraction,
eliminates a crime or infraction, or changes the penalty for a crime
or infraction, within the meaning of Section 17556 of the Government
Code, or changes the definition of a crime within the meaning of
Section 6 of Article XIIIB of the California Constitution.