BILL NUMBER: SB 5 CHAPTERED 09/28/99 CHAPTER 537 FILED WITH SECRETARY OF STATE SEPTEMBER 28, 1999 APPROVED BY GOVERNOR SEPTEMBER 27, 1999 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.