BILL ANALYSIS
AB 56
Page 1
ASSEMBLY THIRD READING
AB 56 (Portantino)
As Amended June 1, 2009
Majority vote
HEALTH 13-6 APPROPRIATIONS 12-5
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|Ayes:|Jones, Ammiano, Block, |Ayes:|De Leon, Ammiano, Charles |
| |Carter, De La Torre, | |Calderon, Davis, Fuentes, |
| |De Leon, Hall, Hayashi, | |Hall, John A. Perez, Price, |
| |Hernandez, Bonnie | |Skinner, Solorio, |
| |Lowenthal, Nava, V. | |Torlakson, Krekorian |
| |Manuel Perez, Salas | | |
| | | | |
|-----+--------------------------+-----+----------------------------|
|Nays:|Fletcher, Adams, Conway, |Nays:|Nielsen, Duvall, Harkey, |
| |Emmerson, Gaines, Audra | |Miller, |
| |Strickland | |Audra Strickland |
| | | | |
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SUMMARY : Requires health insurers to provide coverage for
mammography upon provider referral by July 1, 2010, and requires
health plans and health insurers to notify female enrollees or
insureds of their eligibility for testing. Specifically, this
bill :
1)Requires every individual or group policy of health insurance
or self-insured employee welfare benefit plan issued, amended,
delivered, or renewed on or after July 1, 2010, to provide
coverage for mammography for screening or diagnostic purposes
upon referral of a participating physician, nurse
practitioner, or certified nurse-midwife.
2)Requires health plans and health insurers to provide female
enrollees or insureds with notice, during the calendar year in
which national guidelines indicate they should start
undergoing tests for screening or diagnosis of breast cancer,
advising that they are eligible for testing.
3)Allows the notice pursuant to 2) above to be provided by
written letter, by publication in a newsletter, by publication
in evidence of coverage documents, by direct phone call, by
electronic transmission, or by any other means that will
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reasonably notify the enrollee or insured of her eligibility
for testing.
4)Exempts from the provisions of this bill Medicare supplement,
vision-only, dental-only, and Civilian Health and Medical
Program of the Uniformed Services-supplement insurance; and,
hospital indemnity, accident-only, and specified disease
insurance that does not pay benefits on a fixed-benefit,
cash-payment-only basis.
EXISTING LAW :
1)Provides for the regulation of health plans by the Department
of Managed Health Care and health insurers by the California
Department of Insurance.
2)Requires health plans to cover mammography for screening or
diagnostic purposes upon the referral of the patient's
physician, nurse practitioner, or certified nurse-midwife.
3)Requires health insurance policies to provide coverage for a
baseline mammogram for women age 35-39, inclusive; a mammogram
for women age 40-49, inclusive, every two years or more,
depending on a physician's recommendation; and, a mammogram
every year for women age 50 and over; for breast cancer
screening or diagnostic purposes.
FISCAL EFFECT :
1)According to the Assembly Appropriations Committee, recent
amendments to this bill provide health plan and insurer
flexibility with respect to mode and timing of communication
with enrollees about mammography recommendations. These
amendments likely reduce or eliminate notification costs.
2)To the extent this bill increases mammography provided to
Medi-Cal recipients, costs will increase accordingly.
Currently, Medi-Cal reimburses analog mammography at $72.
Therefore an increase of 1,000 mammography screenings results
in $72,000 (50% General Fund) in increased Medi- Cal costs.
This bill will have unknown impacts on the private insurance
market.
COMMENTS : According to the author, this bill is needed to
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remove the age based utilization of mammograms contained in the
Insurance Code. The author believes that a woman's decision to
have a mammogram should be based upon the specific risks of the
woman, and in consultation with her physician, rather than
dictated based on her age. The author states that existing law
requiring insurance companies to pay for a baseline mammogram at
35 years of age, a mammogram every other year at age 40 and then
every year starting at age 50 was enacted 20 years ago and needs
to be updated to reflect national screening guidelines that
generally call for mammography to begin at age 40 for most
women. The author adds that the notification requirement in
this bill will increase the number of women receiving
mammograms, save lives, and reduce treatment costs.
Several organizations have adopted evidence-based national
recommendations for breast cancer screening including the U.S.
Preventive Services Task Force (USPSTF), convened by the U.S.
Department of Health and Human Services, the American Cancer
Society (ACS), the American College of Radiology, the American
College of Obstetrician-Gynecologists, and the American College
of Physicians. Generally these guidelines recommend that
mammography be performed every 1-2 years beginning at age 40 or
50 for those women of average risk for breast cancer, but no
longer suggest routine baseline mammograms in women younger than
40 years. However, the most widely accepted guidelines, those
developed by USPSTF and ACS, recommend breast cancer screening
for women starting at age 30 if they have certain high risk
factors, including specific genetic mutations, a personal or
family history of breast cancer, prior exposure to chest
radiation, or extremely dense breast tissue.
AB 1996 (Thomson), Chapter 795, Statutes of 2002, requests the
University of California to assess legislation proposing a
mandated benefit or service, and prepare a written analysis with
relevant data on the public health, medical, and economic impact
of proposed health plan and health insurance benefit mandate
legislation. The California Health Benefits Review Program
(CHBRP) was created in response to AB 1996 and extended for four
additional years in SB 1704 (Kuehl), Chapter 684, Statutes of
2006. In reviewing this bill, CHBRP focused its analysis on
screening instead of diagnosis, based on the broad agreement
between multiple national organizations that breast cancer
screening should begin as early as age 40 for women of average
risk for breast cancer, and assumed the written notification
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requirement in this bill would be met through a one-time generic
letter sent to each covered woman during the calendar year she
reaches age 40.
According to CHBRP, a preponderance of evidence shows that
mammography screening is medically effective for women ages
40-49 years after 10-14 years of follow-up but the reduction in
breast cancer mortality as a result of screening is lower than
for women who are 50 and older, and false-positive rates are
higher for women under the age of 50. CHBRP also found a
preponderance of evidence showing that patient reminders for
mammography screening increase the number of women completing
mammography and increase the overall mammography screening rate
by about one-third.
CHBRP reported that approximately 21.3 million individuals in
California are enrolled in health plans or policies that would
be subject to the mandate in this bill. CHBRP's coverage survey
of health plans and insurers in California indicated that an
estimated 100% of health plans and insurers cover mammography as
a routine screening test when referred by a provider.
Currently, about 51% of women receive a mammogram during their
40th year - the age at which annual screening is recommended to
begin. CHBRP estimated that the cost of a single mammogram is
about $96 and the unit price of a mammogram plus the costs of
services due to false-positive test results is estimated at
$169. While this bill is not expected to affect the unit cost
of mammography or increase the mammography rate due to increases
in coverage, CHBRP indicated that this bill will increase
utilization as a result of the required notification, with the
expected total annual number of mammograms increasing by 0.38%
or 20,000, if the notification is provided via a one-time
generic letter.
According to CHBRP, it is estimated that screening an additional
20,000 women with mammography would, over time, prevent
approximately 16 deaths per year from breast cancer. It would
take roughly 14 years following implementation of this bill for
this reduction in mortality to be realized, although qualitative
improvements, such as a decrease in the aggressiveness of cancer
and less treatment for metastatic disease would be expected
sooner. CHBRP also added that an estimated reduction in 16
premature deaths annually as a result of this bill would
translate into savings of 366 life-years and $5.2 million in
productivity that would otherwise be lost. Finally, CHBRP
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stated that while this bill will result in premium increases of
less than 1%, it is unlikely that this bill will result in an
increase in the uninsured or contribute to the long-term health
impacts of being uninsured.
Supporters, including the sponsor, the American College of
Obstetricians and Gynecologists, ACS, and the California Medical
Association, state that this bill will make changes to the
insurance mandate for mammography coverage to provide health
care providers the flexibility to ensure that women receive the
most appropriate breast cancer screening services regardless of
age. They also point out that the notice required in this bill
will serve as an important reminder to women about the
importance of screening for their health.
The Association of California Life and Health Insurance
Companies and Health Net are opposed to this bill and contend
that the requirement to send a notice for the testing of one
specific medical condition will be costly, burdensome, and
counterproductive to the insurance industry's efforts to make
health insurance more affordable and available to all
Californians.
Analysis Prepared by : Cassie Rafanan / HEALTH / (916)
319-2097
FN: 0001297