BILL ANALYSIS
AB 2093
Page 1
ASSEMBLY THIRD READING
AB 2093 (V. Manuel Perez)
As Amended May 28, 2010
Majority vote
HEALTH 15-0 APPROPRIATIONS 13-4
-----------------------------------------------------------------
|Ayes:|Monning, Fletcher, |Ayes:|Fuentes, Ammiano, |
| |Ammiano, Carter, | |Bradford, |
| |Bradford, De Leon, | |Charles Calderon, Coto, |
| |Emmerson, Eng, Hayashi, | |Davis, Harkey, Monning, |
| |Hernandez, Jones, | |Ruskin, Skinner, Solorio, |
| |Bonnie Lowenthal, Nava, | |Torlakson, Torrico |
| |V. Manuel Perez, Salas | | |
| | | | |
|-----+--------------------------+-----+--------------------------|
| | |Nays:|Conway, Miller, Nielsen, |
| | | |Norby |
-----------------------------------------------------------------
SUMMARY : Requires a health care service plan or health insurer
(collectively carriers) that provides coverage for childhood and
adolescent immunizations to reimburse a physician or physician
group the entire cost of acquiring and administering the
vaccine, and prohibits a carrier from requiring cost-sharing
from immunizations. Specifically, this bill :
1)Requires a carrier that covers childhood and adolescent
immunizations to reimburse a physician or physician group in
an amount not less than the actual cost of acquiring the
vaccine plus the cost of administration of the vaccine.
Specifies the following:
a) The actual cost of acquiring the vaccine is the
vaccine's private sector cost per dose, as published on the
most current Pediatric Vaccine Price List of the federal
Centers for Disease Control and Prevention, plus reasonable
costs associated with shipping and handling; and,
b) The cost of administration of the vaccine, which
includes physician time, clinical staff time, and office
staff time, as well as other practice expenses associated
with providing the immunization such a storage, insurance,
supplies, and medical equipment, to be an amount not less
AB 2093
Page 2
than that specified in the most current annual Medicare
physician fee schedule.
2)Excludes from 1) above services provided under contracts
entered between carriers and the State Department of Health
Care Services for enrolled Medi-Cal beneficiaries.
3)Excludes from 1) above services provided under contracts
entered between carriers and the Managed Risk Medical
Insurance Board for enrolled Healthy Families beneficiaries.
4)Requires a health plan to reimburse a physician or physician
group, in an amount not less than that specified in 1) above,
for immunizations for children that are not part of a current
contract, including, but not limited to, immunizations in the
most current versions of the Recommended Childhood and
Adolescent Immunization Schedules jointly approved by the
federal Advisory Committee on Immunization Practices, the
American Academy of Pediatrics, and the American Academy of
Family Physicians.
5)Prohibits a health plan from including the costs of acquiring
or administering required immunizations for children in the
capitation rate of a physician who is individually capitated.
6)Prohibits a health plan contract or health insurance policy
from imposing a deductible, copayment, coinsurance, or other
cost-sharing mechanism for the administration, or procedures
related to the administration, of a childhood or adolescent
immunization.
7)Prohibits a health plan contract or health insurance policy
from containing a dollar limit that includes the
administration of childhood and adolescent immunizations.
8)Excludes from 1) above services provided under contracts
entered between carriers and the Board of Administration of
the Public Employees' Retirement System.
9)Makes legislative findings and declarations regarding
immunizations as a successful and cost-effective public health
intervention; rising pediatric vaccine acquisition costs;
physician costs for vaccines; the effects of inadequate
provider reimbursement for vaccines; insured families'
AB 2093
Page 3
financial barriers to immunizations; and, the importance of
ensuring continued access to vaccines.
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 (CDI).
2)Requires health plans licensed under the Knox-Keene Health
Care Service Plan Act of 1975 to cover all medically necessary
basic health care services, as defined. Defines basic health
care services to include: physician services; hospital
inpatient and outpatient services; including outpatient
physical, occupational, and speech therapy; diagnostic
laboratory and X-ray services; preventive and routine care,
such as vaccinations and routine checkups; emergency and
urgent care services, including ambulance and out-of-area
emergency services; and, medically appropriate home health
services. There is no requirement for health insurers subject
to regulation by CDI to cover medically necessary basic
services or any specific minimum basic benefits.
3)Prohibits a risk-based contract between a physician or
physician group and a health plan from requiring a physician
or physician group to assume financial risk for the cost of
acquiring required immunizations for children as a condition
of accepting the contract. Prohibits a health plan from
requiring a physician to assume financial risk for
immunizations that are not part of the contract.
4)Requires a health plan to reimburse a physician for
immunizations within 45 days of receiving from the physician
documentation that the immunizations were administered.
FISCAL EFFECT : According to the Appropriations Committee this
bill:
1)Addresses access problems privately insured children may face
if physicians start dropping pediatric immunization due to
cost issues. Although similar cost issues may face Healthy
Families Providers who care for one million low-income
children, this bill does not address this portion of the
health care market. Children in the Medi-Cal program are
AB 2093
Page 4
supported by the federally funded Vaccines for Children
Program, which appears to provide adequate reimbursement.
2)Will result in the following fiscal impact: Private health
insurance market premium pressures of millions of dollars.
3)Applies to approximately five million privately insured
children. The American Academy of Pediatrics research shows a
need for increases in some vaccine reimbursement of up to 50%.
According to data lifetime immunization costs for children
are more than $1,500. Therefore pressures of $10 per child
would result in premium pressures of $50 million.
COMMENTS : According to the author, pediatric immunizations have
proven to be one of the most successful, safe, and
cost-effective public health interventions of the 20th Century.
While the author maintains that existing law prohibits carriers
from requiring physicians or physician groups to assume
financial risk for the costs of acquiring required immunizations
for children, the author argues that the cost of administering a
vaccine is not included in the prohibition. The author
specifies administration costs associated with giving
immunizations to include refrigeration and storage, clinical
staff time, and medical supplies such as gloves and syringes.
The author contends that health plans and insurers often do not
reimburse for the entire cost of providing vaccines, which
forces physicians to absorb these costs. The author states that
as small businesses, physicians face severe financial strain
when they absorb the costs associated with vaccine
administration. According to the author, some physicians may be
forced to discontinue or delay offering the most costly
vaccinations, or require parents to pay up front, which could
shift the burden of vaccine financing to parents' out-of-pocket
expenses or to public programs. The author further argues that
as costlier new vaccines are approved and recommended, the
problem will only get worse. The author states this bill is
intended to ensure that physicians are fully reimbursed for the
costs to acquire and administer recommended vaccines and that
out-of-pocket expenses do not deter patients from immunizing
their children.
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097
AB 2093
Page 5
FN: 0004686