BILL NUMBER: SB 630	INTRODUCED
	BILL TEXT


INTRODUCED BY   Senator Steinberg

                        FEBRUARY 27, 2009

   An act to amend Section 1367.63 of the Health and Safety Code, and
to amend Section 10123.88 of the Insurance Code, relating to health
care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   SB 630, as introduced, Steinberg. Health care coverage:
reconstructive surgery: dental and orthodontic services.
   Existing law provides for the licensure and regulation of health
care service plans by the Department of Managed Health Care. Existing
law provides for the regulation of health insurers by the Department
of Insurance. A willful violation of the provisions governing health
care service plans is a crime. Existing law requires health care
service plan contracts and health insurance policies to cover
reconstructive surgery, as defined.
   This bill would provide that the requirement to cover
reconstructive surgery includes dental or orthodontic services that
are medically necessary and related to the reconstructive surgery.
Because a willful violation of the provision by a health care service
plan is a crime, the bill would impose a state-mandated local
program.
   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.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.


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

  SECTION 1.  Section 1367.63 of the Health and Safety Code is
amended to read:
   1367.63.  (a) Every health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, renewed, or delivered in this state on or after July 1,
1999, shall cover reconstructive surgery, as defined in subdivision
(c), that is necessary to achieve the purposes specified in 
paragraphs   paragraph  (1) or (2) of subdivision
(c). Nothing in this section shall be construed to require a plan to
provide coverage for cosmetic surgery, as defined in subdivision (d).

   (b) No individual, other than a licensed physician competent to
evaluate the specific clinical issues involved in the care requested,
may deny initial requests for authorization of coverage for
treatment pursuant to this section. For a treatment authorization
request submitted by a podiatrist or an oral and maxillofacial
surgeon, the request may be reviewed by a similarly licensed
individual, competent to evaluate the specific clinical issues
involved in the care requested.
   (c)  (1)    "Reconstructive surgery" means
surgery performed to correct or repair abnormal structures of the
body caused by congenital defects, developmental abnormalities,
trauma, infection, tumors, or disease to do either of the following:

   (1) 
    (A)  To improve function. 
   (2) 
    (B)  To create a normal appearance, to the extent
possible. 
   (2) No plan contract shall exclude coverage for dental or
orthodontic services that are related to, and medically necessary to
provide or complete, the reconstructive surgery required by this
section. 
   (d) "Cosmetic surgery" means surgery that is performed to alter or
reshape normal structures of the body in order to improve
appearance.
   (e) In interpreting the definition of reconstructive surgery, a
health care service plan may utilize prior authorization and
utilization review that may include, but need not be limited to, any
of the following:
   (1) Denial of the proposed surgery if there is another more
appropriate surgical procedure that will be approved for the
enrollee.
   (2) Denial of the proposed surgery or surgeries if the procedure
or procedures, in accordance with the standard of care as practiced
by physicians specializing in reconstructive surgery, offer only a
minimal improvement in the appearance of the enrollee.
   (3) Denial of payment for procedures performed without prior
authorization.
   (4) For services provided under the Medi-Cal program (Chapter 7
(commencing with Section 14000) of Part 3 of Division 9 of the
Welfare and Institutions Code), denial of the proposed surgery if the
procedure offers only a minimal improvement in the appearance of the
enrollee, as may be defined in any regulations that may be
promulgated by the State Department of Health  Care 
Services.
  SEC. 2.  Section 10123.88 of the Insurance Code is amended to read:

   10123.88.  (a) Every policy of  disability  
health  insurance covering hospital, medical, or surgical
expenses that is issued, amended, renewed, or delivered in this state
on or after July 1, 1999, shall cover reconstructive surgery, as
defined in subdivision (c), that is necessary to achieve the purposes
specified in  paragraphs   paragraph  (1)
or (2) of subdivision (c). Nothing in this section shall be construed
to require a policy to provide coverage for cosmetic surgery, as
defined in subdivision (d). This section shall only apply to health
benefit plans, as defined in subdivision (a) of Section 10198.6,
except that for accident only, specified disease, or hospital
indemnity insurance, coverage for benefits under this section shall
apply to the extent that the benefits are covered under the general
terms and conditions that apply to all other benefits under the
policy. Nothing in this section shall be construed as imposing a new
benefit mandate on accident only, specified disease, or hospital
indemnity insurance.
   (b) No individual, other than a licensed physician competent to
evaluate the specific clinical issues involved in the care requested,
may deny initial requests for authorization of coverage for
treatment pursuant to this section. For a treatment authorization
request submitted by a podiatrist or an oral and maxillofacial
surgeon, the request may be reviewed by a similarly licensed
individual, competent to evaluate the specific clinical issues
involved in the care requested.
   (c)  (1)    "Reconstructive surgery" means
surgery performed to correct or repair abnormal structures of the
body caused by congenital defects, developmental abnormalities,
trauma, infection, tumors, or disease to do either of the following:

   (1) 
    (A)  To improve function. 
   (2) 
    (B)  To create a normal appearance, to the extent
possible. 
   (2) No policy shall exclude coverage for dental or orthodontic
services that are related to, and medically necessary to provide or
complete, the reconstructive surgery required by this section. 
   (d) Nothing in this section shall be construed to require an
insurer to provide coverage for cosmetic surgery. "Cosmetic surgery"
means surgery that is performed to alter or reshape normal structures
of the body in order to improve the patient's appearance.
   (e) In interpreting the definition of reconstructive surgery, an
insurer may utilize prior authorization and utilization review that
may include, but need not be limited to, any of the following:
   (1) Denial of the proposed surgery if there is another more
appropriate surgical procedure that will be approved for the
enrollee.
   (2) Denial of the proposed surgery or surgeries if the procedure
or procedures, in accordance with the standard of care as practiced
by physicians specializing in reconstructive surgery, offer only a
minimal improvement in the appearance of the enrollee.
   (3) Denial of payment for procedures performed without prior
authorization.
  SEC. 3.  It is the intent of the Legislature to clarify and confirm
that any dental or orthodontic services, when related to and
medically necessary to provide or complete reconstructive surgery,
are services that are already required by the statutory provisions
amended by this act.
  SEC. 4.  No reimbursement is required by this act pursuant to
Section 6 of Article XIII B 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 XIII B of the California
Constitution.