BILL ANALYSIS
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|SENATE RULES COMMITTEE | SB 630|
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UNFINISHED BUSINESS
Bill No: SB 630
Author: Steinberg (D), et al
Amended: 9/4/09
Vote: 21
SENATE HEALTH COMMITTEE : 10-0, 4/15/09
AYES: Alquist, Strickland, Aanestad, Cedillo, Cox,
DeSaulnier, Leno, Negrete McLeod, Pavley, Wolk
NO VOTE RECORDED: Maldonado
SENATE APPROPRIATIONS COMMITTEE : 12-0, 5/28/09
AYES: Kehoe, Cox, Corbett, Denham, DeSaulnier, Hancock,
Leno, Oropeza, Runner, Walters, Wyland, Yee
NO VOTE RECORDED: Wolk
SENATE FLOOR : 34-0, 6/3/09
AYES: Aanestad, Alquist, Ashburn, Cedillo, Cogdill,
Corbett, Correa, Cox, Denham, DeSaulnier, Ducheny,
Dutton, Florez, Hancock, Harman, Hollingsworth, Huff,
Kehoe, Leno, Liu, Lowenthal, Maldonado, Negrete McLeod,
Oropeza, Romero, Simitian, Steinberg, Strickland,
Walters, Wiggins, Wolk, Wright, Wyland, Yee
NO VOTE RECORDED: Benoit, Calderon, Padilla, Pavley,
Runner, Vacancy
ASSEMBLY FLOOR : 58-10, 9/9/09 - See last page for vote
SUBJECT : Health care coverage: reconstructive surgery:
dental and
orthodontic services
CONTINUED
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SOURCE : California Society of Plastic Surgeons
DIGEST : This bill defines reconstructive surgery, as of
July 1, 2010, to include medically necessary dental or
orthodontic services that are an integral part of
reconstructive surgery for cleft palate procedures, except
as specified. Because a willful violation of this
provision by a health care service plan would be a crime,
this bill imposes a state-mandated local program.
Assembly Amendments (1) make clarifying changes in
definitions, (2) add an operative date of July 1, 2010, and
(3) delete legislative intent language.
ANALYSIS :
Existing law:
1. Provides for the regulation of health care service plans
(health plans) by the Department of Managed Health Care
and for the regulation of health insurers by the
Department of Insurance. Health plans and insurers are
required by law to cover various health care services,
including basic health care services, such as physician
services, hospital inpatient and ambulatory care
services, diagnostic laboratory services, preventive
health services, emergency health care services, and
hospice care.
2. Allows health plans and insurers, through "utilization
review," to deny, modify, or delay coverage for a
particular benefit or service, due to a finding that the
benefit or service is not medically necessary.
3. Establishes an independent medical review process for
third-party review of a health plan's or insurer's
decision to deny a benefit or service due to such
findings.
4. Requires health plans and insurers to provide coverage
for reconstructive surgery, including surgeries to
correct or repair congenital defects and developmental
abnormalities, such as cleft lip, cleft palate, and
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other craniofacial abnormalities.
5. Allows health plans and health insurers to apply
specific prior authorization and utilization review
procedures to requests for such surgeries.
6. Defines reconstructive surgery as 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: (a) improve function or (b) create a
normal appearance, to the extent possible.
7. Requires that health plans and health insurers offer
coverage for certain benefits and services, such as
orthotic and prosthetic devices, alcoholism treatment,
and acupuncture services; meaning that they must provide
subscribers the option to purchase the benefit.
This bill clarifies that the existing requirement for
health plans and health insurers to cover reconstructive
surgery includes, as of July 1, 2010, medically necessary
dental or orthodontic services that are an integral part of
reconstructive surgery for cleft palates. Specifically,
this bill:
1. Clarifies that the requirement in existing law for
health plans and health insurers to provide coverage for
reconstructive surgery applies, as of July 1, 2010, to
medically necessary dental or orthodontic services that
are an integral part of reconstructive surgery for cleft
palates performed to improve function or to create a
normal appearance, to the extent possible.
2. Defines "cleft palate" for purposes of this bill as a
condition that may include cleft palate, cleft lip, or
other craniofacial anomalies associated with cleft
palate.
3. Exempts from the provisions of this bill certain
contracts entered into between the Department of Health
Care Services and a health plan for enrolled Medi-Cal
beneficiaries that do not cover services provided by the
California Children's Services program, as specified.
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Background
Cleft palate is the common term for a birth defect which
can include cleft palate, cleft lip, or other craniofacial
anomalies. A cleft palate is an opening in the roof of the
mouth in which the two sides of the palate did not fuse, or
join together, as an unborn baby was developing. A cleft
lip is a separation of the two sides of the lip. The
separation often includes the bones of the upper jaw and/or
upper gum. Because the lip and the palate develop
separately, it is possible for the child to have a cleft
lip, a cleft palate, or both cleft lip and cleft palate, or
other craniofacial anomalies, caused by the condition,
which can vary.
According to the California Birth Defects Monitoring
Program, this condition is one of the most common birth
defects in California, with nearly 700 cases reported in
the state each year. Of these, approximately 300 cases,
per year, are children who have health insurance coverage
arrangements that would be subject to this bill.
A child born with a cleft palate frequently requires
several different types of services, such as surgery,
dental and orthodontic care, and speech therapy, all of
which need to be provided in a coordinated manner over a
period of years. This coordinated care is provided by
interdisciplinary cleft palate and/or craniofacial teams
comprised of professionals from a variety of health care
disciplines. A child born with a cleft palate can also
have associated problems with body functions which include
breathing, skeletal growth and development, hearing, speech
and language ability, and learning difficulties. Social
integration problems, due to having a severe chronic
condition, in general, and the effects of disfigurement,
also exist, especially among school age children.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: Yes
According to the Senate Appropriations Committee:
Fiscal Impact (in thousands)
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Major Provisions 2009-10 2010-11 2011-12 Fund
Public Employees' unknown, but potentially more
thanGeneral/
Retirement System (PERS) $50 General Funds
andSpecial*
state employers' cost $150 Special Funds annually
* Each state agency pays its employees premiums to PERS
out of its budget. Approximately 55 percent of employee
premiums are from the General Fund and 45 percent are
from other state funds. These other funds are made up of
approximately 67 percent special funds and 33 percent
moneys from other sources such as federal funds.
SUPPORT : (Verified 9/11/09)
California Society of Plastic Surgeons (source)
American Federation of State, County and Municipal
Employees
California Dental Association
California Medical Association
OPPOSITION : (Verified 9/11/09)
Association of California Life and Health Insurance
Companies
Blue Shield of California
California Association of Health Plans
California Chamber of Commerce
National Federation of Independent Business
ARGUMENTS IN SUPPORT : The bill's sponsor, the California
Society of Plastic Surgeons (CSPS), states that children
born with cleft palate or craniofacial anomalies have teeth
that are missing, malpositioned, or abnormally shaped.
Additionally, the jaw may be in more than one piece because
of bony clefts, and the scars created to repair the cleft
may impair the growth of jawbone and teeth. Uncorrected,
these dental abnormalities can result in additional
problems. CSPS argues that dental care in such cases is
obviously needed for medical reasons, and that under
current law some health plans and insurers do not feel
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obligated to provide this dental care.
ARGUMENTS IN OPPOSITION : The National Federation of
Independent Business (NFIB) states that this bill expands
the existing reconstructive surgery mandate to include
dental and orthodontic services. NFIB further states that
the cumulative impact of a number of mandated benefit bills
in the legislative process right now, in addition to the
benefit mandates already on the books, will significantly
increase premiums on employers and employees. NFIB
contends that, for small businesses, more than half of whom
cannot afford coverage for their employees, mandated bills
put coverage even further out of reach.
ASSEMBLY FLOOR :
AYES: Adams, Ammiano, Arambula, Beall, Tom Berryhill,
Blakeslee, Block, Blumenfield, Brownley, Buchanan,
Caballero, Charles Calderon, Carter, Chesbro, Coto,
Davis, De La Torre, De Leon, Eng, Evans, Feuer, Fong,
Fuentes, Furutani, Galgiani, Gilmore, Hagman, Hall,
Hayashi, Hernandez, Hill, Huber, Huffman, Jeffries,
Jones, Krekorian, Lieu, Bonnie Lowenthal, Ma, Monning,
Nava, John A. Perez, V. Manuel Perez, Portantino, Ruskin,
Salas, Saldana, Silva, Skinner, Smyth, Solorio, Swanson,
Torlakson, Torres, Torrico, Tran, Yamada, Bass
NOES: Anderson, Conway, DeVore, Fletcher, Gaines, Logue,
Nestande, Niello, Nielsen, Villines
NO VOTE RECORDED: Bill Berryhill, Cook, Duvall, Emmerson,
Fuller, Garrick, Harkey, Knight, Mendoza, Miller, Audra
Strickland, Vacancy
CTW/RJG:mw 9/11/09 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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