BILL ANALYSIS �
AB 137
Page 1
ASSEMBLY THIRD READING
AB 137 (Portantino)
As Introduced January 23, 2012
Majority vote
HEALTH 18-0 APPROPRIATIONS 17-0
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|Ayes:|Monning, Logue, Ammiano, |Ayes:|Fuentes, Harkey, |
| |Atkins, Bonilla, Eng, | |Blumenfield, Bradford, |
| |Garrick, Gordon, Hayashi, | |Charles Calderon, Campos, |
| |Bonnie Lowenthal, | |Chesbro, Donnelly, Gatto, |
| |Mansoor, Mitchell, | |Hall, Hill, Ammiano, |
| |Nestande, Pan, | |Mitchell, Nielsen, Norby, |
| |V. Manuel P�rez, Silva, | |Solorio, Wagner |
| |Smyth, Williams | | |
| | | | |
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SUMMARY : Requires health care service plan (health plan)
contracts and health insurance policies that are issued,
amended, delivered, or renewed, on or after July 1, 2013, to
provide coverage for mammography for screening or diagnostic
purposes upon referral by a health care professional, based on
medical need, regardless of age. Specifically, this bill :
1)Requires health plan contracts and health insurance policies
that are issued, amended, delivered, or renewed to provide
coverage for mammography for screening or diagnostic purposes
upon referral of certain health care professionals, regardless
of age.
2)Exempts specialized health insurance, Medicare supplement
insurance, short-term limited duration health insurance,
CHAMPUS supplement insurance, TRI-CARE supplement insurance,
or to hospital indemnity, accident-only, or specified disease
insurance.
3)Authorizes practicing physician assistants providing care to
the patient and operating within the scope of practice
provided under existing law to refer patients to mammography
services.
4)Requires health plans and health insurers, on or after July 1,
2013, to provide subscribers and policyholders with
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information regarding recommended timelines for breast cancer
screening or diagnosis through written letter, publication in
a newsletter, publication in evidence of coverage, direct
telephone call, electronic transmission, Web-based portal
containing various plan and benefit information (if the
enrollee or insured has access to that portal), or by any
other means that will reasonably notify the enrollee or
insured of recommended timelines for testing.
EXISTING FEDERAL LAW :
1)Enacts, in federal law, the Patient Protection and Affordable
Care Act (ACA) to, among other things, make statutory changes
affecting the regulation of, and payment for, certain types of
private health insurance. Includes the definition of
essential health benefits (EHBs) that all qualified health
plans must cover, at a minimum, with some exceptions.
2)Provides that the essential health benefits EHBs package in 1)
above will be determined by the federal Department of Health
and Human Services Secretary and must include, at a minimum:
ambulatory patient services; emergency services;
hospitalizations; mental health and substance abuse disorder
services, including behavioral health; prescription drugs;
and, rehabilitative and habilitative services and devices,
among other things.
EXISTING STATE LAW :
1)Establishes the Knox-Keene Health Care Service Plan Act of
1975 to regulate and license health plans and specialized
health plans by the Department of Managed Health Care and
provides for the regulation of 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.
1)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
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screening or diagnostic purposes.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, the California Health Benefits Review Program
indicates that all plans in California affected by this bill are
already compliant with coverage and notification requirements.
Thus, this bill will result in no impact on coverage for
mammograms and has no associated cost. The Assembly
Appropriations Committee further states that federal regulations
implementing the federal health reform law, the ACA, may impact
the costs of this bill in future years. However, as mammography
is widely covered and considered a standard preventative
service, it is unlikely that there would be additional future
state costs associated with this bill.
COMMENTS : According to the author, this bill is needed to
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 by statute based on her age.
On December 16, 2011, the federal Center for Consumer
Information and Insurance Oversight (CCIIO) issued a bulletin
proposing that EHBs be defined using a benchmark approach.
Under the CCIIO intended approach, states would have the
flexibility to select a benchmark plan that reflects the scope
of services offered by a "typical employer plan." This approach
would give states the flexibility to select a plan that would
best meet the needs of their residents. In accordance with the
guidance, the benchmark options include:
1)One of the three largest small group plans in the state by
enrollment.
2)One of the three largest state employee health plans by
enrollment.
3)One of the three largest federal employee health plan options
by enrollment.
4)The largest HMO plan offered in the state's commercial market
by enrollment.
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The benefits and services included in the benchmark plan
selected by the state would be the EHB package.
To meet the EHB coverage standard, a health plan or health
insurer would offer benefits that are "substantially equal" to
the benchmark plan selected by the state and modified as
necessary to reflect the 10 coverage categories. The bulletin
indicates that states must select their benchmark plan in the
third quarter two years prior to the coverage year (by September
2012). The ACA requires states to defray the cost of any
benefits required by state law to be covered by health plans and
health insurers beyond the EHBs. The federal bulletin implies
that existing state mandates could be incorporated in EHBs to
the extent they are included in a benchmark plan existing in
2012. However, the federal rules are not final or entirely
clear on this point. Comments on the federal bulletin are due
by January 31, 2012. Further evaluation of individual state
mandates pending this year will need to be considered in the
context of a broader discussion about California's benchmark
plan.
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097
FN: 0003071