BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 137
AUTHOR: Portantino
AMENDED: January 23, 2012
HEARING DATE: June 27, 2012
CONSULTANT: Trueworthy
SUBJECT : Health care coverage: mammographies.
SUMMARY : Requires health care service plan (health plan)
contracts and individual or group policies of health insurance
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 certain health care
professionals, regardless of age, and requires plans and
insurers to provide subscribers or policyholders with
information regarding recommended timelines for an individual to
undergo tests for the screening or diagnosis of breast cancer.
Existing law:
1.Provides for the regulation of health plans by the Department
of Managed Health Care (DMHC) under the Knox-Keene Health Care
Service Plan Act of 1975 (Knox-Keene Act) and health insurers
by California Department of Insurance (CDI) under the
Insurance Code.
2.Establishes the Patient Protection Affordability Care Act
(ACA), which imposes various requirements, some of which take
effect on January 1, 2014, on states, health plans and health
insurers (referred to collectively as "carriers"), employers,
and individuals regarding health care coverage.
3.Requires, under the ACA, carriers that offer coverage in the
small group or individual market to ensure that coverage
includes the Essential Health Benefits (EHB) package.
4.Provides that the EHB package will be determined by the
federal Department of Health and Human Services (HHS)
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.
Continued---
AB 137 | Page 2
5.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.
6.Requires health insurance policies to provide coverage for a
baseline mammogram for women ages 35 to 39, inclusive; a
mammogram for women ages 40 to 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.
This bill:
1. Requires carrier contracts and policies that are issued,
amended, delivered, or renewed to provide coverage for
mammography for screening or diagnostic purposes, upon
referral by a participating nurse practitioner,
participating certified nurse-midwife, participating
physician assistant, or participating physician.
2. Requires, after July 1, 2013, every individual or group
policy of health insurance regulated under CDI , that is
issued, amended, delivered, or renewed to provide coverage
for mammography for screening or diagnostic purposes, upon
referral by a participating nurse practitioner,
participating certified nurse-midwife, participating
physician assistant, or participating physician, regardless
of the policyholder's age. Deletes age guidelines currently
in statute.
3. Exempts specialized health insurance, Medicare
supplement insurance, short-term limited-duration health
insurance, CHAMPUS supplement insurance, TRI-CARE
supplement insurance, or hospital indemnity, accident-only,
or specified disease insurance from these requirements.
4. Authorizes participating nurse practitioners,
participating certified nurse-midwives, and participating
physician assistants providing care to the patient and
operating within the scope of practice provided under
existing law to refer patients to mammography services.
5. Requires carriers, after July 1, 2013 to provide
subscribers and policyholders with information regarding
recommended timelines for breast cancer screening or
diagnosis through written letter, publication in a
newsletter, publication in evidence of coverage, direct
AB 137 | Page
3
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.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, the California Health Benefits Review Program (CHBRP)
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 states that federal regulations
implementing 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.
PRIOR VOTES :
Assembly Health: 18- 0
Assembly Appropriations:17- 0
Assembly Floor: 71- 0
COMMENTS :
1.Author's statement. AB 137 will require carriers to cover
mammograms for screening purposes of breast cancer when it is
ordered by a physician or other designated health
professional. Existing California law mandates that health
insurance companies regulated under CDI must provide coverage
for mammograms to screen for breast cancer according to a
woman's age as specified in statute. Existing law establishes
in statute a national guideline that is now over twenty years
old. As science and medical practice changes, the guidelines
on when women should be screened for breast cancer will
change. Statutory law should not list the guidelines.
AB 137 will require health plans, under DMHC and CDI, to
provide information to women when they should begin to be
screened for breast cancer. Many women do not know when they
should begin being screened for breast cancer. This measure
will inform these women that they should be screened. This
will save lives and save treatment dollars by catching breast
cancer in an earlier stage.
The author states that mammography screening for breast cancer
AB 137 | Page 4
is already a covered benefit. In an easy, almost cost free
manner, AB 137 merely requires insurance companies to provide
information to enrollees on when to begin being screened for
breast cancer.
2.Prevalence of breast cancer. According to the American Cancer
Society's "Breast Cancer Facts & Figures 2009-2010," excluding
cancers of the skin, breast cancer is the most common cancer
among women; accounting for more than one in four cancers
diagnosed in U.S. women. It is the second leading cause of
death of women in California. According to the California
Breast Cancer Research Program, the breast cancer death rate
in California has dropped 20 percent since 1973, but
California women are more likely to get breast cancer today
than in 1973. While the death rate for breast cancer has
dropped, the gains have not been shared equally among all
women. Minority and low-income women are less likely than
other women to be diagnosed at an early stage, receive
effective treatment, and survive the disease. CHBRP reports
that white women are most likely to get the disease, followed
closely by African American women, Asian Pacific Islander
women, and Hispanic women. African American women have the
highest death rate despite being less likely than white women
to get the disease.
3.National guidelines. Several organizations have adopted
evidence-based national recommendations for breast cancer
screening, including the U.S. Preventive Services Task Force
(USPSTF), convened by HHS, the American Cancer Society, 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 one to two years beginning at
age 40, or 50 for those women of average risk for breast
cancer. By and large, routine baseline mammograms in women
younger than 40 years are not recommended.
In November 2009, USPSTF issued new screening guidelines that
recommend against routine screening mammography in women ages
40 to 49. The guidelines instead recommend screening every
other year for women ages 50 to 74. The recommendations state
that the decision to start regular, biennial screening
mammography before the age of 50 years should be an individual
one and take patient context into account, including the
patient's values regarding specific benefits and harms.
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4.Federal health care reform. On March 23, 2010, President
Obama signed the ACA (Public Law 111-148), as amended by the
Health Care and Education Reconciliation Act of 2010 (Public
Law 111-152). Among other provisions, the new law makes
statutory changes affecting the regulation of and payment for
certain types of private health insurance. Beginning in 2014,
individuals will be required to maintain health insurance or
pay a penalty, with exceptions for financial hardship (if
health insurance premiums exceed eight percent of household
adjusted gross income), religion, incarceration, and
immigration status. Included in the ACA are several insurance
market reforms, such as prohibitions against health insurers
imposing lifetime benefit limits and preexisting health
condition exclusions. These reforms impose new requirements on
states related to the allocation of insurance risk, prohibit
insurers from basing eligibility for coverage on health
status-related factors, allow the offering of premium
discounts or rewards based on enrollee participation in
wellness programs, impose nondiscrimination requirements,
require insurers to offer coverage on a guaranteed issue and
renewal basis, and determine premiums based on adjusted
community rating (age, family, geography and tobacco use).
5.EHB package. Effective January 1, 2014, federal law requires
Medicaid benchmark and benchmark-equivalent plans, plans sold
through the Exchange and the Basic Health Program (if
enacted), and health plans and health insurers providing
coverage to individuals and small employers to ensure coverage
of EHB, as defined by the HHS Secretary. HHS is required to
ensure that the scope of EHB is equal to the scope of benefits
provided under a typical employer plan, as determined by the
Secretary.
Under federal law, EHB must include 10 general categories
and the items and services covered within the following
categories:
� Ambulatory patient services;
� Emergency services;
� Hospitalization;
� Maternity and newborn care;
� Mental health and substance use disorder services, including
behavioral health treatment;
� Prescription drugs;
� Rehabilitative and habilitative services and devices;
� Laboratory services;
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� Preventive and wellness services and chronic disease
management; and
� Pediatric services, including oral and vision care.
1.EHB Bulletin. On December 16, 2011, the HHS Center for
Consumer Information and Insurance Oversight released an EHB
Bulletin proposing that EHB be defined using a benchmark
approach. This gives states the flexibility to select a
benchmark plan that reflects the scope of services offered by
a "typical employer plan." If a state does not choose a
benchmark health plan, the default benchmark plan for the
state would be the largest plan by enrollment in the largest
product in the small group market.
EHB must include coverage of services and items in all 10
statutory categories listed above, but states would choose
one of the following benchmark health insurance plans:
� One of the three largest small group plans in the state
by enrollment-in California, these options are Anthem PPO
licensed by CDI, Kaiser HMO licensed by DMHC, or Anthem PPO
licensed by DMHC;
� One of the three largest state employee health plans by
enrollment-in California, these options are CalPERS Blue
Shield Basic HMO, CalPERS Choice, or CalPERS Kaiser HMO;
� One of the three largest federal employee health plan
options by enrollment, which are Government Employee Health
Association, Blue Cross and Blue Shield (BCBS) Basic, or
BCBS Standard; or
� The largest HMO plan offered in the state's commercial
market by enrollment, which is the Kaiser Large Group
Commercial HMO.
AB 1461 (Monning) and SB 951 (Hernandez) have selected the
Kaiser Small Group health plan to serve as California's EHB
benchmark plan. According to the Kaiser Small Group Evidence
of Coverage, preventive mammograms are a covered benefit at no
charge.
1.CHBRP report. Pursuant to AB 1996 (Thomson), Chapter 795,
Statutes of 2002, and SB 1704 (Kuehl), Chapter 684, Statutes
of 2006, which ask the University of California to assess
legislation proposing a mandated benefit or service, or the
repeal of a mandated benefit or service, CHBRP provides an
analysis of the relevant public health, medical, and economic
impacts. CHBRP's analysis report of this bill stated the
following:
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a. Medical effectiveness. A preponderance of evidence
shows that mammography screening is medically effective for
women ages 40 to 49 after 10 to 14 years of follow-up, but
the reduction in breast cancer mortality as a result of
screening is lower for women who are 50 and older, and
false-positive rates are higher for women under the age of
50. For women age 50 and older, evidence shows that the
mortality benefit is achieved after 7 to 9 years of
initiating screening. CHBRP concluded that false-positive
results are more likely in women under the age of 50 due to
overall lower disease prevalence and the problems of
analyzing mammography results because of the denser breast
tissue of younger women. CHBRP also found that there is a
preponderance of evidence that for women for whom national
guidelines recommend mammography screening, notification
through written notices or telephone calls increases the
percentage of eligible women screened.
b. Utilization, cost, and coverage impacts. Approximately
21.9 million individuals in California are enrolled in
health plans or policies that would be subject to this
mandate. CHBRP's coverage survey of carriers in California
indicated that an estimated 100 percent of health plans and
insurers cover mammography as a routine screening test when
referred by a provider. CHBRP reports that all carriers are
compliant with some form of notification. publicly funded
plans, such as the California Public Employees' Retirement
System, Medi-Cal Managed Care Plans, Healthy Families
Program, Access for Infants and Mothers, and Major Risk
Medical Insurance Program, have mammography coverage
compliant with this bill.
CHBRP estimated that the cost of a single mammogram is about
$190, which includes the follow-up costs, other noninvasive
procedures, and office visits due to false-positive
results. CHBRP reports that AB 137 is not expected to
affect the per-unit cost of mammography or of notification
regarding timelines for breast cancer screening because an
estimated 100 percent of enrollees have mammography
coverage and receive notification in compliance with this
bill. Considering the diversity of notification and the
confounding effects associated to them, CHBRP determined
that it is not possible to estimate its per-unit cost.
c. Public health impact. In California, 84.6 percent of
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women ages 40 to 64 years with health insurance had a
mammogram within the last 2 years. There is evidence that
mammography can reduce mortality from breast cancer;
however, CHBRP found that no public health impact is
projected due to the implementation of this bill. According
to CHBRP, 99.3 percent of breast cancer cases occur among
women. There are approximately 4, 200 deaths each year in
California due to breast cancer, a rate of 21.4 deaths per
100,000 women. According to CHBRP, it is estimated that
for each life lost prematurely to breast cancer, there is a
loss of 22.9 life-years and a cost of lost productivity of
$272,000. Although breast cancer is related to economic
loss, CHBRP found that this bill is not estimated to change
the utilization of mammography or result in a corresponding
reduction in economic loss.
Racial and ethnic disparities exist, not only in breast
cancer prevalence, but also in early diagnosis and
mortality rates as well. The research on mammography
utilization by race/ethnicity, according to CHBRP, suggests
that some of the differences in health outcomes among
non-white women can be explained by their lower rates of
mammography utilization.
2.Related legislation. SB 173 (Simitian) would require, under
specified circumstances, carriers contracts and policies to
include additional benefits for comprehensive breast cancer
screening. Would require a health care practitioner who
performs a mammography exam to include specified information
on breast density in the mammography report. SB 173 is pending
before the Assembly Health Committee.
3.Prior legislation. AB 113 (Portantino) of 2010 was identical
to this bill. Governor Schwarzenegger vetoed AB 113, stating
in his veto message that the bill was unnecessary and had no
practical impact on the current state of health coverage in
California.
AB 56 (Portantino) of 2009 contained provisions substantially
similar to those contained in this bill. Governor
Schwarzenegger vetoed AB 56, stating, in part, "California has
over 40 mandates on its health care service plans and health
insurance policies. While these mandates are well-intentioned,
the costs associated with the cumulative effect of these
mandates mean that these costs are passed through to the
purchaser and consumer."
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AB 2234 (Portantino) of 2008 would have required health plans
and health insurers to provide coverage for tests necessary
for screening or diagnoses of breast conditions, in accordance
with national guidelines, upon referral of a specified health
care provider and would have required carriers to notify
female enrollees or policyholders in writing of their
eligibility for testing. AB 2234 was held in the Assembly
Appropriations Committee.
4.Support. American Federation of State, County and Municipal
Employees writes in support that this bill will require
insurance companies to cover mammograms for screening purposes
for breast cancer. California Nurse Midwives Association
(CNMA) writes in support that certified nurse midwives are
often the initial contact for women in providing ongoing
health care and provide quality health care to women in a
variety of settings. CNMA contends AB 137 will help enhance
the quality of health care for many women in our state. The
American Congress of Obstetricians and Gynecologists (ACOG)
writes in support that this bill would correct an
inconsistency in the Insurance Code relative to mammography
coverage. ACOG maintains that it rectifies this discrepancy by
mirroring the language for mammography coverage in Knox-Keene.
Knox Keene regulations on HMOs provide for mammography, upon
referral by a physician subject to medical necessity standards
and practice guidelines.
5.Opposition. America's Health Insurance Plans (AHIP) opposes
insurance mandate bills, including AB 137. AHIP argues adding
additional mandates to California's existing mandates will
have a harmful effect on program costs to California's budget.
6.Policy comments.
a. What is the purpose of the bill? Health plans and
insurers are already providing coverage of mammogram, and
this benefit will become a part of the state's EHB package
beginning in 2014. The state's EHB package will not
contain the age guidelines currently in statute.
b. The bill also requires a patient be given information
regarding "recommended timelines" for an individual to
undergo screening for breast cancer. It is unclear who
would determine the recommended guidelines.
SUPPORT AND OPPOSITION :
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Support: American Congress of Obstetricians and Gynecologists
District IX California
American Federation of State, County and Municipal
Employees, AFL-CIO
Association of Northern California Oncologists
California Commission on the Status of Women
California Communities United Institute
California Medical Association
California Nurse Midwives Association
Disability Rights Legal Center
Medical Oncology Association of Southern California
Planned Parenthood Affiliates of California
Planned Parenthood Mar Monte
Susan G. Komen for the Cure - Central Valley Affiliate
Susan G. Komen for the Cure - Inland Empire Affiliate
Susan G. Komen for the Cure - Los Angeles County
Affiliate
Susan G. Komen for the Cure - Orange County Affiliate
Susan G. Komen for the Cure - Sacramento Valley
Affiliate
Susan G. Komen for the Cure - San Diego Affiliate
Susan G. Komen for the Cure - San Francisco Bay Area
Affiliate
Oppose: America's Health Insurance Plans
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