BILL ANALYSIS �
Senate Appropriations Committee Fiscal Summary
Senator Christine Kehoe, Chair
AB 1000 (Perea) - Health care coverage: cancer treatment.
Amended: August 6, 2012 Policy Vote: Health 6-2
Urgency: No Mandate: Yes
Hearing Date: August 6, 2012
Consultant: Brendan McCarthy
This bill does not meet the criteria for referral to the
Suspense File.
Bill Summary: AB 1000 would prohibit health plans and health
insurers that cover prescription drugs and chemotherapy
treatment from imposing higher copayments, deductibles, or
coinsurance for oral anticancer drugs than would be imposed for
intravenous anticancer drugs.
Fiscal Impact:
Minor costs to the Department of Managed Care and the
Department of Insurance to review plan filings.
No state costs to state health care programs. Medi-Cal,
Healthy Families, and Access for Infants and Mothers have no
or limited cost sharing for anticancer drugs. The bill
specifically exempts CalPERS contracted health plans and
insurance policies.
It is unlikely that the bill will require the state to
provide coverage subsidies through the California Health
Benefit Exchange due to any coverage mandate in the bill.
The bill would only apply to plans that already cover
anticancer drugs and specifies that no benefits that exceed
essential health benefits are required to be provided under
the bill. (See below.)
Background: Under current law, health plans are regulated by the
Department of Managed Care and health insurers are regulated by
the Department of Insurance. Current law and regulation place a
variety requirements and restrictions on health plans and health
insurers.
Under current law and practice, intravenous anticancer
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medications may be treated differently than oral anticancer
medication when it comes to cost-sharing by patients. Often,
intravenous anticancer medications are provided in a doctor's
office or hospital, and are covered as a medical benefit. On the
other hand, oral anticancer medications are often covered under
a pharmacy benefit. It is common for health plans and health
insurers to have limited copayment requirements or coinsurance
requirements for medical benefits; whereas larger copayment
requirements or significant coinsurance requirements may apply
to pharmacy benefits. Thus, a patient could pay significantly
more in out-of-pocket costs for oral anticancer drugs than
intravenous anticancer drugs.
Under the federal Patient Protection and Affordable Care Act
(Affordable Care Act), health plans and health insurers that
offer coverage in the individual market or the small group
market must provide coverage that is equivalent to the benefits
of a specified essential health benefits benchmark plan. Federal
guidance allows states to determine which plan will be the
benchmark plan.
Also under the Affordable Care Act, individuals with household
income less than 400 percent of the federal poverty level and
certain small businesses purchasing health plans through the
California Health Benefit Exchange will be eligible for
subsidies. The Affordable Care Act requires the state to pay for
the subsidies attributable to any state-mandated benefits that
are not provided under the benchmark plan.
Proposed Law: AB 1000 would prohibit health plans and health
insurers that cover prescription drugs and chemotherapy
treatment from imposing higher copayments, deductibles, or
coinsurance for oral anticancer drugs than would be imposed for
intravenous anticancer drugs.
Other provisions of the bill include:
The bill would prohibit a health plan or health insurer
from complying with the bill by increasing copayment,
deductible, or coinsurance for intravenous anticancer
medications.
The bill specifies that it would not limit a health plan or
health insurer from requiring prior authorization or
conducting utilization review.
The bill would not apply to CalPERS contracted health plans
AB 1000 (Perea)
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or health insurers.
The bill specifies that it would not require any additional
benefit to be provided beyond what is required the essential
health benefits that all plans will be required to provide
under the Affordable Care Act.
Related Legislation:
SB 961 (Wright, 2010) and SB 161 (Wright, 2009) were
substantially similar to this bill. Both of those measures
were vetoed by Governor Schwarzenegger.
AB 369 (Huffman) would prohibit health plans and health
insurers from requiring a patient to try and fail on two
pain medications before allowing the patient to access the
prescribed pain medication. That bill will be heard in this
committee.
AB 1800 (Ma) imposes maximum out-of-pocket cost limits on
health plans and health insurers. That bill will be heard in
this committee.
Staff Comments: The recently adopted author's amendments make
definitional changes to the bill.
Under the bill, the only costs that may be incurred by a local
agency relate to crimes or infractions. Under the California
Constitution, such costs are not reimbursable by the state.