BILL NUMBER: SB 173 INTRODUCED
BILL TEXT
INTRODUCED BY Senator Simitian
FEBRUARY 7, 2011
An act to amend Section 1367.65 of the Health and Safety Code, and
to amend Section 10123.81 of the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 173, as introduced, Simitian. Health care coverage: mammograms.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975
(Knox-Keene Act), provides for the licensure and regulation of health
care service plans by the Department of Managed Health Care, and
makes a willful violation of its provisions a crime. Existing law
provides for the licensure and regulation of health insurers by the
Department of Insurance. Existing law requires health care service
plan contracts, except specialized health care service plan
contracts, and certain health insurance policies to provide a certain
level of coverage for mammograms and breast cancer screening and
diagnosis, as specified.
This bill would require those health care service plan contracts
and health insurance policies to include additional benefits for
comprehensive ultrasound screening under specified circumstances. The
bill would require a patient receiving treatment under those
coverage provisions to also receive information on breast density, as
specified.
Because a willful violation of the bill's provisions under the
Knox-Keene Act 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 1367.65 of the Health and Safety Code is
amended to read:
1367.65. (a) (1) On or after January 1,
2000, every health care service plan contract, except a specialized
health care service plan contract, that is issued, amended,
delivered, or renewed shall be deemed to provide coverage for
mammography for screening or diagnostic purposes upon referral by a
participating nurse practitioner, participating certified nurse
midwife, or participating physician and surgeon ,
providing care to the patient and operating within the scope of
practice provided under existing law.
(2) In addition to the coverage required under paragraph (1), on
or after January 1, 2012, every health care service plan contract
that is issued, amended, delivered, or renewed shall also provide
additional benefits for comprehensive ultrasound screening of an
entire breast or breasts if a mammogram demonstrates heterogeneous or
dense breast tissue based on the Breast Imaging Reporting and Data
System established by the American College of Radiology or if a
patient is believed to be at increased risk for breast cancer due to
family history or prior history of breast cancer, positive genetic
testing, or other indications as determined by his or her nurse
practitioner, nurse midwife, or physician and surgeon.
(3) On and after January 1, 2012, every mammography report
provided to a patient pursuant to the coverage specified under
paragraph (1) or (2) shall include information about breast density,
based on the Breast Imaging Reporting and Data System established by
the American College of Radiology. When applicable, the report shall
also include the following notice:
"If your mammogram demonstrates that you have dense breast tissue,
which could hide small abnormalities, you might benefit from
supplementary screening tests, which can include a breast ultrasound
screening or a breast MRI examination, or both, depending on your
individual risk factors. A report of your mammography results, which
contains information about your breast density, has been sent to your
physician's office and you should contact your physician if you have
any questions or concerns about this report."
(b) Nothing in this section shall be construed to prevent
application of copayment or deductible provisions in a plan, nor
shall this section be construed to require that a plan be extended to
cover any other procedures under an individual or a group health
care service plan contract. Nothing in this section shall be
construed to authorize a plan enrollee to receive the services
required to be covered by this section if those services are
furnished by a nonparticipating provider, unless the plan enrollee is
referred to that provider by a participating physician and
surgeon , nurse practitioner, or certified nurse midwife
providing care.
SEC. 2. Section 10123.81 of the Insurance Code is amended to read:
10123.81. (a) On or after January 1, 2000,
every individual or group policy of disability insurance or
self-insured employee welfare benefit plan that is issued, amended,
or renewed, shall be deemed to provide coverage for at least the
following, upon the referral of a nurse practitioner, certified nurse
midwife, or physician and surgeon , providing care to the
patient and operating within the scope of practice provided under
existing law for breast cancer screening or diagnostic purposes:
(a)
(1) A baseline mammogram for women age 35 to
39, inclusive.
(b)
(2) A mammogram for women age 40 to 49,
inclusive, every two years or more frequently based on the women's
physician's recommendation.
(c)
(3) A mammogram every year for women age 50
and over.
(b) In addition to the coverage required under subdivision (a), on
or after January 1, 2012, every health insurance policy that is
issued, amended, delivered, or renewed shall also provide additional
benefits for comprehensive ultrasound screening of an entire breast
or breasts if a mammogram demonstrates heterogeneous or dense breast
tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology or if a patient is
believed to be at increased risk for breast cancer due to family
history or prior history of breast cancer, positive genetic testing,
or other indications as determined by his or her nurse practitioner,
nurse midwife, or physician and surgeon.
(c) On and after January 1, 2012, every mammography report
provided to a patient pursuant to the coverage specified under
subdivision (a) or (b) shall include information about breast
density, based on the Breast Imaging Reporting and Data System
established by the American College of Radiology. When applicable,
the report shall also include the following notice:
"If your mammogram demonstrates that you have dense breast tissue,
which could hide small abnormalities, you might benefit from
supplementary screening tests, which can include a breast ultrasound
screening or a breast MRI examination, or both, depending on your
individual risk factors. A report of your mammography results, which
contains information about your breast density, has been sent to your
physician's office and you should contact your physician if you have
any questions or concerns about this report."
Nothing
(d) Nothing in this section shall
be construed to require an individual or group policy to cover the
surgical procedure known as mastectomy or to prevent application of
deductible or copayment provisions contained in the policy or plan,
nor shall this section be construed to require that coverage under an
individual or group policy be extended to any other procedures.
Nothing
(e) Nothing in this section shall
be construed to authorize an insured or plan member to receive the
coverage required by this section if that coverage is furnished by a
nonparticipating provider, unless the insured or plan member is
referred to that provider by a participating physician and
surgeon , nurse practitioner, or certified nurse midwife
providing care.
SEC. 3. 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.