BILL NUMBER: SB 173 AMENDED
BILL TEXT
AMENDED IN SENATE MARCH 30, 2011
INTRODUCED BY Senator Simitian
FEBRUARY 7, 2011
An act to add Section 687 to the Business and Professions
Code, 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 amended, 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 provides for the
regulation of health care practitioners, as defined. 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 breast cancer
screening under specified circumstances. The bill would require
a patient receiving treatment a health care
practitioner who performs a mammography examination under those
coverage provisions to also receive
include in the mammography report 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 687 is added to the
Business and Professions Code , to read:
687. (a) A health care practitioner who performs a mammography
examination pursuant to Section 1367.65 of the Health and Safety Code
or Section 10123.81 of the Insurance Code shall include in the
mammography report 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) "Health care practitioner" means a person licensed or
certified pursuant to this division or licensed pursuant to the
Osteopathic Initiative Act.
SECTION 1. SEC. 2. 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
, except a specialized 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. SEC. 3. 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:
(1) A baseline mammogram for women age 35 to 39, inclusive.
(2) A mammogram for women age 40 to 49, inclusive, every two years
or more frequently based on the women's physician's recommendation.
(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 ,
except a specialized 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."
(d)
(c) 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.
(e)
(d) 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. SEC. 4. 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.