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SB-172 Health care coverage: fertility preservation.(2017-2018)

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Date Published: 05/01/2017 03:27 PM
SB172:v97#DOCUMENT

Amended  IN  Senate  May 01, 2017
Amended  IN  Senate  March 07, 2017

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Senate Bill No. 172


Introduced by Senator Portantino

January 23, 2017


An act to add Section 1374.551 to the amend Section 1345 of the Health and Safety Code, and to add Section 10119.61 to the Insurance Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


SB 172, as amended, Portantino. Health care coverage: fertility preservation.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract to provide subscribers and enrollees all of the basic health care services, and defines “basic health care services” to include, among other things, physician services, hospital inpatient services and ambulatory care services, and preventive health services. Existing law requires an individual or small group health care service plan contract and health insurance policy issued, amended, or renewed on or after January 1, 2017, to include, at a minimum, coverage for essential health benefits, and defines “essential health benefits” to include, among other things, medically necessary basic health care services, as defined. Existing law requires every group health care service plan contract and health insurance policy that covers hospital, medical, or surgical expenses to offer coverage for the treatment of infertility, as defined, except in vitro fertilization.
This bill would expand the definition of basic health care services to include standard fertility preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility. The bill would require an individual or group health care service plan contract or health insurance policy issued, amended, or renewed on and after January 1, 2018, that covers hospital, medical, surgical, and other iatrogenic expenses for diagnoses with medical interventions that may directly or indirectly cause iatrogenic infertility, or surgical expenses to include coverage for evaluation and treatment of iatrogenic infertility, as specified. standard fertility preservation services when a medically necessary medical treatment may directly or indirectly cause iatrogenic infertility. The bill would specify that it does not apply to a specialized health care service plan or a specialized health insurance policy. The bill would define terms for these purposes.
Because a willful violation of these provisions by a health care service plan would be a crime, this bill would impose 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   Local Program: YES  

The people of the State of California do enact as follows:


SECTION 1.Section 1374.551 is added to the Health and Safety Code, to read:
1374.551.

(a)An individual or group health care service plan contract issued, amended, or renewed on and after January 1, 2018, that covers hospital, medical, surgical, and other iatrogenic expenses for diagnoses with medical interventions that may directly or indirectly cause iatrogenic infertility shall include coverage for evaluation and treatment of iatrogenic infertility including, but not limited to, standard fertility preservation services.

(b)For purposes of this section, the following terms have the following meanings:

(1)“Iatrogenic” means relating to illness caused by medical examination or treatment.

(2)“Iatrogenic infertility” means infertility caused by a medical intervention, including, but not limited to, reactions from prescribed drugs or from medical and surgical procedures.

(3)“Infertility” means the result of a disease, an interruption, cessation, or disorder of body functions, systems, or organs, of the male or female reproductive tract that prevents the conception of a child or the ability to carry a pregnancy to delivery.

(4)“May directly or indirectly cause” means treatment with a likely side effect of infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other reputable professional organization.

(5)“Standard fertility preservation services” means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other reputable professional medical organization.

(c)This section does not apply to a specialized health care service plan.

SECTION 1.

 Section 1345 of the Health and Safety Code is amended to read:

1345.
 As used in this chapter:
(a)  “Advertisement” means any written or printed communication or any communication by means of recorded telephone messages or by radio, television, or similar communications media, published in connection with the offer or sale of plan contracts.
(b)  “Basic health care services” means all of the following:
(1)  Physician services, including consultation and referral.
(2)  Hospital inpatient services and ambulatory care services.
(3)  Diagnostic laboratory and diagnostic and therapeutic radiologic services.
(4)  Home health services.
(5)  Preventive health services.
(6)  Emergency health care services, including ambulance and ambulance transport services and out-of-area coverage. “Basic health care services” includes ambulance and ambulance transport services provided through the “911” emergency response system.
(7)  Hospice care pursuant to Section 1368.2.
(8) Standard fertility preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility. For purposes of this subdivision, the following definitions apply:
(A) “Iatrogenic” means relating to illness caused by medical examination or treatment.
(B) “Iatrogenic infertility” means infertility caused by a medical intervention, including, but not limited to, reactions from prescribed drugs or from medical and surgical procedures.
(C) “Infertility” means the result of a disease, an interruption, cessation, or disorder of body functions, systems, or organs, of the male or female reproductive tract that prevents the conception of a child or the ability to carry a pregnancy to delivery.
(D) “May directly or indirectly cause” means treatment with a likely side effect of infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other reputable professional organization.
(E) “Standard fertility preservation services” means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other reputable professional medical organization.
(c)  “Enrollee” means a person who is enrolled in a plan and who is a recipient of services from the plan.
(d)  “Evidence of coverage” means any certificate, agreement, contract, brochure, or letter of entitlement issued to a subscriber or enrollee setting forth the coverage to which the subscriber or enrollee is entitled.
(e)  “Group contract” means a contract which by its terms limits the eligibility of subscribers and enrollees to a specified group.
(f)  “Health care service plan” or “specialized health care service plan” means either of the following:
(1)  Any person who undertakes to arrange for the provision of health care services to subscribers or enrollees, or to pay for or to reimburse any part of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the subscribers or enrollees.
(2)  Any person, whether located within or outside of this state, who solicits or contracts with a subscriber or enrollee in this state to pay for or reimburse any part of the cost of, or who undertakes to arrange or arranges for, the provision of health care services that are to be provided wholly or in part in a foreign country in return for a prepaid or periodic charge paid by or on behalf of the subscriber or enrollee.
(g)  “License” means, and “licensed” refers to, a license as a plan pursuant to Section 1353.
(h)  “Out-of-area coverage,” for purposes of paragraph (6) of subdivision (b), means coverage while an enrollee is anywhere outside the service area of the plan, and shall also include coverage for urgently needed services to prevent serious deterioration of an enrollee’s health resulting from unforeseen illness or injury for which treatment cannot be delayed until the enrollee returns to the plan’s service area.
(i)  “Provider” means any professional person, organization, health facility, or other person or institution licensed by the state to deliver or furnish health care services.
(j)  “Person” means any person, individual, firm, association, organization, partnership, business trust, foundation, labor organization, corporation, limited liability company, public agency, or political subdivision of the state.
(k)  “Service area” means a geographical area designated by the plan within which a plan shall provide health care services.

( l)

(l) “Solicitation” means any presentation or advertising conducted by, or on behalf of, a plan, where information regarding the plan, or services offered and charges therefor, is disseminated for the purpose of inducing persons to subscribe to, or enroll in, the plan.
(m)  “Solicitor” means any person who engages in the acts defined in subdivision ( l). (l).
(n)  “Solicitor firm” means any person, other than a plan, who through one or more solicitors engages in the acts defined in subdivision ( l). (l).
(o)  “Specialized health care service plan contract” means a contract for health care services in a single specialized area of health care, including dental care, for subscribers or enrollees, or which pays for or which reimburses any part of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the subscribers or enrollees.
(p)  “Subscriber” means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.
(q)  Unless the context indicates otherwise, “plan” refers to health care service plans and specialized health care service plans.
(r)  “Plan contract” means a contract between a plan and its subscribers or enrollees or a person contracting on their behalf pursuant to which health care services, including basic health care services, are furnished; and unless the context otherwise indicates it includes specialized health care service plan contracts; and unless the context otherwise indicates it includes group contracts.
(s)  All references in this chapter to financial statements, assets, liabilities, and other accounting items mean those financial statements and accounting items prepared or determined in accordance with generally accepted accounting principles, and fairly presenting the matters which they purport to present, subject to any specific requirement imposed by this chapter or by the director.

SEC. 2.

 Section 10119.61 is added to the Insurance Code, to read:

10119.61.
 (a) An individual or group health insurance policy issued, amended, or renewed on and after January 1, 2018, that covers hospital, medical, surgical, and other iatrogenic expenses for diagnoses with medical interventions that may directly or indirectly cause iatrogenic infertility shall include coverage for evaluation and treatment of iatrogenic infertility including, but not limited to, standard fertility preservation services. or surgical expenses shall include coverage for standard fertility preservation services when a medically necessary medical treatment may directly or indirectly cause iatrogenic infertility.
(b) For purposes of this section, the following terms have the following meanings:
(1) “Iatrogenic” means relating to illness caused by medical examination or treatment.
(2) “Iatrogenic infertility” means infertility caused by a medical intervention, including, but not limited to, reactions from prescribed drugs or from medical and surgical procedures.
(3) “Infertility” means the result of a disease, an interruption, cessation, or disorder of body functions, systems, or organs, of the male or female reproductive tract that prevents the conception of a child or the ability to carry a pregnancy to delivery.
(4) “May directly or indirectly cause” means treatment with a likely side effect of infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other reputable professional organization.
(5) “Standard fertility preservation services” means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other reputable professional medical organization.
(c) This section does not apply to a specialized health insurance policy.

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.