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AB-632 Health care coverage: prostate cancer screening.(2023-2024)

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Date Published: 09/11/2023 09:00 PM
AB632:v97#DOCUMENT

Enrolled  September 11, 2023
Passed  IN  Senate  September 06, 2023
Passed  IN  Assembly  September 07, 2023
Amended  IN  Senate  June 15, 2023

CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill
No. 632

Introduced by Assembly Member Gipson

February 09, 2023

An act to amend Section 1367.64 of the Health and Safety Code, and to amend Section 10123.835 of the Insurance Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


AB 632, Gipson. Health care coverage: prostate cancer screening.
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 provides for the regulation of health insurers by the Department of Insurance. Existing law requires an individual and group health care service plan contract or health insurance policy to provide coverage for the screening and diagnosis of prostate cancer when medically necessary and consistent with good professional practice. Under existing law, the application of a deductible or copayment for those services is not prohibited.
This bill would instead require that coverage when medically necessary and consistent with nationally recognized, evidence-based clinical guidelines. The bill would prohibit a health care service plan or a health insurance policy issued, amended, renewed, or delivered on or after January 1, 2024, from applying a deductible, copayment, or coinsurance to coverage for prostate cancer screening services for an enrollee or insured who is at a high risk of prostate cancer, consistent with specified guidelines, and is either 55 years of age or older or 40 years of age or older and high risk, as determined by the attending or treating health care provider. Because a willful violation of these provisions by a health care service plan would be 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   Local Program: YES  

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


SECTION 1.

 Section 1367.64 of the Health and Safety Code is amended to read:

1367.64.
 (a)  Every individual or group health care service plan contract, except for a specialized health care service plan contract, that is issued, amended, or renewed on or after January 1, 1999, shall be deemed to provide coverage for the screening and diagnosis of prostate cancer, including prostate-specific antigen testing and digital rectal examinations, when medically necessary and consistent with nationally recognized, evidence-based clinical guidelines.
(b) This section does not establish a new mandated benefit or to prevent application of deductible or copayment provisions in a policy or plan, nor does this section require that a policy or plan be extended to cover any other procedures under a health care service plan contract. This section does not authorize an enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the enrollee is referred to that provider by a participating physician or nurse practitioner providing care.
(c) (1) Notwithstanding subdivision (b), a health care service plan contract, except a specialized health care service plan contract, that is issued, amended, or renewed on or after January 1, 2024, shall not apply a deductible, copayment, or coinsurance to coverage for screening services for prostate cancer described in subdivision (a) for an enrollee who is at a high risk of prostate cancer, consistent with nationally recognized, evidence-based clinical guidelines, and is either of the following:
(A) A person with a prostate who is 55 years of age or older.
(B) A person with a prostate who is 40 years of age or older and who is high risk, as determined by the attending or treating health care provider. For purposes of this subparagraph, “high risk” includes a person with a prostate who is Black, has a family history of prostate cancer, has a genetic predisposition to prostate cancer, or is a veteran.
(2) For high deductible plans, this subdivision is subject to federal guidance on the preventive care safe harbor for the absence of a preventive care deductible provided for under Section 223(c)(2)(C) of Title 26 of the United States Code.

SEC. 2.

 Section 10123.835 of the Insurance Code is amended to read:

10123.835.
 (a) A health insurance policy that is issued, amended, or renewed on or after January 1, 1999, shall be deemed to provide coverage for the screening and diagnosis of prostate cancer, including prostate-specific antigen testing and digital rectal examinations, when medically necessary and consistent with nationally recognized, evidence-based clinical guidelines.
(b) This section does not require a health insurance policy to cover the surgical and other procedures known as radical prostatectomy, external beam radiation therapy, radiation seed implants, and combined hormonal therapy, or to prevent application of deductible or copayment provisions contained in the policy, nor does this section require that coverage under a health insurance policy be extended to any other procedures.
(c) (1) Notwithstanding subdivision (b), a health insurance policy that is issued, amended, or renewed on or after January 1, 2024, shall not apply a deductible, copayment, or coinsurance to coverage for screening services for prostate cancer described in subdivision (a) for an insured who is at a high risk of prostate cancer, consistent with nationally recognized, evidence-based clinical guidelines, and is either of the following:
(A) A person with a prostate who is 55 years of age or older.
(B) A person with a prostate who is 40 years of age or older and who is high risk, as determined by the attending or treating health care provider. For purposes of this subparagraph, “high risk” includes a person with a prostate who is Black, has a family history of prostate cancer, has a genetic predisposition to prostate cancer, or is a veteran.
(2) For high deductible plans, this subdivision is subject to federal guidance on the preventive care safe harbor for the absence of a preventive care deductible provided for under Section 223(c)(2)(C) of Title 26 of the United States Code.
(d) This section does not apply to specialized health insurance, specified accident, specified disease, hospital indemnity, Medicare supplement, or long-term care health insurance policies.

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.