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 generally regulates contractual provisions between health care service plans and health insurers and their contracting health care providers.

This bill would require a contract between a health care service plan or health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, to authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with immediate postpartum contraception if the birth takes place in a general acute care hospital or licensed birth center. The bill would prohibit that provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure. Because a violation of the bills requirements 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.

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 generally regulates contractual provisions between health care service plans and health insurers and their contracting health care providers.

This bill would require a contract between a health care service plan or health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, to authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with immediate postpartum contraception if the birth takes place in a general acute care hospital or licensed birth center. The bill would prohibit that provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure. Because a violation of the bills requirements 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.

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 generally regulates contractual provisions between health care service plans and health insurers and their contracting health care providers.

This bill would require a contract between a health care service plan or health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, to authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with immediate postpartum contraception if the birth takes place in a general acute care hospital or accredited birthing licensed birth center. The bill would prohibit that provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure. Because a violation of the bills requirements 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.

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 generally regulates contractual provisions between health care service plans and health insurers and their contracting health care providers.

This bill would require a contract between a health care service plan or health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, to authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with immediate postpartum contraception if the birth takes place in a licensed hospital general acute care hospital or accredited birthing center. The bill would prohibit that provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure. Because a violation of the bills requirements 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.

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 generally regulates contractual provisions between health care service plans and health insurers and their contracting health care providers.

This bill would require a contract between a health care service plan or health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, to authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with immediate postpartum contraception if the birth takes place in a licensed hospital or birthing center. The bill would prohibit that provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure. Because a violation of the bills requirements 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.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 2129

Author:(Petrie-Norris)

As Amended Ver:July 3, 2024

Majority vote

SUMMARY

Authorizes a health care provider, in a contract between a health plan or insurer, to separately bill for devices, implants, or professional services, or a combination thereof, associated with immediate postpartum contraception (IPPC) if the birth takes place in a general acute care hospital or licensed birth center. Prohibits the provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure.

Senate Amendments

Identify a licensed birth center instead of accredited birthing center.

COMMENTS

1. Long Acting reversible Contraceptives (LARCs). LARCs are highly effective birth control devices inserted into the body. They include intrauterine devices (IUDs) and implants, which can stay in the body for several years and can be removed if an individual wants to become pregnant. Due to the good safety profile and high patient satisfaction, as well as very high efficacy, evidence-based clinical guidelines such as those issued by the American College of Obstetricians and Gynecologists (ACOG) advocate for improving access to and removing barriers to use of LARCs. ACOG recommends that women should be counseled about all forms of postpartum contraception in a context that allows informed decision-making and LARC should be offered as an effective option for postpartum contraception. Obstetric care providers should discuss LARC during the antepartum period and counsel all pregnant women about options for immediate postpartum initiation.
2. Immediate Postpartum LARC. According to an ACOG Policy Brief, LARCs can be offered immediately postpartum (the period following childbirth and prior to hospital discharge) as a safe, effective option for postpartum contraception. Postpartum contraception is usually offered and provided during the 6-week postpartum visit. However, approximately 10- 40% of women do not return for this visit and are at risk for subsequent unintended, short-interval pregnancy. For those who do return, nearly 60% may have resumed intercourse and could already be at risk for another pregnancy. Adolescents are at higher risk for a rapid repeat pregnancy, with estimates of 12-49% of postpartum adolescents experiencing a pregnancy within one year of delivery. Unintended and short-interval pregnancies can result in a higher risk of preterm birth and worsened neonatal outcomes. Immediate postpartum LARC has the potential to reduce unintended and short-interval pregnancy. However, more widespread adoption of immediate postpartum LARC has been hampered by systems barriers, such as the inability to obtain reimbursement for LARC devices and services provided immediately postpartum.
3. Reimbursement for LARC. According to information from the author, when insurance policies do not cover the hospital's cost of IPPC LARC placement, providers cannot offer this contraceptive option to their patients since LARC devices are among the most expensive methods of pregnancy prevention (with some priced as high as $1300). Without guaranteed reimbursement from insurers for providing LARCs immediately following childbirth, hospitals are disincentivized to offer the service. Most insurance plans use a standard method of payment called a Diagnosis Related Group (DRG) to reimburse hospitals for a patient's labor and delivery. Also called a "global" or "bundled" payment, the DRG is a single, predetermined, fixed amount that is all-inclusive of most labor and delivery care that's provided. Under many commercial insurance plans, IPPC LARC is assumed to be included in the DRG. But some services, including anesthesiology or tubal ligation performed after a cesarean delivery, are not included and thus can be billed separately from the DRG. This is known as "debundling" payment, and it allows providers and hospitals to bill and be reimbursed for the true cost of these expensive services. In 2016, Centers for Medicare and Medicaid Services (CMS) encouraged payers to consider reimbursing for immediate postpartum insertion LARCs by unbundling payment for LARC from other labor and delivery services and nearly 40 states have revised their Medicaid reimbursement policies for IPPC access.

According to the Author

Since 2016, CMS encouraged payers to consider "reimbursing for immediate postpartum insertion of LARC by unbundling payment for LARC from other labor and delivery services." Nearly 40 states have since revised their Medicaid reimbursement policies for IPPC access, allowing the reimbursement of immediate postpartum LARCs separate from the global fee for labor and delivery. Unfortunately, existing payment structures in California for commercial payers do not consistently carve out the payment from the global labor and delivery fee, leading to confusion among patients and providers. The author concludes that this bill will remove barriers for patient access to these devices through the standardization of benefits for LARC and allow providers to receive payment for IPPC when provided in a hospital or a birth center.

Arguments in Support

ACOG, the sponsor of this bill, states that studies show that healthy birth spacing helps reduce adverse health outcomes for both parents and babies. Most of the data from observational studies in the United States suggest a modest increase in risk of adverse outcomes associated with intervals of less than 18 months and more significant risk of adverse outcome with intervals of less than six months between birth and the start of the next pregnancy. Despite these risks, short intervals between pregnancies still occur, and at least 70% of pregnancies within one year after delivery were unintended. ACOG believes everyone who desires LARC should have timely access to contraceptive implants and IUDs. Obstetrician– gynecologists and other reproductive health care clinicians can best serve those who want to delay or avoid pregnancy by all medically appropriate contraceptive methods, but they can only do so if it is available. LARC devices should be easily accessible to all people who want them, including adolescents, those who have never given birth, and after spontaneous or induced abortion and childbirth. ACOG has long recommended and supported removing financial barriers to contraception by advocating for coverage and appropriate payment and reimbursement for all contraceptive methods by all payers for all eligible patients.

Arguments in Opposition

There is no known registered opposition.

FISCAL COMMENTS

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM HEALTH: 16-0-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Flora, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Sanchez, Santiago, Schiavo, Weber

ASM APPROPRIATIONS: 14-0-1

YES: Wicks, Sanchez, Arambula, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Grayson, Haney, Hart, Jim Patterson, Pellerin, Ta

ABS, ABST OR NV: Villapudua

ASSEMBLY FLOOR: 73-0-7

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Wicks, Wilson, Wood, Zbur

ABS, ABST OR NV: Calderon, Megan Dahle, Flora, Low, Mathis, Weber, Robert Rivas

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

SENATE FLOOR: 36-0-4

YES: Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Eggman, Glazer, Gonzalez, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ABS, ABST OR NV: Allen, Alvarado-Gil, Durazo, Grove

UPDATED

VERSION: July 3, 2024

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0003792

 THIRD READING  

Bill No: AB 2129

Author: Petrie-Norris (D), et al.

Amended: 7/3/24 in Senate

Vote: 21

PRIOR SENATE FLOOR VOTE NOT RELVEANT

SENATE HEALTH COMMITTEE: 11-0, 6/5/24

AYES: Roth, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 73-0, 5/2/24 (Consent) - See last page for vote

SUBJECT: Immediate postpartum contraception

SOURCE: California Lieutenant Governor Eleni Kounalakis

American College of Obstetricians and Gynecologists District IX

DIGEST:

This bill requires a contract between a health plan or health insurer and a health care provider to authorize a provider to separately bill for devices, implants, and professional services associated with immediate postpartum contraception, if the birth takes place in a general acute care hospital or licensed birth center.

Senate Floor Amendments of 7/3/24 replace “accredited birthing” with “licensed birth” center.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); California Department of Insurance (CDI) to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [HSC §1340, et seq., INS §106, et seq., and WIC §14000, et seq.]
   
2. Establishes, as California's essential health benefits (EHBs) benchmark, the Kaiser Small Group Health Maintenance Organization, existing California mandates (including medically necessary basic health care services), and ten federal Affordable Care Act (ACA) mandated benefits as described below. Requires non-grandfathered individual and small group plan contracts and insurance policies to cover EHBs:
   1. Ambulatory patient services;
   2. Emergency services;
   3. Hospitalization;
   4. Maternity and newborn care;
   5. Mental health and substance use disorder services, including behavioral health treatment;
   6. Prescription drugs;
   7. Rehabilitative and habilitative services and devices;
   8. Laboratory services;
   9. Preventive and wellness services and chronic disease management; and,
   10. Pediatric services, including oral and vision care. [HSC §1367.005 and INS §10112.27]
       
3. Requires all DMHC regulated health plans and CDI regulated large group health insurance policies to cover medically necessary basic health care services, defined as:
   1. Physician services, including consultation and referral;
   2. Hospital inpatient services and ambulatory care services;
   3. Diagnostic laboratory 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; and,
   7. Hospice care, as specified. [HSC §1345 and INS §10112.281]
      
4. Requires a health plan contract, except a specialized health plan contract, to provide coverage for all FDA-approved contraceptive drugs, devices, and products available over the counter at in-network pharmacies without cost-sharing or medical management; voluntary tubal ligation and other similar sterilization procedures and vasectomy; clinical services related to the provision or use of contraception; and, follow-up services including management of side effects, counseling, and device removal. Prohibits the imposition of a deductible or coinsurance except in the case of a grandfathered plan. Includes a religious employer exception, as specified. [HSC §1367.25, §1367.255 and INS §10123.1945, §10123.196]

This bill:

1. Requires a contract between a health plan or health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, to authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with “immediate postpartum contraception” if the birth takes place in a general acute care hospital or licensed birth center. Prohibits the provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure.
   
2. Defines “immediate postpartum contraception” as the postpartum insertion of intrauterine devices (IUD) or contraceptive implants performed before the enrollee/insured is discharged from the general acute care hospital or licensed birth center and includes the devices or implants themselves.
   
3. Indicates that this bill does not affect an enrollee’s or insured’s right to directly access women’s health care services, including contraceptive services, and informed consent.

Comments

1. Author’s statement. According to the author, since 2016, the Centers for Medicare and Medicaid Services encouraged payers to consider reimbursing for immediate postpartum insertion of long-acting reversible contraception (LARC) by unbundling payment for LARC from other labor and delivery services. Nearly 40 states have since revised their Medicaid reimbursement policies for immediate postpartum contraceptive access, allowing the reimbursement of immediate postpartum LARCs separate from the global fee for labor and delivery. Unfortunately, existing payment structures in California for commercial payers do not consistently carve out the payment from the global labor and delivery fee, leading to confusion among patients and providers. This bill will remove barriers for patient access to these devices through the standardization of benefits for LARC and allow providers to receive payment for immediate postpartum contraception when provided in a hospital or a birth center.
2. LARC. According to an October 2022 Journal of the American Medical Association Patient Page, LARC is long-lasting and easily reversible birth control such as contraceptive implants and IUDs. These can be inserted soon after delivery and pregnancy can occur immediately after removal. These devices are more than 99% effective and are safe while breast-feeding. With these devices, some people experience no to light bleeding while others may experience unpredictable bleeding and some pain. Contraceptive implants provide effective contraception for up to five years. Hormonal IUDs are effective from three to eight years, and nonhormonal IUDs are effective up to 12 years. Some women with certain types of cancers (breast, endometrial, cervical) and other conditions should not use these devices.
   
3. Global obstetric care fees. According to a Medi-Cal Explainer on maternity service payments published by the California HealthCare Foundation, global payments for providers who render total obstetric care, including prenatal, delivery, and postpartum care is all-inclusive for the obstetrician. Routine urinalysis and ultrasounds are included and cannot be billed separately. Anesthesiology or other complications such as gestational diabetes or hypertension are not included. Claims are submitted at the point of delivery. Global billing and payments are more often used by private practice providers. Based on recent Medi-Cal Targeted Provider Rate Increases, beginning January 1, 2024, these global payments now range from a low of $2,091 to a high of $2,320. Information provided by this bill’s co-sponsor, American College of Obstetricians and Gynecologists District IX, the cost of inserting an IUD, including the cost of the device, at one particular facility is around $600-$700 and the global obstetrician fee for maternity averages around $2,800.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 7/3/24)

California Lieutenant Governor Eleni Kounalakis (co-source)

American College of Obstetricians and Gynecologists District IX (co-source)

California Academy of Family Physicians

California Life Sciences

California Medical Association

California Primary Care Association Advocates

Health Officers Association of California

Junior Leagues of California

Junior Leagues of Orange County

Reproductive Freedom for All

OPPOSITION: (Verified 7/3/24)

None received

ARGUMENTS IN SUPPORT: American College of Obstetricians and Gynecologists District IX, this bill’s co-sponsor, indicates that this bill aligns commercial payments with Medi-Cal, which already allows reimbursement for immediate postpartum contraception outside of the bundled obstetric payment. Placing LARC in the immediate postpartum period is particularly beneficial because many women, including those at highest risk of short interpregnancy intervals, have low postpartum visit follow-up rates. As many as 40% of women do not attend the postpartum visit, which typically occurs at four to six weeks after childbirth and is the next opportunity to have a LARC placed after giving birth in the hospital. Despite these recommendations and statistics, access to contraception after giving birth remains a challenge due to a lack of consistent payment methods for LARCs that disincentivize providers from offering them. While some commercial insurers may claim their policies cover immediate postpartum LARC, in fact they are rolling the cost of providing that method into the global obstetric code payment already negotiated with the hospital, and this leads to confusion among both patients and providers. This billing practice does not account for how expensive IUDs and implants can be, and as a result, hospitals cannot afford to stock these methods for patients who want them. Patients with commercial coverage are being denied access to extremely effective contraception they want at the time when they are most likely to continue using it to prevent unintended pregnancy. Standardizing the way these benefits are covered across insurance plans will improve contraceptive access by eliminating the need for complex insurance benefit navigation by both patients and providers.

ASSEMBLY FLOOR: 73-0, 5/2/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Wicks, Wilson, Wood, Zbur

NO VOTE RECORDED: Calderon, Megan Dahle, Flora, Low, Mathis, Weber, Robert Rivas

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

8/6/24 16:10:44

**** END ****

 CONSENT  

Bill No: AB 2129

Author: Petrie-Norris (D)

Amended: 4/11/24 in Assembly

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 6/5/24

AYES: Roth, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

ASSEMBLY FLOOR: 73-0, 5/2/24 (Consent) - See last page for vote

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SUBJECT: Immediate postpartum contraception

SOURCE: Eleni Kounalakis, Lieutenant Governor

American College of Obstetricians and Gynecologists District IX

DIGEST:

This bill requires a contract between a health plan or health insurer and a health care provider to authorize a provider to separately bill for devices, implants, and professional services associated with immediate postpartum contraception, if the birth takes place in a general acute care hospital or accredited birthing center.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); California Department of Insurance (CDI) to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [Health and Safety Code (HSC) § 1340 et seq., Insurance Code (INS) § 106 et seq., and Welfare and Institutions Code (WIC) § 14000 et seq.]
   
2. Establishes, as California's essential health benefits (EHBs) benchmark, the Kaiser Small Group Health Maintenance Organization, existing California mandates (including medically necessary basic health care services), and ten federal Affordable Care Act (ACA) mandated benefits as described below. Requires non-grandfathered individual and small group plan contracts and insurance policies to cover EHBs:
   1. Ambulatory patient services;
   2. Emergency services;
   3. Hospitalization;
   4. Maternity and newborn care;
   5. Mental health and substance use disorder services, including behavioral health treatment;
   6. Prescription drugs;
   7. Rehabilitative and habilitative services and devices;
   8. Laboratory services;
   9. Preventive and wellness services and chronic disease management; and,
   10. Pediatric services, including oral and vision care. [HSC §1367.005 and INS §10112.27]
       
3. Requires all DMHC regulated health plans and CDI regulated large group health insurance policies to cover medically necessary basic health care services, defined as:
   1. Physician services, including consultation and referral;
   2. Hospital inpatient services and ambulatory care services;
   3. Diagnostic laboratory 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; and,
   7. Hospice care, as specified. [HSC §1345 and INS §10112.281]
      
4. Requires a health plan contract, except a specialized health plan contract, to provide coverage for all FDA-approved contraceptive drugs, devices, and products available over the counter at in-network pharmacies without cost-sharing or medical management; voluntary tubal ligation and other similar sterilization procedures and vasectomy; clinical services related to the provision or use of contraception; and, follow-up services including management of side effects, counseling, and device removal. Prohibits the imposition of a deductible or coinsurance except in the case of a grandfathered plan. Includes a religious employer exception, as specified. [HSC §1367.25, §1367.255 and INS §10123.1945, §10123.196]

This bill:

1. Requires a contract between a health plan or health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, to authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with “immediate postpartum contraception” if the birth takes place in a general acute care hospital or accredited birthing center. Prohibits the provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure.
   
2. Defines “immediate postpartum contraception” as the postpartum insertion of intrauterine devices (IUD) or contraceptive implants performed before the enrollee/insured is discharged from the general acute care hospital or accredited birthing center and includes the devices or implants themselves.
   
3. Indicates that this bill does not affect an enrollee’s or insured’s right to directly access women’s health care services, including contraceptive services, and informed consent.

Comments

1. Author’s statement. According to the author, since 2016, the Centers for Medicare and Medicaid Services encouraged payers to consider reimbursing for immediate postpartum insertion of long-acting reversible contraception (LARC) by unbundling payment for LARC from other labor and delivery services. Nearly 40 states have since revised their Medicaid reimbursement policies for immediate postpartum contraceptive access, allowing the reimbursement of immediate postpartum LARCs separate from the global fee for labor and delivery. Unfortunately, existing payment structures in California for commercial payers do not consistently carve out the payment from the global labor and delivery fee, leading to confusion among patients and providers. This bill will remove barriers for patient access to these devices through the standardization of benefits for LARC and allow providers to receive payment for immediate postpartum contraception when provided in a hospital or a birth center.
2. LARC. According to an October 2022 Journal of the American Medical Association Patient Page, LARC is long-lasting and easily reversible birth control such as contraceptive implants and IUDs. These can be inserted soon after delivery and pregnancy can occur immediately after removal. These devices are more than 99% effective and are safe while breast-feeding. With these devices, some people experience no to light bleeding while others may experience unpredictable bleeding and some pain. Contraceptive implants provide effective contraception for up to five years. Hormonal IUDs are effective from three to eight years, and nonhormonal IUDs are effective up to 12 years. Some women with certain types of cancers (breast, endometrial, cervical) and other conditions should not use these devices.
   
3. Global obstetric care fees. According to a Medi-Cal Explainer on maternity service payments published by the California HealthCare Foundation, global payments for providers who render total obstetric care, including prenatal, delivery, and postpartum care is all-inclusive for the obstetrician. Routine urinalysis and ultrasounds are included and cannot be billed separately. Anesthesiology or other complications such as gestational diabetes or hypertension are not included. Claims are submitted at the point of delivery. Global billing and payments are more often used by private practice providers. Based on recent Medi-Cal Targeted Provider Rate Increases, beginning January 1, 2024, these global payments now range from a low of $2,091 to a high of $2,320. Information provided by this bill’s sponsor, ACOG, District IX, the cost of inserting an IUD, including the cost of the device, at one particular facility is around $600-$700 and the global obstetrician fee for maternity averages around $2,800.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 6/17/24)

Eleni Kounalakis, Lieutenant Governor (co-source)

American College of Obstetricians and Gynecologists District IX (co-source)

California Life Sciences

California Medical Association

CPCA Advocates

Health Officers Association of California

Junior Leagues of California

Junior Leagues of Orange County

Reproductive Freedom for All

OPPOSITION: (Verified 6/17/24)

None received

ARGUMENTS IN SUPPORT: American College of Obstetricians and Gynecologists District IX, this bill’s sponsor, indicates that this bill aligns commercial payments with Medi-Cal, which already allows reimbursement for immediate postpartum contraception outside of the bundled obstetric payment. Placing LARC in the immediate postpartum period is particularly beneficial because many women, including those at highest risk of short interpregnancy intervals, have low postpartum visit follow-up rates. As many as 40% of women do not attend the postpartum visit, which typically occurs at four to six weeks after childbirth and is the next opportunity to have a LARC placed after giving birth in the hospital. Despite these recommendations and statistics, access to contraception after giving birth remains a challenge due to a lack of consistent payment methods for LARCs that disincentivize providers from offering them. While some commercial insurers may claim their policies cover immediate postpartum LARC, in fact they are rolling the cost of providing that method into the global obstetric code payment already negotiated with the hospital, and this leads to confusion among both patients and providers. This billing practice does not account for how expensive IUDs and implants can be, and as a result, hospitals cannot afford to stock these methods for patients who want them. Patients with commercial coverage are being denied access to extremely effective contraception they want at the time when they are most likely to continue using it to prevent unintended pregnancy. Standardizing the way these benefits are covered across insurance plans will improve contraceptive access by eliminating the need for complex insurance benefit navigation by both patients and providers.

ASSEMBLY FLOOR: 73-0, 5/2/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Wicks, Wilson, Wood, Zbur

NO VOTE RECORDED: Calderon, Megan Dahle, Flora, Low, Mathis, Weber, Robert Rivas

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

6/19/24 14:16:34

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: AB 2129

SUBJECT: Immediate postpartum contraception

SUMMARY:

Requires a contract between a health plan or health insurer and a health care provider to authorize a provider to separately bill for devices, implants, and professional services associated with immediate postpartum contraception, if the birth takes place in a general acute care hospital or accredited birthing center.

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); California Department of Insurance (CDI) to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [HSC §1340, et seq., INS §106, et seq., and WIC §14000, et seq.]
   
2. Establishes, as California's essential health benefits (EHBs) benchmark, the Kaiser Small Group Health Maintenance Organization, existing California mandates (including medically necessary basic health care services), and ten federal Affordable Care Act (ACA) mandated benefits as described below. Requires non-grandfathered individual and small group plan contracts and insurance policies to cover EHBs:
   1. Ambulatory patient services;
   2. Emergency services;
   3. Hospitalization;
   4. Maternity and newborn care;
   5. Mental health and substance use disorder services, including behavioral health treatment;
   6. Prescription drugs;
   7. Rehabilitative and habilitative services and devices;
   8. Laboratory services;
   9. Preventive and wellness services and chronic disease management; and,
   10. Pediatric services, including oral and vision care. [HSC §1367.005 and INS §10112.27]
       
3. Requires all DMHC regulated health plans and CDI regulated large group health insurance policies to cover medically necessary basic health care services, defined as:
   1. Physician services, including consultation and referral;
   2. Hospital inpatient services and ambulatory care services;
   3. Diagnostic laboratory 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; and,
   7. Hospice care, as specified. [HSC §1345 and INS §10112.281]
      
4. Requires a health plan contract, except a specialized health plan contract, to provide coverage for all FDA-approved contraceptive drugs, devices, and products available over the counter at in-network pharmacies without cost-sharing or medical management; voluntary tubal ligation and other similar sterilization procedures and vasectomy; clinical services related to the provision or use of contraception; and, follow-up services including management of side effects, counseling, and device removal. Prohibits the imposition of a deductible or coinsurance except in the case of a grandfathered plan. Includes a religious employer exception, as specified. [HSC §1367.25, §1367.255 and INS §10123.1945, §10123.196]

This bill:

1. Requires a contract between a health plan or health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, to authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with “immediate postpartum contraception” if the birth takes place in a general acute care hospital or accredited birthing center. Prohibits the provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure.
   
2. Defines “immediate postpartum contraception” as the postpartum insertion of intrauterine devices (IUD) or contraceptive implants performed before the enrollee/insured is discharged from the general acute care hospital or accredited birthing center and includes the devices or implants themselves.
   
3. Indicates that this bill does not affect an enrollee’s or insured’s right to directly access women’s health care services, including contraceptive services, and informed consent.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, minor and absorbable costs to DMHC and no costs to CDI.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, since 2016, the Centers for Medicare and Medicaid Services encouraged payers to consider reimbursing for immediate postpartum insertion of long-acting reversible contraception (LARC) by unbundling payment for LARC from other labor and delivery services. Nearly 40 states have since revised their Medicaid reimbursement policies for immediate postpartum contraceptive access, allowing the reimbursement of immediate postpartum LARCs separate from the global fee for labor and delivery. Unfortunately, existing payment structures in California for commercial payers do not consistently carve out the payment from the global labor and delivery fee, leading to confusion among patients and providers. This bill will remove barriers for patient access to these devices through the standardization of benefits for LARC and allow providers to receive payment for immediate postpartum contraception when provided in a hospital or a birth center.
2. LARC. According to an October 2022 Journal of the American Medical Association Patient Page, LARC is long-lasting and easily reversible birth control such as contraceptive implants and IUDs. These can be inserted soon after delivery and pregnancy can occur immediately after removal. These devices are more than 99% effective and are safe while breast-feeding. With these devices, some people experience no to light bleeding while others may experience unpredictable bleeding and some pain. Contraceptive implants provide effective contraception for up to five years. Hormonal IUDs are effective from three to eight years, and nonhormonal IUDs are effective up to 12 years. Some women with certain types of cancers (breast, endometrial, cervical) and other conditions should not use these devices.
   
3. Global obstetric care fees. According to a Medi-Cal Explainer on maternity service payments published by the California HealthCare Foundation, global payments for providers who render total obstetric care, including prenatal, delivery, and postpartum care is all-inclusive for the obstetrician. Routine urinalysis and ultrasounds are included and cannot be billed separately. Anesthesiology or other complications such as gestational diabetes or hypertension are not included. Claims are submitted at the point of delivery. Global billing and payments are more often used by private practice providers. Based on recent Medi-Cal Targeted Provider Rate Increases, beginning January 1, 2024, these global payments now range from a low of $2,091 to a high of $2,320. Information provided by this bill’s sponsor, ACOG, District IX, the cost of inserting an IUD, including the cost of the device, at one particular facility is around $600-$700 and the global obstetrician fee for maternity averages around $2,800.
   
4. Related legislation. AB 90 (Petrie-Norris of 2023) clarifies that the Family Planning, Access, Care, and Treatment comprehensive clinical family planning services include inpatient services relating to the placement or insertion of a contraceptive device. AB 90 is pending in this Committee.
   
5. Prior legislation. SB 523 (Leyva, Chapter 630, Statutes of 2022) prohibits employment-related discrimination on the basis of reproductive health decision-making, and, beginning in 2024, modifies several aspects of the laws governing health benefits plans and health insurance policies in order to expand coverage, reduce costs, and lower barriers to reproductive health services.
   

SB 1053 (Mitchell, Chapter 576, Statutes of 2014) requires a health plan contract or health insurance policy to provide coverage for women for all prescribed and FDA-approved female contraceptive drugs, devices, and products, as well as voluntary sterilization procedures, contraceptive education and counseling, and related follow-up services. SB 1053 prohibits a non-grandfathered plan contract or health insurance policy from imposing any cost-sharing requirements or other restrictions or delays with respect to this coverage, as specified.

1. Support. ACOG, District IX, this bill’s sponsor, indicates that this bill aligns commercial payments with Medi-Cal, which already allows reimbursement for immediate postpartum contraception outside of the bundled obstetric payment. Placing LARC in the immediate postpartum period is particularly beneficial because many women, including those at highest risk of short interpregnancy intervals, have low postpartum visit follow-up rates. As many as 40% of women do not attend the postpartum visit, which typically occurs at four to six weeks after childbirth and is the next opportunity to have a LARC placed after giving birth in the hospital. Despite these recommendations and statistics, access to contraception after giving birth remains a challenge due to a lack of consistent payment methods for LARCs that disincentivize providers from offering them. While some commercial insurers may claim their policies cover immediate postpartum LARC, in fact they are rolling the cost of providing that method into the global obstetric code payment already negotiated with the hospital, and this leads to confusion among both patients and providers. This billing practice does not account for how expensive IUDs and implants can be, and as a result, hospitals cannot afford to stock these methods for patients who want them. Patients with commercial coverage are being denied access to extremely effective contraception they want at the time when they are most likely to continue using it to prevent unintended pregnancy. Standardizing the way these benefits are covered across insurance plans will improve contraceptive access by eliminating the need for complex insurance benefit navigation by both patients and providers.
   

SUPPORT AND OPPOSITION:

Support: American College of Obstetricians and Gynecologists District IX (cosponsor)

Eleni Kounalakis, Lieutenant Governor (cosponsor)

California Life Sciences

California Medical Association

CPCA Advocates

Health Officers Association of California

Junior Leagues of California

Junior Leagues of Orange County

Reproductive Freedom for All

Oppose: None received

-- END --

Date of Hearing: April 24, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 2129

Author:(Petrie-Norris) – As Amended Ver:April 11, 2024

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill authorizes a health care provider, in a contract with a health plan or insurer, to bill for devices, implants, or professional services associated with immediate postpartum contraception (IPPC) after a delivery in a licensed hospital or birthing center, and prohibits the provider contract from considering the IPPC devices, implants, or services to be part of a payment for a general obstetric procedure.

FISCAL EFFECT:

Minor and absorbable costs to the Department of Managed Health Care and no costs to the Department of Insurance.

COMMENTS:

1. Purpose. This bill is sponsored by the American College of Obstetricians and Gynecologists (ACOG). According to the author:

Since 2016, the [federal Centers for Medicare and] Medicaid Services has encouraged payers to consider “reimbursing for immediate postpartum insertion of long acting reversible contraceptives (LARC) by unbundling payment for LARC from other labor and delivery services.” Nearly 40 states have since revised their Medicaid reimbursement policies for immediate postpartum contraceptive (IPPC) access, allowing the reimbursement of immediate postpartum LARCs separate from the global fee for labor and delivery. Unfortunately, existing payment structures in California for commercial payers do not consistently carve out the payment from the global labor and delivery fee, leading to confusion among patients and providers. AB 2129 will remove barriers for patient access to these devices through the standardization of benefits for long-acting reversible contraceptives and allow providers to receive payment for immediate postpartum contraception when provided in a hospital or a birth center.

1. Background.
   1. LARCs. LARCs are birth control devices inserted into the body, such as IUDs and implants, which can stay in the body for several years and can be removed if an individual wants to become pregnant. Due to LARCs’ very high efficacy, good safety profile, and high patient satisfaction, evidence-based clinical guidelines, such as those issued by ACOG, advocate for improving access to and removing barriers to use of LARCs. ACOG recommends obstetric care providers discuss LARCs during the antepartum period and counsel all pregnant women about options for immediate postpartum initiation.

An ACOG Policy Brief states LARCs can be offered immediately postpartum, in other words, following childbirth and prior to hospital discharge, as a safe, effective option for postpartum contraception. Postpartum contraception is usually offered and provided during the six-week postpartum visit. However, approximately 10% to 40% of women do not return for this visit and are at risk for subsequent unintended pregnancy within a short interval. For those who do return, nearly 60% may have resumed intercourse and could already be at risk for another pregnancy. Adolescents are at high risk for a rapid repeat pregnancy, increasing risk of preterm birth and poorer neonatal outcomes.

• 1. Reimbursement for LARC. Adoption of immediate postpartum LARC has been hampered by the inability to obtain reimbursement for LARC devices and services provided immediately postpartum. According to information from the author, when insurance policies do not cover the hospital’s cost of IPPC LARC placement, providers cannot offer LARC to their patients because LARC devices can be expensive, with some priced as high as $1,300. Most insurance plans use a standard method of payment called a Diagnosis Related Group (DRG) to reimburse hospitals for a patient’s labor and delivery. Also called a “global” or “bundled” payment, the DRG is a single, predetermined, fixed amount that is inclusive of most labor and delivery care that is provided. But some services, including anesthesiology or tubal ligation performed after a cesarean delivery, are not included and thus can be billed separately from the DRG. This is known as “debundling” payment, and it allows providers and hospitals to bill and be reimbursed for the true cost of expensive services. In 2016, the federal Centers for Medicare and Medicaid Services encouraged payers to consider reimbursing for IPPC LARCs by debundling payment for LARC from other labor and delivery services. Nearly 40 states have revised their Medicaid reimbursement policies for IPPC access.

1. Related Legislation. AB 90 (Petrie-Norris) clarifies that the Family Planning, Access, Care, and Treatment (Family PACT, administered by the Department of Health Care Services) comprehensive clinical family planning services include services relating to the placement or insertion of a contraceptive device, such as LARCs. AB 90 is pending in Senate Health Committee; the author states the Administration modified regulations to address this issue.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 9, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 2129 (

Author:(Petrie-Norris) – As Introduced Ver:February 6, 2024

SUBJECT: Immediate postpartum contraception.

SUMMARY: Authorizes a health care provider, in a contract between a health plan or insurer, to separately bill for devices, implants, or professional services, or a combination thereof, associated with immediate postpartum contraception (IPPC) if the birth takes place in a licensed hospital or birthing center. Prohibits the provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure. Specifically, this bill:

1. Authorizes a health care provider, in a contract between a health plan or insurer, to separately bill for devices, implants, or professional services, or a combination thereof, associated with IPPC if the birth takes place in a licensed hospital or birthing center.
2. Prohibits the provider contract from considering those devices, implants, or services to be part of a payment for a general obstetric procedure.
3. Defines IPPC as the postpartum insertion of intrauterine devices (IUD) or contraceptive implants performed before the enrollee or insured is discharged from the licensed hospital or birthing center and includes the devices or implants.
4. Specifies that this bill does not affect an enrollee or insured’s right to directly access women’s health care services, including contraceptive services.

EXISTING LAW:

1. Establishes the Department of Managed Health Care to regulate health plans and California Department of Insurance to regulate health insurance. [Health and Safety Code (HSC) §1340, et seq.; Insurance Code (INS) §106, et seq.]
2. Establishes as California's essential health benefits benchmark, the Kaiser Small Group Health Maintenance Organization contract, existing California mandates, and 10 federal Patient Protection and Affordable Care Act mandated benefits, including pregnancy and childbirth. [HSC §1367.005 and INS §10112.27]
3. Requires health plans and health insurers, except for a specialized health plan contract or a specialized health insurance policy, to provide coverage for all of the following services and contraceptive methods for women:
   1. All Food and Drug Administration (FDA) approved contraceptive drugs, devices, and other products for women, including all FDA-approved contraceptive drugs, devices, and products available over the counter, as prescribed by the enrollee’s or insured’s provider;
   2. Voluntary sterilization procedures;
   3. Patient education and counseling on contraception; and,
   4. Follow-up services related to the drugs, devices, products, and procedures, including, but not limited to, management of side effects, counseling for continued adherence, and device insertion and removal. [HSC § 1367.25 and INS § 10123.196]
      
4. Requires health plans to ensure that all services are readily available at reasonable times to each enrollee consistent with good professional practice, and to the extent feasible, a health plan to make all services readily accessible to all enrollees consistent with existing law on timely access to health care services. [HSC §1367]

FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, since 2016, the Centers for Medicare and Medicaid Services (CMS) encouraged payers to consider “reimbursing for immediate postpartum insertion of long acting reversible contraceptives (LARC) by unbundling payment for LARC from other labor and delivery services.” Nearly 40 states have since revised their Medicaid reimbursement policies for IPPC access, allowing the reimbursement of immediate postpartum LARCs separate from the global fee for labor and delivery. Unfortunately, existing payment structures in California for commercial payers do not consistently carve out the payment from the global labor and delivery fee, leading to confusion among patients and providers. The author concludes that this bill will remove barriers for patient access to these devices through the standardization of benefits for LARC and allow providers to receive payment for IPPC when provided in a hospital or a birth center.
2. BACKGROUND.
   1. LARCs. LARCs are highly effective birth control devices inserted into the body. They include IUDs and implants, which can stay in the body for several years and can be removed if an individual wants to become pregnant. Due to the good safety profile and high patient satisfaction, as well as very high efficacy, evidence-based clinical guidelines such as those issued by the American College of Obstetricians and Gynecologists (ACOG) advocate for improving access to and removing barriers to use of LARCs. ACOG recommends that women should be counseled about all forms of postpartum contraception in a context that allows informed decision-making and LARC should be offered as an effective option for postpartum contraception. Obstetric care providers should discuss LARC during the antepartum period and counsel all pregnant women about options for immediate postpartum initiation.
   2. Immediate Postpartum LARC. According to an ACOG Policy Brief, LARCs can be offered immediately postpartum (the period following childbirth and prior to hospital discharge) as a safe, effective option for postpartum contraception. Postpartum contraception is usually offered and provided during the 6-week postpartum visit. However, approximately 10- 40% of women do not return for this visit and are at risk for subsequent unintended, short-interval pregnancy. For those who do return, nearly 60% may have resumed intercourse and could already be at risk for another pregnancy. Adolescents are at higher risk for a rapid repeat pregnancy, with estimates of 12-49% of postpartum adolescents experiencing a pregnancy within one year of delivery. Unintended and short-interval pregnancies can result in a higher risk of preterm birth and worsened neonatal outcomes. Immediate postpartum LARC has the potential to reduce unintended and short-interval pregnancy. However, more widespread adoption of immediate postpartum LARC has been hampered by systems barriers, such as the inability to obtain reimbursement for LARC devices and services provided immediately postpartum.
   3. Reimbursement for LARC. According to information from the author, when insurance policies do not cover the hospital’s cost of IPPC LARC placement, providers cannot offer this contraceptive option to their patients since LARC devices are among the most expensive methods of pregnancy prevention (with some priced as high as $1300). Without guaranteed reimbursement from insurers for providing LARCs immediately following childbirth, hospitals are disincentivized to offer the service. Most insurance plans use a standard method of payment called a Diagnosis Related Group (DRG) to reimburse hospitals for a patient’s labor and delivery. Also called a “global” or “bundled” payment, the DRG is a single, predetermined, fixed amount that is all-inclusive of most labor and delivery care that’s provided. Under many commercial insurance plans, IPPC LARC is assumed to be included in the DRG. But some services, including anesthesiology or tubal ligation performed after a cesarean delivery, are not included and thus can be billed separately from the DRG. This is known as “debundling” payment, and it allows providers and hospitals to bill and be reimbursed for the true cost of these expensive services. In 2016, CMS encouraged payers to consider reimbursing for immediate postpartum insertion LARCs by unbundling payment for LARC from other labor and delivery services and nearly 40 states have revised their Medicaid reimbursement policies for IPPC access.
3. SUPPORT. ACOG, the sponsor of this bill, states that studies show that healthy birth spacing helps reduce adverse health outcomes for both parents and babies. Most of the data from observational studies in the United States suggest a modest increase in risk of adverse outcomes associated with intervals of less than 18 months and more significant risk of adverse outcome with intervals of less than six months between birth and the start of the next pregnancy. Despite these risks, short intervals between pregnancies still occur, and at least 70% of pregnancies within one year after delivery were unintended. ACOG believes everyone who desires LARC should have timely access to contraceptive implants and IUDs. Obstetrician– gynecologists and other reproductive health care clinicians can best serve those who want to delay or avoid pregnancy by all medically appropriate contraceptive methods, but they can only do so if it is available. LARC devices should be easily accessible to all people who want them, including adolescents, those who have never given birth, and after spontaneous or induced abortion and childbirth. ACOG has long recommended and supported removing financial barriers to contraception by advocating for coverage and appropriate payment and reimbursement for all contraceptive methods by all payers for all eligible patients.
4. RELATED LEGISLATION.
   1. AB 90 (Petrie-Norris) of 2023 clarifies that the Family Planning, Access, Care, and Treatment (Family PACT administered by the Department of Health Care Services) comprehensive clinical family planning services include inpatient services relating to the placement or insertion of a contraceptive device. It should be noted that the author states that the Administration modified their regulations to address this issue. AB 90 is pending in Senate Health Committee.
   2. SB 1053 (Mitchell), Chapter 576, Statutes of 2014, requires a health plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2016, to provide coverage for women for all prescribed and FDA-approved female contraceptive drugs, devices, and products, as well as voluntary sterilization procedures, contraceptive education and counseling, and related follow-up services. Prohibits a nongrandfathered plan contract or health insurance policy from imposing any cost-sharing requirements or other restrictions or delays with respect to this coverage, as specified.
5. PREVIOUS LEGISLATION. SB 1234 (Pan) of 2022 would have expanded eligibility for sexually transmitted disease-related services through the Family PACT Program to individuals not at risk for experiencing or causing an unintended pregnancy, and not in need of contraceptive services, and required related reporting. SB 1234 was vetoed based on concerns it expanded Family PACT services beyond the federal definition of family planning and would have put ongoing cost pressure on the General Fund.
6. AMENDMENTS.  The author wishes to amend this bill as follows:
   1. Clarify that the provisions apply to general acute care hospital or accredited birthing centers; and,
   2. Clarify that this bill does not affect informed consent protections in existing law. 

REGISTERED SUPPORT / OPPOSITION:

Support

American College of Obstetricians and Gynecologists (sponsor)
California Medical Association

California Life Sciences

Junior Leagues of California State Public Affairs Committee

Reproductive Freedom for All

Opposition

None on file.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097