Health care coverage: dementia.

Plain English Breakdown

The official source material does not provide specific details on cost implications for health care plans and insurers, only that no reimbursement from local agencies or school districts is required.

Health Care Coverage for Dementia

The bill requires health care plans and insurance policies to cover medically necessary treatments and medications approved by the FDA for Alzheimer's disease or other related dementias, starting in 2027.

What This Bill Does

• Requires health care service plan contracts and health insurance policies issued, amended, or renewed after January 1, 2027, to include coverage for all medically necessary treatments or medications approved by the FDA for Alzheimer's disease or other related dementias.
• Does not require plans to cover multiple versions of the same drug if they are pharmaceutically equivalent and approved by the FDA.
• Prohibits health insurers from requiring patients to try other drugs before getting a specific treatment for Alzheimer’s or related dementias, except as provided.
• Requires health care service plans that cover nonself-administered treatments for dementia to also include them as outpatient prescription benefits.

Who It Names or Affects

• People with health insurance who have been diagnosed with Alzheimer's disease or other types of dementia.
• Health care service plans and health insurers in California.

Terms To Know

FDA

The United States Food and Drug Administration, which approves medications and treatments for safety and effectiveness.

Step therapy protocols

A process where patients must try one or more drugs before getting a specific treatment their doctor recommends.

Limits and Unknowns

• The bill does not specify what happens if the FDA approves multiple versions of the same drug.
• It is unclear how much this will cost health care plans and insurers, but it states that no reimbursement from local agencies or school districts is required for this act.

Official Summary Text

SB 950, as amended, Weber Pierson.
Health care coverage: dementia.
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’s requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law prohibits specified health care service plan contracts and disability insurance policies from excluding persons covered by the plan from receiving benefits if they are diagnosed as having any significant destruction of brain tissue with resultant loss of brain function, including Alzheimer’s disease.
This bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2027, to include coverage for all medically necessary
treatments or medications, as determined by a health care provider, approved by the United States Food and Drug Administration (FDA) for the treatment of Alzheimer’s disease or other related dementia.
Under the bill, contracts and policies would not be required to cover drugs or treatments that are pharmaceutically equivalent drug products if the FDA approves more than one.
On and after January 1, 2027, the bill would prohibit a health care service plan or health insurer from imposing step therapy protocols as a prerequisite to authorizing that coverage, except as provided.
The bill would require a health care service plan or health insurer that, as a medical benefit, covers nonself-administered treatments approved by the FDA for the treatment of Alzheimer’s disease or other medical conditions affecting memory to also include those nonself-administered treatments as an outpatient prescription drug benefit.
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.

Current Bill Text

Download Bill PDF