BILL NUMBER: AB 171	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  JANUARY 23, 2012
	AMENDED IN ASSEMBLY  MAY 3, 2011
	AMENDED IN ASSEMBLY  APRIL 6, 2011

INTRODUCED BY   Assembly Member Beall
   (Coauthors: Assembly Members Ammiano, Blumenfield, Brownley,
Carter, Chesbro, Eng, Huffman, Mitchell, Swanson, Wieckowski,
Williams, and Yamada)

                        JANUARY 20, 2011

   An act to add Section  1374.73   1374.745
 to the Health and Safety Code, and to add Section 
10144.51   10144.53  to the Insurance Code,
relating to health care coverage.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 171, as amended, Beall.  Autism spectrum disorder.
  Pervasive developmental disorder or autism. 
   (1) Existing law provides for licensing and regulation of health
care service plans by the Department of Managed Health Care. A
willful violation of these provisions is a crime. Existing law
provides for  licensing and   the 
regulation of health insurers by the Insurance Commissioner. Existing
law requires health care service plan contracts and health insurance
policies to provide  benefits for specified conditions,
including certain mental health conditions.   coverage
for the diagnosis and treatment of severe mental illnesses, including
pervasive developmental disorder or autism, under the  
same terms and conditions applied to other medical conditions, as
specified. Commencing July 1, 2012   , and until July 1,
2014, existing law requires health care service plan contracts and
health insurance policies to provide coverage for behavioral health
treatment, as defined, for pervasive developmental disorder or
autism. 
   This bill would require health care service plan contracts and
health insurance policies to provide coverage for the screening,
diagnosis, and treatment , other than behavioral health
treatment,  of  autism spectrum disorders  
pervasive developmental disorder or autism  . The bill would,
however, provide that no benefits are required to be provided
 by a health benefit plan offered through the California
Health Benefit Exchange that exceed the essential health benefits
required   that exceed the essential health benefits
that will be required  under  specified  federal law.
The bill would prohibit  coverage from being denied for
specified reasons   health care service plans and health
insurers from denying, terminating, or refusing to renew coverage
solely because the individual is diagnosed with or has received
treatment for pervasive developmental disorder or autism  .
Because the bill would change the definition of a crime with respect
to health care service plans, it would thereby impose a
state-mandated local program.
   (2) 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  1374.73   1374.745 
is added to the Health and Safety Code, to read:
    1374.73.   1374.745.   (a) Every health
care service plan contract issued, amended, or renewed on or after
January 1,  2012   2013  , that provides
hospital, medical, or surgical coverage shall provide coverage for
the screening, diagnosis, and treatment of  autism spectrum
disorders.   pervasive developmental disorder or autism.

   (b) A health care service plan shall not terminate coverage, or
refuse to deliver, execute, issue, amend, adjust, or renew coverage,
to an enrollee solely because the individual is diagnosed with, or
has received treatment for,  an autism spectrum disorder
  pervasive developmental disorder or autism  .
   (c) Coverage required to be provided under this section shall
extend to all medically necessary services and shall not be subject
to any limits regarding age, number of visits, or dollar amounts.
Coverage required to be provided under this section shall not be
subject to provisions relating to lifetime maximums, deductibles,
copayments, or coinsurance or other terms and conditions that are
less favorable to an enrollee than lifetime maximums, deductibles,
copayments, or coinsurance or other terms and conditions that apply
to physical illness generally under the plan contract.
   (d) Coverage required to be provided under this section is a
health care service and a covered health care benefit for purposes of
this chapter. Coverage shall not be denied  on the basis of the
location of delivery of the treatment   or on the basis
that the treatment is habilitative, nonrestorative, educational,
academic, or custodial in nature.
   (e) A health care service plan may request, no more than once
annually, a review of treatment provided to an enrollee for 
autism spectrum disorders   pervasive developmental
disorder or autism . The cost of obtaining the review shall be
borne by the plan. This subdivision does not apply to inpatient
services.
   (f) A health care service plan shall establish and maintain an
adequate network of  qualified autism  service
providers with appropriate training and experience in  autism
spectrum disorders   pervasive developmental disorder
or autism  to ensure that enrollees have a choice of providers,
and have timely access, continuity of care, and ready referral to all
services required to be provided by this section consistent with
Sections 1367 and 1367.03 and the regulations adopted pursuant
thereto.
   (g) (1) This section shall not be construed as reducing any
obligation to provide services to an enrollee under an individualized
family service plan, an individualized program plan, a prevention
program plan, an individualized education program, or an
individualized service plan.
   (2) This section shall not be construed as limiting  or
excluding  benefits that are otherwise available to an enrollee
under a health care service  plan.   plan,
including, but not limited to, benefits that are required to be
covered pursuant to Sections 1374.72 and 1374.73.  
   (3) This section shall not be construed to mean that the services
required to be covered pursuant to this section are not required to
be covered under other provisions of this chapter. 
   (3) 
    (4)  This section shall not be construed as affecting
litigation that is pending on January 1, 2012. 
   (h) On and after January 1, 2014, to the extent that this section
requires health benefits to be provided that exceed the essential
health benefits required to be provided under Section 1302(b) of the
federal Patient Protection and Affordable Care Act (Public Law
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152) by qualified health
plans offering those benefits in the California Health Benefit
Exchange pursuant to Title 22 (commencing with Section 100500) of the
Government Code, the specific benefits that exceed the federally
required essential health benefits are not required to be provided
when offered by a health care service plan contract through the
Exchange. However, those specific benefits are required to be
provided if offered by a health care service plan contract outside of
the Exchange.  
   (h) Notwithstanding subdivision (a), on and after January 1, 2014,
this section does not require any benefits to be provided that
exceed the essential health benefits that all health plans will be
required by federal regulations to provide under Section 1302(b) of
the federal Patient Protection and Affordable Care Act (Public Law
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152). 
   (i) As used in this section, the following terms shall have the
following meanings: 
   (1) "Autism spectrum disorder" means a neurobiological condition
that includes autistic disorder, Asperger's disorder, Rett's
disorder, childhood disintegrative disorder, and pervasive
developmental disorder not otherwise specified.  
   (2) "Behavioral health treatment" means professional services and
treatment programs, including behavioral intervention therapy,
applied behavioral analysis, and other intensive behavioral programs,
that have demonstrated efficacy to develop, maintain, or restore, to
the maximum extent practicable, the functioning or quality of life
of an individual and that have been demonstrated to treat the core
symptoms associated with autism spectrum disorder.  

   (3) "Behavioral intervention therapy" means the design,
implementation, and evaluation of environmental modifications, using
behavioral stimuli and consequences, to produce socially significant
improvement in behaviors, including the use of direct observation,
measurement, and functional analyses of the relationship between
environment and behavior.  
   (4) 
    (1)  "Diagnosis of  autism spectrum disorders"
  pervasive developmental disorder or autism" 
means medically necessary assessment, evaluations, or tests to
diagnose whether an individual has  one of the autism
spectrum disorders   pervasive developmental disorder or
autism  . 
   (5) "Evidence-based research" means research that applies
rigorous, systematic, and objective procedures to obtain valid
knowledge relevant to autism spectrum disorders.  
   (2) "Pervasive developmental disorder or autism" shall have the
same meaning and interpretation as used in Section 1374.72. 

   (6) 
    (3)  "Pharmacy care" means medications prescribed by a
licensed physician and surgeon or other appropriately licensed or
certified provider and any health-related services deemed medically
necessary to determine the need or effectiveness of the medications.

   (7) 
    (4)  "Psychiatric care" means direct or consultative
psychiatric services provided by a psychiatrist  or any other
appropriately licensed or certified provider   licensed
in the state in which he or she practices  . 
   (8) 
    (5)  "Psychological care" means direct or consultative
psychological services provided by a psychologist  or any
other appropriately licensed or certified provider  
licensed in the state in which he or she practices  . 
   (9) "Qualified autism service provider" shall include any
nationally or state licensed or certified person, entity, or group
that designs, supervises, or provides treatment of autism spectrum
disorders and the unlicensed personnel supervised by the licensed or
certified person, entity, or group, provided the services are within
the experience and scope of practice of the licensed or certified
person, entity, or group. "Qualified autism service provider" shall
also include any service provider that is vendorized by a regional
center to provide those same services for autism spectrum disorders
under Division 4.5 (commencing with Section 4500) of the Welfare and
Institutions Code or Title 14 (commencing with Section 95000) of the
Government Code and the unlicensed personnel supervised by that
provider, or a State Department of Education nonpublic, nonsectarian
agency as defined in Section 56035 of the Education Code approved to
provide those same services for autism spectrum disorders and the
unlicensed personnel supervised by that agency. A qualified autism
service provider shall ensure criminal background screening and
fingerprinting, and adequate training and supervision of all
personnel utilized to implement services. Any national license or
certification recognized by this section shall be accredited by the
National Commission for Certifying Agencies (NCCA). 

   (10) 
    (6)  "Therapeutic care" means services provided by 
a  licensed or certified speech  therapists 
 therapist  ,  an  occupational  therapists
  therapist  , or  a  physical 
therapists or any other appropriately licensed or certified provider.
  therapist.  
   (11) 
    (7)  "Treatment for  autism spectrum disorders"
    pervasive developmental disorder or autism
  "  means all of the following care, including
necessary equipment,  that develops, maintains, or restores to
the maximum extent practicable the functioning or quality of life of
an individual with pervasive developmental disorder or autism and is
 prescribed or ordered for an individual diagnosed with 
one of the autism spectrum disorders   pervasive
developmental disorder or autism  by a licensed physician and
surgeon or a licensed psychologist  or any other
appropriately licensed or certified provider  who determines
the care to be medically necessary: 
   (A) Behavioral health treatment.  
   (B) 
    (A)  Pharmacy care , if the plan contract includes
coverage for prescription drugs  . 
   (C) 
    (B)  Psychiatric care. 
   (D) 
    (C)  Psychological care. 
   (E) 
    (D)  Therapeutic care. 
   (F) Any care for individuals with autism spectrum disorders that
is demonstrated, based upon best practices or evidence-based
research, to be medically necessary.  
   (8) "Treatment for pervasive developmental disorder or autism"
does not include behavioral health treatment, as defined in Section
1374.73. 
   (j) This section, with the exception of subdivision (b), shall not
apply to dental-only or vision-only health care service plan
contracts.
  SEC. 2.  Section  10144.51   10144.53  is
added to the Insurance Code, to read:
    10144.51.   10144.53.   (a) Every
health insurance policy issued, amended, or renewed on or after
January 1,  2012,   2013,  that provides
hospital, medical, or surgical coverage shall provide coverage for
the screening, diagnosis, and treatment of  autism spectrum
disorders   pervasive developmental disorder or autism
 .
   (b) A health insurer shall not terminate coverage, or refuse to
deliver, execute, issue, amend, adjust, or renew coverage, to an
insured solely because the individual is diagnosed with, or has
received treatment for,  an autism spectrum disorder
  pervasive developmental disorder or autism  .
   (c) Coverage required to be provided under this section shall
extend to all medically necessary services and shall not be subject
to any limits regarding age, number of visits, or dollar amounts.
Coverage required to be provided under this section shall not be
subject to provisions relating to lifetime maximums, deductibles,
copayments, or coinsurance or other terms and conditions that are
less favorable to an insured than lifetime maximums, deductibles,
copayments, or coinsurance or other terms and conditions that apply
to physical illness generally under the policy.
   (d) Coverage required to be provided under this section is a
health care service and a covered health care benefit for purposes of
this part. Coverage shall not be denied  on the basis of the
location of delivery of the treatment or  on the basis that the
treatment is habilitative, nonrestorative, educational, academic, or
custodial in nature.
   (e) A health insurer may request, no more than once annually, a
review of treatment provided to an insured for  autism
spectrum disorders   pervasive developmental disorder or
autism . The cost of obtaining the review shall be borne by the
insurer. This subdivision does not apply to inpatient services.
   (f) A health insurer shall establish and maintain an adequate
network of  qualified autism  service providers with
appropriate training and experience in  autism spectrum
disorders   pervasive developmental disorder or autism
 to ensure that insureds have a choice of providers, and have
timely access, continuity of care, and ready referral to all services
required to be provided by this section consistent with Sections
10133.5 and 10133.55 and the regulations adopted pursuant thereto.
   (g) (1) This section shall not be construed as reducing any
obligation to provide services to an insured under an individualized
family service plan, an individualized program plan, a prevention
program plan, an individualized education program, or an
individualized service plan.
   (2) This section shall not be construed as limiting  or
excluding  benefits that are otherwise available to an enrollee
under a health insurance policy  , including, but not limited to,
benefits that are required to be covered under Sections 10144.5 and
10144.51  . 
   (3) This section shall not be construed to mean that the services
required to be covered pursuant to this section are not required to
be covered under other provisions of this chapter.  
   (3) 
    (4)  This section shall not be construed as affecting
litigation that is pending on January 1, 2012. 
   (h) On and after January 1, 2014, to the extent that this section
requires health benefits to be provided that exceed the essential
health benefits required to be provided under Section 1302(b) of the
federal Patient Protection and Affordable Care Act (Public Law
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152) by qualified health
plans offering those benefits in the California Health Benefit
Exchange pursuant to Title 22 (commencing with Section 100500) of the
Government Code, the specific benefits that exceed the federally
required essential health benefits are not required to be provided
when offered by a health insurance policy through the Exchange.
However, those specific benefits are required to be provided if
offered by a health insurance policy outside of the Exchange.
 
   (h) Notwithstanding subdivision (a), on and after January 1, 2014,
this section does not require any benefits to be provided that
exceed the essential health benefits that all health plans will be
required by federal regulations to provide under Section 1302(b) of
the federal Patient Protection and Affordable Care Act (Public Law
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152). 
   (i) As used in this section, the following terms shall have the
following meanings: 
   (1) "Autism spectrum disorder" means a neurobiological condition
that includes autistic disorder, Asperger's disorder, Rett's
disorder, childhood disintegrative disorder, and pervasive
developmental disorder not otherwise specified.  
   (2) "Behavioral health treatment" means professional services and
treatment programs, including behavioral intervention therapy,
applied behavioral analysis, and other intensive behavioral programs,
that have demonstrated efficacy to develop, maintain, or restore, to
the maximum extent practicable, the functioning or quality of life
of an individual and that have been demonstrated to treat the core
symptoms associated with autism spectrum disorder.  

   (3) "Behavioral intervention therapy" means the design,
implementation, and evaluation of environmental modifications, using
behavioral stimuli and consequences, to produce socially significant
improvement in behaviors, including the use of direct observation,
measurement, and functional analyses of the relationship between
environment and behavior.  
   (4) 
    (1)  "Diagnosis of  autism spectrum disorders"
  pervasive developmental disorder or autism" 
means medically necessary assessment, evaluations, or tests to
diagnose whether an individual has  one of the autism
spectrum disorders   pervasive developmental disorder or
autism  . 
   (5) "Evidence-based research" means research that applies
rigorous, systematic, and objective procedures to obtain valid
knowledge relevant to autism spectrum disorders.  
   (2) "Pervasive developmental disorder or autism" shall have the
same meaning and interpretation as used in Section 1374.72. 

   (6) 
    (3)  "Pharmacy care" means medications prescribed by a
licensed physician and surgeon or other appropriately licensed or
certified provider and any health-related services deemed medically
necessary to determine the need or effectiveness of the medications.

   (7) 
    (4)  "Psychiatric care" means direct or consultative
psychiatric services provided by a psychiatrist  or any other
appropriately licensed or certified provider   licensed
in the state in which he or she practices  . 
   (8) 
    (5)  "Psychological care" means direct or consultative
psychological services provided by a psychologist  or any
other appropriately licensed or certified provider  
licensed in the state in which he or she practices  . 
   (9) "Qualified autism service provider" shall include any
nationally or state licensed or certified person, entity, or group
that designs, supervises, or provides treatment of autism spectrum
disorders and the unlicensed personnel supervised by the licensed or
certified person, entity, or group, provided the services are within
the experience and scope of practice of the licensed or certified
person, entity, or group. "Qualified autism service provider" shall
also include any service provider that is vendorized by a regional
center to provide those same services for autism spectrum disorders
under Division 4.5 (commencing with Section 4500) of the Welfare and
Institutions Code or Title 14 (commencing with Section 95000) of the
Government Code and the unlicensed personnel supervised by that
provider, or a State Department of Education nonpublic, nonsectarian
agency as defined in Section 56035 of the Education Code approved to
provide those same services for autism spectrum disorders and the
unlicensed personnel supervised by that agency. A qualified autism
service provider shall ensure criminal background screening and
fingerprinting, and adequate training and supervision of all
personnel utilized to implement services. Any national license or
certification recognized by this section shall be accredited by the
National Commission for Certifying Agencies (NCCA). 

   (10) 
    (6)  "Therapeutic care" means services provided by 
a  licensed or certified speech therapists 
 therapist  ,  an  occupational  therapists
  therapist  , or  a  physical 
therapists or any other appropriately licensed or certified provider
  therapist  . 
   (11) 
    (7)  "Treatment for  autism spectrum disorders"
  pervasive developmental disorder or autism" 
means all of the following care, including necessary equipment, 
that develops, maintains, or restores to the maximum extent
practicable the functioning or quality of life of an individu 
 al with pervasive developmental disorder or autism and is 
prescribed or ordered for an individual diagnosed with  one
of the autism spectrum disorders   pervasive
developmental disorder or autism  by a licensed physician and
surgeon or a licensed psychologist  or any other
appropriately licensed or certified provider  who determines
the care to be medically necessary: 
   (A) Behavioral health treatment.  
   (B) 
    (A)  Pharmacy care  , if the policy includes
coverage for prescription drugs  . 
   (C) 
    (B)  Psychiatric care. 
   (D) 
    (C)  Psychological care. 
   (E) 
    (D)  Therapeutic care. 
   (F) Any care for individuals with autism spectrum disorders that
is demonstrated, based upon best practices or evidence-based
research, to be medically necessary.  
   (8) "Treatment for pervasive developmental disorder or autism"
does not include behavioral health treatment, as defined in Section
10144.51. 
   (j) This section, with the exception of subdivision (b), shall not
apply to dental-only or vision-only 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.