BILL ANALYSIS Ó
AB 1231
Page 1
Date of Hearing: April 30, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 1231 (V. Manuel Pérez) - As Amended: April 24, 2013
SUBJECT : Regional centers: telehealth and teledentistry.
SUMMARY : Requires the Department of Developmental Services
(DDS) to inform regional centers that behavioral health
treatment and dentistry may be provided through telehealth and
teledentistry, respectively, and makes other changes to promote
the use of telehealth and teledentistry in the regional center
system. Specifically, this bill :
1)Requires DDS to do all of the following:
a) Inform all regional centers that behavioral health
treatment may be provided through the use of telehealth;
b) Inform all regional centers that dentistry may be
provided through the use of teledentistry;
c) Request regional centers to include a consideration of
telehealth and teledentistry in each individual program
plan (IPP) and individualized family service plan (IFSP)
that includes a discussion of behavioral health treatment
or dental health care; and
d) Provide, using existing resources, and in partnership
with other organizations, resources, and stakeholders,
technical assistance to regional centers regarding the use
of telehealth and teledentistry.
2)Requires the use of telehealth and teledentistry to be
considered for inclusion in training programs for parents,
including group training programs that are provided in lieu of
in-home parent training, as specified.
3)Authorizes DDS to implement appropriate vendorization subcodes
for telehealth and teledentistry services and programs.
4)Requires providers of telehealth and teledentistry services to
maintain the privacy and security of all confidential consumer
information.
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5)Provides that telehealth and teledentistry services must be
received voluntarily and may be discontinued upon request, as
specified, and requires regional centers to subsequently
convene a review to determine alternative, appropriate means
for providing the service.
6)Requires DDS, by December 1, 2017, to forward to the fiscal
and appropriate policy committees of the Legislature any
information provided by the regional centers on the
effectiveness and appropriateness of providing telehealth and
teledentistry services to regional center consumers, as
specified.
7)Requires telehealth or teledentistry providers to be
responsible for all expenses and costs related to equipment,
transmission, storage, infrastructure, and other related
expenses.
8)Defines "teledentistry" as the use of information technology
and telecommunications for dental care, consultation,
education, and public awareness in the same manner as
described in the current law definition of telehealth.
9)Includes a sunset date of January 1, 2019.
10)States legislative intent to do all of the following:
a) Improve access to treatments and intervention services
for individuals with autism spectrum disorders (ASD) or
other developmental disabilities and their families in
underserved populations;
b) Provide more cost-effective treatments and intervention
services for individuals with ASD or other developmental
disabilities and their families;
c) Maximize the effectiveness of the interpersonal and
face-to-face interactions that are utilized for the
treatment of individuals with ASD or other developmental
disabilities.
d) Continue maintenance and support of the existing service
workforce for individuals with ASD or other developmental
disabilities; and
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e) Utilize telehealth and teledentistry to improve services
for individuals with ASD and other developmental
disabilities;
11)Includes legislative findings and declarations related to
ASD, its rising incidence rate, the effectiveness of
behavioral health treatment for ASD treatment, and the
significant number of individuals with ASD who suffer from
inadequate dental care.
EXISTING LAW :
1)Defines "telehealth" as the mode of delivering health care
services and public health via information and communication
technologies for diagnosis, consultation, treatment,
education, care management, and self-management while a health
care provider is at a distant site relative to a patient, as
specified.
2)Prohibits health plans and insurers, including Medi-Cal and
the Program for All-Inclusive Care for the Elderly, from
requiring in-person contact between a health care provider and
a patient before paying for covered services appropriately
provided through telehealth, as specified. Prohibits these
health plans and insurers from limiting the type of setting
where services are provided through telehealth, as provided.
3)Requires the State Department of Health Care Services to allow
psychiatrists to receive fee-for-service Medi-Cal
reimbursement for services provided through telehealth in
accordance with the Medicaid state plan.
4)Allows the Medical Board of California to establish a pilot
program to expand the use of telehealth for persons with
chronic diseases.
5)States legislative intent that all medical information
transmitted during the delivery of health care via telehealth
become part of the patient's medical record maintained by the
licensed health care provider.
6)States that all laws regarding the confidentiality of health
care information and a patient's rights to his or her medical
information apply to telehealth interactions.
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7)Existing federal law, the Health Insurance Portability and
Accountability Act, establishes standards to protect
individuals' medical records and other personal health
information and applies to health plans, health care
clearinghouses, and health care providers who transmit any
health information in electronic form, as specified.
8)Requires all health care service plan contracts that provide
hospital, medical, or surgical coverage, and all health
insurance policies, to provide coverage for behavioral health
treatment for pervasive developmental disorder (PDD) or
autism, with specified exceptions.
9)Defines "behavioral health treatment," for purposes of the
requirement in 8) above, as professional services and
treatment programs, including applied behavior analysis and
evidence-based behavior intervention programs, that develop or
restore, to the maximum extent practicable, the functioning of
an individual with PDD or autism and that meet specified
criteria.
10)Requires that behavioral health treatment, for purposes of
the requirement in 8) above, to be provided by a qualified
autism service provider, professional, or paraprofessional, as
specified.
11)Establishes the Lanterman Developmental Disabilities Services
Act (Lanterman Act), under which DDS is authorized to contract
with private non-profit regional centers to provide case
management services and arrange for, or purchase, services
that meet the individual needs and choices of each person with
developmental disabilities, as specified.
12)Grants all individuals with developmental disabilities the
right to treatment and habilitation services and supports in
the least restrictive environment.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . The author of this bill writes that
approximately two-thirds of all new regional center consumers
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are diagnosed with ASD and require 25-40 hours per week of
behavioral health treatment. Additionally, poor dental care
is an ongoing problem for developmentally disabled individuals
whose challenges may prevent them from following typical
dental protocols and increase the likelihood that unfamiliar
faces (dental professionals) and noises (dental tools) will be
difficult to tolerate. Many regional center consumers do not
have adequate access to behavioral health treatment and dental
care. When regional center consumers forego dental care or
sufficient hours of behavioral health treatment, the cost to
the state is significant. Often, the author writes,
telehealth is a viable, affordable alternative to in-person
care and treatment.
According to the Center for Autism and Related Disorders, this
bill's sponsor, it is the experience of providers that
regional centers are reluctant to integrate telehealth into
their treatment models without explicit authorization from the
DDS. Therefore, this bill's provisions are intended to
facilitate the adoption of telehealth, for the delivery of
behavioral health treatment, and teledentistry in the regional
center system.
2)BACKGROUND .
a) Lanterman Act . The Lanterman Act entitles
developmentally disabled individuals (commonly referred to
as "consumers") to treatment and habilitation services and
supports in the least restrictive environment. Lanterman
Act services are designed to enable all consumers to live
more independent and productive lives in the community.
Direct responsibility for implementation of the Lanterman
Act service system is shared by DDS and 21 regional
centers, which are private nonprofit entities that contract
with DDS to carry out many of the state's responsibilities
under the Lanterman Act. The principal roles of regional
centers include intake and assessment, IPP development,
case management, and securing services through generic
agencies (e.g., school districts, In-Home Supportive
Services) or by purchasing services provided by vendors.
Regional centers also share primary responsibility with
local education agencies for provision of early
intervention services under the California Early
Intervention Services Act. The regional center caseload
includes over 250,000 consumers who receive services such
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as residential placements, supported living services,
respite care, transportation, day treatment programs, work
support programs, and various social and therapeutic
activities.
Services provided to people with developmental disabilities
are determined through the IPP process. Under this
process, planning teams, which include, among others, the
consumer, his or her legally authorized representative, and
one or more regional center representatives, jointly
prepare an IPP based on the consumer's needs and choices.
The Lanterman Act requires that the IPP promote community
integration and maximize opportunities for each consumer to
develop relationships, be part of community life, increase
control over his or her life, and acquire increasingly
positive roles in the community. The IPP must give the
highest preference to those services and supports that
allow minors to live with their families and adults to live
as independently as possible in the community.
b) Access to Regional Center Services . On April 12, 2012,
the Senate Select Committee on Autism and Related Disorders
held an informational hearing, "Ensuring Fair & Equal
Access to Regional Center Services for Autism Spectrum
Disorders." Testimony addressed disparities, including
racial and ethnic disparities, in access to regional center
services, often based on where in the state the consumer
lives. Access issues exist particularly within low-income
communities or rural areas where services may not exist, or
where other barriers, such as inadequate transportation,
are common.
c) Parent Training through Telehealth . Studies have begun
to show that telehealth may be an efficacious delivery
method for behavioral health treatment for ASD. For
example, a study published in 2012 (Laurie A. Vismara,
Gregory S. Young, and Sally J. Rogers. "Telehealth for
Expanding the Reach of Early Autism Training to Parents."
Autism research and treatment 2012) provided parents of
children diagnosed with autism or PDD with training using
an Internet-based, password-protected video-conferencing
program. This technology allowed the therapist and parents
to see, hear, and communicate with one another in real
time. Researchers trained parents over 12 sessions in the
Early Start Denver Model (ESDM), a behavioral intervention
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for infants to preschool-aged children with ASD that
integrates applied behavior analysis with developmental and
relationship-based approaches. The study found that
parents, on average, achieved "fidelity in the ESDM" after
six weeks of telehealth training, similar to the findings
of a study that provided parents with ESDM training in
person. Moreover, the study found a significant increase
in parent and child engagement and in children's social and
communicative behaviors over the course of the 12 sessions.
d) Virtual Dental Homes . In July 2012, researchers at the
University of the Pacific School of Dentistry reported on
the preliminary phase of a demonstration project that is
studying the efficacy of providing dental services through
telehealth using a model called "virtual dental homes."
(Paul Glassman, et al. "The virtual dental home: bringing
oral health to vulnerable and underserved populations."
Journal of the California Dental Association 2012). The
virtual dental home is a community-based oral health
delivery system in which people receive preventive and
early intervention therapeutic services or receive
educational, social, or general health services using
telehealth technology to link allied dental personnel
(registered dental hygienists in alternative practice,
registered dental hygienists working in public health
programs, and registered dental assistants) in the
community with dentists at remote office sites. There are
nine sites currently operating this model of care in
California (two elementary schools in Sacramento and San
Diego counties, a consortium of Head Start centers in San
Francisco and San Diego, residential facilities associated
with three regional centers for persons with developmental
disabilities, four long-term care facilities, and one
community clinic).
The report indicates that more than 750 patients have been
enrolled in the project. Of these, 40% are children, 24%
are adults in rural or low-income communities, 17% are
patients in long-term care facilities, and 15% are disabled
adults living in residential care settings. According to
the report, dentists have determined that almost half of
the patients seen to date can be kept healthy through the
services of the allied dental personnel performing
preventive and early intervention services in the
community. The other half are being referred to dental
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offices or clinics for the services only dentists can
provide. The report maintains that this project has begun
the process of normalizing daily oral care and emphasizing
the importance of oral health. The demonstration project
will continue through December 1, 2013. According to the
Office of Statewide Health Planning and Development, which
authorized the project, a thorough evaluation of the
project will be done when the project is completed.
3)SUPPORT . The Center for Autism and Related Disorders (CARD),
the sponsor of this bill, writes that telehealth is a powerful
tool in the effort to increase access to cost-effectiveness of
behavioral health treatment and some dental services and to
overcome obstacles inherent in providing behavioral health
treatment and dental services to low-income and underserved
Californians, as well as those individuals living in more
remote areas. CARD states that successful implementation of
effective and efficient telehealth services can help address
issues of provider shortages, transportation costs, and lost
time from work and school. CARD maintains that this bill
offers a way to increase access to vital healthcare, maintain
a high standard of care, and decrease transportation costs
that are crippling regional center budgets. Moreover, when
children with ASD have access to the care they need earlier,
they are more likely to fulfill their potential and become
contributing members of society.
The Special Needs Network (SNN), in support, writes that the
federal Centers for Disease Control and Prevention recently
announced an estimate that the prevalence of ASD has increased
to one in 50 U.S. schoolchildren. Low-income and minority
children are especially vulnerable, and regional center
services are often the only option to manage or improve their
conditions. SNN believes that this bill will offer more
flexibility to struggling regional center consumers, reduce
costs to both the family and the state, and continue to
provide quality service to the child.
4)RELATED LEGISLATION .
a) AB 809 (Logue), pending the Assembly Business,
Professions, and Consumer Protection Committee, would
replace a verbal consent requirement that applies to health
care providers prior to the delivery of health care via
telehealth with a requirement to obtain a waiver for
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treatment involving telehealth services.
b) AB 318 (Logue), pending in the Assembly Health
Committee, would authorize Medi-Cal payments for
teledentistry services provided to individuals
participating in the Medi-Cal program.
c) AB 1174 (Bocanegra), pending in the Assembly Health
Committee, would expand duties of registered dental
assistants (RDAs), RDAs in extended functions, and
registered dental hygienists, and would authorize Medi-Cal
payments for teledentistry services provided to individuals
participating in the Medi-Cal program.
d) SB 126 (Steinberg), pending in the Senate Health
Committee, would extend the sunset on the requirement for
health plans and insurers to cover behavioral health
treatment for autism or PDD until July 1, 2019.
e) SB 163 (Hueso), pending in the Senate Appropriations
Committee, would require a regional center to pay any
applicable co-payment, co-insurance, and deductible imposed
by a health insurance policy or health care service plan
for a service or support required by a consumer's IPP or
IFSP, as specified, and would prohibit regional centers
from charging or seeking reimbursement for these costs.
f) SB 784 (Fuller), pending in the Senate Rules Committee,
would require the team developing an IPP or an IFSP to
consider the consumer's, and his or her family's, needs
related to issues that include nontraditional service
hours, flexibility regarding treatment settings, parental
participation requirements, and the scope of services
available for adult consumers, and the use of treatment
interventions, including, among others, center-based
intensive behavioral interventions, as defined.
5)PREVIOUS LEGISLATION .
a) SB 764 (Steinberg) of 2012 would have required each IPP
team to consider the use of telehealth whenever applicable
for the purpose of improving access to intervention and
therapeutic services and facilitating better and
cost-effective services, as specified. SB 764 was vetoed
by Governor Brown. The Governor's veto message read, "I
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appreciate the author's desire to bring more efficiency to
regional centers as well as promote the value of
telehealth. The goals of this bill, however, can already
be accomplished under existing law. Mandating every
individual program planning team to consider telehealth
appears excessive. Where beneficial and available, I
expect they will consider it, without the state telling
them to do so."
b) SB 1050 (Alquist) of 2012 would have required DDS to
establish an autism telehealth taskforce to be administered
and led by a public or nonprofit entity responsible for the
activities and work of the taskforce, would have provided
that the lead administrator appoint members of the
taskforce who have knowledge or experience, as specified,
and would have required the taskforce to provide technical
assistance and recommendations in the area of telehealth
services for individuals with ASD, as specified. SB 1050
was vetoed by Governor Brown. The Governor's veto message
said, "I am returning SB 1050 without my signature. Last
year I signed AB 415 (Logue), the Telehealth Advancement
Act of 2011, to update our statutes on the use of
telehealth. As we work to improve and modernize our health
care system, we can expect telehealth to play an
increasingly prominent role in rural and urban areas, for
many diseases and conditions. Such advancements and
collaboration are occurring now, and a privately funded,
disease-specific task force set forth in statute does not
appear to be warranted."
c) AB 1733 (Logue), Chapter 782, Statutes of 2012, updates
several code sections to replace the term "telemedicine"
with "telehealth" and expands the potential for the use of
telehealth in additional health care programs administered
by the Department of Health Care Services such as the
Program of All-Inclusive Care for the Elderly.
d) AB 171 (Beall) of 2011 would have required health plans
and insurers to provide coverage for behavioral health
treatment for autism or PDD. AB 171 died in the Senate
Health Committee without a hearing.
e) AB 415 (Logue), Chapter 547, Statutes of 2011,
establishes the Telehealth Advancement Act of 2011 to
revise and update existing law to facilitate the
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advancement of telehealth as a service delivery mode in
managed care and the Medi-Cal program.
f) SB 166 (Steinberg) of 2011 would have required health
care service plans and health insurers to provide coverage
for behavioral health treatment for autism or PDD. SB 166
died in the Senate Health Committee without a hearing.
g) SB 946 (Steinberg and Evans), Chapter 650, Statutes of
2011, requires health plans and health insurance policies
to cover behavioral health therapy for PDD or autism,
requires plans and insurers to maintain adequate networks
of autism service providers, and establishes an Autism
Advisory Task Force in the Department of Managed Health
Care.
h) AB 329 (Nakanishi), Chapter 386, Statutes of 2007,
authorizes the Medical Board of California (MBC) to
establish a pilot program to expand the practice of
telemedicine and to convene a working group. AB 329
specifies that the purpose of the pilot program is to
develop methods, using a telemedicine model, of delivering
health care to those with chronic diseases and delivering
other health information, and requires MBC to make
recommendations regarding its findings to the Legislature
within one calendar year of the commencement date of the
pilot program. MBC reports that this pilot program is
currently commencing.
i) AB 1224 (Hernandez), Chapter 507, Statutes of 2007, adds
optometrists to the list of health care providers covered
under laws governing telemedicine services.
j) SB 1665 (Thompson), Chapter 864, Statutes of 1996,
establishes the Telemedicine Development Act (TDA) to set
standards for the use of telemedicine by health care
practitioners and insurers. TDA specifies, in part, that
face-to-face contact between a health care provider and a
patient shall not be required under the Medi-Cal program
for services appropriately provided through telemedicine,
when those services are otherwise covered by the Medi-Cal
program, and requires a health care practitioner to obtain
verbal and written consent prior to providing services
through telemedicine.
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6)DOUBLE REFERRAL . This bill has been double-referred. It
passed the Assembly Committee on Human Services with a vote of
7-0 on April 16, 2013.
7)SUGGESTED AMENDMENTS :
a) This bill defines "teledentistry" as "the use of
information technology and telecommunications for dental
care, consultation, education, and public awareness in the
same manner as described in paragraph (6) of subdivision
(a) of Section 2290.5 of the Business and Professions Code
[the current law definition of telehealth]." This contains
some redundant terminology and includes "public awareness,"
which is not currently a part of the definition of
telehealth. To eliminate redundancy and improve
consistency, the Committee may wish to amend this bill to
change the definition of "teledentistry" to "telehealth
used to deliver dental health care services and public
dental health."
b) This bill defines "behavioral health treatment" by
referencing a code section that only applies to individuals
with autism or PDD. In contrast, this bill's provisions
related to teledentistry are not similarly restrictive.
Because access issues and disparities do not exist only for
regional center consumers with autism or PDD, the Committee
may wish to amend this bill to provide a definition of
"behavioral health treatment" that is not limited to
treatment of autism and PDD.
c) This bill requires providers of telehealth and
teledentistry services to maintain the privacy and security
of all confidential consumer information. Under current
law, all laws regarding the confidentiality of health care
information and a patient's rights to his or her medical
information apply to telehealth interactions, making this
bill's requirement related to privacy and security of
confidential information unnecessary. Therefore, the
Committee may wish to amend this bill to strike the
requirement for privacy and security.
d) This bill requires DDS to request regional centers to
consider telehealth and teledentistry in the IPP/IFSP
process. This bill also requires regional centers to
consider telehealth and teledentistry in training programs
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for parents in the IPP/IFSP process. For consistency, the
Committee may wish to amend this bill to require DDS to
request regional centers to consider telehealth and
teledentistry in training programs for parents.
REGISTERED SUPPORT / OPPOSITION :
Support
Center for Autism and Related Disorders (sponsor)
ACT Today!
Association of Regional Center Agencies
Autism Research Group
Children's Partnership
Institute for Behavioral Training
Law Offices of Bonnie Z. Yates, Inc.
Special Needs Network
One individual
Opposition
None on file.
Analysis Prepared by : Ben Russell / HEALTH / (916) 319-2097