BILL ANALYSIS Ó
AB 2299
Page A
Date of Hearing: April 29, 2014
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Mark Stone, Chair
AB 2299 (Nazarian) - As Amended: March 28, 2014
SUBJECT : Developmental services: health insurance copayments
SUMMARY : Requires a regional center to pay applicable
copayment, coinsurance, and deductibles needed to ensure a
regional center consumer can receive necessary services and
supports identified in his or her individual program plan (IPP)
or individualized family service plan (IFSP).
Specifically, this bill :
1)Requires a regional center to pay the applicable coinsurance,
copayment, or deductible associated with services in the
consumer's IPP or IFSP that are paid for, in whole or in part,
by the health care service plan or health insurance policy of
the consumer or the consumer's parent, guardian, or caregiver
or the adult consumer, provided that the consumer is covered
by his or her own health care service plan or insurance
policy, or that of his or her parent, guardian, or caregiver,
and provided that no other third party has liability for the
cost of the service or support, as specified.
2)Deletes the requirement that a regional center only pay an
applicable copayment or coinsurance if the consumer or the
consumer's family's gross income is less than 400% of the
federal poverty level, and deletes the associated requirements
to self-certify gross income information or provide regional
centers with information related to changes in income that
would cause a change in eligibility for regional center
payment of a copayment or coinsurance.
3)Deletes the requirement that, in cases where the gross income
of the consumer or the consumer's family exceeds 400% of the
federal poverty level, a regional center only pay an
applicable copayment or coinsurance for a consumer if the
payment is necessary to maintain a child at home or an adult
consumer in the least restrictive setting and the parents or
consumer meet certain hardship criteria, as specified.
4)Deletes the prohibition against a regional center paying a
AB 2299
Page B
health care service plan or health insurance policy
deductible.
5)Provides that a regional center may directly provide a service
or support in lieu of paying a copayment, coinsurance, or
deductible if the cost of a copayment, coinsurance, or
deductible exceeds the cost of directly providing the
associated service or support.
EXISTING LAW
1)Establishes an entitlement to services for individuals with
developmental disabilities under the Lanterman Developmental
Disabilities Services Act (Lanterman Act). (WIC 4500 et seq.)
2)Grants all individuals with developmental disabilities, among
all other rights and responsibilities established for any
individual by the United States Constitution and laws and the
California Constitution and laws, the right to treatment and
habilitation services and supports in the least restrictive
environment. (WIC 4502)
3)Establishes a system of 21 nonprofit regional centers
throughout the state to identify needs and coordinate services
for eligible individuals with developmental disabilities and
requires the Department of Developmental Services (DDS) to
contract with regional centers to provide case management
services and arrange for or purchase services that meet the
needs of individuals with developmental disabilities, as
defined. (WIC 4620 et seq.)
4)Requires the development of an IPP for each regional center
consumer, which specifies services to be provided to the
consumer, based on his or her individualized needs
determination and preferences, and defines that planning
process as the vehicle to ensure that services and supports
are customized to meet the needs of consumers who are served
by regional centers. (WIC 4512)
5)Requires the IPP planning processes to include:
a) A statement of the individual's goals and objectives, a
schedule of the type and nature of services to be provided
and other information and considerations, as specified;
AB 2299
Page C
b) Review and modification, as necessary, by the regional
center's planning team no less frequently than every three
years; and
c) Statewide training and review of the IPP plan creation,
as specified. (WIC 4646.5)
1)Establishes that an infant or toddler under age 3 who is
eligible for regional center services shall have an IFSP to
direct services, as specified, and defines the types of
services, supports and staffing that should be considered when
creating the plan. (GOV 95020)
2)Authorizes regional centers to solicit an individual or agency
through a request for proposals or other means to provide
needed services or supports not presently available, provided
it is necessary to expand the availability of needed services
of good quality. (WIC 4648(e)(1))
3)Prohibits a regional center from providing direct treatment
and therapeutic services to a consumer and instead requires
the utilization of appropriate public and private community
agencies and service providers to obtain those services for
its consumers, except in emergency situations. (WIC 4648 (f))
4)Requires regional centers to provide the consumer, his or her
parent, legal guardian, or other appropriate authorized
representative, as specified, at least annually, a statement
of services and supports the regional center purchased, for
the purpose of ensuring that the services are delivered. (WIC
4648(h))
1)Requires regional centers to identify and pursue all possible
sources of funding for consumers receiving regional center
services, as specified. (WIC 4659 (a) and (b))
2)Prohibits a regional center from purchasing a service that
would otherwise be available from a health care service plan
or private insurance when a consumer or family meets the
criteria for coverage but chooses not to pursue that coverage.
(WIC 4659 (c))
3)Requires health care service plan contracts and health
insurance policies to cover behavioral health treatment for
pervasive developmental disorder or autism, as specified, and
AB 2299
Page D
provides that coverage for such treatment shall not affect
services for which a regional center consumer is otherwise
eligible. (H&S 1374.73, INS 10144.51)
4)Authorizes a regional center to, when it is necessary to
ensure a consumer receives a service or support, pay the
coinsurance or copayment associated with services in the
consumer's IPP or IFSP that are paid for, in whole or in part,
by the health care service plan or health insurance policy of
the consumer's parent, guardian, or caregiver or the adult
consumer, provided that the gross income of the family or the
consumer does not exceed 400% of the federal poverty level and
other specified criteria are met. (WIC 4659.1 (a) and (b))
5)Authorizes a regional center to, when it is necessary to
ensure a consumer receives a service or support, pay the
coinsurance or copayment associated with services in the
consumer's IPP or IFSP that are paid for, in whole or in part,
by the health care service plan or health insurance policy of
the consumer's parent, guardian, or caregiver or the adult
consumer, in cases where the gross income of the family or the
consumer exceeds 400% of the federal poverty level if the
service or support is necessary to successfully maintain the
child at home or the adult consumer in the least-restrictive
setting and other specified criteria are met. (WIC 4659.1
(c))
6)Requires the parent, guardian, or caregiver of a consumer, or
an adult consumer with a health care service plan or health
insurance policy to self-certify the family's gross annual
income to the regional center, as specified, and to notify the
regional center when a change in income occurs that would
change in the consumer's eligibility for regional center
payment of copayments or coinsurance. (WIC 4659.1 (d) and
(e))
7)Prohibits regional centers from paying health care service
plan or health insurance policy deductibles. (WIC 4659.1 (g))
FISCAL EFFECT : Unknown
COMMENTS : This bill seeks to ensure regional center consumers
have full access to services and supports included in their IPPs
and IFSPs that are covered by health care service plans or
health insurance policies by requiring regional centers to pay
AB 2299
Page E
for a consumer's applicable copayment, coinsurance, or
deductible payment, regardless of the consumer's financial
situation.
Background : The Lanterman Act guides the provision of services
and supports for Californians with developmental disabilities.
Each individual under the Act, typically referred to as a
"consumer," is legally entitled 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.
The term "developmental disability" means a disability that
originates before an individual attains 18 years of age, is
expected to continue indefinitely, and constitutes a substantial
disability for that individual. It includes intellectual
disabilities, cerebral palsy, epilepsy, and pervasive
developmental disorder/autism spectrum disorder (PDD/ASD).
Other developmental disabilities are those disabling conditions
similar to an intellectual disability that require treatment
(i.e., care and management) similar to that required by
individuals with an intellectual disability. This does not
include conditions that are solely psychiatric or physical in
nature, and the conditions must occur before age 18, result in a
substantial disability, be likely to continue indefinitely, and
involve brain damage or dysfunction. Examples of conditions
might include intracranial neoplasms, degenerative brain disease
or brain damage associated with accidents.
Direct responsibility for implementation of the Lanterman Act
service system is shared by the Department of Developmental
Services (DDS) and 21 regional centers, which are private
nonprofit entities, established pursuant to the Lanterman Act,
that contract with DDS to carry out many of the state's
responsibilities under the Act. The principal roles of regional
centers include intake and assessment, individualized program
plan development, case management, and securing services through
generic agencies or 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.
Regional centers : The 21 regional centers throughout the state
serve over 260,000 consumers who receive services such as
residential placements, supported living services, respite care,
AB 2299
Page F
transportation, day treatment programs, work support programs,
and various social and therapeutic services and activities.
Approximately 1,300 consumers reside at one of California's four
Developmental Centers-and one state-operated, specialized
community facility-which provide 24-hour habilitation and
medical and social treatment services.
Services provided to people with developmental disabilities are
determined through an individual planning 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
Individual Program Plan (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.
Autism Spectrum Disorders : Defined as a group of
neurodevelopmental disorders linked to atypical biology and
chemistry in the brain that generally appears within the first
three years of life, autism is a growing epidemic among
children. While there are many "autisms," the diagnosis is
often characterized by delayed, impaired or otherwise atypical
verbal and social communication skills, sensitivity to sensory
stimulation, atypical behaviors and body movements, and
sensitivity to changes in routines. Although symptoms and
severity differ among individuals with an autism diagnosis, all
individuals affected by the disorder have impaired communication
skills, difficulties initiating and sustaining social
interactions and restricted, repetitive patterns of behavior
and/or interests. Autism spectrum disorder (ASD), is one of the
commonly-used terms to describe the various "autisms" and other
pervasive developmental disorders (PDD), and it more
appropriately captures the array of symptoms and varying levels
in the severity of symptoms experienced by individuals with a
diagnosis within ASD.
Information released in March 2014 by the Centers for Disease
Control (CDC) Autism and Developmental Disabilities Monitoring
(ADDM) Network, estimates prevalence of ASD for children born in
AB 2299
Page G
2002 and surveyed in 2010 to be 14.7 per 1,000 children, which
translates to one in 68 children. This is a drastic increase
from CDC data for children born in 2000 and surveyed in 2008,
which estimated the prevalence of children with ASD to be one in
88. Average prevalence for children surveyed in 2006 was one in
110 children. ASD continues to be five times more prevalent for
boys than for girls.<1>
March 2014 DDS data shows that 65,706 regional center consumers
have an autism diagnosis, which is more than double the number
of individuals with the same diagnosis served by regional
centers in 2006. An additional 4,562 regional center consumers
are on the autism spectrum with a diagnosis of pervasive
developmental disorder (PDD). Among the individuals with
ASD/PDD served by the regional centers, 12,481 are female and
57,787 are male, and nearly 40% of the population with an autism
or PDD diagnosis is 0 to 9 years old.<2>
Insurance coverage of behavioral health treatment for autism :
In 2011, Governor Brown signed SB 946 (Steinberg), Chapter 650,
Statute of 2011, which required health care service plans and
health insurance companies in California to begin covering
behavioral health treatment for pervasive developmental
disorders or autism by July 1, 2012. State law defines
behavioral health treatment, for purposes of the coverage
mandate, as professional services and treatment programs,
including applied behavior analysis (ABA) and evidence-based
behavior intervention programs, that develop or restore, to the
maximum extent practicable, the functioning of an individual
with pervasive developmental disorder or autism and that meet
specified criteria related to who prescribes and provides the
treatment. The delivery of behavioral health treatment is
varied based on a consumer's needs and can be delivered in a
one-to-one or small group format based on the appropriateness
for the individual(s) being treated. The coverage mandate
resulted in savings to the state, as regional centers were
required to purchase most behavioral health services provided
for in consumers' IPPs and IFSPs prior to passage of the
mandate.
As insurers and health plans began paying for services pursuant
to SB 946 requirements, some families reported their inability
---------------------------
<1> http://www.cdc.gov/ncbddd/autism/data.html
<2>
http://www.dds.ca.gov/FactsStats/docs/QR/March2014_Quarterly.pdf
AB 2299
Page H
to access the amount of behavioral services approved in the
consumer's IPP or IFSP due to the out-of-pocket expenses related
to the insurance coverage. The copayments paid by the insured
directly to the health care provider for each service or visit,
the coinsurance paid by the insured for services in excess of
what the policy covers, and deductibles associated with the
treatments covered in their policies, became too costly for some
families. In response to this emerging issue, most regional
centers paid copayments and deductibles on a discretionary basis
when a regional center determined that payment was critical for
a consumer to receive the necessary and approved treatment and
services. However, due to the varied practices around
copayments and deductibles between regional centers, DDS argued
that statutory clarification was necessary to establish a clear
statewide policy.
As a result, the developmental services trailer bill included in
the 2013-14 state Budget Act (AB 89, Chapter 25, Statutes of
2013) provided increased funding to regional centers for the
payment of copayments and coinsurance tied to services in a
consumer's IPP or IFSP covered by health plans and insurance
policies for cases in which the adult consumer, or the family of
a consumer, has income at or below 400% of the federal poverty
level and there is no third party responsible for payment.
Trailer bill language also provided some flexibility for the
payment of copayments and coinsurance for adult consumers or
child consumers in families with income above 400% of FPL under
extraordinary circumstances and when needed to successfully
maintain the child at home or adult consumer in the least
restrictive setting. The trailer bill prohibited regional
center payment of health care service plan and health insurance
policy deductibles.
Regional center payment of deductibles : While this bill seeks
to eliminate the means-test for regional center payments for
what would otherwise be out-of-pocket expenses for consumers
receiving IPP- and IFSP-approved services paid for by health
plans and health insurers, the most controversial issue in
recent years has been the requirement for regional centers to
also pay consumers' deductibles for such services. During
budget conversations leading to passage of the 2013-14
developmental services trailer bill, DDS indicated that
administering deductible coverage could be more complex than
copayments and coinsurance because deductibles are not as
directly linked to utilization of a specific service that is
AB 2299
Page I
included in an IPP or IFSP and may apply to an entire family,
not just the developmental services consumer. Some stakeholders
have disagreed with this characterization, indicating that
billings for deductibles can, and sometimes already do, specify
both the service and the recipient of that service.
Need for this bill : Prior to the insurance and health plan
coverage mandate for certain behavioral health treatment,
regional centers were obligated to pay the full cost of those
services if they were included in consumers' IPPs and IFSPs.
The author notes that since the passage of the developmental
services trailer bill in 2013, families have been required to
pay for services that used to be free to them. The author
states:
"There have been several challenges to AB 89 at the Office of
Administrative Hearings (OAH) by families who cannot afford the
co-pay or deductible. In those cases, judges have consistently
sided with families and have required the regional center to
either pay the cost of the co-payment or the full cost of
treatment, if the family cannot afford the deductible? [This
bill] reverses the AB 89 policy and reinstates the entitlement
of the Lanterman Act by expressly requiring regional centers to
pay for co-payments, coinsurance and deductibles for individuals
with developmental disabilities. This bill ensures that
regional center families will no longer be discouraged from
obtaining insurance or incentivized to drop their existing
health plan. [This bill] will allow regional centers to
continue to access private insurance dollars, minimizing their
fiscal obligation, while ensuring access for families."
PROPOSED AMENDMENTS
Current law prohibits regional centers from providing direct
treatments or therapeutic services to consumers (WIC 4648 (f)).
However, the provisions in this bill allow a regional center to
directly provide a service or support if the cost of providing
the service or support is less than paying for the copayment,
coinsurance, or deductible payment for that service or support.
To clarify this provision in the bill while maintaining the
requirement that a regional center only provide direct treatment
in emergency situations, committee staff recommends the
following amendments:
Page 4
AB 2299
Page J
22 (b)Notwithstanding subdivision (a), if the cost of a
copayment,
23 coinsurance, or deductible payment associated with a
service or
24 support is more than the cost of directly providing
purchasing the service or
25 support, a regional center may directly provide purchase
the service or
26 support in lieu of paying the copayment, coinsurance, or
deductible
27 payment.
PRIOR LEGISLATION
SB 163 (Hueso) 2013 would have required regional centers to pay
any copayment, coinsurance, or deductible required under a
health plan or health insurance policy that provides coverage
for services included in a regional center consumer's Individual
Program Plan or Individualized Family Service Plan. The bill
was held on suspense in the Senate Appropriations Committee.
SB 946 (Steinberg) Chapter 650, Statutes of 2011, required
health care service plans and health insurance policies to
provide coverage for behavioral health treatment for autism and
related disorders, as specified.
SB 166 (Steinberg) 2011, would have required health care service
plans licensed by the Department of Managed Health Care (DMHC)
and health insurers licensed by the Department of Insurance
(DOI) to provide coverage for behavioral intervention therapy
for autism. It was held in the Senate Health Committee.
SB 770 (Steinberg and Evans) 2011, required health plans and
insurers, except plans that contracted with Medi-Cal, to provide
coverage for behavioral health treatment and to permit licensed
or unlicensed providers to provide services. Held in the
Assembly Appropriations Committee.
REGISTERED SUPPORT / OPPOSITION :
Support
AB 2299
Page K
Autism Speaks
Center for Autism and Related Disorders (CARD)
California State Council on Developmental Disabilities
Steering Committee of the Alliance of California Autism
Organizations (ACAO) co-sponsor
Opposition
None on file.
Analysis Prepared by : Myesha Jackson / HUM. S. / (916)
319-2089