BILL ANALYSIS Ó
AB 2299
Page A
ASSEMBLY THIRD READING
AB 2299 (Nazarian)
As Amended May 23, 2014
Majority vote
HUMAN SERVICES 6-0 APPROPRIATIONS 13-0
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|Ayes:|Stone, Maienschein, |Ayes:|Gatto, Bocanegra, |
| |Ammiano, | |Bradford, |
| |Ian Calderon, Garcia, | |Ian Calderon, Campos, |
| |Hall | |Eggman, Gomez, Holden, |
| | | |Linder, Pan, Quirk, |
| | | |Ridley-Thomas, Weber |
|-----+--------------------------+-----+--------------------------|
| | | | |
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SUMMARY : Deletes the means test related to a regional center's
authority to pay applicable copayments and coinsurance necessary
to ensure a consumer can receive services and supports
identified in his or her individual program plan (IPP) or
individualized family service plan (IFSP). Specifically, this
bill :
1)Deletes the requirement that a regional center only pay the
applicable coinsurance or copayment associated with services
in a 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 if the consumer or his or her family's gross income
is less than 400% of the federal poverty level. Deletes the
associated requirements to self-certify gross income
information and 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.
2)Authorizes a regional center to pay a deductible associated
with a service provided to the consumer that is paid for by
the health care service plan or health insurance policy of the
consumer or the consumer's parent, guardian, or caregiver only
if the service or support is necessary to keep the child
consumer at home or the adult consumer in the least
restrictive setting and payment of the deductible is not
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feasible, as specified, for the consumer or the consumer's
parent, guardian, or caregiver.
EXISTING LAW :
1)Establishes an entitlement to services for individuals with
developmental disabilities under the Lanterman Developmental
Disabilities Services Act (Lanterman Act). (Welfare and
Institutions Code (WIC) Section 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 Section 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 Section 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 Section 4512)
5)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. (Government Code Section 95020)
1)Requires regional centers to identify and pursue all possible
sources of funding for consumers receiving regional center
services, as specified. (WIC Sections 4659 (a) and (b))
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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 Section 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
provides that coverage for such treatment shall not affect
services for which a regional center consumer is otherwise
eligible. (Health and Safety Code Section 1374.73, Insurance
Code Section 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 Sections 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 Section
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
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payment of copayments or coinsurance. (WIC Sections 4659.1
(d) and (e))
7)Prohibits regional centers from paying health care service
plan or health insurance policy deductibles. (WIC Section
4659.1(g))
FISCAL EFFECT : According to the Assembly Appropriations
Committee:
1)Potential ongoing costs in the range of $2 to $4 million
(General Fund (GF)) to pay for additional regional center
consumers' health insurance copayments/coinsurance.
2)Potential ongoing costs in the low millions (GF) to pay for
regional center consumers' health insurance deductibles.
3)Unknown, ongoing administrative costs (GF) to manage payments
to families or insurance companies and health plans by the
regional centers.
COMMENTS : This bill seeks to reduce financial hardship for
regional center consumers receiving services that are covered
under health care service plans or health insurance policies by
deleting the prohibition on regional centers paying copayments
and coinsurance for such services based on the financial means
of the consumer or his or her family.
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
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individuals with an intellectual disability.
Regional centers: Direct responsibility for implementation of
the Lanterman Act service system is shared by the 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 21 regional centers throughout the state serve over
270,000 consumers who receive services such as residential
placements, supported living services, respite care,
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 IPP
based on the consumer's needs and choices that promotes
community integration and maximizes 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
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and/or interests. ASD is one of the commonly-used terms to
describe the various "autisms" and other PDDs, 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
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 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,
Statutes 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
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<1> http://www.cdc.gov/ncbddd/autism/data.html
<2>
http://www.dds.ca.gov/FactsStats/docs/QR/March2014_Quarterly.pdf
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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
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
eliminates the means-test for regional center payment of
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copayments and coinsurance, which would otherwise be
out-of-pocket expenses for consumers and their families, the
most controversial issue in recent years has been the desire to
allow regional centers to also pay consumers' deductibles for
services covered by health plans and health insurance. 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
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 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."
Analysis Prepared by : Myesha Jackson / HUM. S. / (916)
319-2089
FN: 0003830