Senate Bill No. 126

Introduced by Senator Steinberg

January 22, 2013

An act to amend Section 1374.73 of the Health and Safety Code, and to amend Sections 10144.51 and 10144.52 of the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

SB 126, as introduced, Steinberg. Health care coverage: pervasive developmental disorder or autism.

Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide benefits for specified conditions, including coverage for behavioral health treatment, as defined, for pervasive developmental disorder or autism, except as specified. A willful violation of these provisions with respect to health care service plans is a crime. These provisions are inoperative on July 1, 2014, and are repealed on January 1, 2015.

This bill would extend the operation of these provisions until July 1, 2019, and would repeal these provisions on January 1, 2020. By extending the operation of provisions establishing crimes, 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.

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 of the Health and Safety Code
is amended to read:

1374.73.  

(a) (1) Every health care service plan contract that
provides hospital, medical, or surgical coverage shall also provide
coverage for behavioral health treatment for pervasive
developmental disorder or autism no later than July 1, 2012. The
coverage shall be provided in the same manner and shall be subject
to the same requirements as provided in Section 1374.72.

(2) Notwithstanding paragraph (1), as of the date that proposed
final rulemaking for essential health benefits is issued, 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).

(3) This section shall not affect services for which an individual
is eligible pursuant to Division 4.5 (commencing with Section
4500) of the Welfare and Institutions Code or Title 14
(commencing with Section 95000) of the Government Code.

(4) This section shall not affect or reduce any obligation to
provide services under an individualized education program, as
defined in Section 56032 of the Education Code, or an
begin delete individualized end delete begin insert individual end insert service plan, as described in Section
5600.4 of the Welfare and Institutions Code, or under the
Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400,
et seq.) and its implementing regulations.

(b) Every health care service plan subject to this section shall
maintain an adequate network that includes qualified autism service
providers who supervise and employ qualified autism service
professionals or paraprofessionals who provide and administer
behavioral health treatment. Nothing shall prevent a health care
service plan from selectively contracting with providers within
these requirements.

(c) For the purposes of this section, the following definitions
shall apply:

(1) “Behavioral health treatment” means 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 pervasive developmental disorder or autism and
that meet all of the following criteria:

(A) The treatment is prescribed by a physician and surgeon
licensed pursuant to Chapter 5 (commencing with Section 2000)
of, or is developed by a psychologist licensed pursuant to Chapter
6.6 (commencing with Section 2900) of, Division 2 of the Business
and Professions Code.

(B) The treatment is provided under a treatment plan prescribed
by a qualified autism service provider and is administered by one
of the following:

(i) A qualified autism service provider.

(ii) A qualified autism service professional supervised and
employed by the qualified autism service provider.

(iii) A qualified autism service paraprofessional supervised and
employed by a qualified autism service provider.

(C) The treatment plan has measurable goals over a specific
timeline that is developed and approved by the qualified autism
service provider for the specific patient being treated. The treatment
plan shall be reviewed no less than once every six months by the
qualified autism service provider and modified whenever
appropriate, and shall be consistent with Section 4686.2 of the
Welfare and Institutions Code pursuant to which the qualified
autism service provider does all of the following:

(i) Describes the patient’s behavioral health impairments to be
treated.

(ii) Designs an intervention plan that includes the service type,
number of hours, and parent participation needed to achieve the
plan’s goal and objectives, and the frequency at which the patient’s
progress is evaluated and reported.

(iii) Provides intervention plans that utilize evidence-based
practices, with demonstrated clinical efficacy in treating pervasive
developmental disorder or autism.

(iv) Discontinues intensive behavioral intervention services
when the treatment goals and objectives are achieved or no longer
appropriate.

(D) The treatment plan is not used for purposes of providing or
for the reimbursement of respite, day care, or educational services
and is not used to reimburse a parent for participating in the
treatment program. The treatment plan shall be made available to
the health care service plan upon request.

(2) “Pervasive developmental disorder or autism” shall have
the same meaning and interpretation as used in Section 1374.72.

(3) “Qualified autism service provider” means either of the
following:

(A) A person, entity, or group that is certified by a national
entity, such as the Behavior Analyst Certification Board, that is
accredited by the National Commission for Certifying Agencies,
and who designs, supervises, or provides treatment for pervasive
developmental disorder or autism, provided the services are within
the experience and competence of the person, entity, or group that
is nationally certified.

(B) A person licensed as a physician and surgeon, physical
therapist, occupational therapist, psychologist, marriage and family
therapist, educational psychologist, clinical social worker,
professional clinical counselor, speech-language pathologist, or
audiologist pursuant to Division 2 (commencing with Section 500)
of the Business and Professions Code, who designs, supervises,
or provides treatment for pervasive developmental disorder or
autism, provided the services are within the experience and
competence of the licensee.

(4) “Qualified autism service professional” means an individual
who meets all of the following criteria:

(A) Provides behavioral health treatment.

(B) Is employed and supervised by a qualified autism service
provider.

(C) Provides treatment pursuant to a treatment plan developed
and approved by the qualified autism service provider.

(D) Is a behavioral service provider approved as a vendor by a
California regional center to provide services as an Associate
Behavior Analyst, Behavior Analyst, Behavior Management
Assistant, Behavior Management Consultant, or Behavior
Management Program as defined in Section 54342 of Title 17 of
the California Code of Regulations.

(E) Has training and experience in providing services for
pervasive developmental disorder or autism pursuant to Division
4.5 (commencing with Section 4500) of the Welfare and
Institutions Code or Title 14 (commencing with Section 95000)
of the Government Code.

(5) “Qualified autism service paraprofessional” means an
unlicensed and uncertified individual who meets all of the
following criteria:

(A) Is employed and supervised by a qualified autism service
provider.

(B) Provides treatment and implements services pursuant to a
treatment plan developed and approved by the qualified autism
service provider.

(C) Meets the criteria set forth in the regulations adopted
pursuant to Section 4686.3 of the Welfare and Institutions Code.

(D) Has adequate education, training, and experience, as
certified by a qualified autism service provider.

(d) This section shall not apply to the following:

(1) A specialized health care service plan that does not deliver
mental health or behavioral health services to enrollees.

(2) A health care service plan contract in the Medi-Cal program
(Chapter 7 (commencing with Section 14000) of Part 3 of Division
9 of the Welfare and Institutions Code).

(3) A health care service plan contract in the Healthy Families
Program (Part 6.2 (commencing with Section 12693) of Division
2 of the Insurance Code).

(4) A health care benefit plan or contract entered into with the
Board of Administration of the Public Employees’ Retirement
System pursuant to the Public Employees’ Medical and Hospital
Care Act (Part 5 (commencing with Section 22750) of Division 5
of Title 2 of the Government Code).

(e) Nothing in this section shall be construed to limit the
obligation to provide services under Section 1374.72.

(f) As provided in Section 1374.72 and in paragraph (1) of
subdivision (a), in the provision of benefits required by this section,
a health care service plan may utilize case management, network
providers, utilization review techniques, prior authorization,
copayments, or other cost sharing.

(g) This section shall become inoperative on July 1, begin delete 2014 end delete begin insert 2019 end insert ,
and, as of January 1, begin delete 2015 end delete begin insert 2020 end insert , is repealed, unless a later enacted
statute, that becomes operative on or before January 1, begin delete 2015 end delete begin insert 2020 end insert ,
deletes or extends the dates on which it becomes inoperative and
is repealed.

SEC. 2.  

Section 10144.51 of the Insurance Code is amended
to read:

10144.51.  

(a) (1) Every health insurance policy shall also
provide coverage for behavioral health treatment for pervasive
developmental disorder or autism no later than July 1, 2012. The
coverage shall be provided in the same manner and shall be subject
to the same requirements as provided in Section 10144.5.

(2) Notwithstanding paragraph (1), as of the date that proposed
final rulemaking for essential health benefits is issued, this section
does not require any benefits to be provided that exceed the
essential health benefits that all health insurers will be required by
federal regulations to provide under Section 1302(b) of the federal
Patient Protection and Affordable Care Act begin delete (P.L. end delete begin insert (Public Law end insert
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 begin delete (P.L. end delete begin insert (Public Law end insert 111-152).

(3) This section shall not affect services for which an individual
is eligible pursuant to Division 4.5 (commencing with Section
4500) of the Welfare and Institutions Code or Title 14
(commencing with Section 95000) of the Government Code.

(4) This section shall not affect or reduce any obligation to
provide services under an individualized education program, as
defined in Section 56032 of the Education Code, or an
begin delete individualized end delete begin insert individual end insert service plan, as described in Section
5600.4 of the Welfare and Institutions Code, or under the
Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400
et seq.) and its implementing regulations.

(b) Pursuant to Article 6 (commencing with Section 2240) of
Title 10 of the California Code of Regulations, every health insurer
subject to this section shall maintain an adequate network that
includes qualified autism service providers who supervise and
employ qualified autism service professionals or paraprofessionals
who provide and administer behavioral health treatment. Nothing
shall prevent a health insurer from selectively contracting with
providers within these requirements.

(c) For the purposes of this section, the following definitions
shall apply:

(1) “Behavioral health treatment” means 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 pervasive developmental disorder or autism, and
that meet all of the following criteria:

(A) The treatment is prescribed by a physician and surgeon
licensed pursuant to Chapter 5 (commencing with Section 2000)
of, or is developed by a psychologist licensed pursuant to Chapter
6.6 (commencing with Section 2900) of, Division 2 of the Business
and Professions Code.

(B) The treatment is provided under a treatment plan prescribed
by a qualified autism service provider and is administered by one
of the following:

(i) A qualified autism service provider.

(ii) A qualified autism service professional supervised and
employed by the qualified autism service provider.

(iii) A qualified autism service paraprofessional supervised and
employed by a qualified autism service provider.

(C) The treatment plan has measurable goals over a specific
timeline that is developed and approved by the qualified autism
service provider for the specific patient being treated. The treatment
plan shall be reviewed no less than once every six months by the
qualified autism service provider and modified whenever
appropriate, and shall be consistent with Section 4686.2 of the
Welfare and Institutions Code pursuant to which the qualified
autism service provider does all of the following:

(i) Describes the patient’s behavioral health impairments to be
treated.

(ii) Designs an intervention plan that includes the service type,
number of hours, and parent participation needed to achieve the
plan’s goal and objectives, and the frequency at which the patient’s
progress is evaluated and reported.

(iii) Provides intervention plans that utilize evidence-based
practices, with demonstrated clinical efficacy in treating pervasive
developmental disorder or autism.

(iv) Discontinues intensive behavioral intervention services
when the treatment goals and objectives are achieved or no longer
appropriate.

(D) The treatment plan is not used for purposes of providing or
for the reimbursement of respite, day care, or educational services
and is not used to reimburse a parent for participating in the
treatment program. The treatment plan shall be made available to
the insurer upon request.

(2) “Pervasive developmental disorder or autism” shall have
the same meaning and interpretation as used in Section 10144.5.

(3) “Qualified autism service provider” means either of the
following:

(A) A person, entity, or group that is certified by a national
entity, such as the Behavior Analyst Certification Board, that is
accredited by the National Commission for Certifying Agencies,
and who designs, supervises, or provides treatment for pervasive
developmental disorder or autism, provided the services are within
the experience and competence of the person, entity, or group that
is nationally certified.

(B) A person licensed as a physician and surgeon, physical
therapist, occupational therapist, psychologist, marriage and family
therapist, educational psychologist, clinical social worker,
professional clinical counselor, speech-language pathologist, or
audiologist pursuant to Division 2 (commencing with Section 500)
of the Business and Professions Code, who designs, supervises,
or provides treatment for pervasive developmental disorder or
autism, provided the services are within the experience and
competence of the licensee.

(4) “Qualified autism service professional” means an individual
who meets all of the following criteria:

(A) Provides behavioral health treatment.

(B) Is employed and supervised by a qualified autism service
provider.

(C) Provides treatment pursuant to a treatment plan developed
and approved by the qualified autism service provider.

(D) Is a behavioral service provider approved as a vendor by a
California regional center to provide services as an Associate
Behavior Analyst, Behavior Analyst, Behavior Management
Assistant, Behavior Management Consultant, or Behavior
Management Program as defined in Section 54342 of Title 17 of
the California Code of Regulations.

(E) Has training and experience in providing services for
pervasive developmental disorder or autism pursuant to Division
4.5 (commencing with Section 4500) of the Welfare and
Institutions Code or Title 14 (commencing with Section 95000)
of the Government Code.

(5) “Qualified autism service paraprofessional” means an
unlicensed and uncertified individual who meets all of the
following criteria:

(A) Is employed and supervised by a qualified autism service
provider.

(B) Provides treatment and implements services pursuant to a
treatment plan developed and approved by the qualified autism
service provider.

(C) Meets the criteria set forth in the regulations adopted
pursuant to Section 4686.3 of the Welfare and Institutions Code.

(D) Has adequate education, training, and experience, as
certified by a qualified autism service provider.

(d) This section shall not apply to the following:

(1) A specialized health insurance policy that does not cover
mental health or behavioral health services or an accident only,
specified disease, hospital indemnity, or Medicare supplement
policy.

(2) A health insurance policy in the Medi-Cal program (Chapter
7 (commencing with Section 14000) of Part 3 of Division 9 of the
Welfare and Institutions Code).

(3) A health insurance policy in the Healthy Families Program
(Part 6.2 (commencing with Section 12693)).

(4) A health care benefit plan or policy entered into with the
Board of Administration of the Public Employees’ Retirement
System pursuant to the Public Employees’ Medical and Hospital
Care Act (Part 5 (commencing with Section 22750) of Division 5
of Title 2 of the Government Code).

(e) Nothing in this section shall be construed to limit the
obligation to provide services under Section 10144.5.

(f) As provided in Section 10144.5 and in paragraph (1) of
subdivision (a), in the provision of benefits required by this section,
a health insurer may utilize case management, network providers,
utilization review techniques, prior authorization, copayments, or
other cost sharing.

(g) This section shall become inoperative on July 1, begin delete 2014 end delete begin insert 2019 end insert ,
and, as of January 1, begin delete 2015 end delete begin insert 2020 end insert , is repealed, unless a later enacted
statute, that becomes operative on or before January 1, begin delete 2015 end delete begin insert 2020 end insert ,
deletes or extends the dates on which it becomes inoperative and
is repealed.

SEC. 3.  

Section 10144.52 of the Insurance Code is amended
to read:

10144.52.  

(a) For purposes of this part, the terms “provider,”
“professional provider,” “network provider,” “mental health
provider,” and “mental health professional” shall include the term
“qualified autism service provider,” as defined in subdivision (c)
of Section 10144.51.

(b) This section shall become inoperative on July 1, begin delete 2014 end delete begin insert 2019 end insert ,
and, as of January 1, begin delete 2015 end delete begin insert 2020 end insert , is repealed, unless a later enacted
statute, that becomes operative on or before January 1, begin delete 2015 end delete begin insert 2020 end insert ,
deletes or extends the dates on which it becomes inoperative and
is repealed.

SEC. 4.  

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.