SB 126, as amended, 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 These provisions are inoperative on July 1, 2014, and are repealed on January 1, 2015.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 1374.73 of the Health and Safety Code
2 is amended to read:
(a) (1) Every health care service plan contract that
4provides hospital, medical, or surgical coverage shall also provide
5coverage for behavioral health treatment for pervasive
6developmental disorder or autism no later than July 1, 2012. The
7coverage shall be provided in the same manner and shall be subject
8to the same requirements as provided in Section 1374.72.
9(2) Notwithstanding paragraph (1), as of the date that proposed
10final rulemaking for essential health benefits is issued, this section
11does not require any benefits to be provided that exceed the
12essential health benefits that all health plans will be required by
13federal regulations to provide under Section 1302(b)
of the federal
14Patient Protection and Affordable Care Act (Public Law 111-148),
15as amended by the federal Health Care and Education
16Reconciliation Act of 2010 (Public Law 111-152).
17(3) This section shall not affect services for which an individual
18is eligible pursuant to Division 4.5 (commencing with Section
194500) of the Welfare and Institutions Code or Title 14
20(commencing with Section 95000) of the Government Code.
21(4) This section shall not affect or reduce any obligation to
22provide services under an individualized education program, as
23defined in Section 56032 of the Education Code, or an individual
24service plan, as described in Section 5600.4 of the Welfare and
25Institutions Code, or under thebegin insert federal
end insert Individuals with Disabilities
26Education Act (20 U.S.C. Sec. 1400, et seq.) and its implementing
27regulations.
28(b) Every health care service plan subject to this section shall
29maintain an adequate network that includes qualified autism service
30providers who supervise and employ qualified autism service
P3 1professionals or paraprofessionals who provide and administer
2behavioral health treatment. Nothing shall prevent a health care
3service plan from selectively contracting with providers within
4these requirements.
5(c) For the purposes of this section, the following definitions
6shall apply:
7(1) “Behavioral health treatment” means professional services
8and treatment programs, including applied
behavior analysis and
9evidence-based behavior intervention programs, that develop or
10restore, to the maximum extent practicable, the functioning of an
11individual with pervasive developmental disorder or autism and
12that meet all of the following criteria:
13(A) The treatment is prescribed by a physician and surgeon
14licensed pursuant to Chapter 5 (commencing with Section 2000)
15of, or is developed by a psychologist licensed pursuant to Chapter
166.6 (commencing with Section 2900) of, Division 2 of the Business
17and Professions Code.
18(B) The treatment is provided under a treatment plan prescribed
19by a qualified autism service provider and is administered by one
20of the following:
21(i) A qualified autism service provider.
22(ii) A qualified autism service professional supervised and
23employed by the qualified autism service provider.
24(iii) A qualified autism service paraprofessional supervised and
25employed by a qualified autism service provider.
26(C) The treatment plan has measurable goals over a specific
27timeline that is developed and approved by the qualified autism
28service provider for the specific patient being treated. The treatment
29plan shall be reviewed no less than once every six months by the
30qualified autism service provider and modified whenever
31appropriate, and shall be consistent with Section 4686.2 of the
32Welfare and Institutions Code pursuant to which the qualified
33autism service provider does all of the following:
34(i) Describes the patient’s behavioral health impairmentsbegin insert
or
35developmental challenges that areend insert to be treated.
36(ii) Designs an intervention plan that includes the service type,
37number of hours, and parent participation needed to achieve the
38plan’s goal and objectives, and the frequency at which the patient’s
39progress is evaluated and reported.
P4 1(iii) Provides intervention plans that utilize evidence-based
2practices, with demonstrated clinical efficacy in treating pervasive
3developmental disorder or autism.
4(iv) Discontinues intensive behavioral intervention services
5when the treatment goals and objectives are achieved or no longer
6appropriate.
7(D) The treatment plan is not
used for purposes of providing or
8for the reimbursement of respite, day care, or educational services
9and is not used to reimburse a parent for participating in the
10treatment program. The treatment plan shall be made available to
11the health care service plan upon request.
12(2) “Pervasive developmental disorder or autism” shall have
13the same meaning and interpretation as used in Section 1374.72.
14(3) “Qualified autism service provider” means either of the
15following:
16(A) A person, entity, or group that is certified by a national
17entity, such as the Behavior Analyst Certification Board, that is
18accredited by the National Commission for Certifying Agencies,
19and who designs, supervises, or provides treatment for pervasive
20developmental
disorder or autism, provided the services are within
21the experience and competence of the person, entity, or group that
22is nationally certified.
23(B) A person licensed as a physician and surgeon, physical
24therapist, occupational therapist, psychologist, marriage and family
25therapist, educational psychologist, clinical social worker,
26professional clinical counselor, speech-language pathologist, or
27audiologist pursuant to Division 2 (commencing with Section 500)
28of the Business and Professions Code, who designs, supervises,
29or provides treatment for pervasive developmental disorder or
30autism, provided the services are within the experience and
31competence of the licensee.
32(4) “Qualified autism service professional” means an individual
33who meets all of the following criteria:
34(A) Provides behavioral health treatment.
35(B) Is employed and supervised by a qualified autism service
36provider.
37(C) Provides treatment pursuant to a treatment plan developed
38and approved by the qualified autism service provider.
39(D) Is a behavioral service provider approved as a vendor by a
40California regional center to provide services as an Associate
P5 1Behavior Analyst, Behavior Analyst, Behavior Management
2Assistant, Behavior Management Consultant, or Behavior
3Management Program as defined in Section 54342 of Title 17 of
4the California Code of Regulations.
5(E) Has training and experience in
providing services for
6pervasive developmental disorder or autism pursuant to Division
74.5 (commencing with Section 4500) of the Welfare and
8Institutions Code or Title 14 (commencing with Section 95000)
9of the Government Code.
10(5) “Qualified autism service paraprofessional” means an
11unlicensed and uncertified individual who meets all of the
12following criteria:
13(A) Is employed and supervised by a qualified autism service
14provider.
15(B) Provides treatment and implements services pursuant to a
16treatment plan developed and approved by the qualified autism
17service provider.
18(C) Meets the criteria set forth in the regulations adopted
19pursuant to Section
4686.3 of the Welfare and Institutions Code.
20(D) Has adequate education, training, and experience, as
21certified by a qualified autism service provider.
22(d) This section shall not apply to the following:
23(1) A specialized health care service plan that does not deliver
24mental health or behavioral health services to enrollees.
25(2) A health care service plan contract in the Medi-Cal program
26(Chapter 7 (commencing with Section 14000) of Part 3 of Division
279 of the Welfare and Institutions Code).
28(3) A health care service plan contract in the Healthy Families
29Program (Part 6.2 (commencing with Section 12693) of
Division
302 of the Insurance Code).
31(4) A health care benefit plan or contract entered into with the
32Board of Administration of the Public Employees’ Retirement
33System pursuant to the Public Employees’ Medical and Hospital
34Care Act (Part 5 (commencing with Section 22750) of Division 5
35of Title 2 of the Government Code).
36(e) Nothing in this section shall be construed to limit the
37obligation to provide services under Section 1374.72.
38(f) As provided in Section 1374.72 and in paragraph (1) of
39subdivision (a), in the provision of benefits required by this section,
40a health care service plan may utilize case management, network
P6 1providers, utilization review techniques, prior authorization,
2copayments, or other cost
sharing.
3(g) This section shall become inoperative on July 1, 2019, and,
4as of January 1, 2020, is repealed, unless a later enacted statute,
5that becomes operative on or before January 1, 2020, deletes or
6extends the dates on which it becomes inoperative and is repealed.
Section 10144.51 of the Insurance Code is amended
8to read:
(a) (1) Every health insurance policy shall also
10provide coverage for behavioral health treatment for pervasive
11developmental disorder or autism no later than July 1, 2012. The
12coverage shall be provided in the same manner and shall be subject
13to the same requirements as provided in Section 10144.5.
14(2) Notwithstanding paragraph (1), as of the date that proposed
15final rulemaking for essential health benefits is issued, this section
16does not require any benefits to be provided that exceed the
17essential health benefits that all health insurers will be required by
18federal regulations to provide under Section 1302(b) of the federal
19Patient Protection and Affordable Care
Act(Public Law 111-148),
20as amended by the federal Health Care and Education
21Reconciliation Act of 2010(Public Law 111-152).
22(3) This section shall not affect services for which an individual
23is eligible pursuant to Division 4.5 (commencing with Section
244500) of the Welfare and Institutions Code or Title 14
25(commencing with Section 95000) of the Government Code.
26(4) This section shall not affect or reduce any obligation to
27provide services under an individualized education program, as
28defined in Section 56032 of the Education Code, or an
individual
29service plan, as described in Section 5600.4 of the Welfare and
30Institutions Code, or under thebegin insert federal end insert Individuals with Disabilities
31Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
32regulations.
33(b) Pursuant to Article 6 (commencing with Section 2240) of
34Title 10 of the California Code of Regulations, every health insurer
35subject to this section shall maintain an adequate network that
36includes qualified autism service providers who supervise and
37employ qualified autism service professionals or paraprofessionals
38who provide and administer behavioral health treatment. Nothing
39shall prevent a health insurer from selectively contracting with
40providers within these requirements.
P7 1(c) For the purposes of this section, the following definitions
2shall apply:
3(1) “Behavioral health treatment” means professional services
4and treatment programs, including applied behavior analysis and
5evidence-based behavior intervention programs, that develop or
6restore, to the maximum extent practicable, the functioning of an
7individual with pervasive developmental disorder or autism, and
8that meet all of the following criteria:
9(A) The treatment is prescribed by a physician and surgeon
10licensed pursuant to Chapter 5 (commencing with Section 2000)
11of, or is developed by a psychologist licensed pursuant to Chapter
126.6 (commencing with Section 2900) of, Division 2 of the Business
13and Professions Code.
14(B) The treatment is provided under a treatment plan prescribed
15by a qualified autism service provider and is administered by one
16of the following:
17(i) A qualified autism service provider.
18(ii) A qualified autism service professional supervised and
19employed by the qualified autism service provider.
20(iii) A qualified autism service paraprofessional supervised and
21employed by a qualified autism service provider.
22(C) The treatment plan has measurable goals over a specific
23timeline that is developed and approved by the qualified autism
24service provider for the specific patient being treated. The treatment
25plan
shall be reviewed no less than once every six months by the
26qualified autism service provider and modified whenever
27appropriate, and shall be consistent with Section 4686.2 of the
28Welfare and Institutions Code pursuant to which the qualified
29autism service provider does all of the following:
30(i) Describes the patient’s behavioral health impairmentsbegin insert or
31developmental challenges that areend insert to be treated.
32(ii) Designs an intervention plan that includes the service type,
33number of hours, and parent participation needed to achieve the
34plan’s goal and objectives, and the frequency at which the patient’s
35progress is evaluated and reported.
36(iii) Provides
intervention plans that utilize evidence-based
37practices, with demonstrated clinical efficacy in treating pervasive
38developmental disorder or autism.
P8 1(iv) Discontinues intensive behavioral intervention services
2when the treatment goals and objectives are achieved or no longer
3appropriate.
4(D) The treatment plan is not used for purposes of providing or
5for the reimbursement of respite, day care, or educational services
6and is not used to reimburse a parent for participating in the
7treatment program. The treatment plan shall be made available to
8the insurer upon request.
9(2) “Pervasive developmental disorder or autism” shall have
10the same meaning and interpretation as used in Section 10144.5.
11(3) “Qualified autism service provider” means either of the
12following:
13(A) A person, entity, or group that is certified by a national
14entity, such as the Behavior Analyst Certification Board, that is
15accredited by the National Commission for Certifying Agencies,
16and who designs, supervises, or provides treatment for pervasive
17developmental disorder or autism, provided the services are within
18the experience and competence of the person, entity, or group that
19is nationally certified.
20(B) A person licensed as a physician and surgeon, physical
21therapist, occupational therapist, psychologist, marriage and family
22therapist, educational psychologist, clinical social worker,
23professional clinical counselor, speech-language
pathologist, or
24audiologist pursuant to Division 2 (commencing with Section 500)
25of the Business and Professions Code, who designs, supervises,
26or provides treatment for pervasive developmental disorder or
27autism, provided the services are within the experience and
28competence of the licensee.
29(4) “Qualified autism service professional” means an individual
30who meets all of the following criteria:
31(A) Provides behavioral health treatment.
32(B) Is employed and supervised by a qualified autism service
33provider.
34(C) Provides treatment pursuant to a treatment plan developed
35and approved by the qualified autism service provider.
36(D) Is a behavioral service provider approved as a vendor by a
37California regional center to provide services as an Associate
38Behavior Analyst, Behavior Analyst, Behavior Management
39Assistant, Behavior Management Consultant, or Behavior
P9 1Management Program as defined in Section 54342 of Title 17 of
2the California Code of Regulations.
3(E) Has training and experience in providing services for
4pervasive developmental disorder or autism pursuant to Division
54.5 (commencing with Section 4500) of the Welfare and
6Institutions Code or Title 14 (commencing with Section 95000)
7of the Government Code.
8(5) “Qualified autism service paraprofessional” means an
9unlicensed and uncertified individual who meets all of the
10following
criteria:
11(A) Is employed and supervised by a qualified autism service
12provider.
13(B) Provides treatment and implements services pursuant to a
14treatment plan developed and approved by the qualified autism
15service provider.
16(C) Meets the criteria set forth in the regulations adopted
17pursuant to Section 4686.3 of the Welfare and Institutions Code.
18(D) Has adequate education, training, and experience, as
19certified by a qualified autism service provider.
20(d) This section shall not apply to the following:
21(1) A specialized health insurance
policy that does not cover
22mental health or behavioral health services or an accident only,
23specified disease, hospital indemnity, or Medicare supplement
24policy.
25(2) A health insurance policy in the Medi-Cal program (Chapter
267 (commencing with Section 14000) of Part 3 of Division 9 of the
27Welfare and Institutions Code).
28(3) A health insurance policy in the Healthy Families Program
29(Part 6.2 (commencing with Section 12693)).
30(4) A health care benefit plan or policy entered into with the
31Board of Administration of the Public Employees’ Retirement
32System pursuant to the Public Employees’ Medical and Hospital
33Care Act (Part 5 (commencing with Section 22750) of Division 5
34of Title 2 of the Government Code).
35(e) Nothing in this section shall be construed to limit the
36obligation to provide services under Section 10144.5.
37(f) As provided in Section 10144.5 and in paragraph (1) of
38subdivision (a), in the provision of benefits required by this section,
39a health insurer may utilize case management, network providers,
P10 1utilization review techniques, prior authorization, copayments, or
2other cost sharing.
3(g) This section shall become inoperative on July 1, 2019, and,
4as of January 1, 2020, is repealed, unless a later enacted statute,
5that becomes operative on or before January 1, 2020, deletes or
6extends the dates on which it becomes inoperative and is repealed.
Section 10144.52 of the Insurance Code is amended
8to read:
(a) For purposes of this part, the terms “provider,”
10“professional provider,” “network provider,” “mental health
11provider,” and “mental health professional” shall include the term
12“qualified autism service provider,” as defined in subdivision (c)
13of Section 10144.51.
14(b) This section shall become inoperative on July 1, 2019, and,
15as of January 1, 2020, is repealed, unless a later enacted statute,
16that becomes operative on or before January 1, 2020, deletes or
17extends the dates on which it becomes inoperative and is repealed.
No reimbursement is required by this act pursuant to
19Section 6 of Article XIII B of the California Constitution because
20the only costs that may be incurred by a local agency or school
21district will be incurred because this act creates a new crime or
22infraction, eliminates a crime or infraction, or changes the penalty
23for a crime or infraction, within the meaning of Section 17556 of
24the Government Code, or changes the definition of a crime within
25the meaning of Section 6 of Article XIII B of the California
26Constitution.
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