BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 126
AUTHOR: Steinberg
INTRODUCED: January 22, 2013
HEARING DATE: May 1, 2013
CONSULTANT: Robinson-Taylor
SUBJECT : Health Care Coverage: pervasive developmental disorder
or autism.
SUMMARY : Extends, until July 1, 2019, the sunset date of an
existing state health benefit mandate that requires health plans
and health insurance policies to cover behavioral health therapy
(BHT) for pervasive developmental disorder or autism (PDD/A) and
requires plans and insurers to maintain adequate networks of
PDD/A service providers.
Existing law:
1.Requires health plans and health insurance policies to cover
BHT for PDD/A, requires plans and insurers to maintain
adequate networks of autism service providers, establishes an
Autism Advisory Task Force (Autism Task Force) in the
Department of Managed Health Care (DMHC), and sunsets the
PDD/A benefit mandate provisions on July 1, 2014.
2.Enacts, in federal law, the Patient Protection and Affordable
Care and Education Reconciliation Act of 2010 (ACA), as
amended by the federal Health Care and Education
Reconciliation Act of 2010, to among other things, makes
statutory changes affecting the regulation of, and payment
for, certain types of private health insurance. Includes the
definition of essential health benefits (EHBs) that all
qualified health plans must cover, at a minimum, with some
exceptions.
3.Establishes as California's EHBs the Kaiser Small Group Health
Maintenance Organization (HMO) plan along with the following
ten ACA mandated benefits:
a. Ambulatory patient services;
b. Emergency services;
c. Hospitalization;
d. Maternity and newborn care;
e. Mental health and substance use disorder services,
Continued---
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including behavioral health treatment;
f. Prescription drugs;
g. Rehabilitative and habilitative services and devices;
h. Laboratory services;
i. Preventive and wellness services and chronic disease
management; and,
j. Pediatric services, including oral and vision care.
4.Establishes the Knox-Keene Health Care Service Plan Act of
1975 (Knox-Keene) to regulate and license health plans and
specialized health plans by DMHC and provides for the
regulation of health insurers by the California Department of
Insurance (CDI).
5.Requires every health plan contract or health insurance policy
issued, amended, or renewed on or after July 1, 2000, that
provides hospital, medical, or surgical coverage to provide
coverage for the diagnosis and medically necessary treatment
of severe mental illness (SMI) of a person of any age, and of
serious emotional disturbances of a child, under the same
terms and conditions applied to other medical conditions, as
specified.
6.Establishes the California Legislative Blue Ribbon Commission
on Autism, until November 30, 2008, to study and investigate
the early identification and intervention of Autism Spectrum
Disorders (ASDs), gaps in programs and services available to
those with ASDs, and to make recommendations to address gaps
in services.
7.Requires the Department of Developmental Services (DDS) to
develop procedures for the diagnosis of ASDs.
This Bill: Extends, until July 1, 2019, the sunset date of an
existing state health benefit mandate that requires health plans
and health insurance policies to cover behavioral health therapy
(BHT) for pervasive developmental disorder or autism (PDD/A) and
requires plans and insurers to maintain adequate networks of
PDD/A service providers.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. SB 946 (Steinberg), Chapter 640, Statutes
of 2011, which I authored requires private health plans and
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insurance companies to provide coverage for BHT for
individuals with PDD/A. The mandate under SB 946 (herein
after referred to as the behavioral health treatment mandate),
which has expanded access to medically necessary treatments
for PDD/A to many Californians, is due to expire on July 1,
2014. This bill will address the "sunset" problem and extend
the current provisions of this behavioral health treatment
mandate until July 1, 2019. Extending the provisions of the
current mandate for five years will allow for the following:
evaluation of the recommendations by the Autism Task Force;
consideration of a "path to licensure" for BHT providers and
paraprofessionals; and, coordination with the ACA and future
guidelines.
2.PDD/A and its prevalence in California. Current law does not
define PDD/A, but regulations governing DMHC-regulated health
plans define PDD/A as inclusive of Asperger's Disorder,
Autistic Disorder, Childhood Disintegrative Disorder,
Pervasive Developmental Disorder not otherwise specified and
Rett's Disorder. According to the California Health Benefits
Review Program (CHBRP), PDD/A are neurodevelopmental disorders
that typically become symptomatic in children aged 2 to 3
years, but may not be diagnosed until age 5 or older,
especially in cases of Asperger's Disorder. They are chronic
conditions characterized by impairments in social
interactions, communication, sensory processing, stereotypic
(repetitive) behaviors or interests, and sometimes cognitive
function. The symptoms of PDD/A range from mild to severe.
According to CHBRP, the cause of PDD/A is unknown, and
research into genetic etiology as well as environmental
factors continues to be explored. CHBRP maintains there is no
cure for PDD/A; however, there is some evidence that
treatment, such as speech therapy, pharmacology, and
behavioral treatments, may improve symptoms.
Estimates of prevalence in the United States and worldwide,
CHBRP reports, have been increasing over the last 20 years.
According to CHBRP, the number of Californians with autism
served by DDS increased 15-fold between 1987 and 2012. The
overall PDD/A prevalence estimates found in the more recent
literature range from 78/100,000 to 114/10,000.
3.BHT. The existing behavioral health treatment mandate
defines BHT as including, but not limited to, applied
behavior analysis (ABA). Specifically it defines BHT as
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"professional services and treatment programs, including ABA
and evidence-based behavior intervention programs, that
develop or restore, to the maximum extent practicable, the
functioning of an individual with PDD/A. The existing
behavioral health treatment mandate requires that treatment
be prescribed by a licensed physician and surgeon or
developed by a licensed psychologist. The mandate requires
that the treatment be provided under a treatment plan
prescribed and administered by a qualified autism service
provider (QAS provider), qualified autism service
professional (QAS professional), or a qualified autism
service paraprofessional (QAS paraprofessional) all of whom
can be licensed or unlicensed. Of those who can administer
BHT to enrollees with PDD/A under the behavioral health
treatment mandate, QAS professionals and paraprofessionals
must be employed and supervised by a QAS provider. The
mandate also requires an adequate network of QAS providers to
be maintained for supervision. Additionally the mandated
benefit must be provided in accordance with California's
mental health parity law which mandates parity with other
benefits in terms of lifetime maximums, copayments, and
deductibles.
4.CHBRP. CHBRP was created in response to AB 1996 (Thomson),
Chapter 795, Statutes of 2002, which requests the University
of California to assess legislation proposing a mandated
benefit or service, and prepare a written analysis with
relevant data on the public health, medical, and economic
impact of proposed health plan and health insurance benefit
mandate legislation. Among CHBRP's findings of their
analysis of SB 126 are the following:
a. Medical Effectiveness . According to CHBRP, many
children with PDD/A are treated with intensive BHT (e.g.,
more than 25 hours per week) interventions that are aimed
at improving behavior and reducing deficits in cognitive
function, language, and social skills. CHBRP maintains
the literature is difficult to synthesize because most
studies compared BHT of differing duration and intensity
or compared interventions based on different theories of
behavior. Many of the studies do not assess outcomes
over sufficiently long periods of time to determine
long-term benefits. However, CHBRP did determine that
the preponderance of evidence from some meta-analyses
suggest that intensive BHT is more effective than
therapies based on other theories or less intensive
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therapies in improving adaptive behavior and increasing
intelligence quotient. Findings were ambiguous for the
effects of BHT on improving expressive language,
receptive language and academic placement.
b. Benefit Coverage, Utilization, Cost and Public
Health Impacts . CHBRP estimates that 127,000 enrollees
are diagnosed with PDD/A in DMHC-regulated or
CDI-regulated policies subject to this bill, of which
12,700 are estimated to currently use BHT. According to
CHBRP, annual expenditures for BHT among these enrollees
is estimated to be $686 million. CHBRP indicates,
however, because coverage for BHT for PDD/A is currently
required under the existing behavioral health mandate
and the current California mental health parity law,
this bill would not require new coverage and will not
result in a measurable change in utilization, total
premiums or health care expenditures. CHBRP estimates
that 100% of DMHC-regulated and CDI-regulated policies
subject to these two state benefit mandates that require
coverage for BHT for PDD/A provide this coverage. CHBRP
also does not expect this bill to produce new public
health impact on persons with PDD/A.
5.EHBs. Effective 2014, the ACA requires non-grandfathered
small-group and individual market health insurance, including
those qualified health plans that will be sold in Covered
California, to cover 10 specified categories of EHBs. The
federal Department of Health and Human Services (HHS) has
allowed each state to define its own EHBs for 2014 and 2015 by
selecting one of a set of specified benchmark plan options.
California has selected the Kaiser Foundation Health Plan
Small Group HMO 30 Plan as its benchmark plan. According to
CHBRP, the ACA allows a state to "require that a qualified
health plan offered in an exchange to offer benefits in
addition to the EHBs." If the state does so, the state must
make payments to defray the cost of those additionally
mandated benefits. However, state benefit mandates enacted on
or before December 31, 2011, would be included in a state's
EHBs for 2014 and 2015, and there would be no requirement that
the state defray the costs of those state mandated benefits.
Because SB 946, the original behavioral health treatment
mandate was enacted before December 31, 2011 this behavioral
health treatment mandate is included in California's EHBs for
2014 and 2015. By extension, the state would not be required
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to defray any costs as a result of this bill in 2014 and 2015.
6.Autism Task Force. SB 946 required DMHC to convene an Autism
Task Force to develop recommendations regarding medically
necessary BHT for individuals with PDD/A, as well as the
appropriate qualifications, training and supervision for
providers of such treatment. The Autism Task Force was also
tasked with developing recommendations regarding the
education, training, and experience requirements that
unlicensed individuals providing BHT must meet in order to
obtain licensure from the state. The Autism Task Force was
comprised of a cross-section of stakeholders, including
researchers, providers, advocates and parents of individuals
with PDD/A and released a report on February 26, 2013 that
provided extensive guidelines and recommendations. The Autism
Task Force, pursuant to SB 946, dissolved December 31, 2012.
7.Related legislation. SB 158 (Correa) establishes a
demonstration program, the Regional Center Excellence in
Community Autism Partnerships, coordinated by a University of
California or California State University campus which defines
underserved communities in Regional Center catchment areas and
establishes guidelines to improve services, as specified. SB
158 is currently in the Senate Appropriations Committee.
SB 163 (Hueso) requires 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 Individual Program Plan or
Individualized Family Services Plan, as specified, and
prohibits regional centers from charging or seeking
reimbursement for these costs. SB 163 is currently in the
Senate Appropriations Committee.
AB 1372 (Bonilla), which is substantially similar to this bill,
extends, until July 1, 2016, the sunset date of the existing
state health benefit mandate that requires health insurance
policies to cover BHT for PDD/A and requires plans and
insurers to maintain adequate networks of PDD/A service
providers. AB 1372 is currently in the Assembly Health
Committee.
8.Prior legislation. SB 946 (Steinberg), Chapter 650, Statutes
of 2011, requires health plans and health insurance policies
to cover BHT for PDD/A, requires plans and insurers to
maintain adequate networks of autism service providers,
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established an Autism Task Force in the DMHC, and sunsets SB
946's autism mandate provisions on July 1, 2014.
SB 770 (Steinberg) of 2011 would have required health plans and
health insurance policies to provide coverage for BHT. SB 770
was held in the Assembly Appropriations Committee.
SB 166 (Steinberg) of 2011, would have required health care
service plans licensed by DMHC and health insurers licensed by
the CDI to provide coverage for BHT for autism. SB 166 was
held in the Senate Health Committee.
AB 1205 (Bill Berryhill) of 2011, would have required the Board
of Behavioral Sciences to license behavioral analysts and
assistant behavioral analysts, on and after January 1, 2015,
and included standards for licensure such as specified higher
education and training, fieldwork, passage of relevant
examinations, and national board accreditation. AB 1205 was
held in the Assembly Appropriations Committee on the suspense
file.
AB 171 (Beall) of 2011, would have required health plans and
health insurers to cover the screening, diagnosis, and
treatment of ASD. AB 171 was held in the Senate Health
Committee.
SB 1283 (Steinberg) of 2010 would have established guidelines
to expedite the appeals process for grievances that are filed
with DMHC and imposed fines on health plans that did not
comply, as specified. SB 1283 was vetoed by Governor
Schwarzenegger stating that, "the measure was overbroad and
impacted all of DMHC's grievance processes."
SB 1563 (Perata) of 2008 would have required DMHC and CDI to
establish the Autism Workgroup for Equitable Health Insurance
Coverage, to examine issues related to health care service
plan and health insurance coverage of PPD/A. SB 1563 was
vetoed by Governor Schwarzenegger stating that, "the
provisions of this bill are currently being accomplished
administratively by DMHC and, therefore, this bill is
unnecessary and duplicative."
SB 88 (Thomson), Chapter 534, Statutes of 1999 requires a
health care service plan contract or disability insurance
policy to provide coverage for SMI, and for the serious
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emotional disturbances of a child under the same terms and
conditions as applied to other medical conditions.
9.Support. Autism Speaks, the sponsor of this bill, writes in
support that since the passage of SB 946, countless children
have received treatment through their health plans. Autism
Speaks sustains that extending the sunset of this behavioral
health treatment mandate will allow children to continue to
receive medically necessary BHT from qualified autism services
providers. The Children's Partnership, the California
Department of Insurance and Health Access all write that this
measure is an important step in maintaining the medically
necessary treatment for children with autism that will ensure
they can succeed in school, in their communities, and reach
their potential for a greater improved quality of life.
SUPPORT AND OPPOSITION :
Support: Autism Speaks (sponsor)
Alameda County Developmental Disabilities Planning and
Advisory Council
Alliance for California Autism Organizations
Autism Health Insurance Project
California Association for Behavior Analysis
California Department of Insurance
California Speech Language-Hearing Association
Developmental Disabilities Area Board 10
East Bay Developmental Disabilities Coalition
Health Access California
Mutual Housing California
Occupational Therapy Association of California
Pediatric Therapy Network
People's Care
Percepta
Southwest Special Education Local Plan Area
Special Needs Network
The Children's Partnership
26 individual
Oppose: None Received.
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