BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 126| |Office of Senate Floor Analyses | | |1020 N Street, Suite 524 | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- THIRD READING Bill No: SB 126 Author: Steinberg (D) Amended: As introduced Vote: 21 SENATE HEALTH COMMITTEE : 9-0, 5/1/13 AYES: Hernandez, Anderson, Beall, De León, DeSaulnier, Monning, Nielsen, Pavley, Wolk SENATE APPROPRIATIONS COMMITTEE : 5-0, 5/13/13 AYES: De León, Hill, Lara, Padilla, Steinberg NO VOTE RECORDED: Walters, Gaines SUBJECT : Health care coverage: pervasive developmental disorder or autism SOURCE : Autism Speaks DIGEST : 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. ANALYSIS : Existing law: 1. Requires health plans and health insurance policies to cover CONTINUED SB 126 Page 2 BHT for PDD/A, requires plans and insurers to maintain adequate networks of autism service providers, 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, make 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 EHB the Kaiser Small Group Health Maintenance Organization (HMO) plan along with specified 10 ACA-mandated benefits: 4. Establishes the Knox-Keene Health Care Service Plan Act of 1975 to regulate and license health plans and specialized health plans by DMHC and provides for the regulation of health insurers by the Department of Insurance (CDI). 5. Requires every health plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2000, to provide coverage for the diagnosis and medically necessary treatment of severe mental illness (SMI) of a person, under the same terms and conditions applied to other medical conditions, as specified. 6. Requires the Department of Developmental Services (DDS) to develop procedures for the diagnosis of autism spectrum disorders (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 BHT for PDD/A and requires plans and insurers to maintain adequate networks of PDD/A service providers. Background PDD/A and its prevalence in California . Existing law does not define PDD/A, but regulations governing DMHC-regulated health CONTINUED SB 126 Page 3 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 two to three years, but may not be diagnosed until age five or older. 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. 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. BHT . The existing behavioral health treatment mandate defines BHT as including, but not limited to, applied behavior analysis (ABA). Specifically, it defines BHT as "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." 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 this bill 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, CONTINUED SB 126 Page 4 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. 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 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 the Department of Managed Health Care (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 will 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. 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 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 CONTINUED SB 126 Page 5 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 to defray any costs as a result of this bill in 2014 and 2015. 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, established an Autism Task Force in the DMHC, and sunsets the bill's autism mandate provisions on July 1, 2014. SB 770 (Steinberg, 2011) would have required health plans and health insurance policies to provide coverage for BHT. The bill was held in the Assembly Appropriations Committee. SB 166 (Steinberg, 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. The bill was held in the Senate Health Committee. AB 1205 (Bill Berryhill, 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. The bill was held in the Assembly Appropriations Committee on the suspense file. AB 171 (Beall, 2011) would have required health plans and health insurers to cover the screening, diagnosis, and treatment of ASD. The bill was held in the Senate Health Committee. SB 1283 (Steinberg, 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. The bill was vetoed by Governor Schwarzenegger. CONTINUED SB 126 Page 6 SB 1563 (Perata, 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. The bill was vetoed by Governor Schwarzenegger. 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 emotional disturbances of a child under the same terms and conditions as applied to other medical conditions. FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes Local: Yes According to the Senate Appropriations Committee: Minor ongoing costs to DMHC and CDI for enforcement. No additional cost to the state to provide subsidies for health coverage costs in the California Health Benefit Exchange . According to an analysis of this bill by CHBRP, health plans and health insurers are already required to provide coverage for BHT (provided it is medically necessary) under state and federal mental health parity requirements. Thus, this bill does not create a new coverage mandate. There is no expected additional enforcement cost to state regulators, since they are already required to enforce existing mental health parity requirements. Similarly, the state will not be required to pay for the cost of subsidizing coverage in the California Health Benefit Exchange, as this bill does not impose a coverage mandate that goes beyond federal or state EHB requirements. SUPPORT : (Verified 5/16/13) Autism Speaks (source) Alameda County Developmental Disabilities Planning and Advisory Council Alliance for California Autism Organizations Association of Regional Center Agencies CONTINUED SB 126 Page 7 Autism Health Insurance Project California Association for Behavior Analysis California Department of Insurance California Speech Language-Hearing Association Center for Autism and Related Disorders Developmental Disabilities Area Board 10 DIR/Floortime Coalition of California 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 ARC and United Cerebral Palsy California Collaboration The Children's Partnership ARGUMENTS IN SUPPORT : According to the author's office, 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. Autism Speaks, the sponsor of this bill, writes 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 CDI and Health Access all write that this bill 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. JL:kd 5/16/13 Senate Floor Analyses SUPPORT/OPPOSITION: SEE ABOVE **** END **** CONTINUED SB 126 Page 8 CONTINUED