BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                            



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                                    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  
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             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  

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          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,  

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             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  

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          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.


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          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

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          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

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