BILL ANALYSIS Ó
SB 126
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Date of Hearing: June 11, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
SB 126 (Steinberg) - As Introduced: January 22, 2013
SENATE VOTE : 37-0
SUBJECT : Health care coverage: pervasive developmental
disorder or autism.
SUMMARY : Extends inoperative dates from July 1, 2014 to July 1,
2019, of statutes implementing requirements on health plans and
insurers to provide coverage for behavioral health treatment
(BHT) for pervasive developmental disorder or autism (PDD/A).
EXISTING LAW :
1)Establishes the Department of Managed Health Care (DMHC) to
regulate health plans under the Knox-Keene Health Care
Services Plan Act of 1975 in the Health and Safety Code; the
California Department of Insurance (CDI) to regulate health
insurers under the Insurance Code; and, the California Health
Benefit Exchange (Exchange) to compare and make available
through selective contracting health insurance for individual
and small business purchasers as authorized under the federal
Patient Protection and Affordable Care Act (ACA).
2)Establishes as California's essential health benefits (EHBs)
benchmark the Kaiser Small Group Health Maintenance
Organization plan along with the following 10 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,
including BHT;
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.
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3)Requires every health plan contract that provides hospital,
medical, or surgical coverage and health insurance policy to
also provide coverage for BHT for PDD/A no later than July 1,
2012. Requires the coverage to be provided in the same manner
and to be subject to the same requirements as provided in
California's mental health parity law, described in 8) below.
4)Provides, notwithstanding 3) above, as of the date that
proposed final rulemaking for EHBs is issued, that this bill
does not require any benefits to be provided that exceed the
EHBs that health plans will be required by federal
regulations to provide under the ACA, as amended by the
federal Health Care and Education Reconciliation Act of 2010.
5)Requires DMHC, in consultation with CDI, to convene a task
force by February 1, 2012, to develop recommendations
regarding BHT that are medically necessary for the treatment
of individuals with PDD/A, as specified. Requires DMHC to
submit a report of the task force to the Governor, President
pro Tem of the Senate, the Speaker of the Assembly, and the
Senate and Assembly Committees on Health by December 31, 2012,
on which date the task force ceases to exist.
6)Exempts from 3) above a specialized health plan or health
insurance policy that does not deliver mental health or
behavioral health services to enrollees, or an accident only,
specified disease, hospital indemnity, or Medicare supplement
policy, a health plan contract or health insurance policy
under Medi-Cal or Healthy Families program, and a health care
benefit plan or contract pursuant to the Public Employees'
Retirement System.
7)Sunsets the provisions described in 3) through 6) above on
July 1, 2014.
8)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 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. (California's mental health parity law.)
9)Establishes the California Legislative Blue Ribbon Commission
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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.
10)Requires the Department of Developmental Services to develop
procedures for the diagnosis of ASDs.
FISCAL EFFECT : According to the Senate Appropriations
Committee, minor ongoing costs to CDI (Insurance Fund) for
enforcement. No additional cost to the state to provide
subsidies for health coverage costs in the Exchange.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, SB 946
(Steinberg), Chapter 650, Statutes of 2011, implemented
important changes in the Health and Safety Code and the
Insurance Code with regard to provisions for BHT coverage of
individuals with PDD/A. The provisions of SB 946, which were
implemented on July 1, 2012, have resulted in significant
benefits that include: expanded access to services related to
PDD/A to many Californians; during the past year, private
health plans and insurance companies have implemented
significant changes to improve services for the individuals
with these disorders and their families and expanded their
network of providers to provide services for these disorders;
and, during the past year, many regional centers have
implemented policy changes to provide financial support for
co-pays and other "out-of-pocket" expenses related to the
implementation of SB 946 incurred by consumers, and their
families. The author also indicates provisions of SB 946 have
resulted in significant savings to the State's General Fund.
The author believes by extending the provisions of the current
autism insurance mandate for five years it will enable
evaluation of the recommendations that have been provided by
the DMHC task force, consideration of a "path to licensure"
for the BHT providers and paraprofessionals, coordination and
synchronization with ACA, and assessment of future federal
guidelines expected in 2018.
2)EHB . The ACA provides for the establishment of an EHB package
that includes coverage of EHBs (as defined by the Secretary of
the Department of Health and Human Services (Secretary)),
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cost-sharing limits, and actuarial value requirements. The ACA
establishes that the Secretary must define EHBs in a manner
that: a) reflects appropriate balance among the 10 statutory
EHB categories; b) is not designed in such a way as to
discriminate based on age, disability, or expected length of
life; c) takes into account the health care needs of diverse
segments of the population; and, d) does not allow denials of
EHBs based on age, life expectancy, or disability. The ACA
specifies that the Secretary periodically review the EHBs,
report the findings of such review to Congress and to the
public, and update the EHBs as needed to address any gaps in
access to care or advances in the relevant evidence base. The
ACA also establishes that states may require a QHP to cover
additional benefits beyond those in the EHB benchmark,
provided that the state defrays the costs of such required
benefits. The final regulations indicate that state mandated
benefits enacted on or before December 31, 2011 (even if not
effective until a later date) may be considered EHBs, which
obviates the requirement for the state to defray costs for
these state-required benefits.
3)BACKGROUND . The Autism Advisory Task Force was established
pursuant to SB 946. The Chair of the task force was the DMHC
Director, who was a nonvoting member, and another 17 members
were appointed by the DMHC. Members of the task force include
parents of children with autism and individuals with legal,
health plan, behavioral health, and medical expertise. The
charge of the task force was to make recommendations to inform
state policymaking and guide future recommendations addressing
six subjects and develop recommendations regarding the
education, training, and experience requirements that
unlicensed individuals providing autism services shall meet in
order to secure a license from the state. The six subjects
are:
a) Interventions that have been scientifically validated
and have demonstrated clinical efficacy;
b) Interventions that have measurable treatment outcomes;
c) Patient selection, monitoring, and duration of therapy;
d) Qualifications, training, and supervision of providers;
e) Adequate networks of providers; and,
f) The education, training, and experience requirements
that unlicensed individuals providing autism services shall
meet in order to secure a license from the state.
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A guiding principle of the task force was that every
individual with PDD/A is unique and the task force concluded
that BHT needs to be highly individualized. With regard to
PDD/A, the task force considers the following diagnoses to
fall under the definition: PDD-not otherwise specified,
Autistic Disorder, Asperger Syndrome, Rett's Syndrome, and
Childhood Disintegrative Disorder. In all 55 recommendations
were adopted, all but one, on a consensus basis. The task
force concludes that all "top level" (undefined) providers
should be licensed by the state, and set forth a process for
establishing a new professional license for "Licensed
Behavioral Health Practitioner." The task force recommended
that the license requirement not take effect until three years
after the license is established, and an interim commission be
formed to implement the new license until a board is able to
do so. The task force also recommended all providers of
autism services be registered with the state's TrustLine
Registry or comparable system as a condition of employment by
service organizations and contracting with health plans and
health insurers. TrustLine uses the criminal history
background check system to check the fingerprints of
applicants, and checks for evidence of additional criminal
records.
4)CHBRP . The California Health Benefits Review Program (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 . Many children with PDD/A are
treated with intensive (e.g., 25 or more hours per week)
interventions based on applied behavioral analysis (ABA),
also referred to as intensive behavioral intervention
therapies, that are aimed at improving behavior and
reducing deficits in cognitive function, language, and
social skills. The medical effectiveness review focuses
on intensive behavioral intervention therapies based on
ABA because this bill specifically mentions ABA.
According to CHBRP, the literature on intensive behavioral
intervention therapies based on ABA has several important
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limitations, and the findings from studies of intensive
behavioral intervention therapies based on ABA are
difficult to synthesize. CHBRP reports the following
outcomes from what are described as "low-quality studies:"
i) The preponderance of evidence suggests that
intensive behavioral intervention therapies based on ABA
are more effective than usual treatment and that
more-intensive ABA-based therapies are more effective
than less intensive ABA-based therapies in improving
adaptive behavior (e.g., communication, and daily
living, motor and social skills).
ii) One meta-analysis of studies found that the
intensive behavioral intervention therapies of longer
duration have greater impact on adaptive behavior.
iii) The preponderance of evidence suggests that
intensive behavioral intervention therapies based on ABA
are more effective in increasing IQ than usual treatment
and that more intensive ABA-based therapies are more
effective than less intensive ABA-based therapies.
Additionally, CHBRP found that most studies found that the
changes in intelligence is not sufficiently large to
enable the majority of children with PDD/A to achieve
levels of intellectual and educational functioning similar
to peers without PDD/A. Findings are ambiguous as to the
effects that intensive behavioral intervention therapies
based on ABA have on both expressive language (i.e.,
ability to verbally express one's needs and wishes) and
receptive language (i.e., ability to respond to requests
from others) relative to usual treatment. Evidence
regarding the relative effectiveness of more intensive
versus less intensive ABA-based therapies is also
ambiguous. Findings are ambiguous as to the effect that
intensive behavioral intervention therapies based on ABA
have on academic placement relative to usual treatment.
b) Utilization, Cost, and Coverage Impacts . CHBRP
estimates that 100% of DHMC-regulated plans and
CDI-regulated policies subject to these two state benefit
mandates that require coverage for intensive behavioral
intervention therapies as a treatment for PDD/A provide
this coverage. CHBRP estimates that 100% of
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DHMC-regulated plans and CDI-regulated policies subject to
the existing BHT mandate maintain an adequate network.
CHBRP estimates that 127,000 enrollees are diagnosed with
PDD/A in DMHC-regulated plans or CDI-regulated policies
subject to this bill, of which 12,700 are estimated to
currently use intensive behavioral intervention therapies.
Current annual expenditures for intensive behavioral
intervention therapies among these enrollees are estimated
to be $686 million. No measurable change in coverage for
these services is expected. As no measurable change in
benefit coverage is expected, no measurable change in
utilization is projected. As no measurable change in
benefit coverage is expected, no measurable changes in
total premiums and total health care expenditures are
expected.
c) Public Health Impact . CHBRP expects the coverage and
utilization of intensive BHT to remain unchanged as
coverage for this therapy for PDD/A is currently required
under both the existing BHT mandate and the current
California mental health parity law. Therefore, CHBRP
does not expect this bill to produce a public health
impact on persons with PDD/A. Additionally, CHBRP
estimates this bill would have no impact on possible
gender and racial/ethnic disparities in health outcomes or
economic loss, and no measurable impact on long-term
health outcomes.
5)EHB . According to CHBRP, since this bill extends the sunset
date of the existing BHT mandate requiring coverage of
intensive behavioral intervention therapies for enrollees
with PDD/A and the existing state benefit mandate was enacted
before December 31, 2011, it is therefore included in
California's EHBs for 2014 and 2015. The state would not be
required to defray any costs as a result of this bill in 2014
and 2015.
6)BUDGET ACTION . The Senate augmented the Medi-Cal budget by
$100 million total funds ($50 million GF) and adopted
placeholder trailer bill language to add ABA services to
Medi-Cal managed care for children ineligible for regional
center services. This funding is intended for the budget
year as a short-term solution. In the long-term, SB 1 X1 (Ed
Hernandez) and AB 1 X1 (John A. Perez) propose to make the
current Medi-Cal benefit package for existing enrollees
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comparable to the Medi-Cal benefit package for the Medi- Cal
expansion. Federal law requires that the benefit package for
the Medi-Cal expansion include the EHBs, which include
behavioral services such as ABA. This issue remains an open
item in the Joint Budget Conference Committee. However,
should this budget action occur, this bill would need
conforming amendments to remove the exemption for Medi-Cal
managed care plans from the BHT mandate.
7)SUPPORT . Proponents of this bill include children's
advocacy, behavioral health and autism organizations, health
underwriters, and many others who support access to early
intervention therapy for children with PDD/A diagnoses that
enable them to succeed in society and school. Proponents
indicate that PDD/A diagnoses have reached epidemic
proportions in California, which leads the nation with at
least 72,000 individuals with this diagnosis. The Alliance
of California Autism Organizations writes that 8,500 children
with PDD/A have benefited from treatment under SB 946. In
addition, the state's public schools and regional centers
could realize savings of close to $200 million over the
coming year. According to the Association of Regional Center
Agencies (ARCA), implementation of SB 946 has been complex
for individuals, families, regional centers, and health care
plans alike as each works to understand new systems and
processes for the provision of BHT. ARCA states that the
Autism Society of California recently surveyed more than 600
family members of individuals with PDD/A. Of those surveyed,
less than one-third have been approved for funding of BHT
through their state-regulated health plans. There have been
significant issues with delays in service initiation, a lack
of providers, and issues related to funding of co-payments,
deductibles, and co-insurance. In order to fully realize the
promise of SB 946, ARCA encourages the Legislature to address
the remaining challenges to accessing health care plan
funding for BHT. According to Autism Speaks, at the time
SB 946 was passed, there were a number of outstanding
questions with regard to mandated benefits, the ACA, and the
state's fiscal responsibility. Because of this, SB 946
included a sunset in 2014 to provide an opportunity for the
legislature to revisit the issue after receiving guidance
from the federal government on implementation of the EHBs
under the ACA. The federal government has since provided
guidance on selection and implementation of the EHBs. Under
the ACA, mandated state benefits enacted by December 31, 2011
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are included as an EHB. In addition, because SB 946 was
signed into law before the December 31st deadline, there are
no additional costs to the state. Since the passage of SB
946, countless children have received treatment through their
health plans, and prior to SB 946, families with health
insurance often paid upwards of $50,000 per year, risking
their homes and the education of their unaffected children.
8)RELATED LEGISLATION .
a) AB 402 (Ammiano) requires disability income insurance
policies to cover disability caused by SMI. AB 402 is
pending hearing in the Senate Insurance Committee.
b) AB 1372 (Bonilla) extends inoperative dates from July 1,
2014 to July 1, 2017, of statutes implementing requirements
on health insurers to provide coverage for BHT for PDD/A.
AB 1372 is currently pending in Assembly Health Committee
c) 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 pending referral in the Assembly.
d) 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
was held on the Senate Appropriations Committee Suspense
File.
e) SB 1 X1 and AB 1 X1 implement various provisions of the
ACA regarding Medi-Cal eligibility and program
simplification and expansion of eligibility in the Medi-Cal
program. The bills are pending in the Assembly Health
Committee and Senate Health Committee, respectively.
9)PREVIOUS LEGISLATION .
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a) SB 946 requires health plans and health insurance
policies to cover BHT for PDD/A, requires health plans and
insurers to maintain adequate networks of autism service
providers, establishes a task force in DMHC, sunsets the
autism mandate provisions on July 1, 2014, and makes other
technical changes to existing law regarding HIV reporting
and mental health services payments.
b) AB 1453 (Monning), Chapter 854, Statutes of 2012, and SB
951 (Ed Hernandez), Chapter 866, Statutes of 2012,
establish California's EHBs.
c) SB 770 (Steinberg) of 2011 would have required health
plans and insurance policies to provide coverage for BHT.
SB 770 was held in the Assembly Appropriations Committee.
d) SB 166 (Steinberg) of 2011 would have required health
care service plans licensed by DMHC and health insurers
licensed by CDI to provide coverage for BHT for autism. SB
166 was held in the Senate Health Committee.
e) 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.
f) 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.
g) 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.
h) 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 PDD/A. SB
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1563 was vetoed by Governor Schwarzenegger.
i) 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.
10)AUTHOR'S AMENDMENTS . The author requests the committee adopt
amendments to add coauthors and on page 3, line 30 and page 7,
line 30 make the following technical change:
(i) Describes the patient's behavioral health impairments
and/or developmental challenges that are to be treated.
REGISTERED SUPPORT / OPPOSITION :
Support
Autism Speaks (cosponsor)
Alliance of California Autism Organizations (cosponsor)
100% Campaign
Arc California and United Cerebral Palsy California
Collaboration
Association of Regional Center Agencies
Autism Health Insurance Project
California Association for Behavior Analysis
California Association of Health Underwriters
Center for Autism and Related Disorders
Children Now
Children's Partnership
Children's Defense Fund - California
Developmental Disabilities Area Board 10
DIR/Floortime Coalition of California
Disability Rights California
Health Access California
Mutual Housing California
Occupational Therapy Association of California
Pediatric Therapy Network
People's Care
PICO California
Southwest Special Education Local Plan Area
Special Education Local Plan Area
Special Needs Network
State of California Board of Behavioral Sciences
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Numerous Individuals
Opposition
None on file.
Analysis Prepared by : Teri Boughton / HEALTH / (916) 319-2097