BILL ANALYSIS Ó
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UNFINISHED BUSINESS
Bill No: SB 126
Author: Steinberg (D)
Amended: 8/8/13
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
SENATE FLOOR : 37-0, 5/16/13
AYES: Anderson, Beall, Berryhill, Block, Calderon, Cannella,
Corbett, Correa, De León, DeSaulnier, Emmerson, Evans, Fuller,
Gaines, Galgiani, Hancock, Hernandez, Hill, Hueso, Huff,
Jackson, Knight, Lara, Leno, Lieu, Liu, Monning, Nielsen,
Padilla, Pavley, Roth, Steinberg, Walters, Wolk, Wright,
Wyland, Yee
NO VOTE RECORDED: Price, Vacancy, Vacancy
ASSEMBLY FLOOR : 78-0, 8/30/13 (Consent) - See last page for
vote
SUBJECT : Health care coverage: pervasive developmental
disorder or autism
SOURCE : Autism Speaks
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DIGEST : This bill extends, until January 1, 2017, the sunset
date of an existing state health benefit mandate that requires
health plans and health insurance policies to cover behavioral
health treatment (BHT) for pervasive developmental disorder or
autism (PDD/A) and requires plans and insurers to maintain
adequate networks of PDD/A service providers.
Assembly Amendments (1) add a sunset date of January 1, 2017, on
an existing state health benefit mandate requiring health plans
and insurance policies to cover BHT or PDD/A; (2) add coauthors;
and (3) make other technical changes.
ANALYSIS :
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, 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 the Department of Managed Health Care (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
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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 the sunset date from July 1, 2014, to January
1, 2017, 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
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 BHT mandate is defined as including, but not
limited to, applied behavior analysis (ABA). Specifically, it
defines BHT as "professional services and treatment programs,
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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,
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 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
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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
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 BHT mandate was
enacted before December 31, 2011, this BHT 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
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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.
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.
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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 8/30/13)
Autism Speaks (source)
Alameda County Developmental Disabilities Planning and Advisory
Council
Alliance for California Autism Organizations
Association of Regional Center Agencies
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
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through their health plans. Autism Speaks sustains that
extending the sunset of this BHT 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.
ASSEMBLY FLOOR : 78-0, 8/30/13
AYES: Achadjian, Alejo, Allen, Ammiano, Atkins, Bigelow, Bloom,
Bocanegra, Bonilla, Bonta, Bradford, Brown, Buchanan, Ian
Calderon, Campos, Chau, Chávez, Chesbro, Conway, Cooley,
Dahle, Daly, Dickinson, Donnelly, Eggman, Fong, Fox, Frazier,
Beth Gaines, Garcia, Gatto, Gomez, Gonzalez, Gordon, Gorell,
Gray, Grove, Hagman, Hall, Harkey, Roger Hernández, Holden,
Jones, Jones-Sawyer, Levine, Linder, Logue, Lowenthal,
Maienschein, Mansoor, Medina, Melendez, Mitchell, Morrell,
Mullin, Muratsuchi, Nazarian, Nestande, Olsen, Pan, Patterson,
Perea, V. Manuel Pérez, Quirk, Quirk-Silva, Rendon, Salas,
Skinner, Stone, Ting, Wagner, Waldron, Weber, Wieckowski,
Wilk, Williams, Yamada, John A. Pérez
NO VOTE RECORDED: Vacancy, Vacancy
JL:k 8/30/13 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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