California Legislature—2015–16 Regular Session

Assembly BillNo. 796


Introduced by Assembly Member Nazarian

(Coauthor: Assembly Member Rendon)

February 26, 2015


An act to amend Section 1374.73 of the Health and Safety Code, and to amend Section 10144.51 of the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

AB 796, as introduced, Nazarian. Health care coverage: autism and pervasive developmental disorders.

Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A violation of those provisions is a crime. Existing law provides for the licensure and regulation of health insurers by the Department of Insurance.

Existing law requires every health care service plan contract and health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism. Existing law requires every health care service plan and health insurance policy to maintain an adequate network that includes qualified autism service providers who supervise and employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. Existing law defines “qualified autism service professional” and “qualified autism service paraprofessional” for this purpose to mean a person who meets specified educational and training requirements.

This bill would expand the eligibility for a person to be a qualified autism service professional to include a person who possesses a bachelor of arts or science degree and meets other specified requirements, a registered psychological assistant, a registered psychologist, or an associate clinical social worker. The bill would also expand the eligibility for a person to be a qualified autism service paraprofessional to include a person with a high school diploma or equivalent and, among other things, 6 months experience working with persons with developmental disabilities.

Vote: majority. Appropriation: no. Fiscal committee: no. State-mandated local program: no.

The people of the State of California do enact as follows:

P2    1

SECTION 1.  

The Legislature finds and declares all of the
2following:

3(a) Autism and other pervasive developmental disorders are
4complex neurobehavioral disorders that include impairments in
5social communication and social interaction combined with rigid,
6repetitive behaviors, interests, and activities.

7(b) Autism covers a large spectrum of symptoms and levels of
8impairment ranging in severity from somewhat limiting to a severe
9disability that may require institutional care.

10(c) One in 68 children born today will be diagnosed with autism
11or another pervasive developmental disorder.

12(d) Research has demonstrated that children diagnosed with
13autism can often be helped with early administration of behavioral
14health treatment.

15(e) There are several forms of evidence-based behavioral health
16treatment, including, but not limited to, applied behavioral analysis.

17(f) Children diagnosed with autism respond differently to
18behavioral health treatment.

19(g) It is critical that each child diagnosed with autism receives
20the specific type of evidence-based behavioral health treatment
21best suited to him or her, as prescribed by his or her physician or
22developed by a psychologist.

23(h) The Legislature intends that all forms of evidence-based
24behavioral health treatment be covered by health care service plans,
25pursuant to Section 1374.73 of the Health and Safety Code, and
26health insurance policies, pursuant to Section 10144.51 of the
27Insurance Code.

P3    1(i) The Legislature intends that health care service plan provider
2networks include qualified professionals practicing all forms of
3evidence-based behavioral health treatment other than just applied
4behavioral analysis.

5

SEC. 2.  

Section 1374.73 of the Health and Safety Code is
6amended to read:

7

1374.73.  

(a) (1) Every health care service plan contract that
8provides hospital, medical, or surgical coverage shall also provide
9coverage for behavioral health treatment for pervasive
10developmental disorder or autism no later than July 1, 2012. The
11coverage shall be provided in the same manner and shall be subject
12to the same requirements as provided in Section 1374.72.

13(2) Notwithstanding paragraph (1), as of the date that proposed
14final rulemaking for essential health benefits is issued, this section
15does not requirebegin delete anyend delete benefits to be provided that exceed the
16essential health benefits that all health plans will be required by
17federal regulations to provide under Section 1302(b) of the federal
18Patient Protection and Affordable Care Act (Public Law 111-148),
19as amended by the federal Health Care and Education
20Reconciliation Act of 2010 (Public Law 111-152).

21(3) This section shall not affect services for which an individual
22is eligible pursuant to Division 4.5 (commencing with Section
234500) of the Welfare and Institutions Code or Title 14
24(commencing with Section 95000) of the Government Code.

25(4) This section shall not affect or reduce any obligation to
26provide services under an individualized education program, as
27defined in Section 56032 of the Education Code, or an individual
28service plan, as described in Section 5600.4 of the Welfare and
29Institutions Code, or under the federal Individuals with Disabilities
30Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
31regulations.

32(b) Every health care service plan subject to this section shall
33maintain an adequate network that includes qualified autism service
34providers who supervise and employ qualified autism service
35professionals or paraprofessionals who provide and administer
36behavioral health treatment. Nothing shall prevent a health care
37service plan from selectively contracting with providers within
38these requirements.

39(c) For the purposes of this section, the following definitions
40shall apply:

P4    1(1) “Behavioral health treatment” means professional services
2and treatment programs, including applied behavior analysis and
3evidence-based behavior intervention programs, that develop or
4restore, to the maximum extent practicable, the functioning of an
5individual with pervasive developmental disorder or autism and
6that meet all of the following criteria:

7(A) The treatment is prescribed by a physician and surgeon
8licensed pursuant to Chapter 5 (commencing with Section 2000)
9of, or is developed by a psychologist licensed pursuant to Chapter
106.6 (commencing with Section 2900) of, Division 2 of the Business
11and Professions Code.

12(B) The treatment is provided under a treatment plan prescribed
13by a qualified autism service provider and is administered by one
14of the following:

15(i) A qualified autism service provider.

16(ii) A qualified autism service professional supervised and
17employed by the qualified autism service provider.

18(iii) A qualified autism service paraprofessional supervised and
19employed by a qualified autism service provider.

20(C) The treatment plan has measurable goals over a specific
21timeline that is developed and approved by the qualified autism
22service provider for the specific patient being treated. The treatment
23plan shall be reviewed no less than once every six months by the
24qualified autism service provider and modified whenever
25appropriate, and shall be consistent with Section 4686.2 of the
26Welfare and Institutions Code pursuant to which the qualified
27autism service provider does all of the following:

28(i) Describes the patient’s behavioral health impairments or
29developmental challenges that are to be treated.

30(ii) Designs an intervention plan that includes the service type,
31number of hours, and parent participation needed to achieve the
32plan’s goal and objectives, and the frequency at which the patient’s
33progress is evaluated and reported.

34(iii) Provides intervention plans that utilize evidence-based
35practices, with demonstrated clinical efficacy in treating pervasive
36developmental disorder or autism.

37(iv) Discontinues intensive behavioral intervention services
38when the treatment goals and objectives are achieved or no longer
39appropriate.

P5    1(D) The treatment plan is not used for purposes of providing or
2for the reimbursement of respite, day care, or educational services
3and is not used to reimburse a parent for participating in the
4treatment program. The treatment plan shall be made available to
5the health care service plan upon request.

6(2) “Pervasive developmental disorder or autism” shall have
7the same meaning and interpretation as used in Section 1374.72.

8(3) “Qualified autism service provider” means either of the
9following:

10(A) A person, entity, or group that is certified by a national
11entity, such as the Behavior Analyst Certification Board, that is
12accredited by the National Commission for Certifying Agencies,
13and who designs, supervises, or provides treatment for pervasive
14developmental disorder or autism, provided the services are within
15the experience and competence of the person, entity, or group that
16is nationally certified.

17(B) A person licensed as a physician and surgeon, physical
18therapist, occupational therapist, psychologist, marriage and family
19therapist, educational psychologist, clinical social worker,
20professional clinical counselor, speech-language pathologist, or
21audiologist pursuant to Division 2 (commencing with Section 500)
22of the Business and Professions Code, who designs, supervises,
23or provides treatment for pervasive developmental disorder or
24autism, provided the services are within the experience and
25competence of the licensee.

26(4) “Qualified autism service professional” means an individual
27who meets all of the following criteria:

28(A) Provides behavioral health treatment.

29(B) Is employed and supervised by a qualified autism service
30provider.

31(C) Provides treatment pursuant to a treatment plan developed
32and approved by the qualified autism service provider.

33(D) Is a behavioral service providerbegin delete approvedend deletebegin insert who meets one
34of the following criteria:end insert

35begin insert(i)end insertbegin insertend insertbegin insertIs approvedend insert as a vendor by a California regional center to
36provide services as an Associate Behavior Analyst, Behavior
37Analyst, Behavior Management Assistant, Behavior Management
38Consultant, or Behavior Management Program as defined in
39Section 54342 of Title 17 of the California Code of Regulations.

begin insert

P6    1(ii) Possesses a bachelor of arts or science degree and has either
2of the following:

end insert
begin insert

3 (I) Twelve semester units from an accredited institute of higher
4learning in either applied behavioral analysis or clinical
5coursework in behavioral health and one year of experience in
6designing or implementing behavioral health treatment.

end insert
begin insert

7(II) two years of experience in designing or implementing
8behavioral health treatment.

end insert
begin insert

9(iii) The person is a registered psychological assistant or
10registered psychologist pursuant to Chapter 6.6 (commencing with
11Section 2900) of Division 2 of the Business and Professions Code.

end insert
begin insert

12(iv) The person is an associate clinical social worker registered
13with the Board of Behavioral Sciences pursuant to Section 4996.18
14of the Business and Professions Code.

end insert

15(E) Has training and experience in providing services for
16pervasive developmental disorder or autism pursuant to Division
174.5 (commencing with Section 4500) of the Welfare and
18Institutions Code or Title 14 (commencing with Section 95000)
19of the Government Code.

20(5) “Qualified autism service paraprofessional” means an
21unlicensed and uncertified individual who meets all of the
22following criteria:

23(A) Is employed and supervised by a qualified autism service
24provider.

25(B) Provides treatment and implements services pursuant to a
26treatment plan developed and approved by the qualified autism
27service provider.

28(C) Meets the criteria set forth in the regulations adopted
29pursuant to Section 4686.3 of the Welfare and Institutionsbegin delete Code.end delete
30begin insert Code or meets all of the following:end insert

begin insert

31(i) Possesses a high school diploma or equivalent.

end insert
begin insert

32(ii) Has six months experience working with persons with a
33developmental disability.

end insert
begin insert

34(iii) Has 30 hours of training in the specific form of
35evidence-based behavioral health treatment administered by a
36qualified autism provider or qualified autism service professional.

end insert
begin insert

37(iv) Has successfully passed a background check conducted by
38a state-approved agency.

end insert

39(D) Has adequate education, training, and experience, as
40certified by a qualified autism service provider.

P7    1(d) This section shall not apply to the following:

2(1) A specialized health care service plan that does not deliver
3mental health or behavioral health services to enrollees.

4(2) A health care service plan contract in the Medi-Cal program
5(Chapter 7 (commencing with Section 14000) of Part 3 of Division
69 of the Welfare and Institutions Code).

7(3) A health care service plan contract in the Healthy Families
8Program (Part 6.2 (commencing with Section 12693) of Division
92 of the Insurance Code).

10(4) A health care benefit plan or contract entered into with the
11Board of Administration of the Public Employees’ Retirement
12System pursuant to the Public Employees’ Medical and Hospital
13Care Act (Part 5 (commencing with Section 22750) of Division 5
14of Title 2 of the Government Code).

15(e) Nothing in this section shall be construed to limit the
16obligation to provide services under Section 1374.72.

17(f) As provided in Section 1374.72 and in paragraph (1) of
18subdivision (a), in the provision of benefits required by this section,
19a health care service plan may utilize case management, network
20providers, utilization review techniques, prior authorization,
21copayments, or other cost sharing.

22(g) This section shall remain in effect only until January 1, 2017,
23and as of that date is repealed, unless a later enacted statute, that
24is enacted before January 1, 2017, deletes or extends that date.

25

SEC. 3.  

Section 10144.51 of the Insurance Code is amended
26to read:

27

10144.51.  

(a) (1) Every health insurance policy shall also
28provide coverage for behavioral health treatment for pervasive
29developmental disorder or autism no later than July 1, 2012. The
30coverage shall be provided in the same manner and shall be subject
31to the same requirements as provided in Section 10144.5.

32(2) Notwithstanding paragraph (1), as of the date that proposed
33final rulemaking for essential health benefits is issued, this section
34does not require any benefits to be provided that exceed the
35essential health benefits that all health insurers will be required by
36federal regulations to provide under Section 1302(b) of the federal
37Patient Protection and Affordable Care Act (Public Law 111-148),
38as amended by the federal Health Care and Education
39Reconciliation Act of 2010 (Public Law 111-152).

P8    1(3) This section shall not affect services for which an individual
2is eligible pursuant to Division 4.5 (commencing with Section
34500) of the Welfare and Institutions Code or Title 14
4(commencing with Section 95000) of the Government Code.

5(4) This section shall not affect or reduce any obligation to
6provide services under an individualized education program, as
7defined in Section 56032 of the Education Code, or an individual
8service plan, as described in Section 5600.4 of the Welfare and
9Institutions Code, or under the federal Individuals with Disabilities
10Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
11regulations.

12(b) Pursuant to Article 6 (commencing with Section 2240) of
13Title 10 of the California Code of Regulations, every health insurer
14subject to this section shall maintain an adequate network that
15includes qualified autism service providers who supervise and
16employ qualified autism service professionals or paraprofessionals
17who provide and administer behavioral health treatment. Nothing
18shall prevent a health insurer from selectively contracting with
19providers within these requirements.

20(c) For the purposes of this section, the following definitions
21shall apply:

22(1) “Behavioral health treatment” means professional services
23and treatment programs, including applied behavior analysis and
24evidence-based behavior intervention programs, that develop or
25restore, to the maximum extent practicable, the functioning of an
26individual with pervasive developmental disorder or autism, and
27that meet all of the following criteria:

28(A) The treatment is prescribed by a physician and surgeon
29licensed pursuant to Chapter 5 (commencing with Section 2000)
30of, or is developed by a psychologist licensed pursuant to Chapter
316.6 (commencing with Section 2900) of, Division 2 of the Business
32and Professions Code.

33(B) The treatment is provided under a treatment plan prescribed
34by a qualified autism service provider and is administered by one
35of the following:

36(i) A qualified autism service provider.

37(ii) A qualified autism service professional supervised and
38employed by the qualified autism service provider.

39(iii) A qualified autism service paraprofessional supervised and
40employed by a qualified autism service provider.

P9    1(C) The treatment plan has measurable goals over a specific
2timeline that is developed and approved by the qualified autism
3service provider for the specific patient being treated. The treatment
4plan shall be reviewed no less than once every six months by the
5qualified autism service provider and modified whenever
6appropriate, and shall be consistent with Section 4686.2 of the
7Welfare and Institutions Code pursuant to which the qualified
8autism service provider does all of the following:

9(i) Describes the patient’s behavioral health impairments or
10developmental challenges that are to be treated.

11(ii) Designs an intervention plan that includes the service type,
12number of hours, and parent participation needed to achieve the
13plan’s goal and objectives, and the frequency at which the patient’s
14progress is evaluated and reported.

15(iii) Provides intervention plans that utilize evidence-based
16practices, with demonstrated clinical efficacy in treating pervasive
17developmental disorder or autism.

18(iv) Discontinues intensive behavioral intervention services
19when the treatment goals and objectives are achieved or no longer
20appropriate.

21(D) The treatment plan is not used for purposes of providing or
22for the reimbursement of respite, day care, or educational services
23and is not used to reimburse a parent for participating in the
24treatment program. The treatment plan shall be made available to
25the insurer upon request.

26(2) “Pervasive developmental disorder or autism” shall have
27the same meaning and interpretation as used in Section 10144.5.

28(3) “Qualified autism service provider” means either of the
29 following:

30(A) A person, entity, or group that is certified by a national
31entity, such as the Behavior Analyst Certification Board, that is
32accredited by the National Commission for Certifying Agencies,
33and who designs, supervises, or provides treatment for pervasive
34developmental disorder or autism, provided the services are within
35the experience and competence of the person, entity, or group that
36is nationally certified.

37(B) A person licensed as a physician and surgeon, physical
38therapist, occupational therapist, psychologist, marriage and family
39therapist, educational psychologist, clinical social worker,
40professional clinical counselor, speech-language pathologist, or
P10   1audiologist pursuant to Division 2 (commencing with Section 500)
2of the Business and Professions Code, who designs, supervises,
3or provides treatment for pervasive developmental disorder or
4autism, provided the services are within the experience and
5competence of the licensee.

6(4) “Qualified autism service professional” means an individual
7who meets all of the following criteria:

8(A) Provides behavioral health treatment.

9(B) Is employed and supervised by a qualified autism service
10provider.

11(C) Provides treatment pursuant to a treatment plan developed
12and approved by the qualified autism service provider.

13(D) Is a behavioral service providerbegin delete approvedend deletebegin insert who meets one
14of the following criteria:end insert

15begin insert(i)end insertbegin insertend insertbegin insertIs approvedend insert as a vendor by a California regional center to
16provide services as an Associate Behavior Analyst, Behavior
17Analyst, Behavior Management Assistant, Behavior Management
18Consultant, or Behavior Management Program as defined in
19Section 54342 of Title 17 of the California Code of Regulations.

begin insert

20(ii) Possesses a bachelor of arts or science degree and has either
21of the following:

end insert
begin insert

22(I) Twelve semester units from an accredited institute of higher
23learning in either applied behavioral analysis or clinical
24coursework in behavioral health and one year of experience in
25designing or implementing behavioral health treatment.

end insert
begin insert

26 (II) Two years of experience in designing or implementing
27behavioral health treatment.

end insert
begin insert

28(iii) The person is a registered psychological assistant or
29registered psychologist pursuant to Chapter 6.6 (commencing with
30Section 2900) of Division 2 of the Business and Professions Code.

end insert
begin insert

31(iv) The person is an associate clinical social worker registered
32with the Board of Behavioral Sciences pursuant to Section 4996.18
33of the Business and Professions Code.

end insert

34(E) Has training and experience in providing services for
35pervasive developmental disorder or autism pursuant to Division
364.5 (commencing with Section 4500) of the Welfare and
37Institutions Code or Title 14 (commencing with Section 95000)
38of the Government Code.

P11   1(5) “Qualified autism service paraprofessional” means an
2unlicensed and uncertified individual who meets all of the
3following criteria:

4(A) Is employed and supervised by a qualified autism service
5provider.

6(B) Provides treatment and implements services pursuant to a
7treatment plan developed and approved by the qualified autism
8service provider.

9(C) Meets the criteria set forth in the regulations adopted
10pursuant to Section 4686.3 of the Welfare and Institutionsbegin delete Code.end delete
11begin insert Code or meets all of the following:end insert

begin insert

12(i) Possesses a high school diploma or equivalent.

end insert
begin insert

13(ii) Has six months experience working with persons with a
14developmental disability.

end insert
begin insert

15(iii) Has 30 hours of training in the specific form of
16evidence-based behavioral health treatment administered by a
17qualified autism provider or qualified autism service professional.

end insert
begin insert

18(iv) Has successfully passed a background check conducted by
19a state-approved agency.

end insert

20(D) Has adequate education, training, and experience, as
21certified by a qualified autism service provider.

22(d) This section shall not apply to the following:

23(1) A specialized health insurance policy that does not cover
24mental health or behavioral health services or an accident only,
25specified disease, hospital indemnity, or Medicare supplement
26policy.

27(2) A health insurance policy in the Medi-Cal program (Chapter
287 (commencing with Section 14000) of Part 3 of Division 9 of the
29Welfare and Institutions Code).

30(3) A health insurance policy in the Healthy Families Program
31(Part 6.2 (commencing with Section 12693)).

32(4) A health care benefit plan or policy entered into with the
33Board of Administration of the Public Employees’ Retirement
34System pursuant to the Public Employees’ Medical and Hospital
35Care Act (Part 5 (commencing with Section 22750) of Division 5
36of Title 2 of the Government Code).

37(e) Nothing in this section shall be construed to limit the
38obligation to provide services under Section 10144.5.

39(f) As provided in Section 10144.5 and in paragraph (1) of
40subdivision (a), in the provision of benefits required by this section,
P12   1a health insurer may utilize case management, network providers,
2utilization review techniques, prior authorization, copayments, or
3 other cost sharing.

4(g) This section shall remain in effect only until January 1, 2017,
5and as of that date is repealed, unless a later enacted statute, that
6is enacted before January 1, 2017, deletes or extends that date.



O

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