Amended in Assembly January 13, 2016

Amended in Assembly January 4, 2016

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 amended, 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 until January 1, 2017, and defines “behavioral health treatment” to mean specified services provided by, among others, a qualified autism service professional supervised and employed by a qualified autism service provider. For purposes of this provision, existing law defines a “qualified autism service professional” to mean a person who, among other requirements, is a behavior service provider approved as a vendor by a California regional center to provide services as an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program pursuant to specified regulations adopted under the Lanterman Developmental Disabilities Services Act.

This bill would extend the operation of these provisions to January 1, 2022. By extending the operation of these provisions, the violation of which by a health care service plan would be a crime, the bill would impose a state-mandated local program. The bill would require the Board of Psychology, no later than December 31, 2017, and thereafter as necessary, to convene a committee to create a list of evidence-based treatment modalities for purposes ofbegin delete developing mandatedend delete behavioral health treatmentbegin delete modalitiesend delete for pervasive developmental disorder orbegin delete autism.end deletebegin insert autism, and to post the list on the department’s Internet Web site no later than January 1, 2019.end insert

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

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

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.

P3    1(f) Children diagnosed with autism respond differently to
2behavioral health treatment.

3(g) It is critical that each child diagnosed with autism receives
4the specific type of evidence-based behavioral health treatment
5best suited to him or her, as prescribed by his or her physician or
6developed by a psychologist.

7(h) The Legislature intends that all forms of evidence-based
8behavioral health treatment be covered by health care service plans,
9pursuant to Section 1374.73 of the Health and Safety Code, and
10health insurance policies, pursuant to Section 10144.51 of the
11Insurance Code.

12(i) The Legislature intends that health care service plan provider
13networks include qualified professionals practicing all forms of
14evidence-based behavioral health treatment other than just applied
15behavioral analysis.

16

SEC. 2.  

Section 1374.73 of the Health and Safety Code is
17amended to read:

18

1374.73.  

(a) (1) Every health care service plan contract that
19provides hospital, medical, or surgical coverage shall also provide
20coverage for behavioral health treatment for pervasive
21developmental disorder or autism no later than July 1, 2012. The
22coverage shall be provided in the same manner and shall be subject
23to the same requirements as provided in Section 1374.72.

24(2) Notwithstanding paragraph (1), as of the date that proposed
25final rulemaking for essential health benefits is issued, this section
26does not require any benefits to be provided that exceed the
27essential health benefits that all health plans will be required by
28federal regulations to provide under Section 1302(b) of the federal
29Patient Protection and Affordable Care Act (Public Law 111-148),
30as amended by the federal Health Care and Education
31Reconciliation Act of 2010 (Public Law 111-152).

32(3) This section shall not affect services for which an individual
33is eligible pursuant to Division 4.5 (commencing with Section
344500) of the Welfare and Institutions Code or Title 14
35(commencing with Section 95000) of the Government Code.

36(4) This section shall not affect or reduce any obligation to
37provide services under an individualized education program, as
38defined in Section 56032 of the Education Code, or an individual
39service plan, as described in Section 5600.4 of the Welfare and
40Institutions Code, or under the federal Individuals with Disabilities
P4    1Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
2regulations.

3(b) Every health care service plan subject to this section shall
4 maintain an adequate network that includes qualified autism service
5providers who supervise and employ qualified autism service
6professionals or paraprofessionals who provide and administer
7behavioral health treatment. Nothing shall prevent a health care
8service plan from selectively contracting with providers within
9these requirements.

10(c) For the purposes of this section, the following definitions
11shall apply:

12(1) “Behavioral health treatment” means professional services
13and treatment programs, including applied behavior analysis and
14evidence-based behavior intervention programs, that develop or
15restore, to the maximum extent practicable, the functioning of an
16individual with pervasive developmental disorder or autism and
17that meet all of the following criteria:

18(A) The treatment is prescribed by a physician and surgeon
19licensed pursuant to Chapter 5 (commencing with Section 2000)
20of, or is developed by a psychologist licensed pursuant to Chapter
216.6 (commencing with Section 2900) of, Division 2 of the Business
22and Professions Code.

23(B) The treatment is provided under a treatment plan prescribed
24by a qualified autism service provider and is administered by one
25of the following:

26(i) A qualified autism service provider.

27(ii) A qualified autism service professional supervised and
28employed by the qualified autism service provider.

29(iii) A qualified autism service paraprofessional supervised and
30employed by a qualified autism service provider.

31(C) The treatment plan has measurable goals over a specific
32 timeline that is developed and approved by the qualified autism
33service provider for the specific patient being treated. The treatment
34plan shall be reviewed no less than once every six months by the
35qualified autism service provider and modified whenever
36appropriate, and shall be consistent with Section 4686.2 of the
37Welfare and Institutions Code pursuant to which the qualified
38autism service provider does all of the following:

39(i) Describes the patient’s behavioral health impairments or
40developmental challenges that are to be treated.

P5    1(ii) Designs an intervention plan that includes the service type,
2number of hours, and parent participation needed to achieve the
3plan’s goal and objectives, and the frequency at which the patient’s
4progress is evaluated and reported.

5(iii) Provides intervention plans that utilize evidence-based
6practices, with demonstrated clinical efficacy in treating pervasive
7developmental disorder or autism.

8(iv) Discontinues intensive behavioral intervention services
9when the treatment goals and objectives are achieved or no longer
10appropriate.

11(D) The treatment plan is not used for purposes of providing or
12for the reimbursement of respite, day care, or educational services
13and is not used to reimburse a parent for participating in the
14treatment program. The treatment plan shall be made available to
15the health care service plan upon request.

16(2) “Pervasive developmental disorder or autism” shall have
17the same meaning and interpretation as used in Section 1374.72.

18(3) “Qualified autism service provider” means either of the
19following:

20(A) A person, entity, or group that is certified by a national
21entity, such as the Behavior Analyst Certification Board, that is
22accredited by the National Commission for Certifying Agencies,
23and who designs, supervises, or provides treatment for pervasive
24developmental disorder or autism, provided the services are within
25the experience and competence of the person, entity, or group that
26is nationally certified.

27(B) A person licensed as a physician and surgeon, physical
28therapist, occupational therapist, psychologist, marriage and family
29therapist, educational psychologist, clinical social worker,
30professional clinical counselor, speech-language pathologist, or
31audiologist pursuant to Division 2 (commencing with Section 500)
32of the Business and Professions Code, who designs, supervises,
33or provides treatment for pervasive developmental disorder or
34autism, provided the services are within the experience and
35competence of the licensee.

36(4) “Qualified autism service professional” means an individual
37who meets all of the following criteria:

38(A) Provides behavioral health treatment.

39(B) Is employed and supervised by a qualified autism service
40provider.

P6    1(C) Provides treatment pursuant to a treatment plan developed
2and approved by the qualified autism service provider.

3(D) Is a behavioral service provider approved as a vendor by a
4California regional center to provide services as an Associate
5Behavior Analyst, Behavior Analyst, Behavior Management
6Assistant, Behavior Management Consultant, or Behavior
7Management Program as defined in Section 54342begin insert of Subchapter
82 of Chapter 3 of Division 2end insert
of Title 17 of the California Code of
9Regulations.

10(E) Has training and experience in providing services for
11pervasive developmental disorder or autism pursuant to Division
124.5 (commencing with Section 4500) of the Welfare and
13Institutions Code or Title 14 (commencing with Section 95000)
14of the Government Code.

15(5) “Qualified autism service paraprofessional” means an
16unlicensed and uncertified individual who meets all of the
17following criteria:

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

20(B) Provides treatment and implements services pursuant to a
21treatment plan developed and approved by the qualified autism
22service provider.

23(C) Meets the criteria set forth in the regulations adopted
24pursuant to Section 4686.3 of the Welfare and Institutions Code.

25(D) Has adequate education, training, and experience, as
26certified by a qualified autism service provider.

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

28(1) A specialized health care service plan that does not deliver
29mental health or behavioral health services to enrollees.

30(2) A health care service plan contract in the Medi-Cal program
31(Chapter 7 (commencing with Section 14000) of Part 3 of Division
329 of the Welfare and Institutions Code).

33(3) A health care service plan contract in the Healthy Families
34Program (Part 6.2 (commencing with Section 12693) of Division
352 of the Insurance Code).

36(4) A health care benefit plan or contract entered into with the
37Board of Administration of the Public Employees’ Retirement
38System pursuant to the Public Employees’ Medical and Hospital
39Care Act (Part 5 (commencing with Section 22750) of Division 5
40of Title 2 of the Government Code).

P7    1(e) Nothing in this section shall be construed to limit the
2obligation to provide services under Section 1374.72.

3(f) As provided in Section 1374.72 and in paragraph (1) of
4subdivision (a), in the provision of benefits required by this section,
5a health care service plan may utilize case management, network
6providers, utilization review techniques, prior authorization,
7copayments, or other cost sharing.

8(g) No later than December 31, 2017, and thereafter as
9necessary, the Board of Psychology, upon appropriation of the
10Legislature, shall convene a committee to create a list of
11evidence-based treatment modalities for purposes ofbegin delete developing
12mandatedend delete
behavioral health treatmentbegin delete modalitiesend delete for pervasive
13developmental disorder or autism.begin insert The Board of Psychology shall
14post the list of evidence-based treatment modalities on its Internet
15Web site no later than January 1, 2019.end insert

16(h) This section shall remain in effect only until January 1, 2022,
17and as of that date is repealed, unless a later enacted statute, that
18is enacted before January 1, 2022, deletes or extends that date.

19

SEC. 3.  

Section 10144.51 of the Insurance Code is amended
20to read:

21

10144.51.  

(a) (1) Every health insurance policy shall also
22provide coverage for behavioral health treatment for pervasive
23developmental disorder or autism no later than July 1, 2012. The
24coverage shall be provided in the same manner and shall be subject
25to the same requirements as provided in Section 10144.5.

26(2) Notwithstanding paragraph (1), as of the date that proposed
27final rulemaking for essential health benefits is issued, this section
28does not require any benefits to be provided that exceed the
29essential health benefits that all health insurers will be required by
30federal regulations to provide under Section 1302(b) of the federal
31Patient Protection and Affordable Care Act (Public Law 111-148),
32as amended by the federal Health Care and Education
33Reconciliation Act of 2010 (Public Law 111-152).

34(3) This section shall not affect services for which an individual
35is eligible pursuant to Division 4.5 (commencing with Section
364500) of the Welfare and Institutions Code or Title 14
37(commencing with Section 95000) of the Government Code.

38(4) This section shall not affect or reduce any obligation to
39provide services under an individualized education program, as
40defined in Section 56032 of the Education Code, or an individual
P8    1service plan, as described in Section 5600.4 of the Welfare and
2Institutions Code, or under the federal Individuals with Disabilities
3Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
4regulations.

5(b) Pursuant to Article 6 (commencing with Section 2240)begin insert of
6Subchapter 2 of Chapter 5end insert
of Title 10 of the California Code of
7Regulations, every health insurer subject to this section shall
8maintain an adequate network that includes qualified autism service
9providers who supervise and employ qualified autism service
10professionals or paraprofessionals who provide and administer
11behavioral health treatment. Nothing shall prevent a health insurer
12from selectively contracting with providers within these
13requirements.

14(c) For the purposes of this section, the following definitions
15shall apply:

16(1) “Behavioral health treatment” means professional services
17and treatment programs, including applied behavior analysis and
18evidence-based behavior intervention programs, that develop or
19restore, to the maximum extent practicable, the functioning of an
20individual with pervasive developmental disorder or autism, and
21that meet all of the following criteria:

22(A) The treatment is prescribed by a physician and surgeon
23licensed pursuant to Chapter 5 (commencing with Section 2000)
24of, or is developed by a psychologist licensed pursuant to Chapter
256.6 (commencing with Section 2900) of, Division 2 of the Business
26and Professions Code.

27(B) The treatment is provided under a treatment plan prescribed
28by a qualified autism service provider and is administered by one
29of the following:

30(i) A qualified autism service provider.

31(ii) A qualified autism service professional supervised and
32employed by the qualified autism service provider.

33(iii) A qualified autism service paraprofessional supervised and
34employed by a qualified autism service provider.

35(C) The treatment plan has measurable goals over a specific
36timeline that is developed and approved by the qualified autism
37service provider for the specific patient being treated. The treatment
38plan shall be reviewed no less than once every six months by the
39qualified autism service provider and modified whenever
40appropriate, and shall be consistent with Section 4686.2 of the
P9    1Welfare and Institutions Code pursuant to which the qualified
2autism service provider does all of the following:

3(i) Describes the patient’s behavioral health impairments or
4developmental challenges that are to be treated.

5(ii) Designs an intervention plan that includes the service type,
6number of hours, and parent participation needed to achieve the
7plan’s goal and objectives, and the frequency at which the patient’s
8progress is evaluated and reported.

9(iii) Provides intervention plans that utilize evidence-based
10practices, with demonstrated clinical efficacy in treating pervasive
11developmental disorder or autism.

12(iv) Discontinues intensive behavioral intervention services
13when the treatment goals and objectives are achieved or no longer
14appropriate.

15(D) The treatment plan is not used for purposes of providing or
16for the reimbursement of respite, day care, or educational services
17and is not used to reimburse a parent for participating in the
18treatment program. The treatment plan shall be made available to
19the insurer upon request.

20(2) “Pervasive developmental disorder or autism” shall have
21the same meaning and interpretation as used in Section 10144.5.

22(3) “Qualified autism service provider” means either of the
23 following:

24(A) A person, entity, or group that is certified by a national
25entity, such as the Behavior Analyst Certification Board, that is
26accredited by the National Commission for Certifying Agencies,
27and who designs, supervises, or provides treatment for pervasive
28developmental disorder or autism, provided the services are within
29the experience and competence of the person, entity, or group that
30is nationally certified.

31(B) A person licensed as a physician and surgeon, physical
32therapist, occupational therapist, psychologist, marriage and family
33therapist, educational psychologist, clinical social worker,
34professional clinical counselor, speech-language pathologist, or
35audiologist pursuant to Division 2 (commencing with Section 500)
36of the Business and Professions Code, who designs, supervises,
37or provides treatment for pervasive developmental disorder or
38autism, provided the services are within the experience and
39competence of the licensee.

P10   1(4) “Qualified autism service professional” means an individual
2who meets all of the following criteria:

3(A) Provides behavioral health treatment.

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

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

8(D) Is a behavioral service provider approved as a vendor by a
9California regional center to provide services as an Associate
10Behavior Analyst, Behavior Analyst, Behavior Management
11Assistant, Behavior Management Consultant, or Behavior
12Management Program as defined in Section 54342begin insert of Subchapter
132 of Chapter 3 of Division 2end insert
of Title 17 of the California Code of
14Regulations.

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 Institutions Code.

30(D) Has adequate education, training, and experience, as
31certified by a qualified autism service provider.

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

33(1) A specialized health insurance policy that does not cover
34mental health or behavioral health services or an accident only,
35specified disease, hospital indemnity, or Medicare supplement
36policy.

37(2) A health insurance policy in the Medi-Cal program (Chapter
387 (commencing with Section 14000) of Part 3 of Division 9 of the
39Welfare and Institutions Code).

P11   1(3) A health insurance policy in the Healthy Families Program
2(Part 6.2 (commencing with Section 12693)).

3(4) A health care benefit plan or policy entered into with the
4Board of Administration of the Public Employees’ Retirement
5System pursuant to the Public Employees’ Medical and Hospital
6Care Act (Part 5 (commencing with Section 22750) of Division 5
7of Title 2 of the Government Code).

8(e) Nothing in this section shall be construed to limit the
9obligation to provide services under Section 10144.5.

10(f) As provided in Section 10144.5 and in paragraph (1) of
11subdivision (a), in the provision of benefits required by this section,
12a health insurer may utilize case management, network providers,
13utilization review techniques, prior authorization, copayments, or
14other cost sharing.

15(g) No later than December 31, 2017, and thereafter as
16necessary, the Board of Psychology, upon appropriation by the
17Legislature, shall convene a committee to create a list of
18evidence-based treatment modalities for purposes ofbegin delete developing
19mandatedend delete
behavioral health treatmentbegin delete modalitiesend delete for pervasive
20developmental disorder or autism.begin insert The Board of Psychology shall
21post the list of evidence-based treatment modalities on its Internet
22Web site no later than January 1, 2019.end insert

23(h) This section shall remain in effect only until January 1, 2022,
24and as of that date is repealed, unless a later enacted statute, that
25is enacted before January 1, 2022, deletes or extends that date.

26

SEC. 4.  

No reimbursement is required by this act pursuant to
27Section 6 of Article XIII B of the California Constitution because
28the only costs that may be incurred by a local agency or school
29district will be incurred because this act creates a new crime or
30infraction, eliminates a crime or infraction, or changes the penalty
31for a crime or infraction, within the meaning of Section 17556 of
32the Government Code, or changes the definition of a crime within
33the meaning of Section 6 of Article XIII B of the California
34Constitution.



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