Amended in Senate June 8, 2016

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 wouldbegin delete extendend deletebegin insert delete the sunset date, thereby extendingend insert the operation of these provisionsbegin delete to January 1, 2022.end deletebegin insert indefinitely.end insert 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.begin delete 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 of behavioral health treatment for pervasive developmental disorder or autism, and to post the list on the department’s Internet Web site no later than January 1, 2019.end deletebegin insert The bill would require the Department of Managed Health Care, in conjunction with the Department of Insurance, to develop procedure codes for evidence-based behavioral health treatment other than applied behavior analysis. The bill would also require the Department of Managed Health Care, in conjunction with the Department of Insurance as the lead agency, to convene a task force, as specified. The bill would also provide that the list of behavioral health treatment modalities developed shall constitute evidence that a particular form of treatment is evidence-based in an independent medical review. The bill would also prohibit the absence of a particular form of treatment from the list of behavioral health treatment modalities developed from constituting evidence that a particular form of treatment is not evidence-based.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:

P3    1(a) Autism and other pervasive developmental disorders are
2complex neurobehavioral disorders that include impairments in
3social communication and social interaction combined with rigid,
4repetitive behaviors, interests, and activities.

5(b) Autism covers a large spectrum of symptoms and levels of
6impairment ranging in severity from somewhat limiting to a severe
7disability that may require institutional care.

8(c) One in 68 children born today will be diagnosed with autism
9or another pervasive developmental disorder.

10(d) Research has demonstrated that children diagnosed with
11autism can often be helped with early administration of behavioral
12health treatment.

13(e) There are several forms of evidence-based behavioral health
14treatment, including, but not limited to, applied behavioral analysis.

15(f) Children diagnosed with autism respond differently to
16behavioral health treatment.

17(g) It is critical that each child diagnosed with autism receives
18the specific type of evidence-based behavioral health treatment
19best suited to him or her, as prescribed by his or her physician or
20developed by a psychologist.

21(h) The Legislature intends that all forms of evidence-based
22behavioral health treatment be covered by health care service plans,
23pursuant to Section 1374.73 of the Health and Safety Code, and
24health insurance policies, pursuant to Section 10144.51 of the
25Insurance Code.

26(i) The Legislature intends that health care service plan provider
27networks include qualified professionals practicing all forms of
28evidence-based behavioral health treatment other than just applied
29behavioral analysis.

30

SEC. 2.  

Section 1374.73 of the Health and Safety Code is
31amended to read:

32

1374.73.  

(a) (1) Every health care service plan contract that
33provides hospital, medical, or surgical coverage shall also provide
34coverage for behavioral health treatment for pervasive
35developmental disorder or autism no later than July 1, 2012. The
36coverage shall be provided in the same manner and shall be subject
37to the same requirements as provided in Section 1374.72.

38(2) Notwithstanding paragraph (1), as of the date that proposed
39final rulemaking for essential health benefits is issued, this section
40does not require any benefits to be provided that exceed the
P4    1essential health benefits that all health plans will be required by
2federal regulations to provide under Section 1302(b) of the federal
3Patient Protection and Affordable Care Act (Public Law 111-148),
4as amended by the federal Health Care and Education
5Reconciliation Act of 2010 (Public Law 111-152).

6(3) This section shall not affect services for which an individual
7is eligible pursuant to Division 4.5 (commencing with Section
84500) of the Welfare and Institutions Code or Title 14
9(commencing with Section 95000) of the Government Code.

10(4) This section shall not affect or reduce any obligation to
11provide services under an individualized education program, as
12defined in Section 56032 of the Education Code, or an individual
13service plan, as described in Section 5600.4 of the Welfare and
14Institutions Code, or under the federal Individuals with Disabilities
15Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
16regulations.

17(b) Every health care service plan subject to this section shall
18 maintain an adequate network that includes qualified autism service
19providers who supervise and employ qualified autism service
20professionals or paraprofessionals who provide and administer
21behavioral health treatment. Nothing shall prevent a health care
22service plan from selectively contracting with providers within
23these requirements.

24(c) For the purposes of this section, the following definitions
25shall apply:

26(1) “Behavioral health treatment” means professional services
27and treatment programs, including applied behavior analysis and
28evidence-based behavior intervention programs, that develop or
29restore, to the maximum extent practicable, the functioning of an
30individual with pervasive developmental disorder or autism and
31that meet all of the following criteria:

32(A) The treatment is prescribed by a physician and surgeon
33licensed pursuant to Chapter 5 (commencing with Section 2000)
34of, or is developed by a psychologist licensed pursuant to Chapter
356.6 (commencing with Section 2900) of, Division 2 of the Business
36and Professions Code.

37(B) The treatment is provided under a treatment plan prescribed
38by a qualified autism service provider and is administered by one
39of the following:

40(i) A qualified autism service provider.

P5    1(ii) A qualified autism service professional supervised and
2employed by the qualified autism service provider.

3(iii) A qualified autism service paraprofessional supervised and
4employed by a qualified autism service provider.

5(C) The treatment plan has measurable goals over a specific
6 timeline that is developed and approved by the qualified autism
7service provider for the specific patient being treated. The treatment
8plan shall be reviewed no less than once every six months by the
9qualified autism service provider and modified whenever
10appropriate, and shall be consistent with Section 4686.2 of the
11Welfare and Institutions Code pursuant to which the qualified
12autism service provider does all of the following:

13(i) Describes the patient’s behavioral health impairments or
14developmental challenges that are to be treated.

15(ii) Designs an intervention plan that includes the service type,
16number of hours, and parent participation needed to achieve the
17plan’s goal and objectives, and the frequency at which the patient’s
18progress is evaluated and reported.

19(iii) Provides intervention plans that utilize evidence-based
20practices, with demonstrated clinical efficacy in treating pervasive
21developmental disorder or autism.

22(iv) Discontinues intensive behavioral intervention services
23when the treatment goals and objectives are achieved or no longer
24appropriate.

25(D) The treatment plan is not used for purposes of providing or
26for the reimbursement of respite, day care, or educational services
27and is not used to reimburse a parent for participating in the
28treatment program. The treatment plan shall be made available to
29the health care service plan upon request.

30(2) “Pervasive developmental disorder or autism” shall have
31the same meaning and interpretation as used in Section 1374.72.

32(3) “Qualified autism service provider” means either of the
33following:

34(A) A person, entity, or group that is certified by a national
35entity, such as the Behavior Analyst Certification Board, that is
36accredited by the National Commission for Certifying Agencies,
37and who designs, supervises, or provides treatment for pervasive
38developmental disorder or autism, provided the services are within
39the experience and competence of the person, entity, or group that
40is nationally certified.

P6    1(B) A person licensed as a physician and surgeon, physical
2therapist, occupational therapist, psychologist, marriage and family
3therapist, educational psychologist, clinical social worker,
4professional clinical counselor, speech-language pathologist, or
5audiologist pursuant to Division 2 (commencing with Section 500)
6of the Business and Professions Code, who designs, supervises,
7or provides treatment for pervasive developmental disorder or
8autism, provided the services are within the experience and
9competence of the licensee.

10(4) “Qualified autism service professional” means an individual
11who meets all of the following criteria:

12(A) Provides behavioral health treatment.

13(B) Is employed and supervised by a qualified autism service
14provider.

15(C) Provides treatment pursuant to a treatment plan developed
16and approved by the qualified autism service provider.

17(D) Is a behavioral service provider approved as a vendor by a
18California regional center to provide services as an Associate
19Behavior Analyst, Behavior Analyst, Behavior Management
20Assistant, Behavior Management Consultant, or Behavior
21Management Program as defined in Section 54342begin insert of Article 3end insert of
22Subchapter 2 of Chapter 3 of Division 2 of Title 17 of the
23California Code of Regulations.

24(E) Has training and experience in providing services for
25pervasive developmental disorder or autism pursuant to Division
264.5 (commencing with Section 4500) of the Welfare and
27Institutions Code or Title 14 (commencing with Section 95000)
28of the Government Code.

29(5) “Qualified autism service paraprofessional” means an
30unlicensed and uncertified individual who meets all of the
31following criteria:

32(A) Is employed and supervised by a qualified autism service
33provider.

34(B) Provides treatment and implements services pursuant to a
35treatment plan developed and approved by the qualified autism
36service provider.

37(C) Meets the criteria set forth in the regulations adopted
38pursuant to Section 4686.3 of the Welfare and Institutions Code.

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.

begin delete

22(g) No later than December 31, 2017, and thereafter as
23necessary, the Board of Psychology, upon appropriation of the
24Legislature, shall convene a committee to create a list of
25evidence-based treatment modalities for purposes of behavioral
26health treatment for pervasive developmental disorder or autism.
27The Board of Psychology shall post the list of evidence-based
28treatment modalities on its Internet Web site no later than January
291, 2019.

30(h) This section shall remain in effect only until January 1, 2022,
31and as of that date is repealed, unless a later enacted statute, that
32is enacted before January 1, 2022, deletes or extends that date.

end delete
begin insert

33
(g) No later than July 1, 2017, the department, in conjunction
34with the Department of Insurance, shall develop procedure codes
35for evidence-based behavioral health treatment other than applied
36behavior analysis.

end insert
begin insert

37
(h) No later than December 31, 2017, and thereafter as
38necessary, the department, in conjunction with the Department of
39Insurance as lead agency, shall convene a task force that, at a
40minimum, shall include a developmental pediatrician, a marriage
P8    1and family therapist, a child and adolescent psychiatrist, a
2psychologist, a neuropsychologist, a board certified behavior
3analyst, and a University of California autism researcher as voting
4representatives, as well as nonvoting representatives from the
5State Department of Developmental Services, the Department of
6Insurance, and the department. All voting members shall be
7professionals trained in interpreting research data and shall
8represent a balanced diversity of treatment modalities, including
9both behavioral and developmental approaches. The task force
10shall do all of the following:

end insert
begin insert

11
(1) Develop a methodology for determining what constitutes an
12evidence-based practice in the field of behavioral health treatment
13for autism and pervasive developmental disorder.

end insert
begin insert

14
(2) Develop a list of behavioral health treatment modalities for
15autism and pervasive developmental disorder supported by
16research that shall be displayed on the department Web site and
17distributed to the State Department of Developmental Services,
18all regional centers, and health care service plans.

end insert
begin insert

19
(3) Develop minimum standards of education, training, and
20professional experience for qualified autism service professionals
21practicing behavioral health treatment other than applied behavior
22analysis that shall be no less rigorous than the requirements as
23defined in subdivision (b) of Section 54342 of Article 3 of
24 Subchapter 2 of Chapter 3 of Division 2 of Title 17 of the
25California Code of Regulations.

end insert
begin insert

26
(4) Develop minimum standards of education, training, and
27professional experience for qualified autism service
28paraprofessionals practicing behavioral health treatment other
29than applied behavior analysis that shall be no less rigorous than
30the education and training qualifications defined in the regulations
31adopted pursuant to Section 4686.3 of the Welfare and Institutions
32Code.

end insert
begin insert

33
(i) The list of behavioral health treatment modalities developed
34pursuant to this section shall constitute evidence that a particular
35form of treatment is evidence-based in an independent medical
36review.

end insert
begin insert

37
(j) The absence of a particular form of treatment from the list
38of behavioral health treatment modalities developed pursuant to
39this section shall not constitute evidence that a particular form of
40treatment is not evidence-based.

end insert
P9    1

SEC. 3.  

Section 10144.51 of the Insurance Code is amended
2to read:

3

10144.51.  

(a) (1) Every health insurance policy shall also
4provide coverage for behavioral health treatment for pervasive
5developmental disorder or autism no later than July 1, 2012. The
6coverage shall be provided in the same manner and shall be subject
7to the same requirements as provided in Section 10144.5.

8(2) Notwithstanding paragraph (1), as of the date that proposed
9final rulemaking for essential health benefits is issued, this section
10does not require any benefits to be provided that exceed the
11essential health benefits that all health insurers will be required by
12federal regulations to provide under Section 1302(b) of the federal
13Patient Protection and Affordable Care Act (Public Law 111-148),
14as amended by the federal Health Care and Education
15Reconciliation Act of 2010 (Public Law 111-152).

16(3) This section shall not affect services for which an individual
17is eligible pursuant to Division 4.5 (commencing with Section
184500) of the Welfare and Institutions Code or Title 14
19(commencing with Section 95000) of the Government Code.

20(4) This section shall not affect or reduce any obligation to
21provide services under an individualized education program, as
22defined in Section 56032 of the Education Code, or an individual
23service plan, as described in Section 5600.4 of the Welfare and
24Institutions Code, or under the federal Individuals with Disabilities
25Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
26regulations.

27(b) Pursuant to Article 6 (commencing with Section 2240) of
28Subchapter 2 of Chapter 5 of Title 10 of the California Code of
29Regulations, every health insurer subject to this section shall
30maintain an adequate network that includes qualified autism service
31providers who supervise and employ qualified autism service
32professionals or paraprofessionals who provide and administer
33behavioral health treatment. Nothing shall prevent a health insurer
34from selectively contracting with providers within these
35requirements.

36(c) For the purposes of this section, the following definitions
37shall apply:

38(1) “Behavioral health treatment” means professional services
39and treatment programs, including applied behavior analysis and
40evidence-based behavior intervention programs, that develop or
P10   1restore, to the maximum extent practicable, the functioning of an
2individual with pervasive developmental disorder or autism, and
3that meet all of the following criteria:

4(A) The treatment is prescribed by a physician and surgeon
5licensed pursuant to Chapter 5 (commencing with Section 2000)
6of, or is developed by a psychologist licensed pursuant to Chapter
76.6 (commencing with Section 2900) of, Division 2 of the Business
8and Professions Code.

9(B) The treatment is provided under a treatment plan prescribed
10by a qualified autism service provider and is administered by one
11of the following:

12(i) A qualified autism service provider.

13(ii) A qualified autism service professional supervised and
14employed by the qualified autism service provider.

15(iii) A qualified autism service paraprofessional supervised and
16employed by a qualified autism service provider.

17(C) The treatment plan has measurable goals over a specific
18timeline that is developed and approved by the qualified autism
19service provider for the specific patient being treated. The treatment
20plan shall be reviewed no less than once every six months by the
21qualified autism service provider and modified whenever
22appropriate, and shall be consistent with Section 4686.2 of the
23Welfare and Institutions Code pursuant to which the qualified
24autism service provider does all of the following:

25(i) Describes the patient’s behavioral health impairments or
26developmental challenges that are to be treated.

27(ii) Designs an intervention plan that includes the service type,
28number of hours, and parent participation needed to achieve the
29plan’s goal and objectives, and the frequency at which the patient’s
30progress is evaluated and reported.

31(iii) Provides intervention plans that utilize evidence-based
32practices, with demonstrated clinical efficacy in treating pervasive
33developmental disorder or autism.

34(iv) Discontinues intensive behavioral intervention services
35when the treatment goals and objectives are achieved or no longer
36appropriate.

37(D) The treatment plan is not used for purposes of providing or
38for the reimbursement of respite, day care, or educational services
39and is not used to reimburse a parent for participating in the
P11   1treatment program. The treatment plan shall be made available to
2the insurer upon request.

3(2) “Pervasive developmental disorder or autism” shall have
4the same meaning and interpretation as used in Section 10144.5.

5(3) “Qualified autism service provider” means either of the
6 following:

7(A) A person, entity, or group that is certified by a national
8entity, such as the Behavior Analyst Certification Board, that is
9accredited by the National Commission for Certifying Agencies,
10and who designs, supervises, or provides treatment for pervasive
11developmental disorder or autism, provided the services are within
12the experience and competence of the person, entity, or group that
13is nationally certified.

14(B) A person licensed as a physician and surgeon, physical
15therapist, occupational therapist, psychologist, marriage and family
16therapist, educational psychologist, clinical social worker,
17professional clinical counselor, speech-language pathologist, or
18audiologist pursuant to Division 2 (commencing with Section 500)
19of the Business and Professions Code, who designs, supervises,
20or provides treatment for pervasive developmental disorder or
21autism, provided the services are within the experience and
22competence of the licensee.

23(4) “Qualified autism service professional” means an individual
24who meets all of the following criteria:

25(A) Provides behavioral health treatment.

26(B) Is employed and supervised by a qualified autism service
27provider.

28(C) Provides treatment pursuant to a treatment plan developed
29and approved by the qualified autism service provider.

30(D) Is a behavioral service provider approved as a vendor by a
31California regional center to provide services as an Associate
32Behavior Analyst, Behavior Analyst, Behavior Management
33Assistant, Behavior Management Consultant, or Behavior
34Management Program as defined in Section 54342begin insert of Article 3end insert of
35Subchapter 2 of Chapter 3 of Division 2 of Title 17 of the
36California Code of Regulations.

37(E) Has training and experience in providing services for
38pervasive developmental disorder or autism pursuant to Division
394.5 (commencing with Section 4500) of the Welfare and
P12   1Institutions Code or Title 14 (commencing with Section 95000)
2of the Government Code.

3(5) “Qualified autism service paraprofessional” means an
4unlicensed and uncertified individual who meets all of the
5following criteria:

6(A) Is employed and supervised by a qualified autism service
7provider.

8(B) Provides treatment and implements services pursuant to a
9treatment plan developed and approved by the qualified autism
10service provider.

11(C) Meets the criteria set forth in the regulations adopted
12pursuant to Section 4686.3 of the Welfare and Institutions Code.

13(D) Has adequate education, training, and experience, as
14certified by a qualified autism service provider.

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

16(1) A specialized health insurance policy that does not cover
17mental health or behavioral health services or an accident only,
18specified disease, hospital indemnity, or Medicare supplement
19policy.

20(2) A health insurance policy in the Medi-Cal program (Chapter
217 (commencing with Section 14000) of Part 3 of Division 9 of the
22Welfare and Institutions Code).

23(3) A health insurance policy in the Healthy Families Program
24(Part 6.2 (commencing with Section 12693)).

25(4) A health care benefit plan or policy entered into with the
26Board of Administration of the Public Employees’ Retirement
27System pursuant to the Public Employees’ Medical and Hospital
28Care Act (Part 5 (commencing with Section 22750) of Division 5
29of Title 2 of the Government Code).

30(e) Nothing in this section shall be construed to limit the
31obligation to provide services under Section 10144.5.

32(f) As provided in Section 10144.5 and in paragraph (1) of
33subdivision (a), in the provision of benefits required by this section,
34a health insurer may utilize case management, network providers,
35utilization review techniques, prior authorization, copayments, or
36other cost sharing.

begin delete

37(g) No later than December 31, 2017, and thereafter as
38necessary, the Board of Psychology, upon appropriation by the
39Legislature, shall convene a committee to create a list of
40evidence-based treatment modalities for purposes of behavioral
P13   1health treatment for pervasive developmental disorder or autism.
2The Board of Psychology shall post the list of evidence-based
3treatment modalities on its Internet Web site no later than January
41, 2019.

5(h) This section shall remain in effect only until January 1, 2022,
6and as of that date is repealed, unless a later enacted statute, that
7is enacted before January 1, 2022, deletes or extends that date.

end delete
8

SEC. 4.  

No reimbursement is required by this act pursuant to
9Section 6 of Article XIII B of the California Constitution because
10the only costs that may be incurred by a local agency or school
11district will be incurred because this act creates a new crime or
12infraction, eliminates a crime or infraction, or changes the penalty
13for a crime or infraction, within the meaning of Section 17556 of
14the Government Code, or changes the definition of a crime within
15the meaning of Section 6 of Article XIII B of the California
16Constitution.



O

    96