Amended in Senate June 21, 2016

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,begin delete andend delete to amend Section 10144.51 of the Insurance Code,begin insert and to add Section 4513.1 to the Welfare and Institutions Code,end insert relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

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

begin insert

Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities and their families. Existing law defines developmental disability for these purposes, to include, among other things, autism.

end insert

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 delete the sunset date, thereby extending the operation of these provisions indefinitely. 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 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 delete

begin insert

The bill would also require the State Department of Developmental Services, no later than July 1, 2018, with input from stakeholders, as specified, to develop a methodology for determining what constitutes an evidence-based practice in the field of behavioral health treatment for autism and pervasive developmental disorder and to update regulations to set forth the minimum standards of education, training, and professional experience for qualified autism service professionals and paraprofessionals, as specified.

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:

P3    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 thatbegin delete all forms ofend delete 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.

28(i) The Legislature intends that health care service plan provider
29networks include qualified professionals practicing all forms of
P4    1evidence-based behavioral health treatment other than just applied
2behavioral analysis.

3

SEC. 2.  

Section 1374.73 of the Health and Safety Code is
4amended to read:

5

1374.73.  

(a) (1) Every health care service plan contract that
6provides hospital, medical, or surgical coverage shall also provide
7coverage for behavioral health treatment for pervasive
8developmental disorder or autism no later than July 1, 2012. The
9coverage shall be provided in the same manner and shall be subject
10to the same requirements as provided in Section 1374.72.

11(2) Notwithstanding paragraph (1), as of the date that proposed
12final rulemaking for essential health benefits is issued, this section
13does not require any benefits to be provided that exceed the
14essential health benefits that all health plans will be required by
15federal regulations to provide under Section 1302(b) of the federal
16Patient Protection and Affordable Care Act (Public Law 111-148),
17as amended by the federal Health Care and Education
18Reconciliation Act of 2010 (Public Law 111-152).

19(3) This section shall not affect services for which an individual
20is eligible pursuant to Division 4.5 (commencing with Section
214500) of the Welfare and Institutions Code or Title 14
22(commencing with Section 95000) of the Government Code.

23(4) This section shall not affect or reduce any obligation to
24provide services under an individualized education program, as
25defined in Section 56032 of the Education Code, or an individual
26service plan, as described in Section 5600.4 of the Welfare and
27Institutions Code, or under the federal Individuals with Disabilities
28Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
29regulations.

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

37(c) For the purposes of this section, the following definitions
38shall apply:

39(1) “Behavioral health treatment” means professional services
40and treatment programs, including applied behavior analysis and
P5    1evidence-based behavior intervention programs, that develop or
2restore, to the maximum extent practicable, the functioning of an
3individual with pervasive developmental disorder or autism and
4that meet all of the following criteria:

5(A) The treatment is prescribed by a physician and surgeon
6licensed pursuant to Chapter 5 (commencing with Section 2000)
7of, or is developed by a psychologist licensed pursuant to Chapter
86.6 (commencing with Section 2900) of, Division 2 of the Business
9and Professions Code.

10(B) The treatment is provided under a treatment plan prescribed
11by a qualified autism service provider and is administered by one
12of the following:

13(i) A qualified autism service provider.

14(ii) A qualified autism service professional supervised and
15employed by the qualified autism service provider.

16(iii) A qualified autism service paraprofessional supervised and
17employed by a qualified autism service provider.

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

26(i) Describes the patient’s behavioral health impairments or
27developmental challenges that are to be treated.

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

32(iii) Provides intervention plans that utilize evidence-based
33practices, with demonstrated clinical efficacy in treating pervasive
34developmental disorder or autism.

35(iv) Discontinues intensive behavioral intervention services
36when the treatment goals and objectives are achieved or no longer
37appropriate.

38(D) The treatment plan is not used for purposes of providing or
39for the reimbursement of respite, day care, or educational services
40and is not used to reimburse a parent for participating in the
P6    1treatment program. The treatment plan shall be made available to
2the health care service plan upon request.

3(2) “Pervasive developmental disorder or autism” shall have
4the same meaning and interpretation as used in Section 1374.72.

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

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 54342 of Article 3 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
P7    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 care service plan that does not deliver
17mental health or behavioral health services to enrollees.

18(2) A health care service plan contract in the Medi-Cal program
19(Chapter 7 (commencing with Section 14000) of Part 3 of Division
209 of the Welfare and Institutions Code).

21(3) A health care service plan contract in the Healthy Families
22Program (Part 6.2 (commencing with Section 12693) of Division
232 of the Insurance Code).

24(4) A health care benefit plan or contract entered into with the
25Board of Administration of the Public Employees’ Retirement
26System pursuant to the Public Employees’ Medical and Hospital
27Care Act (Part 5 (commencing with Section 22750) of Division 5
28of Title 2 of the Government Code).

29(e) Nothing in this section shall be construed to limit the
30obligation to provide services under Section 1374.72.

31(f) As provided in Section 1374.72 and in paragraph (1) of
32subdivision (a), in the provision of benefits required by this section,
33a health care service plan may utilize case management, network
34providers, utilization review techniques, prior authorization,
35copayments, or other cost sharing.

begin delete

36(g) No later than July 1, 2017, the department, in conjunction
37with the Department of Insurance, shall develop procedure codes
38for evidence-based behavioral health treatment other than applied
39behavior analysis.

P8    1(h) No later than December 31, 2017, and thereafter as
2necessary, the department, in conjunction with the Department of
3Insurance as lead agency, shall convene a task force that, at a
4minimum, shall include a developmental pediatrician, a marriage
5and family therapist, a child and adolescent psychiatrist, a
6psychologist, a neuropsychologist, a board certified behavior
7analyst, and a University of California autism researcher as voting
8representatives, as well as nonvoting representatives from the State
9Department of Developmental Services, the Department of
10Insurance, and the department. All voting members shall be
11professionals trained in interpreting research data and shall
12represent a balanced diversity of treatment modalities, including
13both behavioral and developmental approaches. The task force
14shall do all of the following:

15(1) Develop a methodology for determining what constitutes
16an evidence-based practice in the field of behavioral health
17treatment for autism and pervasive developmental disorder.

18(2) Develop a list of behavioral health treatment modalities for
19autism and pervasive developmental disorder supported by research
20that shall be displayed on the department Web site and distributed
21to the State Department of Developmental Services, all regional
22centers, and health care service plans.

23(3) Develop minimum standards of education, training, and
24professional experience for qualified autism service professionals
25practicing behavioral health treatment other than applied behavior
26analysis that shall be no less rigorous than the requirements as
27defined in subdivision (b) of Section 54342 of Article 3 of
28 Subchapter 2 of Chapter 3 of Division 2 of Title 17 of the
29California Code of Regulations.

30(4) Develop minimum standards of education, training, and
31professional experience for qualified autism service
32paraprofessionals practicing behavioral health treatment other than
33applied behavior analysis that shall be no less rigorous than the
34education and training qualifications defined in the regulations
35adopted pursuant to Section 4686.3 of the Welfare and Institutions
36Code.

37(i) The list of behavioral health treatment modalities developed
38pursuant to this section shall constitute evidence that a particular
39form of treatment is evidence-based in an independent medical
40review.

P9    1(j) The absence of a particular form of treatment from the list
2of behavioral health treatment modalities developed pursuant to
3this section shall not constitute evidence that a particular form of
4treatment is not evidence-based.

end delete
5

SEC. 3.  

Section 10144.51 of the Insurance Code is amended
6to read:

7

10144.51.  

(a) (1) Every health insurance policy shall also
8provide coverage for behavioral health treatment for pervasive
9developmental disorder or autism no later than July 1, 2012. The
10coverage shall be provided in the same manner and shall be subject
11to the same requirements as provided in Section 10144.5.

12(2) Notwithstanding paragraph (1), as of the date that proposed
13final rulemaking for essential health benefits is issued, this section
14does not require any benefits to be provided that exceed the
15essential health benefits that all health insurers will be required by
16federal regulations to provide under Section 1302(b) of the federal
17Patient Protection and Affordable Care Act (Public Law 111-148),
18as amended by the federal Health Care and Education
19Reconciliation Act of 2010 (Public Law 111-152).

20(3) This section shall not affect services for which an individual
21is eligible pursuant to Division 4.5 (commencing with Section
224500) of the Welfare and Institutions Code or Title 14
23(commencing with Section 95000) of the Government Code.

24(4) This section shall not affect or reduce any obligation to
25provide services under an individualized education program, as
26defined in Section 56032 of the Education Code, or an individual
27service plan, as described in Section 5600.4 of the Welfare and
28Institutions Code, or under the federal Individuals with Disabilities
29Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
30regulations.

31(b) Pursuant to Article 6 (commencing with Section 2240) of
32Subchapter 2 of Chapter 5 of Title 10 of the California Code of
33Regulations, every health insurer subject to this section shall
34maintain an adequate network that includes qualified autism service
35providers who supervise and employ qualified autism service
36professionals or paraprofessionals who provide and administer
37behavioral health treatment. Nothing shall prevent a health insurer
38from selectively contracting with providers within these
39requirements.

P10   1(c) For the purposes of this section, the following definitions
2shall apply:

3(1) “Behavioral health treatment” means professional services
4and treatment programs, including applied behavior analysis and
5evidence-based behavior intervention programs, that develop or
6restore, to the maximum extent practicable, the functioning of an
7individual with pervasive developmental disorder or autism, and
8that meet all of the following criteria:

9(A) The treatment is prescribed by a physician and surgeon
10licensed pursuant to Chapter 5 (commencing with Section 2000)
11of, or is developed by a psychologist licensed pursuant to Chapter
126.6 (commencing with Section 2900) of, Division 2 of the Business
13and Professions Code.

14(B) The treatment is provided under a treatment plan prescribed
15by a qualified autism service provider and is administered by one
16of the following:

17(i) A qualified autism service provider.

18(ii) A qualified autism service professional supervised and
19employed by the qualified autism service provider.

20(iii) A qualified autism service paraprofessional supervised and
21employed by a qualified autism service provider.

22(C) The treatment plan has measurable goals over a specific
23timeline that is developed and approved by the qualified autism
24service provider for the specific patient being treated. The treatment
25plan shall be reviewed no less than once every six months by the
26qualified autism service provider and modified whenever
27appropriate, and shall be consistent with Section 4686.2 of the
28Welfare and Institutions Code pursuant to which the qualified
29autism service provider does all of the following:

30(i) Describes the patient’s behavioral health impairments or
31developmental challenges that are to be treated.

32(ii) Designs an intervention plan that includes the service type,
33number of hours, and parent participation needed to achieve the
34plan’s goal and objectives, and the frequency at which the patient’s
35progress is evaluated and reported.

36(iii) Provides intervention plans that utilize evidence-based
37practices, with demonstrated clinical efficacy in treating pervasive
38developmental disorder or autism.

P11   1(iv) Discontinues intensive behavioral intervention services
2when the treatment goals and objectives are achieved or no longer
3appropriate.

4(D) The treatment plan is not used for purposes of providing or
5for the reimbursement of respite, day care, or educational services
6and is not used to reimburse a parent for participating in the
7treatment program. The treatment plan shall be made available to
8the insurer upon request.

9(2) “Pervasive developmental disorder or autism” shall have
10the same meaning and interpretation as used in Section 10144.5.

11(3) “Qualified autism service provider” means either of the
12 following:

13(A) A person, entity, or group that is certified by a national
14entity, such as the Behavior Analyst Certification Board, that is
15accredited by the National Commission for Certifying Agencies,
16and who designs, supervises, or provides treatment for pervasive
17developmental disorder or autism, provided the services are within
18the experience and competence of the person, entity, or group that
19is nationally certified.

20(B) A person licensed as a physician and surgeon, physical
21therapist, occupational therapist, psychologist, marriage and family
22therapist, educational psychologist, clinical social worker,
23professional clinical counselor, speech-language pathologist, or
24audiologist pursuant to Division 2 (commencing with Section 500)
25of the Business and Professions Code, who designs, supervises,
26or provides treatment for pervasive developmental disorder or
27autism, provided the services are within the experience and
28competence of the licensee.

29(4) “Qualified autism service professional” means an individual
30who meets all of the following criteria:

31(A) Provides behavioral health treatment.

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

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

36(D) Is a behavioral service provider approved as a vendor by a
37California regional center to provide services as an Associate
38Behavior Analyst, Behavior Analyst, Behavior Management
39Assistant, Behavior Management Consultant, or Behavior
40Management Program as defined in Section 54342 of Article 3 of
P12   1Subchapter 2 of Chapter 3 of Division 2 of Title 17 of the
2California Code of Regulations.

3(E) Has training and experience in providing services for
4pervasive developmental disorder or autism pursuant to Division
54.5 (commencing with Section 4500) of the Welfare and
6Institutions Code or Title 14 (commencing with Section 95000)
7of the Government Code.

8(5) “Qualified autism service paraprofessional” means an
9unlicensed and uncertified individual who meets all of the
10following criteria:

11(A) Is employed and supervised by a qualified autism service
12provider.

13(B) Provides treatment and implements services pursuant to a
14treatment plan developed and approved by the qualified autism
15service provider.

16(C) Meets the criteria set forth in the regulations adopted
17pursuant to Section 4686.3 of the Welfare and Institutions Code.

18(D) Has adequate education, training, and experience, as
19certified by a qualified autism service provider.

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

21(1) A specialized health insurance policy that does not cover
22mental health or behavioral health services or an accident only,
23specified disease, hospital indemnity, or Medicare supplement
24policy.

25(2) A health insurance policy in the Medi-Cal program (Chapter
267 (commencing with Section 14000) of Part 3 of Division 9 of the
27Welfare and Institutions Code).

28(3) A health insurance policy in the Healthy Families Program
29(Part 6.2 (commencing with Section 12693)).

30(4) A health care benefit plan or policy entered into with the
31Board of Administration of the Public Employees’ Retirement
32System pursuant to the Public Employees’ Medical and Hospital
33Care Act (Part 5 (commencing with Section 22750) of Division 5
34of Title 2 of the Government Code).

35(e) Nothing in this section shall be construed to limit the
36obligation to provide services under Section 10144.5.

37(f) As provided in Section 10144.5 and in paragraph (1) of
38subdivision (a), in the provision of benefits required by this section,
39a health insurer may utilize case management, network providers,
P13   1utilization review techniques, prior authorization, copayments, or
2other cost sharing.

3begin insert

begin insertSEC. 4.end insert  

end insert

begin insertSection 4513.1 is added to the end insertbegin insertWelfare and Institutions
4Code
end insert
begin insert, to read:end insert

begin insert
5

begin insert4513.1.end insert  

(a) The department, no later than July 1, 2018, with
6input from the stakeholders identified in subdivision (b), shall do
7both of the following:

8
(1) Develop a methodology for determining what constitutes an
9evidence-based practice in the field of behavioral health treatment
10for autism and pervasive developmental disorder.

11
(2) Update regulations to set forth the minimum standards of
12education, training, and professional experience for qualified
13autism service professionals and paraprofessionals practicing
14behavioral health treatment other than applied behavioral analysis
15that shall be no less rigorous than the requirements set forth in
16subdivision (b) of Section 54342 of Article 3 of Subchapter 2 of
17Chapter 3 of Division 2 of Title 17 of the California Code of
18Regulations.

19
(b) Stakeholders shall include professionals trained in
20interpreting research data and shall represent a balanced diversity
21of treatment modalities, including both behavioral and
22developmental approaches. These professionals shall include, at
23a minimum, a developmental pediatrician, a marriage and family
24therapist, a child and adolescent psychiatrist, a psychologist, a
25neuropsychologist, a board certified behavior analyst, and a
26University of California autism researcher.

end insert
27

begin deleteSEC. 4.end delete
28
begin insertSEC. 5.end insert  

No reimbursement is required by this act pursuant to
29Section 6 of Article XIII B of the California Constitution because
30the only costs that may be incurred by a local agency or school
31district will be incurred because this act creates a new crime or
32infraction, eliminates a crime or infraction, or changes the penalty
33for a crime or infraction, within the meaning of Section 17556 of
34the Government Code, or changes the definition of a crime within
35the meaning of Section 6 of Article XIII B of the California
36Constitution.



O

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