Amended in Senate June 30, 2016

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, to amend Section 10144.51 of the Insurance Code, and to add Section 4513.1 to the Welfare and Institutions 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, 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.

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.

The bill would also require the State Department of Developmental Services, no later than July 1, 2018, with input from stakeholders,begin delete 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 andend delete to update regulations to set forth the minimum standards of education, training, and professional experience for qualified autism service professionals and paraprofessionals, as specified.

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 evidence-based behavioral
22health treatment be covered by health care service plans, pursuant
23to Section 1374.73 of the Health and Safety Code, and health
24insurance policies, pursuant to Section 10144.51 of the Insurance
25Code.

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 54342 of Article 3 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.

22

SEC. 3.  

Section 10144.51 of the Insurance Code is amended
23to read:

24

10144.51.  

(a) (1) Every health insurance policy shall also
25provide coverage for behavioral health treatment for pervasive
26developmental disorder or autism no later than July 1, 2012. The
27coverage shall be provided in the same manner and shall be subject
28to the same requirements as provided in Section 10144.5.

29(2) Notwithstanding paragraph (1), as of the date that proposed
30final rulemaking for essential health benefits is issued, this section
31does not require any benefits to be provided that exceed the
32essential health benefits that all health insurers will be required by
33federal regulations to provide under Section 1302(b) of the federal
34Patient Protection and Affordable Care Act (Public Law 111-148),
35as amended by the federal Health Care and Education
36Reconciliation Act of 2010 (Public Law 111-152).

37(3) This section shall not affect services for which an individual
38is eligible pursuant to Division 4.5 (commencing with Section
394500) of the Welfare and Institutions Code or Title 14
40(commencing with Section 95000) of the Government Code.

P8    1(4) This section shall not affect or reduce any obligation to
2provide services under an individualized education program, as
3defined in Section 56032 of the Education Code, or an individual
4service plan, as described in Section 5600.4 of the Welfare and
5Institutions Code, or under the federal Individuals with Disabilities
6Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
7regulations.

8(b) Pursuant to Article 6 (commencing with Section 2240) of
9Subchapter 2 of Chapter 5 of Title 10 of the California Code of
10Regulations, every health insurer subject to this section shall
11maintain an adequate network that includes qualified autism service
12providers who supervise and employ qualified autism service
13professionals or paraprofessionals who provide and administer
14behavioral health treatment. Nothing shall prevent a health insurer
15from selectively contracting with providers within these
16requirements.

17(c) For the purposes of this section, the following definitions
18shall apply:

19(1) “Behavioral health treatment” means professional services
20and treatment programs, including applied behavior analysis and
21evidence-based behavior intervention programs, that develop or
22restore, to the maximum extent practicable, the functioning of an
23individual with pervasive developmental disorder or autism, and
24that meet all of the following criteria:

25(A) The treatment is prescribed by a physician and surgeon
26licensed pursuant to Chapter 5 (commencing with Section 2000)
27of, or is developed by a psychologist licensed pursuant to Chapter
286.6 (commencing with Section 2900) of, Division 2 of the Business
29and Professions Code.

30(B) The treatment is provided under a treatment plan prescribed
31by a qualified autism service provider and is administered by one
32of the following:

33(i) A qualified autism service provider.

34(ii) A qualified autism service professional supervised and
35employed by the qualified autism service provider.

36(iii) A qualified autism service paraprofessional supervised and
37employed by a qualified autism service provider.

38(C) The treatment plan has measurable goals over a specific
39timeline that is developed and approved by the qualified autism
40service provider for the specific patient being treated. The treatment
P9    1plan shall be reviewed no less than once every six months by the
2qualified autism service provider and modified whenever
3appropriate, and shall be consistent with Section 4686.2 of the
4Welfare and Institutions Code pursuant to which the qualified
5autism service provider does all of the following:

6(i) Describes the patient’s behavioral health impairments or
7developmental challenges that are to be treated.

8(ii) Designs an intervention plan that includes the service type,
9number of hours, and parent participation needed to achieve the
10plan’s goal and objectives, and the frequency at which the patient’s
11progress is evaluated and reported.

12(iii) Provides intervention plans that utilize evidence-based
13practices, with demonstrated clinical efficacy in treating pervasive
14developmental disorder or autism.

15(iv) Discontinues intensive behavioral intervention services
16when the treatment goals and objectives are achieved or no longer
17appropriate.

18(D) The treatment plan is not used for purposes of providing or
19for the reimbursement of respite, day care, or educational services
20and is not used to reimburse a parent for participating in the
21treatment program. The treatment plan shall be made available to
22the insurer upon request.

23(2) “Pervasive developmental disorder or autism” shall have
24the same meaning and interpretation as used in Section 10144.5.

25(3) “Qualified autism service provider” means either of the
26 following:

27(A) A person, entity, or group that is certified by a national
28entity, such as the Behavior Analyst Certification Board, that is
29accredited by the National Commission for Certifying Agencies,
30and who designs, supervises, or provides treatment for pervasive
31developmental disorder or autism, provided the services are within
32the experience and competence of the person, entity, or group that
33is nationally certified.

34(B) A person licensed as a physician and surgeon, physical
35therapist, occupational therapist, psychologist, marriage and family
36therapist, educational psychologist, clinical social worker,
37professional clinical counselor, speech-language pathologist, or
38audiologist pursuant to Division 2 (commencing with Section 500)
39of the Business and Professions Code, who designs, supervises,
40or provides treatment for pervasive developmental disorder or
P10   1autism, provided the services are within the experience and
2competence of the licensee.

3(4) “Qualified autism service professional” means an individual
4who meets all of the following criteria:

5(A) Provides behavioral health treatment.

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

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

10(D) Is a behavioral service provider approved as a vendor by a
11California regional center to provide services as an Associate
12Behavior Analyst, Behavior Analyst, Behavior Management
13Assistant, Behavior Management Consultant, or Behavior
14Management Program as defined in Section 54342 of Article 3 of
15Subchapter 2 of Chapter 3 of Division 2 of Title 17 of the
16California Code of Regulations.

17(E) Has training and experience in providing services for
18pervasive developmental disorder or autism pursuant to Division
194.5 (commencing with Section 4500) of the Welfare and
20Institutions Code or Title 14 (commencing with Section 95000)
21of the Government Code.

22(5) “Qualified autism service paraprofessional” means an
23unlicensed and uncertified individual who meets all of the
24following criteria:

25(A) Is employed and supervised by a qualified autism service
26provider.

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

30(C) Meets the criteria set forth in the regulations adopted
31pursuant to Section 4686.3 of the Welfare and Institutions Code.

32(D) Has adequate education, training, and experience, as
33certified by a qualified autism service provider.

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

35(1) A specialized health insurance policy that does not cover
36mental health or behavioral health services or an accident only,
37specified disease, hospital indemnity, or Medicare supplement
38policy.

P11   1(2) A health insurance policy in the Medi-Cal program (Chapter
27 (commencing with Section 14000) of Part 3 of Division 9 of the
3Welfare and Institutions Code).

4(3) A health insurance policy in the Healthy Families Program
5 (Part 6.2 (commencing with Section 12693)).

6(4) A health care benefit plan or policy entered into with the
7Board of Administration of the Public Employees’ Retirement
8System pursuant to the Public Employees’ Medical and Hospital
9Care Act (Part 5 (commencing with Section 22750) of Division 5
10of Title 2 of the Government Code).

11(e) Nothing in this section shall be construed to limit the
12obligation to provide services under Section 10144.5.

13(f) As provided in Section 10144.5 and in paragraph (1) of
14subdivision (a), in the provision of benefits required by this section,
15a health insurer may utilize case management, network providers,
16utilization review techniques, prior authorization, copayments, or
17other cost sharing.

18

SEC. 4.  

Section 4513.1 is added to the Welfare and Institutions
19Code
, to read:

20

4513.1.  

begin delete(a)end deletebegin deleteend deleteThe department, no later than July 1, 2018, with
21input frombegin delete the stakeholders identified in subdivision (b), shall do
22both of the following:end delete

begin delete

23(1) Develop a methodology for determining what constitutes
24an evidence-based practice in the field of behavioral health
25treatment for autism and pervasive developmental disorder.

end delete

26begin delete(2)end deletebegin deleteend deletebegin deleteUpdate regulationsend deletebegin insert stakeholders, shall update regulations
27as appropriateend insert
to set forth the minimum standards of education,
28training, and professional experience for qualified autism service
29professionals and paraprofessionals practicing behavioral health
30treatment other than applied behavioral analysis that shall be no
31less rigorous than the requirements set forth in subdivision (b) of
32Section 54342 of Article 3 of Subchapter 2 of Chapter 3 of Division
332 of Title 17 of the California Code of Regulations.

begin delete

34(b) Stakeholders shall include professionals trained in
35interpreting research data and shall represent a balanced diversity
36of treatment modalities, including both behavioral and
37developmental approaches. These professionals shall include, at
38a minimum, a developmental pediatrician, a marriage and family
39therapist, a child and adolescent psychiatrist, a psychologist, a
P12   1neuropsychologist, a board certified behavior analyst, and a
2University of California autism researcher.

end delete
3

SEC. 5.  

No reimbursement is required by this act pursuant to
4Section 6 of Article XIII B of the California Constitution because
5the only costs that may be incurred by a local agency or school
6district will be incurred because this act creates a new crime or
7infraction, eliminates a crime or infraction, or changes the penalty
8for a crime or infraction, within the meaning of Section 17556 of
9the Government Code, or changes the definition of a crime within
10the meaning of Section 6 of Article XIII B of the California
11Constitution.



O

    94