Amended in Senate August 16, 2016

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,begin insert andend insert to amend Section 10144.51 of the Insurance Code,begin delete and to add Section 4513.1 to the Welfare and Institutions Code,end delete 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 abegin delete behaviorend deletebegin insert behavioralend insert 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 also require the State Department of Developmental Services, no later than July 1, 2018, with input from stakeholders, 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 delete

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:

begin delete
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.

end delete
30

begin deleteSEC. 2.end delete
31
begin insertSECTION 1.end insert  

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

33

1374.73.  

(a) (1) Every health care service plan contract that
34provides hospital, medical, or surgical coverage shall also provide
35coverage for behavioral health treatment for pervasive
36developmental disorder or autism no later than July 1, 2012. The
37coverage shall be provided in the same manner and shall be subject
38to the same requirements as provided in Section 1374.72.

39(2) Notwithstanding paragraph (1), as of the date that proposed
40final rulemaking for essential health benefits is issued, this section
P4    1does not require any benefits to be provided that exceed the
2essential health benefits that all health plans will be required by
3federal regulations to provide under Section 1302(b) of the federal
4Patient Protection and Affordable Care Act (Public Law 111-148),
5as amended by the federal Health Care and Education
6Reconciliation Act of 2010 (Public Law 111-152).

7(3) This section shall not affect services for which an individual
8is eligible pursuant to Division 4.5 (commencing with Section
94500) of the Welfare and Institutions Code or Title 14
10(commencing with Section 95000) of the Government Code.

11(4) This section shall not affect or reduce any obligation to
12provide services under an individualized education program, as
13defined in Section 56032 of the Education Code, or an individual
14service plan, as described in Section 5600.4 of the Welfare and
15Institutions Code, or under the federal Individuals with Disabilities
16Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
17regulations.

18(b) Every health care service plan subject to this section shall
19 maintain an adequate network that includes qualified autism service
20providers who supervise and employ qualified autism service
21professionals or paraprofessionals who provide and administer
22behavioral health treatment. Nothing shall prevent a health care
23service plan from selectively contracting with providers within
24these requirements.

25(c) For the purposes of this section, the following definitions
26shall apply:

27(1) “Behavioral health treatment” means professional services
28and treatment programs, including applied behavior analysis and
29evidence-based behavior intervention programs, that develop or
30restore, to the maximum extent practicable, the functioning of an
31individual with pervasive developmental disorder or autism and
32that meet all of the following criteria:

33(A) The treatment is prescribed by a physician and surgeon
34licensed pursuant to Chapter 5 (commencing with Section 2000)
35of, or is developed by a psychologist licensed pursuant to Chapter
366.6 (commencing with Section 2900) of, Division 2 of the Business
37and Professions Code.

38(B) The treatment is provided under a treatment plan prescribed
39by a qualified autism service provider and is administered by one
40of the following:

P5    1(i) A qualified autism service provider.

2(ii) A qualified autism service professional supervised and
3employed by the qualified autism service provider.

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

6(C) The treatment plan has measurable goals over a specific
7 timeline that is developed and approved by the qualified autism
8service provider for the specific patient being treated. The treatment
9plan shall be reviewed no less than once every six months by the
10qualified autism service provider and modified whenever
11appropriate, and shall be consistent with Section 4686.2 of the
12Welfare and Institutions Code pursuant to which the qualified
13autism service provider does all of the following:

14(i) Describes the patient’s behavioral health impairments or
15developmental challenges that are to be treated.

16(ii) Designs an intervention plan that includes the service type,
17number of hours, and parent participation needed to achieve the
18plan’s goal and objectives, and the frequency at which the patient’s
19progress is evaluated and reported.

20(iii) Provides intervention plans that utilize evidence-based
21practices, with demonstrated clinical efficacy in treating pervasive
22developmental disorder or autism.

23(iv) Discontinues intensive behavioral intervention services
24when the treatment goals and objectives are achieved or no longer
25appropriate.

26(D) The treatment plan is not used for purposes of providing or
27for the reimbursement of respite, day care, or educational services
28and is not used to reimburse a parent for participating in the
29treatment program. The treatment plan shall be made available to
30the health care service plan upon request.

31(2) “Pervasive developmental disorder or autism” shall have
32the same meaning and interpretation as used in Section 1374.72.

33(3) “Qualified autism service provider” means either of the
34following:

35(A) A person, entity, or group that is certified by a national
36entity, such as the Behavior Analyst Certification Board, that is
37accredited by the National Commission for Certifying Agencies,
38and who designs, supervises, or provides treatment for pervasive
39developmental disorder or autism, provided the services are within
P6    1the experience and competence of the person, entity, or group that
2is nationally certified.

3(B) A person licensed as a physician and surgeon, physical
4therapist, occupational therapist, psychologist, marriage and family
5therapist, educational psychologist, clinical social worker,
6professional clinical counselor, speech-language pathologist, or
7audiologist pursuant to Division 2 (commencing with Section 500)
8of the Business and Professions Code, who designs, supervises,
9or provides treatment for pervasive developmental disorder or
10autism, provided the services are within the experience and
11competence of the licensee.

12(4) “Qualified autism service professional” means an individual
13who meets all of the following criteria:

14(A) Provides behavioral health treatment.

15(B) Is employed and supervised by a qualified autism service
16provider.

17(C) Provides treatment pursuant to a treatment plan developed
18and approved by the qualified autism service provider.

19(D) Is a behavioral service provider approved as a vendor by a
20California regional center to provide services as an Associate
21Behavior Analyst, Behavior Analyst, Behavior Management
22Assistant, Behavior Management Consultant, or Behavior
23Management Program as defined in Section 54342 of Article 3 of
24Subchapter 2 of Chapter 3 of Division 2 of Title 17 of the
25California Code of Regulations.

26(E) Has training and experience in providing services for
27pervasive developmental disorder or autism pursuant to Division
284.5 (commencing with Section 4500) of the Welfare and
29Institutions Code or Title 14 (commencing with Section 95000)
30of the Government Code.

31(5) “Qualified autism service paraprofessional” means an
32unlicensed and uncertified individual who meets all of the
33following criteria:

34(A) Is employed and supervised by a qualified autism service
35provider.

36(B) Provides treatment and implements services pursuant to a
37treatment plan developed and approved by the qualified autism
38service provider.

39(C) Meets the criteria set forth in the regulations adopted
40pursuant to Section 4686.3 of the Welfare and Institutions Code.

P7    1(D) Has adequate education, training, and experience, as
2certified by a qualified autism service provider.

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

4(1) A specialized health care service plan that does not deliver
5mental health or behavioral health services to enrollees.

6(2) A health care service plan contract in the Medi-Cal program
7(Chapter 7 (commencing with Section 14000) of Part 3 of Division
89 of the Welfare and Institutions Code).

9(3) A health care service plan contract in the Healthy Families
10Program (Part 6.2 (commencing with Section 12693) of Division
112 of the Insurance Code).

12(4) A health care benefit plan or contract entered into with the
13Board of Administration of the Public Employees’ Retirement
14System pursuant to the Public Employees’ Medical and Hospital
15Care Act (Part 5 (commencing with Section 22750) of Division 5
16of Title 2 of the Government Code).

17(e) Nothing in this section shall be construed to limit the
18obligation to provide services under Section 1374.72.

19(f) As provided in Section 1374.72 and in paragraph (1) of
20subdivision (a), in the provision of benefits required by this section,
21a health care service plan may utilize case management, network
22providers, utilization review techniques, prior authorization,
23copayments, or other cost sharing.

24

begin deleteSEC. 3.end delete
25
begin insertSEC. 2.end insert  

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

27

10144.51.  

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

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

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

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

12(b) Pursuant to Article 6 (commencing with Section 2240) of
13Subchapter 2 of Chapter 5 of Title 10 of the California Code of
14Regulations, every health insurer subject to this section shall
15maintain an adequate network that includes qualified autism service
16providers who supervise and employ qualified autism service
17professionals or paraprofessionals who provide and administer
18behavioral health treatment. Nothing shall prevent a health insurer
19from selectively contracting with providers within these
20requirements.

21(c) For the purposes of this section, the following definitions
22shall apply:

23(1) “Behavioral health treatment” means professional services
24and treatment programs, including applied behavior analysis and
25evidence-based behavior intervention programs, that develop or
26restore, to the maximum extent practicable, the functioning of an
27individual with pervasive developmental disorder or autism, and
28that meet all of the following criteria:

29(A) The treatment is prescribed by a physician and surgeon
30licensed pursuant to Chapter 5 (commencing with Section 2000)
31of, or is developed by a psychologist licensed pursuant to Chapter
326.6 (commencing with Section 2900) of, Division 2 of the Business
33and Professions Code.

34(B) The treatment is provided under a treatment plan prescribed
35by a qualified autism service provider and is administered by one
36of the following:

37(i) A qualified autism service provider.

38(ii) A qualified autism service professional supervised and
39employed by the qualified autism service provider.

P9    1(iii) A qualified autism service paraprofessional supervised and
2employed by a qualified autism service provider.

3(C) The treatment plan has measurable goals over a specific
4timeline that is developed and approved by the qualified autism
5service provider for the specific patient being treated. The treatment
6plan shall be reviewed no less than once every six months by the
7qualified autism service provider and modified whenever
8appropriate, and shall be consistent with Section 4686.2 of the
9Welfare and Institutions Code pursuant to which the qualified
10autism service provider does all of the following:

11(i) Describes the patient’s behavioral health impairments or
12developmental challenges that are to be treated.

13(ii) Designs an intervention plan that includes the service type,
14number of hours, and parent participation needed to achieve the
15plan’s goal and objectives, and the frequency at which the patient’s
16progress is evaluated and reported.

17(iii) Provides intervention plans that utilize evidence-based
18practices, with demonstrated clinical efficacy in treating pervasive
19developmental disorder or autism.

20(iv) Discontinues intensive behavioral intervention services
21when the treatment goals and objectives are achieved or no longer
22appropriate.

23(D) The treatment plan is not used for purposes of providing or
24for the reimbursement of respite, day care, or educational services
25and is not used to reimburse a parent for participating in the
26treatment program. The treatment plan shall be made available to
27the insurer upon request.

28(2) “Pervasive developmental disorder or autism” shall have
29the same meaning and interpretation as used in Section 10144.5.

30(3) “Qualified autism service provider” means either of the
31 following:

32(A) A person, entity, or group that is certified by a national
33entity, such as the Behavior Analyst Certification Board, that is
34accredited by the National Commission for Certifying Agencies,
35and who designs, supervises, or provides treatment for pervasive
36developmental disorder or autism, provided the services are within
37the experience and competence of the person, entity, or group that
38is nationally certified.

39(B) A person licensed as a physician and surgeon, physical
40therapist, occupational therapist, psychologist, marriage and family
P10   1therapist, educational psychologist, clinical social worker,
2professional clinical counselor, speech-language pathologist, or
3audiologist pursuant to Division 2 (commencing with Section 500)
4of the Business and Professions Code, who designs, supervises,
5or provides treatment for pervasive developmental disorder or
6autism, provided the services are within the experience and
7competence of the licensee.

8(4) “Qualified autism service professional” means an individual
9who meets all of the following criteria:

10(A) Provides behavioral health treatment.

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

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

15(D) Is a behavioral service provider approved as a vendor by a
16California regional center to provide services as an Associate
17Behavior Analyst, Behavior Analyst, Behavior Management
18Assistant, Behavior Management Consultant, or Behavior
19Management Program as defined in Section 54342 of Article 3 of
20Subchapter 2 of Chapter 3 of Division 2 of Title 17 of the
21California Code of Regulations.

22(E) Has training and experience in providing services for
23pervasive developmental disorder or autism pursuant to Division
244.5 (commencing with Section 4500) of the Welfare and
25Institutions Code or Title 14 (commencing with Section 95000)
26of the Government Code.

27(5) “Qualified autism service paraprofessional” means an
28unlicensed and uncertified individual who meets all of the
29following criteria:

30(A) Is employed and supervised by a qualified autism service
31provider.

32(B) Provides treatment and implements services pursuant to a
33treatment plan developed and approved by the qualified autism
34service provider.

35(C) Meets the criteria set forth in the regulations adopted
36pursuant to Section 4686.3 of the Welfare and Institutions Code.

37(D) Has adequate education, training, and experience, as
38certified by a qualified autism service provider.

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

P11   1(1) A specialized health insurance policy that does not cover
2mental health or behavioral health services or an accident only,
3specified disease, hospital indemnity, or Medicare supplement
4policy.

5(2) A health insurance policy in the Medi-Cal program (Chapter
67 (commencing with Section 14000) of Part 3 of Division 9 of the
7Welfare and Institutions Code).

8(3) A health insurance policy in the Healthy Families Program
9(Part 6.2 (commencing with Section 12693)).

10(4) A health care benefit plan or policy 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 10144.5.

17(f) As provided in Section 10144.5 and in paragraph (1) of
18subdivision (a), in the provision of benefits required by this section,
19a health insurer may utilize case management, network providers,
20utilization review techniques, prior authorization, copayments, or
21other cost sharing.

begin delete22

SEC. 4.  

Section 4513.1 is added to the Welfare and Institutions
23Code
, to read:

24

4513.1.  

The department, no later than July 1, 2018, with input
25from stakeholders, shall update regulations as appropriate to set
26forth the minimum standards of education, training, and
27professional experience for qualified autism service professionals
28and paraprofessionals practicing behavioral health treatment other
29than applied behavioral analysis that shall be no less rigorous than
30the requirements set forth in subdivision (b) of Section 54342 of
31Article 3 of Subchapter 2 of Chapter 3 of Division 2 of Title 17
32of the California Code of Regulations.

end delete
33

begin deleteSEC. 5.end delete
34
begin insertSEC. 3.end insert  

No reimbursement is required by this act pursuant to
35Section 6 of Article XIII B of the California Constitution because
36the only costs that may be incurred by a local agency or school
37district will be incurred because this act creates a new crime or
38infraction, eliminates a crime or infraction, or changes the penalty
39for a crime or infraction, within the meaning of Section 17556 of
40the Government Code, or changes the definition of a crime within
P12   1the meaning of Section 6 of Article XIII B of the California
2Constitution.



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