BILL ANALYSIS Ó
AB 796
Page 1
Date of Hearing: May 5, 2015
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Susan Bonilla, Chair
AB 796
(Nazarian) - As Introduced February 26, 2015
NOTE: This bill is double referred, and if passed by this
Committee, it will be referred to the Assembly Health Committee.
SUBJECT: Health care coverage: autism and pervasive
developmental disorders.
SUMMARY: Expands the eligibility for a person to be a qualified
autism service professional to include a person who possesses a
bachelor of arts or science degree and meets other requirements
as specified, or is a registered psychological assistant, a
registered psychologist or an associate clinical social worker.
Expands the eligibility for a person to be a qualified autism
service paraprofessional to include a person with a high school
diploma or equivalent, and six months experience working with
persons with developmental disabilities.
EXISTING LAW:
1)Establishes the Board of Psychology, within the Department of
Consumer Affairs (DCA), to license and regulate the practice
of psychology. (BPC § 2900 et seq.)
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2)Establishes the Board of Behavioral Sciences, within the DCA,
to license and regulate clinical social workers, professional
clinical counselors, marriage and family therapists and
educational psychologists. (BPC § 4990 et seq.)
3)Establishes the Medical Board, within the DCA, to license
physicians and surgeons and regulate the practice of medicine.
(BPC § 2000 et seq.)
4)Establishes the Physical Therapy Board, within the DCA, to
license physical therapists, and regulate the practice of
physical therapy. (BPC § 2600 et seq.)
5)Establishes the Occupational Therapy Board, within DCA, to
license occupational therapists, and regulate the practice of
occupational therapy. (BPC § 2570 et seq.)
6)Establishes the Speech-Language Pathologists and Audiologists
and Hearing Aid Dispensers Board, within DCA, to license and
regulate the practice or speech-language pathology, audiology
and hearing aid dispensing. (BPC § 2530 et seq.)
7)Establishes an entitlement to services for individuals with
developmental disabilities under the Lanterman Developmental
Disabilities Services Act (Lanterman Act). (Welfare and
Institutions Code (WIC) § 4500 et seq.)
8)Grants all individuals with developmental disabilities, among
all other rights and responsibilities established for any
individual by the United States Constitution and laws and the
California Constitution and laws, the right to treatment and
habilitation services and supports in the least restrictive
environment. (WIC § 4502)
9)Defines "behavioral health treatment," for purposes of payment
under a health care service plan contract or a health
insurance policy, as professional services and treatment
programs, including applied behavior analysis and
evidence-based behavior intervention programs, which develop
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or restore, to the maximum extent practicable, the functioning
of an individual with pervasive developmental disorder or
autism, and sets forth criteria that must be met related to
the treatment plan, prescription of the treatment, and the
providers authorized to provide such treatment, which includes
qualified autism service professionals, as specified. (Health
and Safety Code (HSC) § 1374.73(c)(1), Insurance Code (INS)
10144.51(c)(1))
10)Defines as "qualified autism service provider" as:
a. A person, entity or group that is certified by a national
entity, such as the Behavior Analyst Certification Board,
that is accredited by the National Commission for Certifying
Agencies, and who designs, supervises, or provides treatment
for pervasive developmental disorders or autism, as
specified; or,
b. A person licensed as a physician and surgeon, physical
therapist, occupational therapist, educational psychologist,
clinical social worker, professional clinical counselor,
speech-language pathologists, or audiologist, who designs,
supervises or provides treatment for pervasive developmental
disorders or autism, as specified. (HSC § 1374.73(c)(3) et
seq.)
11)Defines a "qualified autism service professional" a
behavioral 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
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management program as defined in Title 17 CCR § 54342. (HSC §
1374.73 (c)(4)(D), INS § 10144.51(c)(4)(D))
12)Defines "qualified autism service paraprofessional" as an
unlicensed and uncertified individuals who is employed and
supervised by a qualified autism service provider; and,
provides treatment and implements services pursuant to a
treatment plan developed and approved by the qualified autism
service provider, as specified. (HSC § 1374.73 (c)(4))
13)Defines a "qualified autism service professional" as an
individual who provides behavioral health treatment and is
employed and supervised by a qualified autism service
provider, as specified. (WIC § 1374.73 (c)(4))
14)Defines a "qualified autism service paraprofessional" as an
unlicensed and uncertified individual who is employed and
supervised by a qualified autism service provider; and,
provides treatment and implements services pursuant to a
treatment plan developed and approved by the qualified autism
service provider. (WIC § 1374.73 (c)(5))
15)Defines a "qualified autism service professional" as an
individual who provides behavioral health treatment; is
employed and supervised by a qualified autism service
provider; provides treatment pursuant to a treatment plan
developed and approved by the provider; and, is a behavioral
service provider, as specified. (INS § 10144.51 (c)(4))
16)Defines a "qualified autism service paraprofessional" as an
unlicensed and uncertified individual who is employed and
supervised by a qualified autism service provider; provides
treatment and implements services pursuant to a treatment plan
developed and approved by the qualified autism service
provider; has adequate education, training and experience as
certified by a qualified autism service provider, as
specified. (INS § 10144.51 (c)(5))
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THIS BILL:
1)Adds additional criteria to the definition of "qualified
autism service professional" within the HSC as follows:
a) Is 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 as
defined in Section 54342 of Title 17 of the California Code
of Regulations.
b) Possesses a bachelor of arts or science degree and has
either of the following:
i) Twelve semester units from an accredited institute
of higher learning in either applied behavioral analysis
or clinical coursework in behavioral health and one year
of experience in designing or implementing behavioral
health treatment; or,
ii)Two years of experience in designing or implementing
behavioral health treatment.
c) The person is a registered psychological assistant or
registered psychologist.
d) The person is an associate clinical social worker
registered with the Board of Behavioral Sciences.
2)Adds additional criteria to the definition of a "qualified
autism service paraprofessional" within the HSC as follows:
a) Meets the criteria set forth in the regulations adopted
pursuant to Section 4686.3 of the WIC or meets all of the
following:
i) Possesses a high school diploma or equivalent;
ii)Has six months experience working with persons with a
developmental disability;
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iii)Has 30 hours of training in the specific form of
evidence-based behavioral health treatment administered
by a qualified autism provider or qualified autism
service professional; and,
iv)Has successfully passed a background check conducted by
a state-approved agency.
3)Adds additional criteria to the definition of a "qualified
autism service professional" within the INS as follows:
a) Is a behavioral service provider who meets one of the
following criteria:
i) Is 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 as defined in Section 54342 of Title 17 of the
California Code of Regulations; or,
ii)Possesses a bachelor of arts or science degree and has
either of the following:
(1)Twelve semester units from an accredited institute of
higher learning in either applied behavioral analysis
or clinical coursework in behavioral health and one
year of experience in designing or implementing
behavioral health treatment; or,
(2)Two years of experience in designing or implementing
behavioral health treatment.
b) The person is a registered psychological assistant or
registered psychologist.
c) The person is an associate clinical social worker
registered with the Board of Behavioral Sciences.
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4)Adds additional criteria to the definition of a "qualified
autism service paraprofessional" within the INS as follows:
a) Meets the criteria set forth in the regulations adopted
pursuant to Section 4686.3 of the WIC or meets all of the
following:
i) Possesses a high school diploma or equivalent;
ii)Has six months experience working with persons with a
developmental disability;
iii)Has 30 hours of training in the specific form of
evidence-based behavioral health treatment administered
by a qualified autism provider or qualified autism
service professional; and,
iv)Has successfully passed a background check conducted by
a state-approved agency.
FISCAL EFFECT: None. This bill has been keyed non-fiscal by
the Legislative Counsel.
COMMENTS:
Purpose. This bill is sponsored by the DIR Floor Time
Coalition . According to the author, "AB 796 recognizes that
there is no one size fits all behavior health treatment for an
individual diagnosed with autism. Every child on the autism
spectrum presents differently, as such treatment options must
reflect that spectrum. This bill ensures children diagnosed
with autism will receive insurance coverage for the type of
evidence-based behavior health treatment that is right and
selected for them by the medical professional that knows the
child best."
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Background. The Lanterman Act guides the provision of services
and supports for Californians with developmental disabilities.
Each individual under the Lanterman Act, is legally entitled to
treatment and habilitation services and supports in the least
restrictive environment. Lanterman Act services are designed to
enable all consumers to live more independent and productive
lives in the community.
The term "developmental disability" means a disability that
originates before an individual attains 18 years of age, is
expected to continue indefinitely, and constitutes a substantial
disability for that individual. It includes intellectual
disabilities, cerebral palsy, epilepsy, and pervasive
developmental disorder/autism spectrum disorder (PDD/ASD).
Other developmental disabilities are those disabling conditions
similar to an intellectual disability that require treatment
(e.g., care and management) similar to that required by
individuals with an intellectual disability.
Autism Spectrum Disorders. Defined as a group of
neurodevelopmental disorders linked to atypical biology and
chemistry in the brain that generally appears within the first
three years of life, autism is a growing epidemic among
children. While there are many "autisms," the diagnosis is
often characterized by delayed, impaired or otherwise atypical
verbal and social communication skills, sensitivity to sensory
stimulation, atypical behaviors and body movements, and
sensitivity to changes in routines. Although symptoms and
severity differ among individuals with an autism diagnosis, all
individuals affected by the disorder have impaired communication
skills, difficulties initiating and sustaining social
interactions and restricted, repetitive patterns of behavior
and/or interests. ASD, is one of the commonly-used terms to
describe the various "autisms" and other PDD, and it more
appropriately captures the array of symptoms and varying levels
in the severity of symptoms experienced by individuals with a
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diagnosis within ASD.
Information released in March 2014 by the Centers for Disease
Control (CDC) Autism and Developmental Disabilities Monitoring
(ADDM) Network, estimates prevalence of ASD for children born in
2002 and surveyed in 2010 to be 14.7 per 1,000 children, which
translates to one in 68 children. This is a drastic increase
from CDC data for children born in 2000 and surveyed in 2008,
which estimated the prevalence of children with ASD to be one in
88. Average prevalence for children surveyed in 2006 was one in
110 children. ASD continues to be five times more prevalent for
boys than for girls.
Early Intervention Services. Research shows that a child's
development can be greatly impacted by early intervention
treatment services, especially when provided during a child's
first three years. During that time, a child is developing
motor skills and language, and begins to socialize with others.
Early intervention services for babies and toddlers that have
been diagnosed with, or seem to be at risk for, a developmental
delay or disability often include physical, cognitive,
communication, social/emotional and self-help skill building.
While there is no proven cure for ASD, early intervention can
dramatically change the trajectory of a child's life over time,
including his or her ability to learn new skills throughout
childhood and an increased ability to integrate into, and have a
positive relationship with, his or her community.
Treatments for ASD. According to information retrieved from the
National Institute of Mental Health, there are various
modalities for treating ASD. Specifically, there are a several
different types of behavioral health treatment that have been
scientifically studied and found to be effective. There are
also a number of behavioral treatments in practice that have not
yet met the criteria to be considered "evidence-based."
Applied Behavior Analysis (ABA). A widely accepted
evidence-based treatment for ASD is ABA. There are many
research articles demonstrating the efficacy of ABA as an
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intervention for individuals with autism. These studies range
from group design outcome studies to single subject studies
supporting the use of one specific intervention or technique.
The goals of ABA are to shape and reinforce new behaviors, such
as learning to speak and play, and reduce undesirable ones.
This is done by systematically applying interventions, based
upon the principles of learning theory, to improve socially
significant behaviors to a meaningful degree. Further, the
contingent use of reinforcement and other important principles
to increase behaviors, generalize learned behaviors or reduce
undesirable behaviors is fundamental to ABA.
For example, ABA techniques use rewards-goldfish crackers,
playing with toys, praise-to teach children all kinds of
behaviors, lessons and life skills, step by tiny step, in
intensive, one-on-one drills.
Developmental, Individual Difference, Relationship-based
(DIR)/Floortime Model-aims to build healthy and meaningful
relationships and abilities by following the natural emotions
and interests of the child. One particular example is the Early
Start Denver Model, which fosters improvements in communication,
thinking, language, and other social skills and seeks to reduce
atypical behaviors. Using developmental and relationship-based
approaches, this therapy can be delivered in natural settings
such as the home or pre-school.
TEACCH (Treatment and Education of Autistic and related
Communication Handicapped Children)-emphasizes adapting the
child's physical environment and using visual cues (for example,
having classroom materials clearly marked and located so that
students can access them independently). Using individualized
plans for each student, TEACCH builds on the child's strengths
and emerging skills.
Interpersonal Synchrony-targets social development and imitation
skills, and focuses on teaching children how to establish and
maintain engagement with others.
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SB 946. SB 946 (Steinberg), Chapter 650, Statutes of 2011,
defined "behavioral health treatment" (BHT) as professional
services and treatment programs, including ABA and
evidence-based behavior intervention programs , that develop or
restore, to the maximum extent practicable, the functioning of
an individual with PDD or ASD. The bill mandated coverage of
all evidence-based BHTs prescribed by a physician and surgeon,
or developed by a psychologist, provided under a treatment plan
prescribed by a qualified autism service provider, and
administered by a qualified autism service provider, a qualified
autism service professional, or qualified autism service
paraprofessional. When defining the minimum requirements for
providers, the bill referred to a section of Title 17 which
references only one type of evidence based BHTs, ABA. The
sponsor believes that this was a mistake. The sponsor also
believes that the spirit of the legislation was to allow for
various modalities of treatment. The sponsor indicates that this
discrepancy in existing law makes it difficult for parents to
obtain coverage for prescribed treatments that their children
need.
Department of Managed Healthcare (DMHC) Task Force. SB 946
called for the DMHC to convene a task force to report to the
Governor and Legislature with recommendations for implementing
SB 946. The 18 member task force met for one year. An excerpt
from the report summarizes the Task Force's recommendations
regarding BHT:
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A guiding principle of the Task Force was that every individual
with autism or PDD is unique. Therefore, behavioral health
interventions need to be highly individualized. Since treatment
selection should be made by a team of individuals, who can
consider the unique needs and history of the individual with
autism or PDD, the Task Force determined that it would not be
informative to state policy makers to merely develop a list of
BHTs that are determined to be effective, based solely on
current scientific literature . Since scientific research and
findings naturally advance, the Task Force determined that the
choice of BHTs should be grounded in scientific evidence,
clinical practice guidelines, and/or evidence based practice .
In regards to the individuals who are most appropriate to
administer BHT, the Task Force concluded:
The Task Force concluded that all top level providers [physician
and surgeon, physical therapist, occupational therapist,
psychologist, marriage and family therapist, educational
psychologist, clinical social worker, professional clinical
counselor, or speech language pathologist or audiologists]
should be licensed by the state.
The Task Force also included requirements for individuals who
are unlicensed and who are not certified as follows:
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a) Have adequate training and specific competence in
implementing BHT for autism, including competence in the
scope of treatments outlined in the treatment plan and a
minimum of 30 hours of interactive, competency-based
autism-specific training, as verified by the treatment plan
developer or treatment provider;
b) Be enrolled in a bachelor's program or possess a
bachelor's degree; be enrolled in an associate's degree
program or possess an associate's degree; or, at minimum,
possess a high school diploma;
c) Receive adequate supervision. At lease 60-75 percent of
the supervision should be direct fact-to-face supervision
and include significant co-therapy with the top or
mid-level supervisor; and,
d) The supervision shall cover the functions of ongoing
treatment planning and case supervision.
Current Related Legislation. SB 479 (Bates), of the current
legislative session, establishes the Behavior Analyst Act which
would require a person to apply for and obtain a license from
the Board of Psychology prior to engaging in the practice of
behavior analysis, as defined, either as a behavior analyst or
an assistant behavior analyst, and meet certain educational and
training requirements. STATUS: This bill passed the Senate
Committee on Business, Professions and Economic Development with
an 8-0 vote and is now in the Senate Appropriations Committee.
Prior Related Legislation. SB 946 (Steinberg), Chapter 650,
Statutes of 2011, required health plan and health insurance
policies to cover behavioral health therapy for pervasive
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developmental disorders or autism. The bill also requires
plans and insurers to maintain adequate networks of autism
service providers.
AB 2041 (Jones) of 2014, would have required that a regional
center classify a vendor as a behavior management consultant
or behavior management assistant if the vendor designs or
implements evidence-based behavioral health treatment, has a
specified amount of experience in designing or implementing
that treatment, and meets other licensure and education
requirements. The bill would have required the Department of
Developmental Services to amend its regulations as necessary
to implement the provisions of the bill. NOTE: The bill died
in the Senate Appropriations Committee.
ARGUMENTS IN SUPPORT:
Hundreds of individuals wrote letters of support. They write,
"When the members of the Legislature passed SB 946, the
definition for "behavioral health treatments" was broadly
defined to include all physician or psychologist prescribed
evidence-based forms of therapy. Despite the best intentions of
the Legislature, the law limited this in practice. Many
children are being denied specific forms of prescribed therapy
they need. AB 796 is right for children with autism, for
parents of those children and for the state. By passing this
bill, children in California will be able to receive the
treatment they need and deserve and state costs will be reduced
as health insurance will cover all forms of prescribed,
evidence-based treatment for autism."
ARGUMENTS IN OPPOSITION:
The Autism Research Group opposes the bill and writes, "?we are
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especially concerned about the potential effects of a bill that
would allow paraprofessionals untrained in applied behavior
analysis to replace ABA professionals. The developmental window
during which children with ASD can optimally benefit from
treatment is narrow, and AB 796 could potentially allow precious
time to be squandered "treating" children with ASD with
experimental treatment, rather than treating children using
ABA."
The California Association of Behavior Analysts also write in
opposition, "Our concern is less about the particular discipline
being employed by the service providers, and more about diluting
the training and education requirements of anyone providing
services for this population. SB 946 established standards
applicable to the principle treatment for autism, which is
behavior analysis. Since its enactment, the health insurance
industry has accepted this as the appropriate treatment for
autism, based both on the science and on the qualifications of
those providing the services. AB 796 proposes to elevate into
the realm of accepted providers for the delivery of behavior
analysis individuals that lack the requisite training and
education to provide those services at the level of 'qualified
autism professional.'"
The Center for Autism & Related Disorders shares their
opposition to the bill, "AB 796 would jeopardize Californians
who seek medically necessary treatment for autism spectrum
disorder by diluting California's professional standards and
allowing children with ASD to be treated by unqualified
personnel."
POLICY ISSUES FOR CONSIDERATION:
This bill would amend the definitions of a qualified autism
service professional and qualified autism service
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paraprofessional. The author contends that there is a need to
expand these definitions to allow more individuals the ability
to offer, and be reimbursed for, a variety of behavioral health
treatment modalities, other than evidence-based treatment and
ABA, for individuals who have ASD and PDD. The Committee may
wish to consider if this bill takes the right approach to
achieving this goal. Currently, providers can only be
reimbursed for ABA and evidence-based interventions.
In the DMHC's Task Force report, it outlines the qualifications
for unlicensed and uncertified front line treatment providers
and many of the recommended qualifications have been codified.
The author has included some of these qualifications in this
bill and aims to allow these unlicensed providers to be
recognized as qualified autism services paraprofessionals. For
example, the author wishes to expand the definition of a
qualified paraprofessional to include an individual who has a
high school diploma and six months of working with individuals
who have a developmental disability.
The author also wishes to expand the definition of a qualified
professional to include an individual who has a bachelors
degree, coursework in behavioral health and experience in
designing or implementing BHT, while current law requires that
the individual be recognized as a vendor approved by a Regional
Center. The vendors that are approved have to be able to show
evidence of being able to provide ABA or evidence-based
treatment. By adding these additional qualifications to the
definition of a qualified professional, additional modalities of
treatment would be permitted to be utilized, such as DIR
Floortime.
It is clear that the author's intent is to allow for other
methodologies to be recognized as reimbursable treatment for
developmental disabilities such as ASD and PDD. The way the
author seeks to do this is by curtailing the existing
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definitions of autism professionals and paraprofessionals which
will allow them to utilize other forms of treatment that are not
evidence-based or currently recognized in the code of
regulations. Rather than curtail the criteria for the providers
of evidence-based treatments for ASD and PDD, that the DMHC has
already thoroughly reviewed and established in law and in the
regulations, perhaps a better approach would be to propose
legislation that would amend the Insurance Code and the Health
and Safety Code to recognize non-evidence-based treatments as
acceptable and reimbursable forms of treatment for developmental
disabilities such as ASD and PDD.
REGISTERED SUPPORT:
Hundreds of individuals
REGISTERED OPPOSITION:
Autism Research Group
California Association of Behavior Analysts
Center for Autism & Related Disorders
Southern California Consortium for Behavior Analysis
Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /
(916) 319-3301
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