BILL ANALYSIS                                                                                                                                                                                                    



                                                                     AB 796


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          Date of Hearing:  January 12, 2016


                   ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS


                                Susan Bonilla, Chair


          AB 796  
          (Nazarian) - As Amended January 4, 2016


          NOTE: This bill is double referred, and if passed by this  
          Committee, it will be referred to the Assembly Committee on  
          Health.


          SUBJECT:  Health care coverage:  autism and pervasive  
          developmental disorders.


          SUMMARY:  Extends the sunset date for health care service plans  
          to contract, and health insurance policies to provide coverage  
          for behavioral health treatment for pervasive developmental  
          disorders, from January 1, 2017 to January 1, 2022, and requires  
          the Board of Psychology to create a list of evidence-based  
          treatment modalities for autism or pervasive developmental  
          disorders by December 31, 2017.


          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.)

          2)Establishes the Board of Behavioral Sciences, within the DCA,  








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            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  
            or restore, to the maximum extent practicable, the functioning  








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            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" as 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  
            management program as defined in Title 17 CCR  54342. (HSC   








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            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))
          THIS BILL:








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          1)Extends the sunset date for health care service plans to  
            contract, and health insurance policies to provide coverage  
            for behavioral health treatment for pervasive developmental  
            disorders, and extends the definition of "behavioral health  
            treatment" and "qualified autism service professional" from  
            January 1, 2017 to January 1, 2022.
          2)Requires the Board of Psychology to convene a committee to  
            create a list of evidence-based treatment modalities for  
            pervasive developmental disorders or autism by December 31,  
            2017.


          FISCAL EFFECT:  Unknown.  This bill is keyed 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." 


          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  








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          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.  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.  According to the  
          American Psychiatric Association, people with ASD tend to have  
          communication deficits, such as responding inappropriately in  
          conversations, misreading nonverbal interactions, or having  
          difficulty building friendships appropriate to their age. In  
          addition, people with ASD may be overly dependent on routines,  
          highly sensitive to changes in their environment, or intensely  
          focused on inappropriate items. The symptoms of people with ASD  
          will fall on a continuum, with some individuals showing mild  
          symptoms and others having much more severe symptoms.











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          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 including a combination of  
          medication, occupational therapy, speech therapy, physical  
          therapy, and behavioral interventions.  With regard to  
          behavioral interventions, there are several different types 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." In California, many practitioners report that  
          the most widely reimbursed evidence-based behavioral treatment  
          for ASD is Applied Behavioral Analysis.  Providers also report  
          that they utilize other forms of behavioral health treatment,  








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          e.g. Developmental, Individual Difference, Relationship-based  
          (DIR) Floortime, but they list the treatment modalities under  
          different billing codes to ensure they receive reimbursement.

          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  
          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.

          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  








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          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:





          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  








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          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:


             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  








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               program or possess an associate's degree; or, at minimum,  
               possess a high school diploma;


             c)   Receive adequate supervision. At least 60 to 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.


          Prior Related Legislation. SB 479 (Bates) of 2015, would have  
          established the Behavior Analyst Act which would have required 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.  NOTE: This bill was held in the Assembly  
          Appropriations Committee.





          SB 946 (Steinberg), Chapter 650, Statutes of 2011, required  
            health plan and health insurance policies to cover behavioral  
            health therapy for pervasive 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  








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            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. 


          POLICY ISSUES:


          1)The author has proposed that a subcommittee of the Board of  
            Psychology develop a list of evidence-based treatments for  
            behavioral health treatment.  This would require the Board to  
            consistently review treatments that emerge and add them to the  
            list.  An alternative would be to task the Board's  
            subcommittee with defining evidence based practices. This may  
            help to clarify the standards that guide the classification of  
            behavioral health treatments as evidence- based. 


          2)The author should consider the following technical and   
            clarifying amendments:


          On page 16, line 19, and on page 20, line 22, consider amending  
          the bill as follows: 


          (g) No later than December 31, 2017, and thereafter as  
          necessary, the Board of Psychology, upon appropriation of the  
          Legislature, shall convene a committee to create a list of  
          evidence-based treatment modalities for purposes of  developing  
          mandated  behavioral health treatment  modalities  for pervasive  
          developmental disorder or autism.  The Board of Psychology shall  
          post the list of evidence-based treatment modalities on their  
          webpage no later than January 1, 2019.  


          REGISTERED SUPPORT:  








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          None on file.




          REGISTERED OPPOSITION:  
          None on file.




          Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /  
          (916) 319-3301