BILL ANALYSIS Ó
AB 796
Page 1
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