BILL ANALYSIS                                                                                                                                                                                                    



                                                                     AB 796


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          Date of Hearing:  January 21, 2016


                        ASSEMBLY COMMITTEE ON APPROPRIATIONS


                                 Jimmy Gomez, Chair


          AB  
          796 (Nazarian) - As Amended January 13, 2016


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          |             |Health                         |     |18 - 0       |
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          Urgency:  No  State Mandated Local Program:  YesReimbursable:   
          No


          SUMMARY:


          This bill requires the Board of Psychology (BOP), no later than  
          December 31, 2017, and thereafter as necessary, upon  
          appropriation of the Legislature, to convene a committee to  
          create a list of evidence-based treatment modalities for  
          purposes of behavioral health treatment for pervasive  
          developmental disorder or autism (PDD/A, hereafter referred to  
          as autism).








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          It also extends the sunset on the existing behavioral health  
          treatment (BHT) mandate for an additional five years, from  
          January 1, 2017 to January 1, 2022.


          FISCAL EFFECT:


          1)Costs to the Board of Psychology of under $50,000 for each  
            update to the list of evidence-based BHT models for an  
            unspecified number of updates between 2017 and the bill's  
            sunset in 2022. 


          2)The California Health Benefits Review Program (CHBRP)  
            estimated no impact on private insurance premium cost or on  
            public health from a previous bill (SB 126 (Steinberg),  
            Chapter 680, Statutes of 2013) that extended the sunset on the  
            BHT mandate from January 1, 2014 to January 1, 2017, given  
            that state mental health parity laws already require coverage  
            for this treatment.   Although a CHBRP analysis was not  
            performed on the current version of this bill, it appears as  
            through the same reasoning would hold, and there would be no  
            premium cost impact from a provision extending the mandate for  
            additional years.


          3)Potential minor and absorbable costs to the Department of  
            Managed Health Care (DMHC) (Managed Care Fund) and the  
            California Department of Insurance (CDI) (Insurance Fund) to  
            oversee compliance with the existing mandate for an additional  
            five years. Compliance costs for coverage of BHT generally are  
            due to state and federal mental health parity laws, and not to  
            this mandate.  However, extending this mandate would extend  
            important definitions of qualified providers and network  
            requirements, as well as some specificity in what must be  
            covered, for an additional five years. 








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          4)The creation of a state-sanctioned list of evidence-based  
            treatments is intended to lead to coverage of more types of  
            behavioral health treatment by health plans and insurers.  
            Although the current mandate already requires coverage of BHT,  
            which is defined to include "evidence-based behavior  
            intervention programs," to the extent this bill increases  
            coverage for and utilization of various BHTs, it could result  
            in unknown cost pressure to premiums in the private market.  
            State-provided health insurance, including Medi-Cal and plans  
            offered by CalPERS, are exempt from this mandate.   


          COMMENTS:


          1)Purpose. The purpose of this bill is to provide expert  
            guidance on what constitutes evidence-based treatment for  
            autism with the intent that such guidance leads to greater  
            coverage of different types of BHT, as well as to extend the  
            existing BHT coverage mandate for five years.  The author  
            indicates autism treatment should not be one-size-fits-all,  
            and this bill is intended to provide guidance that will allow  
            children to receive coverage for the type of evidence-based  
            treatment that is appropriate for their unique needs.   
            Specifically, it appears this bill is attempting to establish  
            a basis for what types of coverage must be offered by health  
            plans, as well as a basis upon which families can challenge  
            coverage denials, by having BOP, a third party made up of  
            psychological professionals, establish a list of what  
            treatments are evidence-based.  
            
            This bill is sponsored by the DIR Floortime Coalition,  
            practitioners of an autism treatment called Developmental,  
            Individual-differences, & Relationship-based (DIR) Floortime.   
            DIR Floortime is a developmental model of treatment used for  
            autism that attempts to build healthy foundations for social,  
            emotional, and intellectual capacities by following the  








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            child's lead (which for young children often means interacting  
            with them through play on the floor). 
             
          2)Autism Treatment. The most well-known and studied treatment  
            for autism is Applied Behavioral Analysis (ABA), a behavioral  
            model that uses learning techniques to increase desirable  
            behaviors and reduce harmful ones.  There are also other, less  
            widely-used treatments, some of which use a developmental  
            model and others that are a hybrid of both models.  A recent  
            evidence review in the Journal of Clinical Child and  
            Adolescent Psychology notes the evidence base for  
            interventions has grown substantially since 2008, and that an  
            increasing number of interventions have some empirical  
            support, while others are emerging as potentially effective.  

          3)Coverage for BHT. SB 946 (Steinberg), Chapter 650, Statutes of  
            2011, instituted the current BHT mandate, which this bill  
            proposes to extend for an additional five years. The mandate  
            requires health plans and insurers to cover BHT for autism if  
            certain criteria are met.  The sunset on the mandate was  
            extended once in 2013 by SB 126, as noted above.  Regulators  
            maintain that even without this mandate, in order to comply  
            with mental health parity laws, BHT would have to be covered.   
            Both state and federal mental health parity laws apply, and  
            they generally require mental health benefits to be covered at  
            "parity" with medical benefits, or subject only to limits that  
            are no more restrictive than those on medical benefits.  
            California's mental health parity law, AB 88 (Thomson),  
            Chapter 534, Statutes of 1999, specifically lists autism as a  
            covered condition.  Anecdotally, this bill's proponents have  
            indicated difficulty in securing health care coverage for  
            treatment other than ABA.  According to figures obtained from  
            CDI and DMHC, the vast majority of independent medical review  
            (IMR) decisions about coverage denials have been resolved in  
            favor of the families seeking coverage.  

          4)DMHC Autism Advisory Task Force.  When the BHT mandate was put  
            into place, SB 946 also required DMHC to convene an Autism  
            Advisory Task Force (Task Force) by February 1, 2012, to  








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            develop recommendations regarding medically necessary BHT for  
            individuals with autism, as well as the appropriate  
            qualifications, training, and supervision for providers of  
            such treatment.  

            The Task Force declined to develop a list of BHTs for autism.  
            The report instead concluded that BHT interventions need to be  
            highly individualized and that treatment selection should be  
            made by a team of individuals who can consider the unique  
            needs and history of the individual with autism.  It further  
            states 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.  It  
            states many scientific studies have addressed the efficacy of  
            BHTs for autism, and that the choice of treatment should be  
            grounded in scientific evidence, clinical practice guidelines,  
            or evidence-based practice. 

          5)Staff Comments.  Treatment and research for autism are rapidly  
            evolving. CHBRP notes in their April 21, 2015 analysis of a  
            previous version of this bill that while a preponderance of  
            evidence suggests that intensive autism treatments are more  
            effective than usual treatments in increasing IQ and improving  
            adaptive behaviors, outcomes for individual children vary  
            widely, and the literature on effectiveness is limited in  
            several respects, including that most studies are not  
            randomized.   Further, there seems to be consensus that  
            individual cases are unique and may respond differently to the  
            same treatment.  Given the confusing, limited, and rapidly  
            evolving evidence base, it is perhaps no surprise providers,  
            parents, and plans have difficulty definitively identifying  
            what may appropriate for an individual child.  

          


          Analysis Prepared by:Lisa Murawski / APPR. / (916)  
          319-2081









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