BILL ANALYSIS Ó AB 796 Page 1 Date of Hearing: January 21, 2016 ASSEMBLY COMMITTEE ON APPROPRIATIONS Jimmy Gomez, Chair AB 796 (Nazarian) - As Amended January 13, 2016 ----------------------------------------------------------------- |Policy |Business and Professions |Vote:|12-0 | |Committee: | | | | | | | | | | | | | | |-------------+-------------------------------+-----+-------------| | |Health | |18 - 0 | | | | | | | | | | | ----------------------------------------------------------------- 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). AB 796 Page 2 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. AB 796 Page 3 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 AB 796 Page 4 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 AB 796 Page 5 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 AB 796 Page 6