BILL ANALYSIS                                                                                                                                                                                                    



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          Date of Hearing:  January 12, 2016


                            ASSEMBLY COMMITTEE ON HEALTH


                                  Rob Bonta, Chair


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


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


          SUMMARY:  Requires the Board of Psychology (BOP) to convene a  
          committee to create a list of evidence-based treatment  
          modalities for purposes of developing mandated behavioral health  
          treatment (BHT) modalities for pervasive development disorder or  
          autism (PDD/A).  Extends the sunset provisions requiring health  
          care service plans to provide health coverage for BHT for PDD/A  
          to January 1, 2022.


          EXISTING LAW:


          1)Requires every health care plan that provides hospital,  
            medical, or surgical coverage to provide coverage for BHT for  
            PDD/A;


          2)Does not require any benefits to be provided that exceed the  
            essential health benefits (EHBs) required by federal  
            regulations pursuant to the federal Patient Protection and  
            Affordable Care Act;









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          3)Exempts from 1) above a specialized health plan or health  
            insurance policy that does not deliver mental health or  
            behavioral health services to enrollees, or an accident only,  
            specified disease, hospital indemnity, or Medicare supplement  
            policy, a health plan contract or health insurance policy  
            under Medi-Cal or Healthy Families program, and a health care  
            benefit plan or contract pursuant to the Public Employees'  
            Retirement System. 


          4)Requires health care plans to maintain an adequate network  
            that includes qualified autism service (QAS) providers who  
            supervise and employ QAS professionals or paraprofessionals  
            who provide and administer BHT;


          5)Sunsets above provisions requiring health care service plans  
            to provide health coverage for BHT for PDD/A on January 1,  
            2017.


          6)Defines "Behavioral health treatment" as professional services  
            and treatment programs, including applied behavior analysis  
            and evidence-based behavior intervention programs, that  
            develop or restore, to the maximum extent practicable, the  
            functioning of an individual with PDD/A and that meet all of  
            the following criteria:


             a)   The treatment is prescribed by a licensed physician and  
               surgeon, or is developed by a licensed psychologist;


             b)   The treatment is provided under a treatment plan  
               prescribed by a QAS provider and is administered by one of  
               the following:










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               i)     A QAS provider;


               ii)    A QAS professional supervised and employed by the  
                 QAS provider; or,


               iii)   A QAS paraprofessional supervised and employed by a  
                 QAS provider.


             c)   The treatment plan has measurable goals over a specific  
               timeline that is developed and approved by the QAS provider  
               for the specific patient being treated.


          7)Requires a treatment plan to be reviewed no less than once  
            every six months by the QAS provider and modified whenever  
            appropriate, and in which the QAS provider does all of the  
            following:


             a)   Describes the patient's behavioral health impairments or  
               developmental challenges that are to be treated;


             b)   Designs an intervention plan that includes the service  
               type, number of hours, and parent participation needed to  
               achieve the plan's goal and objectives, and the frequency  
               at which the patient's progress is evaluated and reported;


             c)   Provides intervention plans that utilize evidence-based  
               practices, with demonstrated clinical efficacy in treating  
               PDD/A; and,


             d)   Discontinues intensive behavioral intervention services  
               when the treatment goals and objectives are achieved or no  








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               longer appropriate.


          8)Prohibits the treatment plan from being used for purposes of  
            providing respite, day care, or educational services or  
            reimbursement and from being used to reimburse a parent for  
            participating in the treatment program; 


          9)Requires the treatment plan to be made available to the health  
            care plan upon request.


          10)Defines "Qualified autism service provider" as either of the  
            following:


             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 PDD/A, provided the services are  
               within the experience and competence of the person, entity,  
               or group that is nationally certified; or,


             b)   A person licensed as a physician and surgeon, physical  
               therapist, occupational therapist, psychologist, marriage  
               and family therapist, educational psychologist, clinical  
               social worker, professional clinical counselor,  
               speech-language pathologist, or audiologist, who designs,  
               supervises, or provides treatment for PDD/A, provided the  
               services are within the experience and competence of the  
               licensee.


          11)Defines "Qualified autism service professional" as an  
            individual who meets all of the following criteria:









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             a)   Provides BHT;


             b)   Is employed and supervised by a QAS provider;


             c)   Provides treatment pursuant to a treatment plan  
               developed and approved by the QAS provider;


             d)   Is 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; and,


             e)   Has training and experience in providing services for  
               PDD/A, as specified.


          12)Defines a "Qualified autism service paraprofessional" as an  
            unlicensed and uncertified individual who meets all of the  
            following criteria:


             a)   Is employed and supervised by a QAS provider;


             b)   Provides treatment and implements services pursuant to a  
               treatment plan developed and approved by the QAS provider;


             c)   Meets the criteria set forth in the regulations adopted  
               pursuant to Section 4686.3 of the Welfare and Institutions  
               Code; and,










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             d)   Has adequate education, training, and experience, as  
               certified by a QAS provider.


          13)Establishes the BOP, which consists of nine members, five of  
            which are professional members and four are public member.   
            Requires the BOP to enforce and administer the Psychology  
            Licensing Law.
          14)Provides for the licensure, registration, and regulation of  
            psychologists and psychological assistants under the  
            Psychology Licensing Law.


          FISCAL EFFECT:  This bill has not yet been analyzed by a fiscal  
          committee.


          COMMENTS:  


          1)PURPOSE OF THIS BILL.  According to the author, this bill  
            recognizes that there is no one size fits all BHT for an  
            individual diagnosed with autism.  Every child on the autism  
            spectrum presents differently, as such treatment options must  
            reflect that spectrum.  The author states that this bill  
            ensures children diagnosed with autism will receive insurance  
            coverage for the type of evidence-based BHT that is right and  
            selected for them by the medical professional that knows the  
            child best.


          2)BACKGROUND.  


             a)   DMHC Autism Advisory Task Force.  SB 946 (Steinberg),  
               Chapter 650, Statutes of 2011, requires the California  
               Department of Managed Health Care (DMHC) to convene an  
               Autism Advisory Task Force (Task Force) by February 1,  
               2012, to develop recommendations regarding medically  








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               necessary BHT for individuals with PDD/A, as well as the  
               appropriate qualifications, training, and supervision for  
               providers of such treatment.  SB 946 also requires the Task  
               Force to develop recommendations regarding the education,  
               training, and experience requirements that unlicensed  
               individuals providing BHT must meet in order to obtain  
               licensure from the state.  The Task Force consisted of 18  
               members including research experts, treating providers,  
               health plan representatives, consumer advocates, and  
               members-at-large, many of whom were also parents of  
               individuals with PDD/A.
               The Task Force concluded that behavioral health  
               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 PDD/A.  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.


               


             b)   California Health Benefits Review Program (CHBRP)  
               Analysis.  AB 1996 (Thomson), Chapter 795, Statutes of  
               2002, requests the University of California to assess  
               legislation proposing or repealing a health coverage  
               mandated benefit or service and prepare a written analysis  
               with relevant data on the medical, economic, and public  
               health impacts of the proposed legislation.  CHBRP was  
               created in response to AB 1996.  SB 125 (Ed Hernandez),  
               Chapter 9, Statutes of 2015, added an impact assessment on  
               EHBs, and legislation that impacts health insurance benefit  
               designs, cost sharing, premiums, and other health insurance  
               topics.  CHBRP completed an analysis of AB 796 on April 21,  
               2015.  However, the CHBRP analysis of this bill was on the  
               introduced version, which changed the definition of QAS  
               professional and QAS paraprofessional and no increase in  








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               cost and benefit was identified.  CHBRP points out, in a  
               letter responding to a request by the Committee for an  
               updated analysis of this bill, that as the Legislature  
               considers the current version of this bill, aspects of  
               California law and federal law that may be relevant include  
               the following: 



                    "First, California's current Essential Health  
                    Benefit (EHB) base benchmark plan, effective  
                    through December 31, 2016, was influenced by the  
                    current benefit mandate (established by SB 946 in  
                    2011).  Similarly, California's 2017 EHB base  
                    benchmark plan, was influenced by the current  
                    benefit mandate.  Therefore, the provisions of SB  
                    946 may be relevant to the small-group market and  
                    individual market plans and policies required to  
                    cover EHBs regardless of whether the current  
                    benefit mandate sunsets.  This issue may warrant  
                    further analysis as well as review by both the  
                    California Department of Managed Health Care  
                    (DMHC) and the California Department of Insurance  
                    (CDI).





                    Second, in terms of requiring coverage for  
                    intensive behavioral intervention therapy (IBIT)  
                    as a treatment for PDD/A, there may be overlap  
                    between the current benefit mandate and  
                    California's mandate regarding mental health  
                    parity, which are applicable to all  
                    DMHC-regulated plans and all CDI-regulated  
                    policies.  However, were the provisions of the  
                    current benefit mandate (established by 2011's SB  
                    946) to sunset, the definitions of QAS  








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                    professionals, QAS paraprofessionals, and QAS  
                    providers might change, which could affect access  
                    to and utilization of IBIT.  This issue, too, may  
                    warrant further analysis as well as review by  
                    both DMHC and CDI."





             c)   Pervasive Developmental Disorders and Autism.  PDD/As  
               are neurodevelopmental disorders that typically become  
               symptomatic in children aged two to three years.  They are  
               chronic conditions characterized by impairments in social  
               interactions, communication, sensory processing, repetitive  
               behaviors or interests, and sometimes cognitive function.   
               Symptoms range from mild to severe, as reflected by the  
               phrase "autism spectrum disorders" (ASD).  CHBRP estimates  
               that approximately 87,000 Californians have PDD/A.  Many  
               persons with PDD/A (primarily children) are treated with  
               IBITs, which aim to improve behavior, cognitive function,  
               language, and social skills.



             d)   Behavioral Health Treatment.  Behavior analysis focuses  
               on the principles that explain how learning takes place.   
               Positive reinforcement is one such principle.  When a  
               behavior is followed by some sort of reward, the behavior  
               is more likely to be repeated.  Through decades of  
               research, the field of behavior analysis has developed many  
               techniques for increasing useful behaviors and reducing  
               those that may cause harm or interfere with learning.  ABA  
               is the use of these techniques and principles to bring  
               about meaningful and positive change in behavior.  ABA  
               emerged in the early 1960's as a treatment therapy and is  
               therefore one of the most researched and recognized  
               therapies.  However, PDD/A is a complex disorder that  
               impacts every child differently and typically involves more  








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               than one type of treatment therapy, of which there are  
               many.  Other therapies include the Early Start Denver  
               Model, a developmental, relationship-based intervention  
               approach that utilizes teaching techniques consistent with  
               ABA, Developmental, Individual-differences, &  
               Relationship-based Floortime (DIR/Floortime) a specific  
               technique to both follow the child's natural emotional  
               interests and at the same time challenge the child towards  
               mastery of the social, emotional, and intellectual  
               capacities. 



             e)   IMR.  Individuals covered by health plans or health  
               insurers in California are entitled to an Independent  
               Medical Review (IMR) if a health plan or insurer denies  
               health care services or payment for health care services  
               based on medical necessity.  An IMR is a process where  
               expert independent medical professionals are selected to  
               review specific medical decisions made by the plans or  
               insurers.  DMHC and CDI administer the IMR program to  
               enable consumers to request an impartial appraisal of  
               medical decisions within certain guidelines specified in  
               law.  An IMR can only be requested if the plan or insurer's  
               decision involves the medical necessity of a treatment, an  
               experimental or investigational therapy for certain medical  
               conditions, or a claims denial for emergency or urgent  
               medical services.  According to CDI, between the years of  
               2011-15, 76 behavioral intensive therapy or applied  
               behavioral analysis cases have gone to IMR and 56, or  
               approximately 74%, were overturned.  According to the DMHC,  
               since 2009, 93% of 148 disputes brought to DMHC by  
               consumers, whose health plans have denied some form of  
               autism treatment, have been resolved in favor of the  
               consumer.
               


             f)   Board of Psychology.  The BOP is one of 30 regulatory  








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               entities which fall under the organizational structure of  
               the Department of Consumer Affairs.  The BOP regulates  
               psychologists, registered psychologists, and psychological  
               assistants. Only licensed psychologists can practice  
               psychology independently in the private sector in  
               California.  Registered psychologists are registered to  
               work and train under supervision in non-profit agencies  
               that receive government funding and registered  
               psychological assistants are employed and supervised by a  
               qualified licensed psychologist in private settings.  The  
               BOP consists of nine appointed members and is composed as  
               follows:  i) five licensed psychologists appointed by the  
               Governor; ii) two public members appointed by the Governor;  
               iii) one public member appointed by the Senate Rules  
               Committee; and, iv) one public member appointed by the  
               Speaker of the Assembly.



               Board members are appointed to the BOP for four-year terms  
               and each member may serve a maximum of two terms.  The BOP  
               is funded through license, application, and examination  
               fees. 


               


          3)SUPPORT.  Hundreds of individuals writing in support of a  
            previous version of this bill state that by requiring  
            frontline providers to be vendored by the regional centers, SB  
            946 limits treatment for ASD to only one therapy, ABA.  This  
            bill would apply the same level of requirements to other  
            evidence-based forms of therapy and will allow parents the  
            opportunity to receive insurance coverage for the BHT that is  
            the most appropriate for their child.











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            The DIR/Floortime Coalition of California writes in strong  
            support to a previous version of the bill that by allowing  
            frontline personnel trained in the specific form of treatment  
            contained within the scope of the treatment plan developed by  
            their physician or psychologist, parents, and treatment  
            providers will be able to seek the most appropriate treatment  
            for their child with Autism. 


            


          4)OPPOSITION.  Center for Autism & Related Disorders (CARD)  
            states in opposition to a previous version of this bill, that  
            it will amend California's landmark autism mandate to expand  
            the definition of "qualified autism service professional" to  
            include individuals who are not qualified to provide  
            evidence-based BHT and who were never intended to be included  
            in the definition of QAS professional.  CARD argues that the  
            effectiveness of evidence-based autism treatment requires  
            trained and experienced individuals to oversee and implement  
            it.  


          5)RELATED LEGISLATION.  SB 479 (Bates) establishes the Behavior  
            Analyst Act which requires a person to apply for and obtain a  
            license from the BOP 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.  SB 479 is pending in the Assembly  
            Appropriations Committee.


          6)PREVIOUS LEGISLATION.  


             a)   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  








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               designs or implements evidence-based BHT, has a specified  
               amount of experience in designing or implementing that  
               treatment, and meets other licensure and education  
               requirements.  AB 2041 would have required the Department  
               of Developmental Services to amend its regulations as  
               necessary to implement the provisions of the bill.  AB 2041  
               died in the Senate Appropriations Committee. 


             b)   SB 126 (Steinberg), Chapter 680, Statutes of 2013,  
               extends the operation of the BHT mandate until January 1,  
               2017.


             c)   SB 946 requires health plans and health insurance  
               policies to cover BHT for PDD/A, requires plans and  
               insurers to maintain adequate networks of autism service  
               providers, establishes an Autism Advisory Task Force in the  
               Department of Managed Health Care, and sunsets autism  
               mandate provisions on July 1, 2014.


          7)DOUBLE REFERRAL.  This bill is double referred and is  
            currently set for hearing on January 12, 2016 in the Assembly  
            Business and Professions Committee. 


          8)COMMITTEE AMENDMENTS.  


             a)   Report Requirements.  This bill requires the BOP to  
               convene a committee to create a list of evidence-based  
               treatment modalities. To ensure that the resulting list is  
               available for appropriate use, the Committee may wish to  
               consider requiring the BOP to post its findings on their  
               Website no later than January 1, 2019.


             b)   Clarifying Amendment.  This bill currently states that  








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               the evidence-based treatment modalities should be  
               established for purposes of developing mandated BHT  
               modalities.  Coverage for BHTs is a mandate established by  
               federal and state mental health parity laws and this bill  
               does not seek to alter that in anyway.  The Committee may  
               wish to amend this bill as follows:  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 behavioral health  
               treatment for pervasive developmental disorder or autism.


          REGISTERED SUPPORT / OPPOSITION:




          Support


          327 Individuals




          Opposition


          Autism Research Group (previous version)


          Center for Autism & Related Disorders (previous version)




          Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097









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