BILL ANALYSIS Ó
AB 796
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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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