BILL ANALYSIS                                                                                                                                                                                                    



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 796    
           --------------------------------------------------------------- 
          |AUTHOR:        |Nazarian                                       |
          |---------------+-----------------------------------------------|
          |VERSION:       |June 8, 2016                                   |
           --------------------------------------------------------------- 
           --------------------------------------------------------------- 
          |HEARING DATE:  |June 15, 2016  |               |               |
           --------------------------------------------------------------- 
           --------------------------------------------------------------- 
          |CONSULTANT:    |Teri Boughton                                  |
           --------------------------------------------------------------- 
          
           SUBJECT  :  Health care coverage:  autism and pervasive  
          developmental disorders

           SUMMARY  :  Requires the Department of Managed Health Care (DMHC) in  
          conjunction with the California Department of Insurance (CDI) to  
          develop procedure codes for evidence-based behavioral health  
          treatment other than applied behavioral analysis. Requires DMHC  
          to convene a task force, with CDI as lead agency, to develop a  
          methodology for determining evidence-based practices in the  
          field of behavioral health treatment, a list of modalities to be  
          distributed to health plans, and minimum education and training  
          standards for qualified autism service professionals and  
          paraprofessionals practicing behavioral health treatment other  
          than applied behavior analysis.
          
          Existing law:
          1)Establishes the DMHC to regulate health plans under the  
            Knox-Keene Health Care Services Plan Act of 1975; the  
            California Department of Insurance (CDI) to regulate health  
            insurers under; and, the California Health Benefit Exchange  
            (Exchange) to compare and make available through selective  
            contracting health insurance for individual and small business  
            purchasers as authorized under the federal Patient Protection  
            and Affordable Care Act (ACA).

          2)Establishes as California's essential health benefits (EHBs)  
            benchmark the Kaiser Small Group Health Maintenance  
            Organization plan, existing California mandates, and the  
            following 10 ACA mandated benefits:

                   a)         Ambulatory patient services;
                   b)         Emergency services;
                   c)         Hospitalization;







          AB 796 (Nazarian)                                  Page 2 of ?
          
          
                   d)         Maternity and newborn care;
                   e)         Mental health and substance use disorder  
                     services, including behavioral health treatment;
                   f)         Prescription drugs;
                   g)         Rehabilitative and habilitative services and  
                     devices;
                   h)         Laboratory services;
                   i)         Preventive and wellness services and chronic  
                     disease management; and,
                   j)         Pediatric services, including oral and  
                     vision care.

          3)Requires every health plan contract that provides hospital,  
            medical, or surgical coverage and health insurance policy to  
            also provide coverage for behavioral health treatment for  
            pervasive developmental disorder or autism no later than July  
            1, 2012.  Requires the coverage to be provided in the same  
            manner and to be subject to the same requirements as provided  
            in California's mental health parity law.

          4)Establishes a definition for "qualified autism service  
            professional" which includes a requirement that the individual  
            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 as defined in existing law and regulations;  
            and a definition for "qualified autism service  
            paraprofessional" which includes a requirement to meet  
            criteria set forth in different section of existing law and  
            regulations.

          5)Requires DMHC, in consultation with CDI, to convene a task  
            force by February 1, 2012, to develop recommendations  
            regarding behavioral health treatment that are medically  
            necessary for the treatment of individuals with pervasive  
            developmental disorder or autism, as specified.  

          6)Exempts from 3) 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'  








          AB 796 (Nazarian)                                  Page 3 of ?
          
          
            Retirement System (CalPERS).

          7)Sunsets the provisions described in 3) through 6) above on  
            January 1, 2017.
          
          This bill:
          1)Requires, no later than July 1, 2017, DMHC, in conjunction  
            with CDI, to develop procedure codes for evidence-based  
            behavioral health treatment other than applied behavioral  
            analysis.

          2)Requires no later than December 31, 2017, and thereafter as  
            necessary, DMHC in conjunction with CDI as lead agency, to  
            convene a task force and requires the task force, at a minimum  
            include a developmental pediatrician, a marriage and family  
            therapist, a child and adolescent psychiatrist, a  
            psychologist, a neuropsychologist, a board certified behavior  
            analyst, and a University of California autism researcher as  
            voting representatives, as well as nonvoting representatives  
            from the California Department of Developmental Services  
            (DDS), CDI, and DMHC.  Requires all voting members to be  
            trained in interpreting research data and to represent a  
            balanced diversity of treatment modalities, including both  
            behavioral and developmental approaches.

          3)Requires the task force to do all of the following:

                  a)        Develop a methodology for determining what  
                    constitutes evidence-based practice in the field of  
                    behavioral health treatment modalities for autism and  
                    pervasive developmental disorder.
                  b)        Develop a list of behavioral health treatment  
                    modalities for autism and pervasive developmental  
                    disorder that will be displayed on the DMHC website  
                    and distributed to DDS, regional centers, and health  
                    care service plans.
                  c)        Develop minimum standards of education,  
                    training, and professional experience for qualified  
                    autism service professionals and paraprofessionals  
                    practicing behavioral health treatment other than  
                    applied behavior analysis that shall be no less  
                    rigorous than the requirements defined in DDS  
                    regulations, as specified.

          4)Requires the list of behavioral health treatment modalities  








          AB 796 (Nazarian)                                  Page 4 of ?
          
          
            developed pursuant to this bill to constitute evidence that a  
            particular form of treatment is evidence-based in an  
            independent medical review.

          5)States that the absence of a particular form of treatment from  
            the list does not constitute evidence that a particular form  
            of treatment is not evidence-based.

          6)Deletes the January 1, 2017 sunset date described in 7) above.  


          7)States legislative intent that all forms of evidence-based  
            behavioral health treatment be covered by health plans and  
            health insurance policies, and that health plan provider  
            networks include qualified professionals practicing all forms  
            of evidence-based behavioral health treatment other than just  
            applied behavioral analysis.

           FISCAL  
          EFFECT  :  According to the Assembly Appropriations Committee:
          1)Costs to the Board of Psychology (BOP) 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. June 8, 2016 amendments transfer this  
            responsibility to DMHC.


          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  
            behavioral health treatment 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 though the same reasoning would hold, and  
            there would be no premium cost impact from a provision  
            extending the mandate for additional years.  June 8, 2016  
            amendments delete the sunset provision.


          3)Potential minor and absorbable costs to DMHC (Managed Care  
            Fund) and CDI (Insurance Fund) to oversee compliance with the  
            existing mandate for an additional five years. Compliance  
            costs for coverage of behavioral health therapy generally are  








          AB 796 (Nazarian)                                  Page 5 of ?
          
          
            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. 


          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  
            behavioral health treatment, which is defined to include  
            "evidence-based behavior intervention programs," to the extent  
            this bill increases coverage for and utilization of various  
            behavioral health treatments, 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.   


           PRIOR  
          VOTES  :  
          
           ----------------------------------------------------------------- 
          |Assembly Floor:                     |75 - 0                      |
          |------------------------------------+----------------------------|
          |Assembly Appropriations Committee:  |17 - 0                      |
          |------------------------------------+----------------------------|
          |Assembly Business and Professions   |  7 - 4                     |
          |Committee:                          |                            |
           ----------------------------------------------------------------- 
           
          COMMENTS  :
          1)Author's statement.  According to the author, this bill would  
            ensure that children diagnosed with autism continue to have  
            access to medically necessary treatments to increase their  
            quality of life and functional independence by removing the  
            2017 sunset on the requirement for health plans and insurers  
            to provide behavioral health treatments to children with  
            autism.  

          2)CHBRP analysis.  AB 1996 (Thomson, Chapter 795, Statutes of  
            2002), requests the University of California to assess  
            legislation proposing a mandated benefit or service and  
            prepare a written analysis with relevant data on the medical,  








          AB 796 (Nazarian)                                  Page 6 of ?
          
          
            economic, and public health impacts of proposed health plan  
            and health insurance benefit mandate legislation. CHBRP was  
            created in response to AB 1996, and reviewed this bill.  CHBRP  
            reviewed an earlier version of this bill, as well as other  
            related bills, and issued a letter in response to a request  
            from the Assembly Health Committee for an updated review of  
            this bill.  Relevant information from CHBRP's earlier analyses  
            and the more recent letter is below.

          The American Academy of Child and Adolescent Psychiatry (AACAP)  
            and the American Academy of Pediatrics (AAP) have developed  
            recommendations for evidence-based behavioral and education  
            treatments (which would include treatments CHBRP is terming  
            intensive behavioral intervention treatments) for children and  
            adolescents with pervasive developmental disorder or autism  
            (Myers, 2007; Volkmar at el., 2014). The primary goals of  
            treatment are to maximize independence, learning, and quality  
            of life by minimizing the core autism disorder attributes.  
            Behavioral interventions such as applied behavioral analysis  
            draw upon the theories of B.F. Skinner and emphasize using  
            reinforcement to teach children with pervasive developmental  
            disorder or autism basic social skill skills such as  
            attention, compliance, and imitation. There are different  
            types of applied behavioral analysis-based programs, such as  
            the Discrete Trial Training, Early Intensive Behavioral  
            Intervention, and Pivotal Response Training. Educational  
            interventions, such as the Early Start Denver Model, combine  
            applied behavioral analysis-based and developmental  
            approaches. An individualized education plan developed by an  
            interdisciplinary team of personnel and parents explicitly  
            describes intensive services to be provided with the goal of  
            enhancing communication, motor, and academic skills. Other  
            intensive behavioral intervention treatments models are based  
            on developmental theory of behavior change, such as the  
            Developmental, Individual Difference, Relationship-based  
            Floortime model (DIR/Floortime). The DIR/Floortime method is  
            relationship-based and emphasizes emotionally meaningful  
            exchanges with the goal to increase skills in the processes of  
            social engagement and communicating. 

            While there is evidence that intensive behavioral intervention  
            treatments are associated with better outcomes, the consensus  
            across the AAP and AACAP is that the quality of research in  
            the area is variable (Volkmar et a., 2014). Among the  
            different intensive behavioral intervention treatment models,  








          AB 796 (Nazarian)                                  Page 7 of ?
          
          
            none has been clearly identified as superior (Myers, 2007).  
            Neither the AACAP nor the AAP have developed recommendations  
            on the optimal personnel for delivering intensive behavioral  
            intervention treatments for children with pervasive  
            developmental disorder or autism. 

            In terms of requiring coverage for intensive behavioral  
            intervention treatments as a treatment for autism and  
            pervasive developmental disorder, 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.

          3)Task Force. The Autism Advisory Task Force was established  
            pursuant to SB 946 (Chapter 650, Statutes of 2011).  The Chair  
            of the task force was the DMHC Director, who was a non-voting  
            member, and another 17 members were appointed by the DMHC  
            Director.  Members of the task force include parents of  
            children with autism and individuals with legal, health plan,  
            behavioral health, and medical expertise.  The charge of the  
            task force was to make recommendations to inform state  
            policymaking and guide future recommendations addressing six  
            subjects and develop recommendations regarding the education,  
            training, and experience requirements that unlicensed  
            individuals providing autism services shall meet in order to  
            secure a license from the state.  The six subjects are:

                    a)          Interventions that have been  
                      scientifically validated and have demonstrated  
                      clinical efficacy;
                    b)          Interventions that have measurable  
                      treatment outcomes;
                    c)          Patient selection, monitoring, and  
                      duration of therapy;
                    d)          Qualifications, training, and supervision  
                      of providers;
                    e)          Adequate networks of providers; and,
                    f)          The education, training, and experience  
                      requirements that unlicensed individuals providing  
                      autism services shall meet in order to secure a  
                      license from the state.

            With regard to pervasive development disorder or autism, the  
            task force considers the following diagnoses to fall under the  
            definition:  pervasive developmental disorder-not otherwise  








          AB 796 (Nazarian)                                  Page 8 of ?
          
          
            specified, Autistic Disorder, Asperger Syndrome, Rett's  
            Syndrome, and Childhood Disintegrative Disorder.  In all 55  
            recommendations were adopted, all but one, on a consensus  
            basis.  

          4) List Not Endorsed. A guiding principle of the task force was  
            that every individual with autism or pervasive developmental  
            disorder is unique. According to the task force report,  
            individuals have different combinations of characteristics,  
            different needs for assistance, and respond differently to  
            treatment. 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 pervasive  
            developmental disorder, the task force determined that it  
            would not be informative to state policy makers to merely  
            develop a list of behavioral health treatments that are  
            determined to be effective, based solely on current scientific  
            literature. Since scientific research and findings naturally  
            advance, the task force determined that the choice of  
            behavioral health treatment should be grounded in scientific  
            evidence, clinical practice guidelines, and/or evidence-based  
            practice. 

          5)Providers should be Licensed. The task force concludes that  
            all "top level" (undefined) providers should be licensed by  
            the state, and set forth a process for establishing a new  
            professional license for "Licensed Behavioral Health  
            Practitioner."  The task force recommended that the license  
            requirement not take effect until three years after the  
            license is established, and an interim commission be formed to  
            implement the new license until a board is able to do so.  The  
            task force also recommended all providers of autism services  
            be registered with the state's TrustLine Registry or  
            comparable system as a condition of employment by service  
            organizations and contracting with health plans and health  
            insurers. TrustLine uses the criminal history background check  
            system to check the fingerprints of applicants, and checks for  
            evidence of additional criminal records.

          6)Double Referral. This bill is double referred.  Should it pass  
            out of this committee, it will be referred to the Senate  
            Committee on Human Services.

          7)Related legislation. SB 1034 (Mitchell), eliminates the sunset  








          AB 796 (Nazarian)                                  Page 9 of ?
          
          
            date on the health insurance mandate to cover behavioral  
            health treatment for pervasive developmental disorder or  
            autism, and makes other revisions to the law such as  
            prohibiting denials for medically necessary behavioral health  
            treatment based on the setting, location or time of the  
            treatment.  SB 1034 is pending in the Assembly.

            SB 479 (Bates) would establish the Behavior Analyst Act (Act),  
            which provides for the licensure, registration, and regulation  
            of behavior analysts and assistant behavior analysts, and  
            requires the California BOP, until January 1, 2021, to  
            administer and enforce the Act.  SB 479 is pending in the  
            Assembly Appropriations Committee.

            AB 1715 (Holden) would establish the Behavior Analyst Act  
            (Act), which provides for the licensure, registration, and  
            regulation of behavior analysts and assistant behavior  
            analysts, and requires the California BOP, until January 1,  
            2022, to administer and enforce the Act.  AB 1715 is pending  
            in the Senate Business, Professions and Economic Development  
            Committee.


          8)Prior legislation. 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 that treatment, and  
            meets other licensure and education requirements. AB 2041  
            would have required DDS to amend its regulations as necessary  
            to implement the provisions of the bill.  AB 2041 died in the  
            Senate Appropriations Committee. 

            SB 126 (Steinberg, Chapter 680, Statutes of 2013), extends,  
            until January 1, 2017, the sunset date of an existing state  
            health benefit mandate that requires health plans and health  
            insurance policies to cover behavioral health treatment for  
            pervasive developmental disorder or autism and requires plans  
            and insurers to maintain adequate networks of these service  
            providers.

            SB 946 (Steinberg, Chapter 650, Statutes of 2011), requires  
            health plans and health insurance policies to cover behavioral  
            health treatment for pervasive developmental disorder or  








          AB 796 (Nazarian)                                  Page 10 of ?
          
          
            autism, requires health plans and insurers to maintain  
            adequate networks of autism service providers, establishes a  
            task force in DMHC, sunsets the autism mandate provisions on  
            July 1, 2014, and makes other technical changes to existing  
            law regarding HIV reporting and mental health services  
            payments.

            SB 770 (Steinberg of 2010), would have required health plans  
            and insurance policies to provide coverage for behavioral  
            health treatment. SB 770 was held in the Assembly  
            Appropriations Committee. 

            SB 166 (Steinberg of 2011), would have required health care  
            service plans licensed by DMHC and health insurers licensed by  
            CDI to provide coverage for behavioral health treatment for  
            autism. SB 166 was held in the Senate Health Committee. 

            AB 1205 (Bill Berryhill of 2011), would have required the  
            Board of Behavioral Sciences to license behavioral analysts  
            and assistant behavioral analysts, on and after January 1,  
                                                      2015, and included standards for licensure such as specified  
            higher education and training, fieldwork, passage of relevant  
            examinations, and national board accreditation. AB 1205 was  
            held in the Assembly Appropriations Committee on the suspense  
            file.

          9)Support.  The DIR Floortime Coalition of California writes  
            that as supporters of SB 946, they are familiar with the  
            intent of the legislation.  The DMHC was tasked with convening  
            a task force to provide recommendations concerning the  
            legislation, and they unanimously adopted the guiding  
            principle that behavioral health interventions should be  
            highly individualized and that the choice of treatment should  
            be grounded in scientific evidence, clinical practice  
            guidelines, and/or evidence-based practice.  Despite this and  
            the best intentions of the Legislature, the law limited this  
            choice of treatment modalities in practice and too many  
            children have been denied the specific form of prescribed  
            therapy they need.  The Occupational Therapy Association of  
            California writes that people with autism benefit from a  
            number of different service models, including occupational  
            therapy. By extending the requirement that health insurance  
            companies continue to cover all types of evidence-based  
            behavioral health services, this bill will ensure that  
            children and others diagnosed with autism receive customized  








          AB 796 (Nazarian)                                  Page 11 of ?
          
          
            treatment that works best.  Another proponent indicates that  
            SB 946 refers the requirements for frontline providers to be  
            vendored by the regional centers in only one form of therapy.  
            This bill would apply the same level of requirements to other  
            evidence-based forms of therapy, which will allow parents the  
            opportunity to receive insurance coverage for the treatment  
            that is most appropriate for their children.
          
          10)Opposition.  DDS writes in opposition that it recognizes that  
            timely and effective behavioral health treatment reduces the  
            lifelong costs associated with providing services to  
            individuals with Autism Spectrum Disorders (ASD) and that  
            conversely, the absence of effective interventions, or use of  
            ineffective or harmful treatment modalities, can inhibit  
            meaningful progress. The determination of effectiveness of  
            treatment modalities must be based on sound, scientifically  
            validated principles and supported by empirical data.  Several  
            well-established sources of information already exist  
            regarding evidence-based practices for ASD.  DDS supports the  
            use of evidence-based treatment modalities and efforts to make  
            information available to the public but it opposes the  
            requirement that BOP (amended recently to DMHC)  develop and  
            post a list of evidence-based treatment modalities for several  
            reasons including:  The SB 946 task force determined that it  
            would not be informative to state policy makers to merely  
            develop a list of behavioral health treatments determined to  
            be effective; a list, devoid of details, could be confusing  
            and lead to inappropriate treatment decisions; several  
            well-established sources of information already exist; and a  
            legislatively mandated list could be interpreted as policy or  
            regulation, viewed as an official endorsement of specific  
            treatment modalities, assumed to prescribe an exclusive course  
            of treatment, or used to replace clinical judgement without  
            preferences of the families.
          
          11)Role of DMHC. DMHC's primary purpose is to regulate health  
            plans and monitor and enforce the laws that apply to those  
            plans. The department's staffing and resources are funded by  
            an assessment on health plans which ultimately is calculated  
            into the premiums purchasers pay for health insurance.
             a)   Procedure Codes. This bill calls upon DMHC to develop  
               procedure codes, related to behavioral health treatment for  
               autism or pervasive developmental disorder that is not  
               applied behavioral analysis. DMHC is a regulator of health  
               plans and not a purchaser of health care services, and does  








          AB 796 (Nazarian)                                  Page 12 of ?
          
          
               not currently develop procedure codes. There are existing  
               entities better suited than DMHC to develop procedure  
               codes, such as the American Medical Association, which has  
               a process for requesting additions and updates to Current  
               Procedural Terminology. The federal Centers for Medicare  
               and Medicaid Services is responsible for the Health Care  
               Common Procedure Coding System.  

             b)   Professional Standard Development. This bill also  
               requires DMHC to convene a task force to develop  
               methodologies, modalities, education standards, training  
               and professional experience requirements related to  
               behavioral health treatment for autism or pervasive  
               developmental disorder that is not applied behavioral  
               analysis. DMHC, as a regulator of health plans, does not  
               develop education standards, training, and professional  
               experience requirements for health care providers.   
               Requiring DMHC to convene a task force that would develop  
               minimum standards of education, training and professional  
               experience for qualified autism service professionals and  
               paraprofessionals is outside of the expertise and mission  
               of DMHC and is more appropriately the role of entities  
               involved in workforce or health profession regulation.  
               Professional boards of experts typically develop such  
               standards and regulate the profession. AB 1715 is  
               legislation pending to establish a licensing structure for  
               behavior analysts.

             c)   DMHC and CDI Responsibilities. This bill tasks DMHC to  
               convene the task force established by this bill and makes  
               CDI the lead agency.  It is not clear how this structure  
               would work and why CDI should be designated the lead entity  
               as its function is to regulate insurance companies.  With  
               regard to health insurance, CDI regulates a very small  
               percentage of the products sold to Californians compared to  
               DMHC. 

          12)Technical Amendments.  This bill should be amended to avoid  
            chaptering out conflicts with SB 1034 (Mitchell).


           SUPPORT AND OPPOSITION  :
          Support:  DIR/Floortime Coalition of California (sponsor)
                    Association of Regional Center Agencies
                    Occupational Therapy Association of California








          AB 796 (Nazarian)                                  Page 13 of ?
          
          
                    Several hundred individuals
          
          Oppose:   Department of Developmental Disabilities (prior  
                    version)

                                      -- END --