BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 796
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|AUTHOR: |Nazarian |
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|VERSION: |June 8, 2016 |
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|HEARING DATE: |June 15, 2016 | | |
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|CONSULTANT: |Teri Boughton |
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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
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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 :
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|Assembly Floor: |75 - 0 |
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|Assembly Appropriations Committee: |17 - 0 |
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|Assembly Business and Professions | 7 - 4 |
|Committee: | |
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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,
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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,
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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
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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
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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
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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
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Several hundred individuals
Oppose: Department of Developmental Disabilities (prior
version)
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