BILL ANALYSIS Ó
SENATE COMMITTEE ON HUMAN SERVICES
Senator McGuire, Chair
2015 - 2016 Regular
Bill No: AB 796
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|Author: |Nazarian |
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|Version: |June 21, 2016 |Hearing |June 28, 2016 |
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|Urgency: |No |Fiscal: |Yes |
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|Consultant|Mareva Brown |
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Subject: Health care coverage: autism and pervasive
developmental disorders
SUMMARY
This bill deletes the sunset date for health care service plans'
required coverage of autism-related behavioral health treatment.
It additionally requires the State Department of Developmental
Services (DDS), no later than July 1, 2018, with input from
specified stakeholders to develop a methodology for determining
what constitutes an evidence-based practice in the field of
behavioral health treatment for autism and pervasive
developmental disorder and to update regulations to set forth
the minimum standards of education, training, and professional
experience for qualified autism service professionals and
paraprofessionals, as specified.
ABSTRACT
Existing law:
1) Establishes the Lanterman Developmental Disabilities
Services Act, which states that California is responsible
for providing an array of services and supports
sufficiently complete to meet the needs and choices of each
person with developmental disabilities, regardless of age
or degree of disability, and at each stage of life and to
support their integration into the mainstream life of the
community. (WIC 4500, et seq.)
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2) Establishes a system of nonprofit Regional Centers,
overseen by DDS, to provide fixed points of contact in the
community for all persons with developmental disabilities
and their families, to coordinate services and supports
best suited to them throughout their lifetime. (WIC 4620)
3) Establishes an Individual Program Plan (IPP) and defines
that planning process as the vehicle to ensure that
services and supports are customized to meet the needs of
consumers who are served by regional centers. (WIC 4512)
4) Requires a regional center to secure services and
supports that meet the needs of the consumer, as determined
in the IPP, and to give highest preference to those which
would allow minors with developmental disabilities to live
with their families, adults to live as independently as
possible in the community, and that allow all consumers to
interact with persons without disabilities in positive,
meaningful ways. (WIC 4648)
5) Requires every health care service plan contract that
provides hospital, medical, or surgical coverage to also
provide coverage for behavioral health treatment for
pervasive developmental disorder or autism, as specified,
with a sunset date of January 1, 2017. (WIC 1374.73. (a)
(1))
6) Requires every health insurance policy to provide
coverage for behavioral health treatment for pervasive
developmental disorder or autism, as specified, with a
sunset date of January 1, 2017. (INS 10144.51)
7) Requires that every health care service plan maintain an
adequate network that includes qualified autism service
providers who supervise and employ qualified autism service
professionals or paraprofessionals who provide and
administer behavioral health treatment. (WIC 1374.73 (b))
8) Defines behavioral health treatment, for purposes of
payment under a health care service plan contract or a
health insurance policy, as professional services and
treatment programs, including applied behavior analysis and
evidence-based behavior intervention programs, which
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develop or restore, to the maximum extent practicable, the
functioning of an individual with pervasive developmental
disorder or autism, and sets requirements for the treatment
plan, prescription of the treatment, and the providers
authorized to provide such treatment, including qualified
autism service professionals, as specified. (HSC
1374.73(c)(1), INS 10144.51(c)(1))
9) Includes in the definition of a "qualified autism
service professional" 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. (HSC
1374.73 (c)(4)(D), INS 10144.51(c)(4)(D))
10) Defines in state regulations, for purposes of regional
center vendorization, Behavior Management Assistant,
Behavior Management Consultant, Behavior Analyst and
Associate Behavior Analyst and requires education or
experience in ABA, as specified. (17 CCR §54342)
This bill:
1) Makes a series of uncodified Legislative findings about
autism, its symptoms and prevalence, the use of behavioral
health treatment to ameliorate its effects, and states
Legislative intent that health care service plan provider
networks include qualified professionals practicing all
forms of evidence-based behavioral health treatment other
than just applied behavioral analysis.
2) Deletes the sunset date of January 1, 2017 for HSC
1374.73 and INS 10144.51, which together require insurance
policies and plans to provide coverage for behavioral
health treatment for pervasive developmental disorder or
autism.
3) Requires DDS no later than July 1, 2018, with input from
specified stakeholders, to do both of the following:
a. Develop a methodology for determining what
constitutes an evidence-based practice in the field of
behavioral health treatment for autism and pervasive
AB 796 (Nazarian) PageD
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development disorder.
b. Update regulations to set forth the minimum
standards of education, training, and professional
experience for qualified autism service professionals
and paraprofessionals practicing behavioral health
treatment other than applied behavioral analysis that
shall be no less rigorous than the requirements set
forth in existing regulations for ABA.
4) Requires that DDS consult stakeholders including
professionals trained in interpreting research data who
represent a balanced diversity of treatment modalities,
including both behavioral and developmental approaches.
These professionals shall include, at a minimum, 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.
FISCAL IMPACT
An analysis by the Assembly Committee on Appropriations
reflected costs related to a prior version of the bill. The
current language of the bill has not been analyzed by a fiscal
committee. However the Assembly Appropriations analysis did note
that 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, the analysis stated.
BACKGROUND AND DISCUSSION
Purpose of the bill:
According to the author, passage of a 2011 bill (SB 946,
Steinberg, Chapter 650, Statutes of 2011) was supposed to ensure
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that health plans and insurance policies would cover behavioral
health therapy for autism or pervasive developmental disorder.
The bill required plans and insurers to maintain adequate
networks of autism service providers. However, the author
states, the number of trained practitioners cannot meet the
growing demand for services.
Additionally, the author states, SB 946 is being narrowly
interpreted by insurance companies to apply to a single type of
behavioral therapy, Applied Behavioral Analysis (ABA), but
children respond uniquely to treatment. "AB 796 recognizes that
there is no one size fits all Behavioral Health Treatment system
for an individual diagnosed with autism," the author states.
Autism Spectrum Disorder
Autism is a neurodevelopmental disorder characterized by
difficulty in language, social interaction, and by the presence
of repetitive and stereotyped behaviors. The National Institutes
of Health describes autism as the most severe form of a range of
conditions that together make up Autism Spectrum Disorder, or
ASD. Other conditions along the spectrum include Asperger
syndrome, and pervasive developmental disorder not otherwise
specified, or PDD-NOS. The most notable feature of ASD is
impaired social interaction, according to the National
Institutes of Health. An infant with ASD may not respond to
people or may focus intently on one item to the exclusion of
others for long periods of time.
Children with ASD may avoid eye contact with other people, or
not respond to verbal commands or conversation. They cannot
interpret facial expressions or changes in voice inflection, so
they do not understand what others are thinking or feeling. ASD
occurs in all ethnic and socioeconomic groups and affects every
age group. Experts estimate that 1 out of 88 children age 8
will have an ASD.<1> Males are four times more likely to have
an ASD than females. DDS data shows that in March 2016, nearly
85,000 regional center consumers had a diagnosis of autism or
PDD-NOS - about one-third of all consumers.
Prevalence
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<1> Centers for Disease Control and Prevention: Morbidity and
Mortality Weekly Report, March 30, 2012
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The prevalence of autism has grown exponentially over the past
several decades. Studies published before 1985, for example,
reported prevalence rates of 4 to 5 per 10,000 children for the
broader autism spectrum, and about 2 per 10,000 for the classic
autism definition. Since then, studies from the UK indicate a
prevalence rate of 16.8 per 10,000 children for autistic
disorder, and 62.6 per 10,000 for the entire classification of
autistic spectrum disorders. In the United States, in 3- to
10-year-old children, there was a prevalence of 40 per 10,000
for autistic disorder and 67 per 10,000 children for the entire
autism spectrum. Researchers have concluded that although many
factors are at play, it is evident that there has been an
increase in autism.<2>
In the United States, the most recent prevalence data released
by the Centers for Disease Control<3> shows about 1 in 68
children has been identified with autism spectrum disorder.
Evaluating Best Practices in treatment
Agency for Health Care Research and Quality
The federal Agency for Healthcare Research and Quality within
the U.S. Department of Health and Human Services conducts
systematic reviews on emerging treatments to provide clinicians
with information and context on the usefulness of these new
treatments. The agency notes that systematic reviews are the
building blocks underlying evidence-based practice. In part,
they focus on the strengths and limitations of evidence from
research studies about the effectiveness and safety of a
clinical intervention.
In 2014, the Agency published a 513-page report entitled,
"Therapies for Children With Autism Spectrum Disorder:
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<2> Merrick, J et al., "Trends in Autism," International Journal
of Adolescent Medicine and Health," March 2006.
<3> http://www.cdc.gov/ncbddd/autism/data.html
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Behavioral Interventions Update."<4> The report concluded that
while a growing evidence base "suggests that behavioral
interventions can be associated with positive outcomes for
children with ASD ? a need remains for studies of interventions
across settings and continued improvements in methodologic
rigor. Substantial scientific advances are needed to enhance our
understanding of which interventions are most effective for
specific children with ASD and to isolate elements or components
of interventions most associated with effects."
National Professional Development Center
In 2015, the National Professional Development Center on Autism
Spectrum Disorder published a report<5> that included
identification of 27-evidence based practices for autism
treatment. The 114-page report compared various methods of
intervention, reviewed research and established a methodology
for determining an evidence-based practice.
Treatment Modalities
The most recognized form of behavioral health treatment for
autism is Applied Behavioral Analysis, or ABA, which focuses on
positive reinforcement and intensive teaching to bring about a
change in behavior. ABA has been acknowledged as effective by
the US Surgeon General, US Department of Education and others.
One of the pioneers of autism treatment, Dr. O Ivar Lovaas at
UCLA, used ABA in one-on-one sessions of 40 hours per week with
children aged 2 or 3 for several years to direct children's
behaviors. According to Lovaas' website, the primary
instructional method during the first year is spent in
individual training in the child's home. In the second year,
children spend increasing amounts of time having supervised
play-dates with typically developing peers to provide
opportunities for peer tutoring and increase social skills,
enter general education preschools to facilitate adjustment to
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<4> Weitlauf AS, et al, "Therapies for Children With Autism
Spectrum Disorder: Behavioral Interventions Update." Comparative
Effectiveness Review No. 137.
<5> Wong, C., et al, "Evidence-based practices for children,
youth, and young adults with autism spectrum disorder: A
comprehensive review." Journal of Autism and Developmental
Disorders. (2015).
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school, and participate in incidental teaching in addition to
discrete trial training. During the third and final year, the
focus is on gradually reducing individual instruction and
increasing inclusion into classroom settings.<6>
ABA encompasses several different treatment modalities, and
there are also other interventions that have been scientifically
studied and found to be effective. One of those is the Early
Start Denver Model, which is a relationship-based intervention
provided in the home by trained therapists and parents during
natural play and daily routines. Researchers at the UC Davis
MIND Institute have been studying the Early Start Denver Model's
effectiveness.
There also are a number of behavioral treatments in practice
that have not been studied and have not met other criteria to be
considered "evidence-based."
California Code of Regulations
Title 17 CCR §54342 defines various types of service providers
for regional center consumers, from dance therapist to
occupational therapist to psychologist, and specifies the type
of billing code for regional centers to use for each. These
definitions include:
Behavior Analyst means an individual who assesses the function
of a behavior of a consumer and designs, implements, and
evaluates instructional and environmental modifications to
produce socially significant improvements in the consumer's
behavior through skill acquisition and the reduction of
behavior. Behavior Analysts engage in functional assessments or
functional analyses to identify environmental factors of which
behavior is a function. A Behavior Analyst shall not practice
psychology, as defined. A regional center shall classify a
vendor as a Behavior Analyst if an individual is recognized by
the national Behavior Analyst Certification Board as a Board
Certified Behavior Analyst.
A regional center shall classify a vendor as an Associate
Behavior Analyst if the vendor assesses the function of a
behavior of a consumer and designs, implements, and evaluates
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<6> http://thelovaascenter.com/aba-treatment/
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instructional and environmental modifications to produce
socially significant improvements in the consumer's behavior
through skill acquisition and the reduction of behavior, under
direct supervision of a Behavior Analyst or Behavior Management
Consultant. A regional center shall classify a vendor as an
Associate Behavior Analyst if an individual is recognized by the
National Behavior Analyst Certification Board as a Board
Certified Associate Behavior Analyst.
A regional center shall classify a vendor as a Behavior
Management Assistant if the vendor designs or implements
behavior modification intervention services under the direct
supervision of a behavior management consultant; or if the
vendor assesses the function of a behavior of a consumer and
designs, implements, and evaluates instructional and
environmental modifications to produce socially significant
improvements in the consumer's behavior under direct supervision
of a Behavior Analyst or Behavior Management Consultant. The
regulations specify educational, training and professional
requirements.
Permits a regional center to classify a vendor as a Behavior
Management Consultant if the vendor designs and/or implements
behavior modification intervention services, has completed 12
semester units in applied behavior analysis and possesses a
license and experience as a psychologist, licensed clinical
social worker, licensed marriage and family therapist or other
licensed professional that designs or implements behavior
modification intervention services and has two years of
experience in designing and implementing these interventions.
Related legislation:
SB 1034 (Mitchell, 2016) modifies the requirements of a
qualified autism service professional and requires that a
treatment plan be reviewed no more than once every 6 months,
unless a shorter period is recommended by the qualified autism
service provider.
AB 2041 (Jones, 2014) would have expanded the scope of treatment
providers in the regional center vendor system to include a
behavior management consultant or behavior management assistant,
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with specified requirements.
SB 946 (Steinberg) Chapter 650, statutes of 2011 required health
plans and insurers to pay for behavioral health treatment when a
consumer's IPP identified the need.
AB 171 (Beall) 2011) would have required health plans and
insurers to cover the screening, diagnosis and treatment of ASD.
This bill died in the Senate Health committee.
Support:
The sponsor of AB 796, DIR Floortime Inc., writes that while a
task force convened in 2011 unanimously adopted the guiding
principle that behavioral health interventions should be highly
individualized and that the choice of BHT should be grounded in
scientific evidence, clinical practice guidelines, and/or
evidence-based practice, most insurance plans are failing to
cover anything except Applied Behavior Analysis.
"We are vitally concerned with the choice of evidence-based
behavioral health treatments available and covered by health
insurance in California. Unfortunately, in far too many cases,
children with autism are being denied coverage for the specific
type of evidence-based treatment recommended or prescribed by
their doctor or psychologist." DIR Floortime Inc. writes that
the existing statutory definition of evidence-based practices is
vague and that DDS-issued regulations only identify requirements
to provide ABA.
Opposition:
The Department of Developmental Services opposes this bill,
noting that there are other "well-established sources of
information" regarding evidence based practices for treating
ASD. The Department expresses concern that the bill does not
establish "definitive criteria for evaluating the quality of the
evidence available on treatment modalities." The Department
writes that any determination of effectiveness of treatment
modalities must be based on sound, scientifically validated
principles and supported by empirical data. However, the
Department cites concerns about this bill, including the fact
that national entities already have published information on
evidence-based treatment.
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COMMENTS
This bill has been amended to shift the responsibility for
conducting a work group to define best practices in behavioral
therapy from the board of psychology to the Department of
Managed Health Care. The most recent amendments move this
responsibility to the Department of Developmental Services,
which already had expressed concerns about the qualifications of
individuals tasked with identifying best practices. Given the
reluctance of various state agencies and boards to convene such
a task force, and expressed concern about the state's role in
defining evidence-based treatments, staff recommends the
following amendments:
WIC 4513.1. (a) The department, no later than July 1, 2018, with
input from the stakeholders identified in subdivision (b), shall
do both of the following:
(1) Develop a methodology for determining what constitutes
an evidence-based practice in the field of behavioral
health treatment for autism and pervasive developmental
disorder.
(2) shall update regulations , as appropriate, to set forth the
minimum standards of education, training, and professional
experience for qualified autism service professionals and
paraprofessionals practicing behavioral health treatment other
than applied behavioral analysis that shall be no less rigorous
than the requirements set forth in subdivision (b) of Section
54342 of Article 3 of Subchapter 2 of Chapter 3 of Division 2 of
Title 17 of the California Code of Regulations.
(b) Stakeholders shall include professionals trained in
interpreting research data and shall represent a balanced
diversity of treatment modalities, including both behavioral and
developmental approaches. These professionals shall include, at
a minimum, 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.
PRIOR VOTES
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|Assembly Floor: |75 - |
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|Assembly Appropriations Committee: |17 - |
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|Assembly Business and Professions Committee: |7 - |
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POSITIONS
Support:
The DIR/Floortime Coalition of California (sponsor)
Autism Business Association
Oppose:
Department of Developmental Services
Center for Autism and Related Disorders
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