BILL ANALYSIS                                                                                                                                                                                                    



          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    |
          |          |                       |Date:      |                 |
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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  









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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



          ---------------------------
          <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:  



          ---------------------------
          <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  
          ---------------------------
          <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  



          ---------------------------

          <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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