BILL ANALYSIS Ó
SENATE COMMITTEE ON APPROPRIATIONS
Senator Ricardo Lara, Chair
2015 - 2016 Regular Session
AB 796 (Nazarian) - Health care coverage: autism and pervasive
developmental disorders
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|Version: June 30, 2016 |Policy Vote: HEALTH 6 - 2, |
| | HUMAN S. 5 - 0 |
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|Urgency: No |Mandate: Yes |
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|Hearing Date: August 1, 2016 |Consultant: Brendan McCarthy |
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This bill meets the criteria for referral to the Suspense File.
Bill
Summary: AB 796 would delete the existing statutory sunset on
the mandate to provide health care coverage for behavioral
health treatment for autism and related disorders. The bill
would require the Department of Developmental Services to update
its regulations to set forth minimum standards for autism
service professionals and paraprofessionals providing behavioral
health treatments other than applied behavioral analysis (ABA).
Fiscal
Impact:
One-time costs of about $50,000 and ongoing costs of $15,000
per year to review health plan filings for compliance with the
requirements of the bill and to undertake any necessary
enforcement actions by the Department of Managed Health Care
(Managed Care Fund).
Likely costs of less than $100,000 per year for review of
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health insurance plan filings and enforcement actions by the
Department of Insurance (Insurance Fund).
No state costs are anticipated due to the elimination of the
existing sunset on the benefit mandate. Current law exempts
Medi-Cal managed care plans and CalPERS coverage from the
benefit mandate. This bill does not eliminate those
exemptions,
While existing law specifically mandates coverage for
behavioral health treatment, separate federal and state mental
health parity requirements and requirements for the provision
of essential health benefits implicitly require coverage for
behavioral health treatment for autism and related disorders.
Therefore, elimination of the statutory sunset will not
materially impact coverage for behavioral health treatment.
Nor will eliminating the sunset require the state to pay for
the costs to subsidize coverage for behavioral health
treatment coverage for subsidized Covered California plans.
Likely one-time costs in the hundreds of thousands for
development of regulations specifying the training and
educational requirements for non-ABA professionals (General
Fund). According to the Department, there are many categories
of professionals and paraprofessionals that are providing or
could provide behavioral health treatments. The Department
would need to evaluate the appropriate level of education and
training for each of those types of service provider.
Unknown potential increased costs for services currently being
provided to regional center consumers (General Fund and
federal funds). By establishing additional standards for
autism service professionals and paraprofessionals, it is
possible that some vendors who are currently providing
services to regional center consumers under different codes
would be able to bill as either a Behavior Management
Assistant or a Behavior Management Consultant. Since those
service codes generally receive higher rates than other
behavioral services, this could increase overall costs for
services currently being provided. For example, if 5 percent
of the hours billed to the regional centers for an Adaptive
Skills Trainer were billed for a Behavior Management
Consultant, the annual costs would be about $670,000 per year.
Similarly, if 5 percent of the hours billed to the regional
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centers for Community Integration were billed for a Behavior
Management Assistant, the annual costs would be about $3.8
million per year.
Unknown potential savings to the state from shifting costs
from the regional centers to private insurance coverage. The
sponsors of this bill have indicated that health insurance
coverage for certain types of non-ABA behavioral health
treatment is being denied by health insurers and health plans.
In such cases, families may seek such services from the
regional center system. The intention of the bill is to expand
the types of providers that can provide non-ABA services in
the regional center system, which would in turn increase those
providers ability to provide services through private
insurance.
According to the California Health Benefits Review Program, to
date there is no indication that the supply of providers is
significantly constraining the coverage for behavioral health
treatment. Therefore, the Program indicates that the bill is
unlikely to result in a significant increase in private
insurance coverage for non-ABA behavioral health treatment.
Thus, it does not seem likely that the state would experience
significant cost savings from shifting of services from the
regional center system to private insurance.
Background:
: Current state law (SB 88, Thompson, Statutes of 1999) requires
health plans and health insurers who provide hospital, medical,
or surgical coverage to provide coverage for the diagnosis and
treatment of severe mental illness (as specified in statute). In
addition, health plans and health insurers are required to
provide additional coverage for serious emotional disturbances
of a child. In both cases, coverage is required to be provided
under the same terms and conditions applied to other medical
conditions. Under current federal law, health plans and health
insurers that offer coverage for mental health or substance
abuse disorders are required to provide that coverage under the
same terms and conditions as other covered benefits.
Collectively, these requirements are referred to as "mental
health parity" requirements.
Current state law (SB 946, Steinberg, Statutes of 2011)
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specifically requires health plans and health insurers to cover
behavioral health therapy for pervasive development disorder or
autism. The statutory sunset in SB 946 was extended to January
1, 2017 in SB 126 (Steinberg, 2013).
Under the federal Patient Protection and Affordable Care Act,
health coverage provided in the small group or individual market
(including through health exchanges) must provide essential
health benefits. Under federal law, individuals purchasing
coverage through health benefit exchanges will be eligible for
subsidies, based on income, paid by the federal government.
However, if a state imposes a benefit mandate after January 1,
2012 that exceeds the benefits provided by the essential health
benefits benchmark plan, the state is responsible for providing
the subsidies for coverage of that mandated benefit.
California provides community-based services to approximately
250,000 persons with developmental disabilities and their
families through a statewide system of 21 regional centers.
Regional centers are private, nonprofit agencies under contract
with the Department of Developmental Services for the provision
of various services and supports to people with developmental
disabilities. As a single point of entry, regional centers
provide diagnostic and assessment services to determine
eligibility; convene planning teams to develop an Individual
Program Plan for each eligible consumer; and either provide or
obtain from generic agencies appropriate services for each
consumer in accordance with the Individual Program Plan.
Over the past several years, there have been a number of medical
entities that have concluded that intensive behavioral
treatments are effective in treating children and adults with
autism. There are a several different types of behavioral health
treatment. One of the best-known and most commonly accepted as
being an evidence-based practice is Applied Behavioral Analysis.
Proposed Law:
AB 796 would delete the existing statutory sunset on the
mandate to provide health care coverage for behavioral health
treatment for autism and related disorders.
The bill would require the Department of Developmental Services
to update its regulations to set forth minimum standards for
AB 796 (Nazarian) Page 4 of
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autism service professionals and paraprofessionals providing
behavioral health treatments other than applied behavioral
analysis (ABA).
Related
Legislation:
SB 1034 (Mitchell) would delete the existing statutory sunset
on the mandate to provide health care coverage for behavioral
health treatment for autism and related disorders. The bill
would also revise the existing benefit mandate and apply the
benefit mandate to health care coverage provided by CalPERS.
That bill is pending in the Assembly.
AB 2041 (Jones, 2014) would have defined the professional
activities and the educational and training requirements
necessary for vendorization by a regional center as a Behavior
Management Assistant or a Behavior Management Consultant. That
bill was held on this committee's Suspense File.
Staff
Comments: The sponsors have indicated that health insurers and health
plans are denying coverage for behavior health treatments that
are not applied behavioral analysis because a provision in
current law that defines a "Qualified Autism Service
professional" as a person vendorized by a regional center to
provide certain services, as defined in regulations. The
sponsors indicate that by requiring the Department of
Developmental Services to adopt regulations specifying the
educational and training requirements for qualified autism
service professionals and paraprofessionals to include
behavioral health treatments in addition to applied behavioral
analysis, this will allow such individuals to provide behavioral
health treatments to individuals covered by private insurance.
However, current law requires that behavioral health treatment
be provided by one of three categories of provider: qualified
autism service providers, qualified autism service
professionals, and qualified autism service paraprofessionals.
Of those categories, only the latter two must be vendorized in
the regional center system. Therefore, it is possible for some
other licensed health care providers (such as a person with
certain national certifications or certain licensed health
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professionals) to provide behavioral health treatment without
being vendorized by a regional center.
As noted above, the California Health Benefits Review Program
did not find that the bill would increase coverage for or
utilization of behavioral health treatments by private insurers
or health plans.
According to data from the Department of Insurance and the
Department of Managed Health Care, challenges by enrollees to
private health insurance or health plan denials of coverage for
behavioral health treatment (both ABA and non-ABA) have
overwhelmingly been ruled in favor of requiring coverage. The
overall number of challenges is less than 200. This may indicate
that enrollees are not aware of their right to an independent
medical review. On the other hand, this may indicate that
consumers are not having problems accessing coverage for
behavioral health treatment.
The only costs that may be incurred by a local agency relate to
crimes and infractions. Under the California Constitution, such
costs are not reimbursable by the state.
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