BILL ANALYSIS                                                                                                                                                                                                    



          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  








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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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