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 ----------------------------------------------------------------- | | | | | | ----------------------------------------------------------------- |--------------------------------+--------------------------------| | | | |Version: June 30, 2016 |Policy Vote: HEALTH 6 - 2, | | | HUMAN S. 5 - 0 | | | | |--------------------------------+--------------------------------| | | | |Urgency: No |Mandate: Yes | | | | |--------------------------------+--------------------------------| | | | |Hearing Date: August 1, 2016 |Consultant: Brendan McCarthy | | | | ----------------------------------------------------------------- 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 AB 796 (Nazarian) Page 1 of ? 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 AB 796 (Nazarian) Page 2 of ? 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) AB 796 (Nazarian) Page 3 of ? 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 ? 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 AB 796 (Nazarian) Page 5 of ? 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. -- END --