Senate BillNo. 1034


Introduced by Senator Mitchell

February 12, 2016


An act to amend Section 1374.73 of the Health and Safety Code, and to amend Sections 10144.51 and 10144.52 of the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

SB 1034, as introduced, Mitchell. Health care coverage: autism.

Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A violation of those provisions is a crime. Existing law provides for the licensure and regulation of health insurers by the Department of Insurance.

Existing law requires every health care service plan contract and health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism until January 1, 2017, and defines “behavioral health treatment” to mean specified services provided by, among others, a qualified autism service professional supervised and employed by a qualified autism service provider. Existing law defines a “qualified autism service professional” to mean a person who, among other requirements, is a behavior 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 pursuant to specified regulations adopted under the Lanterman Developmental Disabilities Services Act. Existing law requires a treatment plan to be reviewed no less than once every 6 months.

This bill would, among other things, modify requirements to be a qualified autism service professional to include providing behavioral health treatment, such as clinical management and case supervision. The bill would require 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. The bill would extend the operation of these provisions indefinitely. The bill would make conforming changes.

By extending the operation of these provisions, the violation of which by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

The people of the State of California do enact as follows:

P2    1

SECTION 1.  

Section 1374.73 of the Health and Safety Code
2 is amended to read:

3

1374.73.  

(a) (1) Every health care service plan contract that
4provides hospital, medical, or surgical coverage shall also provide
5coverage for behavioral health treatment for pervasive
6developmental disorder or autism no later than July 1, 2012. The
7coverage shall be provided in the same manner and shall be subject
8to the same requirements as provided in Section 1374.72.

9(2) Notwithstanding paragraph (1), as of the date that proposed
10final rulemaking for essential health benefits is issued, this section
11does not require any benefits to be provided that exceed the
12essential health benefits that all health plans will be required by
13federal regulations to provide under Section 1302(b) of the federal
14Patient Protection and Affordable Care Act (Public Law 111-148),
15as amended by the federal Health Care and Education
16Reconciliation Act of 2010 (Public Law 111-152).

17(3) This section shall not affect services for which an individual
18is eligible pursuant to Division 4.5 (commencing with Section
194500) of the Welfare and Institutions Code or Title 14
20(commencing with Section 95000) of the Government Code.

P3    1(4) This section shall not affect or reduce any obligation to
2provide services under an individualized education program, as
3defined in Section 56032 of the Education Code, or an individual
4service plan, as described in Section 5600.4 of the Welfare and
5Institutions Code, or under the federal Individuals with Disabilities
6Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
7regulations.

8(b) Every health care service plan subject to this section shall
9maintain an adequate network that includes qualified autism service
10providers who supervisebegin delete and employend delete qualified autism service
11professionals or paraprofessionals who provide and administer
12behavioral health treatment. Nothing shall prevent a health care
13service plan from selectively contracting with providers within
14these requirements.

15(c) For the purposes of this section, the following definitions
16shall apply:

17(1) “Behavioral health treatment” means professional services
18and treatment programs, including applied behavior analysis and
19begin insert otherend insert evidence-based behavior intervention programs, thatbegin delete developend delete
20begin insert develop, maintain,end insert or restore, to the maximum extent practicable,
21the functioning of an individual with pervasive developmental
22disorder or autism and that meet all of the following criteria:

23(A) The treatment is prescribed by a physician and surgeon
24licensed pursuant to Chapter 5 (commencing with Section 2000)
25of, or is developed by a psychologist licensed pursuant to Chapter
266.6 (commencing with Section 2900) of, Division 2 of the Business
27and Professions Code.

28(B) The treatment is provided under a treatment plan prescribed
29by a qualified autism service provider and is administered by one
30of the following:

31(i) A qualified autism service provider.

32(ii) A qualified autism service professional supervisedbegin delete and
33employedend delete
by the qualified autism service provider.

34(iii) A qualified autism service paraprofessional supervisedbegin delete and
35employedend delete
by a qualified autism service provider.

36(C) The treatment plan has measurable goals over a specific
37timeline that is developed and approved by the qualified autism
38service provider for the specific patient being treated. The treatment
39plan shall be reviewed nobegin delete lessend deletebegin insert moreend insert than once every six months
40by the qualified autism servicebegin delete providerend deletebegin insert provider, unless a shorter
P4    1period is recommended by the qualified autism service provider,end insert

2 and modified whenever appropriate, and shall be consistent with
3Section 4686.2 of the Welfare and Institutions Code pursuant to
4which the qualified autism service provider does all of the
5following:

6(i) Describes the patient’s behavioral health impairments or
7developmental challenges that are to be treated.

8(ii) Designs an intervention plan that includes the service type,
9number of hours, and parentbegin insert or caregiverend insert participation
10begin insert recommended by the qualified autism service provider,end insert needed to
11achieve the plan’s goal and objectives, and the frequency at which
12the patient’s progress is evaluated and reported.begin insert end insertbegin insertLack of parent or
13caregiver participation shall not be used to deny or reduce
14medically necessary behavioral health treatment.end insert

15(iii) Provides intervention plans that utilize evidence-based
16practices, with demonstrated clinical efficacy in treating pervasive
17developmental disorder or autism.

18(iv) Discontinues intensive behavioral intervention services
19when the treatment goals and objectives are achieved or no longer
20begin delete appropriate.end deletebegin insert appropriateend insertbegin insert, and continued therapy is not necessary
21to maintain function or prevent deterioration.end insert

22(D) begin insert(i)end insertbegin insertend insert The treatment plan is not used for purposes of providing
23or for the reimbursement of respite, day care, or educational
24services and is not used to reimburse a parent for participating in
25the treatment program.begin delete Theend delete

begin insert

26(ii) Notwithstanding the clause (i), all medically necessary
27behavioral health treatment shall be covered in all settings
28regardless of time or location of delivery.

end insert

29begin insert(iii)end insertbegin insertend insertbegin insertTheend insert treatment plan shall be made available to the health
30care service plan upon request.

31(2) “Pervasive developmental disorder or autism” shall have
32the same meaning and interpretation as used in Section 1374.72.

33(3) “Qualified autism service provider” means either of the
34following:

35(A) A person, entity, or group that is certified by a national
36entity, such as the Behavior Analyst Certification Board, that is
37accredited by the National Commission for Certifying Agencies,
38and who designs, supervises, or provides treatment for pervasive
39developmental disorder or autism, provided the services are within
P5    1the experience and competence of the person, entity, or group that
2is nationally certified.

3(B) A person licensed as a physician and surgeon, physical
4therapist, occupational therapist, psychologist, marriage and family
5therapist, educational psychologist, clinical social worker,
6professional clinical counselor, speech-language pathologist, or
7audiologist pursuant to Division 2 (commencing with Section 500)
8of the Business and Professions Code, who designs, supervises,
9or provides treatment for pervasive developmental disorder or
10autism, provided the services are within the experience and
11competence of the licensee.

12(4) “Qualified autism service professional” means an individual
13who meets all of the following criteria:

14(A) Provides behavioral healthbegin delete treatment.end deletebegin insert treatmentend insertbegin insert, including
15clinical management and case supervision.end insert

16(B) Isbegin delete employed andend delete supervised by a qualified autism service
17provider.

18(C) Provides treatment pursuant to a treatment plan developed
19and approved by the qualified autism service provider.

20(D) Is a behavioral service providerbegin delete approved as a vendor by a
21California regional center to provide services asend delete
begin insert who meets the
22education and experience qualifications defined in Section 5432
23of Title 17 of the California Code of Regulations forend insert
an Associate
24Behavior Analyst, Behavior Analyst, Behavior Management
25Assistant, Behavior Management Consultant, or Behavior
26Managementbegin delete Program as defined in Section 54342 of Title 17 of
27the California Code of Regulations.end delete
begin insert Program.end insert

28(E) Has training and experience in providing services for
29pervasive developmental disorder or autism pursuant to Division
304.5 (commencing with Section 4500) of the Welfare and
31Institutions Code or Title 14 (commencing with Section 95000)
32of the Government Code.

33(5) “Qualified autism service paraprofessional” means an
34unlicensed and uncertified individual who meets all of the
35following criteria:

36(A) Isbegin delete employed andend delete supervised by a qualified autism service
37provider.

38(B) Provides treatment and implements services pursuant to a
39treatment plan developed and approved by the qualified autism
40servicebegin delete provider.end deletebegin insert provider or qualified autism service professional.end insert

P6    1(C) Meets thebegin delete criteria set forthend deletebegin insert education and experience
2qualifications definedend insert
in the regulations adopted pursuant to Section
34686.3 of the Welfare and Institutions Code.

4(D) Has adequate education, training, and experience, as
5certified by a qualified autism service provider.

6(d) This section shall not apply to the following:

7(1) A specialized health care service plan that does not deliver
8mental health or behavioral health services to enrollees.

9(2) A health care service plan contract in thebegin delete Mediend deletebegin insert MDIend insert-Cal
10program (Chapter 7 (commencing with Section 14000) of Part 3
11of Division 9 of the Welfare and Institutions Code).

begin delete

12(3) A health care service plan contract in the Healthy Families
13Program (Part 6.2 (commencing with Section 12693) of Division
142 of the Insurance Code).

15(4) A health care benefit plan or contract entered into with the
16Board of Administration of the Public Employees’ Retirement
17System pursuant to the Public Employees’ Medical and Hospital
18Care Act (Part 5 (commencing with Section 22750) of Division 5
19of Title 2 of the Government Code).

end delete

20(e) begin deleteNothing in this section shall be construed to end deletebegin insertThis section
21does not end insert
limit the obligation to provide servicesbegin delete underend deletebegin insert pursuant
22toend insert
Section 1374.72.

23(f) As provided in Section 1374.72 and in paragraph (1) of
24subdivision (a), in the provision of benefits required by this section,
25a health care service plan may utilize case management, network
26providers, utilization review techniques, prior authorization,
27copayments, or other cost sharing.

begin delete

28(g) This section shall remain in effect only until January 1, 2017,
29and as of that date is repealed, unless a later enacted statute, that
30is enacted before January 1, 2017, deletes or extends that date.

end delete
31

SEC. 2.  

Section 10144.51 of the Insurance Code is amended
32to read:

33

10144.51.  

(a) (1) Every health insurance policy shall also
34provide coverage for behavioral health treatment for pervasive
35developmental disorder or autism no later than July 1, 2012. The
36coverage shall be provided in the same manner and shall be subject
37to the same requirements as provided in Section 10144.5.

38(2) Notwithstanding paragraph (1), as of the date that proposed
39final rulemaking for essential health benefits is issued, this section
40does not require any benefits to be provided that exceed the
P7    1essential health benefits that all health insurers will be required by
2federal regulations to provide under Section 1302(b) of the federal
3Patient Protection and Affordable Care Act (Public Law 111-148),
4as amended by the federal Health Care and Education
5Reconciliation Act of 2010 (Public Law 111-152).

6(3) This section shall not affect services for which an individual
7is eligible pursuant to Division 4.5 (commencing with Section
84500) of the Welfare and Institutions Code or Title 14
9(commencing with Section 95000) of the Government Code.

10(4) This section shall not affect or reduce any obligation to
11provide services under an individualized education program, as
12defined in Section 56032 of the Education Code, or an individual
13service plan, as described in Section 5600.4 of the Welfare and
14Institutions Code, or under the federal Individuals with Disabilities
15Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
16regulations.

17(b) Pursuant to Article 6 (commencing with Section 2240) of
18Title 10 of the California Code of Regulations, every health insurer
19subject to this section shall maintain an adequate network that
20includes qualified autism service providers who supervisebegin delete and
21employend delete
qualified autism service professionals or paraprofessionals
22who provide and administer behavioral health treatment. Nothing
23shall prevent a health insurer from selectively contracting with
24providers within these requirements.

25(c) For the purposes of this section, the following definitions
26shall apply:

27(1) “Behavioral health treatment” means professional services
28and treatment programs, including applied behavior analysis and
29begin insert otherend insert evidence-based behavior intervention programs, thatbegin delete developend delete
30begin insert develop, maintain,end insert or restore, to the maximum extent practicable,
31the functioning of an individual with pervasive developmental
32disorder or autism, and that meet all of the following criteria:

33(A) The treatment is prescribed by a physician and surgeon
34licensed pursuant to Chapter 5 (commencing with Section 2000)
35of, or is developed by a psychologist licensed pursuant to Chapter
366.6 (commencing with Section 2900) of, Division 2 of the Business
37and Professions Code.

38(B) The treatment is provided under a treatment plan prescribed
39by a qualified autism service provider and is administered by one
40of the following:

P8    1(i) A qualified autism service provider.

2(ii) A qualified autism service professional supervisedbegin delete and
3employedend delete
by the qualified autism service provider.

4(iii) A qualified autism service paraprofessional supervisedbegin delete and
5employedend delete
by a qualified autism service provider.

6(C) The treatment plan has measurable goals over a specific
7timeline that is developed and approved by the qualified autism
8service provider for the specific patient being treated. The treatment
9plan shall be reviewed nobegin delete lessend deletebegin insert moreend insert than once every six months
10by the qualified autism servicebegin delete providerend deletebegin insert provider,end insertbegin insert unless a shorter
11period is recommended by the qualified autism service provider,end insert

12 and modified whenever appropriate, and shall be consistent with
13Section 4686.2 of the Welfare and Institutions Code pursuant to
14which the qualified autism service provider does all of the
15following:

16(i) Describes the patient’s behavioral health impairments or
17developmental challenges that are to be treated.

18(ii) Designs an intervention plan that includes the service type,
19number of hours, and parentbegin insert or caregiverend insert participation
20begin insert recommended by a qualified autism service providerend insert needed to
21achieve the plan’s goal and objectives, and the frequency at which
22 the patient’s progress is evaluated and reported.begin insert Lack of parent or
23caregiver participation shall not be used to deny or reduce
24medically necessary behavioral health treatment.end insert

25(iii) Provides intervention plans that utilize evidence-based
26practices, with demonstrated clinical efficacy in treating pervasive
27developmental disorder or autism.

28(iv) Discontinues intensive behavioral intervention services
29when the treatment goals and objectives are achieved or no longer
30begin delete appropriate.end deletebegin insert appropriateend insertbegin insert, and continued therapy is not necessary
31to maintain function or prevent deterioration.end insert

32(D) begin insert(i)end insertbegin insertend insert The treatment plan is not used for purposes of providing
33or for the reimbursement of respite, day care, or educational
34services and is not used to reimburse a parent for participating in
35the treatment program.begin delete Theend delete

begin insert

36 (ii) Notwithstanding the above, all medically necessary
37behavioral health treatment shall be covered in all settings
38regardless of time or location of delivery.

end insert

39begin insert(iii)end insertbegin insertend insertbegin insertTheend insert treatment plan shall be made available to the insurer
40upon request.

P9    1(2) “Pervasive developmental disorder or autism” shall have
2the same meaning and interpretation as used in Section 10144.5.

3(3) “Qualified autism service provider” means either of the
4following:

5(A) A person, entity, or group that is certified by a national
6entity, such as the Behavior Analyst Certification Board, that is
7accredited by the National Commission for Certifying Agencies,
8and who designs, supervises, or provides treatment for pervasive
9developmental disorder or autism, provided the services are within
10the experience and competence of the person, entity, or group that
11is nationally certified.

12(B) A person licensed as a physician and surgeon, physical
13therapist, occupational therapist, psychologist, marriage and family
14therapist, educational psychologist, clinical social worker,
15professional clinical counselor, speech-language pathologist, or
16audiologist pursuant to Division 2 (commencing with Section 500)
17of the Business and Professions Code, who designs, supervises,
18or provides treatment for pervasive developmental disorder or
19autism, provided the services are within the experience and
20competence of the licensee.

21(4) “Qualified autism service professional” means an individual
22who meets all of the following criteria:

23(A) Provides behavioral healthbegin delete treatment.end deletebegin insert treatment, including
24clinical management and case supervision.end insert

25(B) Is employed and supervised by a qualified autism service
26provider.

27(C) Provides treatment pursuant to a treatment plan developed
28and approved by the qualified autism service provider.

29(D) Is a behavioral service providerbegin delete approved as a vendor by a
30California regional center to provide services asend delete
begin insert who meets the
31education and experience qualifications defined in Section 5432
32of Title 17 of the California Code of Regulations forend insert
begin insert end insert an Associate
33Behavior Analyst, Behavior Analyst, Behavior Management
34Assistant, Behavior Management Consultant, or Behavior
35Managementbegin delete Program as defined in Section 54342 of Title 17 of
36the California Code of Regulations.end delete
begin insert Program.end insert

37(E) Has training and experience in providing services for
38pervasive developmental disorder or autism pursuant to Division
394.5 (commencing with Section 4500) of the Welfare and
P10   1Institutions Code or Title 14 (commencing with Section 95000)
2of the Government Code.

3(5) “Qualified autism service paraprofessional” means an
4unlicensed and uncertified individual who meets all of the
5following criteria:

6(A) Isbegin delete employed andend delete supervised by a qualified autism service
7provider.

8(B) Provides treatment and implements services pursuant to a
9treatment plan developed and approved by the qualified autism
10servicebegin delete provider.end deletebegin insert provideend insertbegin insertr or qualified autism service professional.end insert

11(C) Meets thebegin delete criteria set forthend deletebegin insert education and experience
12qualifications definedend insert
in the regulations adopted pursuant to Section
134686.3 of the Welfare and Institutions Code.

14(D) Has adequate education, training, and experience, as
15certified by a qualified autism service provider.

16(d) This section shall not apply to the following:

17(1) A specialized health insurance policy that does not cover
18mental health or behavioral health services or an accident only,
19specified disease, hospital indemnity, or Medicare supplement
20policy.

21(2) A health insurance policy in thebegin delete Mediend deletebegin insert MDIend insert-Cal program
22(Chapter 7 (commencing with Section 14000) of Part 3 of Division
239 of the Welfare and Institutions Code).

begin delete

24(3) A health insurance policy in the Healthy Families Program
25(Part 6.2 (commencing with Section 12693)).

end delete
begin delete

26(4) A health care benefit plan or policy entered into with the
27Board of Administration of the Public Employees’ Retirement
28System pursuant to the Public Employees’ Medical and Hospital
29Care Act (Part 5 (commencing with Section 22750) of Division 5
30of Title 2 of the Government Code).

end delete
begin delete

31(e) Nothing in this section shall be construed to limit the
32obligation to provide services under Section 10144.5.

end delete
begin delete

33(f)

end delete

34begin insert(end insertbegin inserte)end insert As provided in Section 10144.5 and in paragraph (1) of
35subdivision (a), in the provision of benefits required by this section,
36a health insurer may utilize case management, network providers,
37utilization review techniques, prior authorization, copayments, or
38other cost sharing.

begin delete

P11   1(g) This section shall remain in effect only until January 1, 2017,
2and as of that date is repealed, unless a later enacted statute, that
3is enacted before January 1, 2017, deletes or extends that date.

end delete
4

SEC. 3.  

Section 10144.52 of the Insurance Code is amended
5to read:

6

10144.52.  

begin delete(a)end delete For purposes of this part, the terms “provider,”
7“professional provider,” “network provider,” “mental health
8provider,” and “mental health professional” shall include the term
9“qualified autism service provider,” as defined in subdivision (c)
10of Section 10144.51.

begin delete

11(b) This section shall remain in effect only until January 1, 2017,
12and as of that date is repealed, unless a later enacted statute, that
13is enacted before January 1, 2017, deletes or extends that date.

end delete
14

SEC. 4.  

No reimbursement is required by this act pursuant to
15Section 6 of Article XIII B of the California Constitution because
16the only costs that may be incurred by a local agency or school
17district will be incurred because this act creates a new crime or
18infraction, eliminates a crime or infraction, or changes the penalty
19for a crime or infraction, within the meaning of Section 17556 of
20the Government Code, or changes the definition of a crime within
21the meaning of Section 6 of Article XIII B of the California
22Constitution.



O

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