SB 1034, as amended, 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:
Section 1374.73 of the Health and Safety Code
2 is amended to read:
(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).
P3 1(3) This section shall not affect services for which an individual
2is eligible pursuant to Division 4.5 (commencing with Section
34500) of the Welfare and Institutions Code or Title 14
4(commencing with Section 95000) of the Government Code.
5(4) This section shall not affect or reduce any obligation to
6provide services under an individualized education program, as
7defined in Section 56032 of the Education Code, or an individual
8service plan, as described in Section 5600.4 of the Welfare and
9Institutions Code, or under the federal Individuals with Disabilities
10Education Act (20 U.S.C. Sec. 1400 et seq.)
and its implementing
11regulations.
12(b) Every health care service plan subject to this section shall
13maintain an adequate network that includes qualified autism service
14providers who supervise qualified autism service professionals or
15paraprofessionals who provide and administer behavioral health
16treatment. Nothing shall prevent a health care service plan from
17selectively contracting with providers within these requirements.
18(c) For the purposes of this section, the following definitions
19shall apply:
20(1) “Behavioral health treatment” means professional services
21and treatment programs, including applied behavior analysis and
22other evidence-based behavior intervention programs, that develop,
23
keep, or restore, to the maximum extent practicable, the functioning
24of an individual with pervasive developmental disorder or autism
25and that meet all of the following criteria:
26(A) The treatment is prescribed by a physician and surgeon
27licensed pursuant to Chapter 5 (commencing with Section 2000)
28of, or is developed by a psychologist licensed pursuant to Chapter
296.6 (commencing with Section 2900) of, Division 2 of the Business
30and Professions Code.
31(B) The treatment is provided under a treatment plan prescribed
32by a qualified autism service provider and is administered by one
33of the following:
34(i) A qualified autism service provider.
35(ii) A qualified autism service professional supervised by the
36qualified autism service provider.
37(iii) A qualified autism service paraprofessional supervised by
38a qualified autism service provider.
39(C) The treatment plan has measurable goals over a specific
40timeline that is developed and approved by the qualified autism
P4 1service provider for the specific patient being treated. The treatment
2plan shall be reviewed no more than once every six months by the
3qualified autism service provider, unless a shorter period is
4recommended by the qualified autism service provider, and
5modified whenever appropriate, and shall be consistent with
6Section 4686.2 of the Welfare and Institutions Code pursuant to
7which the qualified autism service provider does all of the
8following:
9(i) Describes the patient’s behavioral health impairments or
10developmental challenges that are to be treated.
11(ii) Designs an intervention plan that includes the service type,
12number of hours, and parent or caregiver participation
13recommended by the qualified autism service provider to achieve
14the plan’s goal and objectives, and the frequency at which the
15patient’s progress is evaluated and reported. Lack of parent or
16caregiver participation shall not be used to deny or reduce
17medically necessary behavioral health treatment.
18(iii) Provides intervention plans that utilize evidence-based
19practices, with demonstrated clinical efficacy in treating pervasive
20developmental disorder or autism.
21(iv) Discontinues intensive behavioral intervention services
22when the treatment goals and objectives are achieved or no longer
23appropriate, and continued therapy is not necessary to maintain
24function or prevent deterioration.
25(D) (i) The treatment plan is not used for purposes of providing
26or for the reimbursement of respite, day care, or academic services
27and is not used to reimburse a parent for participating in the
28treatment program.
29(ii) The setting, location, or time of treatment shall not be used
30as a reason to deny medically necessary behavioral health
31treatment.
32(iii) The treatment plan shall be made available to the health
33care
service plan upon request.
34(2) “Pervasive developmental disorder or autism” shall have
35the same meaning and interpretation as used in Section 1374.72.
36(3) “Qualified autism service provider” means either of the
37following:
38(A) A person, entity, or group that is certified by a national
39entity, such as the Behavior Analyst Certification Board, that is
40accredited by the National Commission for Certifying Agencies,
P5 1and who designs, supervises, or provides treatment for pervasive
2developmental disorder or autism, provided the services are within
3the experience and competence of the person, entity, or group that
4is nationally certified.
5(B) A person licensed as a
physician and surgeon, physical
6therapist, occupational therapist, psychologist, marriage and family
7therapist, educational psychologist, clinical social worker,
8professional clinical counselor, speech-language pathologist, or
9audiologist pursuant to Division 2 (commencing with Section 500)
10of the Business and Professions Code, who designs, supervises,
11or provides treatment for pervasive developmental disorder or
12autism, provided the services are within the experience and
13competence of the licensee.
14(4) “Qualified autism service professional” means an individual
15who meets all of the following criteria:
16(A) Provides behavioral health treatment, including clinical
17management and case supervision.
18(B) Is supervised by a qualified autism service provider.
19(C) Provides treatment pursuant to a treatment plan developed
20and approved by the qualified autism service provider.
21(D) Is a behavioral service provider who meets the education
22and experience qualifications defined in Section 54342 of Title 17
23of the California Code of Regulations for an Associate Behavior
24Analyst, Behavior Analyst, Behavior Management Assistant,
25Behavior Management Consultant, or Behavior Management
26Program.
27(E) Has training and experience in providing services for
28pervasive developmental disorder or autism pursuant to Division
294.5 (commencing with Section 4500) of the Welfare and
30Institutions Code or Title 14 (commencing with Section 95000)
31of the Government
Code.
32(5) “Qualified autism service paraprofessional” means an
33unlicensed and uncertified individual who meets all of the
34following criteria:
35(A) Is supervised by a qualified autism service provider.
36(B) Provides treatment and implements services pursuant to a
37treatment plan developed and approved by the qualified autism
38service provider or qualified autism service professional.
P6 1(C) Meets the education and training qualifications defined in
2the regulations adopted pursuant to Section 4686.3 of the Welfare
3and 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 the Medi-Cal program
10(Chapter 7 (commencing with Section 14000) of Part 3 of Division
119 of the Welfare and Institutions Code).
12(e) This section does not limit the obligation to provide services
13pursuant to Section 1374.72.
14(f) As provided in Section 1374.72 and in paragraph (1) of
15subdivision (a), in the provision of benefits required by this section,
16a
health care service plan may utilize case management, network
17providers, utilization review techniques, prior authorization,
18copayments, or other cost sharing.
19
(g) This section shall not be construed to require coverage for
20services that are included in a patient’s individualized education
21program.
Section 10144.51 of the Insurance Code is amended
23to read:
(a) (1) Every health insurance policy shall also
25provide coverage for behavioral health treatment for pervasive
26developmental disorder or autism no later than July 1, 2012. The
27coverage shall be provided in the same manner and shall be subject
28to the same requirements as provided in Section 10144.5.
29(2) Notwithstanding paragraph (1), as of the date that proposed
30final rulemaking for essential health benefits is issued, this section
31does not require any benefits to be provided that exceed the
32essential health benefits that all health insurers will be required by
33federal regulations to provide under Section 1302(b) of the federal
34Patient Protection and Affordable
Care Act (Public Law 111-148),
35as amended by the federal Health Care and Education
36Reconciliation Act of 2010 (Public Law 111-152).
37(3) This section shall not affect services for which an individual
38is eligible pursuant to Division 4.5 (commencing with Section
394500) of the Welfare and Institutions Code or Title 14
40(commencing with Section 95000) of the Government Code.
P7 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) Pursuant to Article 6 (commencing with Section 2240) of
9Title 10 of the California Code of Regulations, every health insurer
10subject to this section shall maintain an adequate network that
11includes qualified autism service providers who supervise qualified
12autism service professionals or paraprofessionals who provide and
13administer behavioral health treatment. Nothing shall prevent a
14health insurer from selectively contracting with providers within
15these requirements.
16(c) For the purposes of this section, the following definitions
17shall apply:
18(1) “Behavioral health treatment” means professional services
19and treatment programs, including applied behavior analysis and
20other evidence-based behavior intervention programs,
that develop,
21keep, or restore, to the maximum extent practicable, the functioning
22of an individual with pervasive developmental disorder or autism,
23and that meet all of the following criteria:
24(A) The treatment is prescribed by a physician and surgeon
25licensed pursuant to Chapter 5 (commencing with Section 2000)
26of, or is developed by a psychologist licensed pursuant to Chapter
276.6 (commencing with Section 2900) of, Division 2 of the Business
28and Professions Code.
29(B) The treatment is provided under a treatment plan prescribed
30by a qualified autism service provider and is administered by one
31of the following:
32(i) A qualified autism service provider.
33(ii) A qualified autism service professional supervised by the
34qualified autism service provider.
35(iii) A qualified autism service paraprofessional supervised by
36a qualified autism service provider.
37(C) The treatment plan has measurable goals over a specific
38timeline that is developed and approved by the qualified autism
39service provider for the specific patient being treated. The treatment
40plan shall be reviewed no more than once every six months by the
P8 1qualified autism service provider, unless a shorter period is
2recommended by the qualified autism service provider, and
3modified whenever appropriate, and shall be consistent with
4Section 4686.2 of the Welfare and Institutions Code pursuant to
5which the qualified autism service provider does all of the
6following:
7(i) Describes the patient’s behavioral health impairments or
8developmental challenges that are to be treated.
9(ii) Designs an intervention plan that includes the service type,
10number of hours, and parent or caregiver participation
11recommended by a qualified autism service provider to achieve
12the plan’s goal and objectives, and the frequency at which
the
13patient’s progress is evaluated and reported. Lack of parent or
14caregiver participation shall not be used to deny or reduce
15medically necessary behavioral health treatment.
16(iii) Provides intervention plans that utilize evidence-based
17practices, with demonstrated clinical efficacy in treating pervasive
18developmental disorder or autism.
19(iv) Discontinues intensive behavioral intervention services
20when the treatment goals and objectives are achieved or no longer
21appropriate, and continued therapy is not necessary to maintain
22function or prevent deterioration.
23(D) (i) The treatment plan is not used for purposes of providing
24or for the reimbursement of respite, day care, or
academic services
25and is not used to reimburse a parent for participating in the
26treatment program.
27(ii) The setting, location, or time of treatment shall not be used
28as a reason to deny medically necessary behavioral health
29treatment.
30(iii) The treatment plan shall be made available to the insurer
31upon request.
32(2) “Pervasive developmental disorder or autism” shall have
33the same meaning and interpretation as used in Section 10144.5.
34(3) “Qualified autism service provider” means either of the
35following:
36(A) A person, entity, or group that is certified by a national
37entity, such
as the Behavior Analyst Certification Board, that is
38accredited by the National Commission for Certifying Agencies,
39and who designs, supervises, or provides treatment for pervasive
40developmental disorder or autism, provided the services are within
P9 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 health treatment, including clinical
15management and case supervision.
16(B) Is employed and 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 provider who meets the education
21and experience qualifications defined in Section 54342 of Title 17
22of the California Code of Regulations for an Associate Behavior
23
Analyst, Behavior Analyst, Behavior Management Assistant,
24Behavior Management Consultant, or Behavior Management
25Program.
26(E) Has training and experience in providing services for
27pervasive developmental disorder or autism pursuant to Division
284.5 (commencing with Section 4500) of the Welfare and
29Institutions Code or Title 14 (commencing with Section 95000)
30of the Government Code.
31(5) “Qualified autism service paraprofessional” means an
32unlicensed and uncertified individual who meets all of the
33following criteria:
34(A) Is supervised by a qualified autism service provider.
35(B) Provides treatment and implements services pursuant to a
36treatment plan
developed and approved by the qualified autism
37service provider or qualified autism service professional.
38(C) Meets the education and training qualifications defined in
39the regulations adopted pursuant to Section 4686.3 of the Welfare
40and Institutions Code.
P10 1(D) Has adequate education, training, and experience, as
2certified by a qualified autism service provider.
3(d) This section shall not apply to the following:
4(1) A specialized health insurance policy that does not cover
5mental health or behavioral health services or an accident only,
6specified disease, hospital indemnity, or Medicare supplement
7policy.
8(2) A health insurance policy in the Medi-Cal program (Chapter
97 (commencing with Section 14000) of Part 3 of Division 9 of the
10Welfare and Institutions Code).
11(e) As provided in Section 10144.5 and in paragraph (1) of
12subdivision (a), in the provision of benefits required by this section,
13a health insurer may utilize case management, network providers,
14utilization review techniques, prior authorization, copayments, or
15other cost sharing.
16
(f) This section shall not be construed to require coverage for
17services that are included in a patient’s individualized education
18program.
Section 10144.52 of the Insurance Code is amended
20to read:
For purposes of this part, the terms “provider,”
22“professional provider,” “network provider,” “mental health
23provider,” and “mental health professional” shall include the term
24“qualified autism service provider,” as defined in subdivision (c)
25of Section 10144.51.
No reimbursement is required by this act pursuant to
27Section 6 of Article XIII B of the California Constitution because
28the only costs that may be incurred by a local agency or school
29district will be incurred because this act creates a new crime or
30infraction, eliminates a crime or infraction, or changes the penalty
31for a crime or infraction, within the meaning of Section 17556 of
32the Government Code, or changes the definition of a crime within
33the meaning of Section 6 of Article XIII B of the California
34Constitution.
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