Amended in Assembly June 30, 2016

Amended in Senate May 31, 2016

Amended in Senate April 26, 2016

Senate BillNo. 1034


Introduced by Senator Mitchell

February 12, 2016


An act to amend Section 1374.73 of the Health and Safety Code,begin delete andend delete to amend Sections 10144.51 and 10144.52 of the Insurance Code,begin insert and to amend Section 14132.56 of the Welfare and Institutions Code,end insert relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

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.begin insert Under existing law, the above provisions do not apply to certain types of health care coverage, including health care service plans and health insurance policies in the Medi-Cal program.end insert

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 provisionsbegin delete indefinitely.end deletebegin insert to January 1, 2022. The bill would require behavioral health treatment for purposes of the Medi-Cal program to expressly comply with the approved Medicaid state plan.end insert The billbegin insert alsoend insert would makebegin insert clarifying andend insert 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
P3    1essential health benefits that all health plans 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) Every health care service plan subject to this section shall
18maintain an adequate network that includes qualified autism service
19providers who supervise qualified autism service professionals or
20paraprofessionals who provide and administer behavioral health
21treatment. Nothing shall prevent a health care service plan from
22selectively contracting with providers within these requirements.

23(c) For the purposes of this section, the following definitions
24shall apply:

25(1) “Behavioral health treatment” means professional services
26and treatment programs, including applied behavior analysis and
27other evidence-based behavior intervention programs, that develop,
28 keep, or restore, to the maximum extent practicable, the functioning
29of an individual with pervasive developmental disorder or autism
30and that meet all of the following criteria:

31(A) The treatment is prescribed by a physician and surgeon
32licensed pursuant to Chapter 5 (commencing with Section 2000)
33of, or is developed by a psychologist licensed pursuant to Chapter
346.6 (commencing with Section 2900) of, Division 2 of the Business
35and Professions Code.

36(B) The treatment is provided under a treatment plan prescribed
37by a qualified autism service provider and is administered by one
38of the following:

39(i) A qualified autism service provider.

P4    1(ii) A qualified autism service professional supervised by the
2qualified autism service provider.

3(iii) A qualified autism service paraprofessional supervised by
4a qualified autism service provider.

5(C) The treatment plan has measurable goals over a specific
6timeline that is developed and approved by the qualified autism
7service provider for the specific patient being treated. The treatment
8plan shall be reviewed no more than once every six months by the
9qualified autism service provider, unless a shorter period is
10recommended by the qualified autism service provider, and
11modified whenever appropriate, and shall be consistent with
12Section 4686.2 of the Welfare and Institutions Code pursuant to
13which the qualified autism service provider does all of the
14following:

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

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

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

27(iv) Discontinues intensive behavioral intervention services
28when the treatment goals and objectives are achieved or no longer
29appropriate, and continued therapy is not necessary to maintain
30function or prevent deterioration.

31(D) (i) The treatment plan is not used for purposes of providing
32or for the reimbursement of respite, day care, or academic services
33and is not used to reimburse a parent for participating in the
34treatment program.

35(ii) The setting, location, or time of treatment shall not be used
36as a reason to deny medically necessary behavioral health
37treatment.

38(iii) The treatment plan shall be made available to the health
39care service plan upon request.

P5    1(2) “Pervasive developmental disorder or autism” shall have
2the same meaning and interpretation as used in Section 1374.72.

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 health treatment, including clinical
24management and case supervision.

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

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

28(D) Is a behavioral service provider who meets the education
29and experience qualifications defined in Section 54342 of Title 17
30of the California Code of Regulations for an Associate Behavior
31Analyst, Behavior Analyst, Behavior Management Assistant,
32Behavior Management Consultant, or Behavior Management
33Program.

34(E) Has training and experience in providing services for
35pervasive developmental disorder or autism pursuant to Division
364.5 (commencing with Section 4500) of the Welfare and
37Institutions Code or Title 14 (commencing with Section 95000)
38of the Government Code.

P6    1(5) “Qualified autism service paraprofessional” means an
2unlicensed and uncertified individual who meets all of the
3following criteria:

4(A) Is supervised by a qualified autism service provider.

5(B) Provides treatment and implements services pursuant to a
6treatment plan developed and approved by the qualified autism
7service provider or qualified autism service professional.

8(C) Meets the education and training qualifications defined in
9the regulations adopted pursuant to Section 4686.3 of the Welfare
10and Institutions Code.

11(D) Has adequate education, training, and experience, as
12certified by a qualified autism service provider.

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

14(1) A specialized health care service plan that does not deliver
15mental health or behavioral health services to enrollees.

16(2) A health care service plan contract in the Medi-Cal program
17(Chapter 7 (commencing with Section 14000) of Part 3 of Division
189 of the Welfare and Institutions Code).begin insert The provision of
19behavioral health treatment in the Medi-Cal program, including
20any associated obligation of a health care service plan in the
21Medi-Cal program, is governed by Section 14132.56 of the Welfare
22and Institutions Code, the approved Medi-Cal state plan and
23waivers, and applicable federal Medicaid law.end insert

24(e) This section does not limit the obligation to provide services
25pursuant to Section 1374.72.

26(f) As provided in Section 1374.72 and in paragraph (1) of
27subdivision (a), in the provision of benefits required by this section,
28a health care service plan may utilize case management, network
29providers, utilization review techniques, prior authorization,
30copayments, or other cost sharing.

31(g) This section shall not be construed to require coverage for
32services that are included in a patient’s individualized education
33program.

begin insert

34
(h) This section shall remain in effect only until January 1, 2022,
35and as of that date is repealed, unless a later enacted statute, that
36is enacted before January 1, 2022, deletes or extends that date.

end insert
37

SEC. 2.  

Section 10144.51 of the Insurance Code is amended
38to read:

39

10144.51.  

(a) (1) Every health insurance policy shall also
40provide coverage for behavioral health treatment for pervasive
P7    1developmental disorder or autism no later than July 1, 2012. The
2coverage shall be provided in the same manner and shall be subject
3to the same requirements as provided in Section 10144.5.

4(2) Notwithstanding paragraph (1), as of the date that proposed
5final rulemaking for essential health benefits is issued, this section
6does not require any benefits to be provided that exceed the
7essential health benefits that all health insurers will be required by
8federal regulations to provide under Section 1302(b) of the federal
9Patient Protection and Affordable Care Act (Public Law 111-148),
10as amended by the federal Health Care and Education
11Reconciliation Act of 2010 (Public Law 111-152).

12(3) This section shall not affect services for which an individual
13is eligible pursuant to Division 4.5 (commencing with Section
144500) of the Welfare and Institutions Code or Title 14
15(commencing with Section 95000) of the Government Code.

16(4) This section shall not affect or reduce any obligation to
17provide services under an individualized education program, as
18defined in Section 56032 of the Education Code, or an individual
19service plan, as described in Section 5600.4 of the Welfare and
20Institutions Code, or under the federal Individuals with Disabilities
21Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
22regulations.

23(b) Pursuant to Article 6 (commencing with Section 2240) of
24Title 10 of the California Code of Regulations, every health insurer
25subject to this section shall maintain an adequate network that
26includes qualified autism service providers who supervise qualified
27autism service professionals or paraprofessionals who provide and
28administer behavioral health treatment. Nothing shall prevent a
29health insurer from selectively contracting with providers within
30these requirements.

31(c) For the purposes of this section, the following definitions
32shall apply:

33(1) “Behavioral health treatment” means professional services
34and treatment programs, including applied behavior analysis and
35other evidence-based behavior intervention programs, that develop,
36keep, or restore, to the maximum extent practicable, the functioning
37of an individual with pervasive developmental disorder or autism,
38and that meet all of the following criteria:

39(A) The treatment is prescribed by a physician and surgeon
40licensed pursuant to Chapter 5 (commencing with Section 2000)
P8    1of, or is developed by a psychologist licensed pursuant to Chapter
26.6 (commencing with Section 2900) of, Division 2 of the Business
3and Professions Code.

4(B) The treatment is provided under a treatment plan prescribed
5by a qualified autism service provider and is administered by one
6of the following:

7(i) A qualified autism service provider.

8(ii) A qualified autism service professional supervised by the
9qualified autism service provider.

10(iii) A qualified autism service paraprofessional supervised by
11a qualified autism service provider.

12(C) The treatment plan has measurable goals over a specific
13timeline that is developed and approved by the qualified autism
14service provider for the specific patient being treated. The treatment
15plan shall be reviewed no more than once every six months by the
16qualified autism service provider, unless a shorter period is
17recommended by the qualified autism service provider, and
18modified whenever appropriate, and shall be consistent with
19Section 4686.2 of the Welfare and Institutions Code pursuant to
20which the qualified autism service provider does all of the
21following:

22(i) Describes the patient’s behavioral health impairments or
23developmental challenges that are to be treated.

24(ii) Designs an intervention plan that includes the service type,
25number of hours, and parent or caregiver participation
26recommended by a qualified autism service provider to achieve
27the plan’s goal and objectives, and the frequency at which the
28patient’s progress is evaluated and reported. Lack of parent or
29caregiver participation shall not be used to deny or reduce
30medically necessary behavioral health treatment.

31(iii) Provides intervention plans that utilize evidence-based
32practices, with demonstrated clinical efficacy in treating pervasive
33developmental disorder or autism.

34(iv) Discontinues intensive behavioral intervention services
35when the treatment goals and objectives are achieved or no longer
36appropriate, and continued therapy is not necessary to maintain
37function or prevent deterioration.

38(D) (i) The treatment plan is not used for purposes of providing
39or for the reimbursement of respite, day care, or academic services
P9    1and is not used to reimburse a parent for participating in the
2treatment program.

3(ii) The setting, location, or time of treatment shall not be used
4as a reason to deny medically necessary behavioral health
5treatment.

6(iii) The treatment plan shall be made available to the insurer
7upon request.

8(2) “Pervasive developmental disorder or autism” shall have
9the same meaning and interpretation as used in Section 10144.5.

10(3) “Qualified autism service provider” means either of the
11following:

12(A) A person, entity, or group that is certified by a national
13entity, such as the Behavior Analyst Certification Board, that is
14accredited by the National Commission for Certifying Agencies,
15and who designs, supervises, or provides treatment for pervasive
16developmental disorder or autism, provided the services are within
17the experience and competence of the person, entity, or group that
18is nationally certified.

19(B) A person licensed as a physician and surgeon, physical
20therapist, occupational therapist, psychologist, marriage and family
21therapist, educational psychologist, clinical social worker,
22professional clinical counselor, speech-language pathologist, or
23audiologist pursuant to Division 2 (commencing with Section 500)
24of the Business and Professions Code, who designs, supervises,
25or provides treatment for pervasive developmental disorder or
26autism, provided the services are within the experience and
27competence of the licensee.

28(4) “Qualified autism service professional” means an individual
29who meets all of the following criteria:

30(A) Provides behavioral health treatment, including clinical
31management and case supervision.

32(B) Is employed and supervised by a qualified autism service
33provider.

34(C) Provides treatment pursuant to a treatment plan developed
35and approved by the qualified autism service provider.

36(D) Is a behavioral service provider who meets the education
37and experience qualifications defined in Section 54342 of Title 17
38of the California Code of Regulations for an Associate Behavior
39 Analyst, Behavior Analyst, Behavior Management Assistant,
P10   1Behavior Management Consultant, or Behavior Management
2Program.

3(E) Has training and experience in providing services for
4pervasive developmental disorder or autism pursuant to Division
54.5 (commencing with Section 4500) of the Welfare and
6Institutions Code or Title 14 (commencing with Section 95000)
7of the Government Code.

8(5) “Qualified autism service paraprofessional” means an
9unlicensed and uncertified individual who meets all of the
10following criteria:

11(A) Is supervised by a qualified autism service provider.

12(B) Provides treatment and implements services pursuant to a
13treatment plan developed and approved by the qualified autism
14service provider or qualified autism service professional.

15(C) Meets the education and training qualifications defined in
16the regulations adopted pursuant to Section 4686.3 of the Welfare
17and Institutions Code.

18(D) Has adequate education, training, and experience, as
19certified by a qualified autism service provider.

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

21(1) A specialized health insurance policy that does not cover
22mental health or behavioral health services or an accident only,
23specified disease, hospital indemnity, or Medicare supplement
24policy.

25(2) A health insurance policy in the Medi-Cal program (Chapter
267 (commencing with Section 14000) of Part 3 of Division 9 of the
27Welfare and Institutions Code).begin insert The provision of behavioral health
28treatment in the Medi-Cal program, including any associated
29obligation of a health insurance policy in the Medi-Cal program,
30is governed by Section 14132.56 of the Welfare and Institutions
31Code, the approved Medi-Cal state plan and waivers, and
32applicable federal Medicaid law.end insert

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

38(f) This section shall not be construed to require coverage for
39services that are included in a patient’s individualized education
40program.

begin insert

P11   1
(g) This section shall remain in effect only until January 1, 2022,
2and as of that date is repealed, unless a later enacted statute, that
3is enacted before January 1, 2022, deletes or extends that date.

end insert
4

SEC. 3.  

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

6

10144.52.  

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

begin insert

11
(b) This section shall remain in effect only until January 1, 2022,
12and as of that date is repealed, unless a later enacted statute, that
13is enacted before January 1, 2022, deletes or extends that date.

end insert
14begin insert

begin insertSEC. 4.end insert  

end insert

begin insertSection 14132.56 of the end insertbegin insertWelfare and Institutions Codeend insert
15
begin insert is amended to read:end insert

16

14132.56.  

(a) (1) Only to the extent required by the federal
17government and effective no sooner than required by the federal
18government, behavioral health treatmentbegin delete (BHT), as defined by
19Section 1374.73 of the Health and Safety Code, end delete
begin insert (BHT) end insertshall be a
20covered Medi-Cal service for individuals under 21 years of age.

21(2) It is the intent of the Legislature that, to the extent the federal
22government requires BHT to be a covered Medi-Cal service, the
23department shall seek statutory authority to implement this new
24benefit in Medi-Cal.

begin insert

25
(3) For purposes of this section, “behavioral health treatment”
26or “BHT” means professional services and treatment programs,
27including applied behavior analysis and evidence-based behavior
28intervention programs that develop or restore, to the maximum
29extent practicable, the functioning of an individual with pervasive
30developmental disorder or autism, and are administered as
31described in the approved state plan.

end insert

32(b) The department shall implement, or continue to implement,
33this section only after all of the following occurs or has occurred:

34(1) The department receives all necessary federal approvals to
35obtain federal funds for the service.

36(2) The department seeks an appropriation that would provide
37the necessary state funding estimated to be required for the
38applicable fiscal year.

39(3) The department consults with stakeholders.

P12   1(c) The department shall develop and define eligibility criteria,
2provider participation criteria, utilization controls, and delivery
3system structure for services under this section, subject to
4limitations allowable under federal law, in consultation with
5stakeholders.

6(d) Notwithstanding Chapter 3.5 (commencing with Section
711340) of Part 1 of Division 3 of Title 2 of the Government Code,
8the department, without taking any further regulatory action, shall
9implement, interpret, or make specific this section by means of
10all-county letters, plan letters, plan or provider bulletins, or similar
11instructions until regulations are adopted. The department shall
12adopt regulations by July 1, 2017, in accordance with the
13 requirements of Chapter 3.5 (commencing with Section 11340) of
14Part 1 of Division 3 of Title 2 of the Government Code.
15Notwithstanding Section 10231.5 of the Government Code,
16beginning six months after the effective date of this section, the
17department shall provide semiannual status reports to the
18Legislature, in compliance with Section 9795 of the Government
19Code, until regulations have been adopted.

20(e) For the purposes of implementing this section, the department
21may enter into exclusive or nonexclusive contracts on a bid or
22negotiated basis, including contracts for the purpose of obtaining
23subject matter expertise or other technical assistance. Contracts
24may be statewide or on a more limited geographic basis. Contracts
25entered into or amended under this subdivision shall be exempt
26from Part 2 (commencing with Section 10100) of Division 2 of
27the Public Contract Code and Chapter 6 (commencing with Section
2814825) of Part 5.5 of Division 3 of the Government Code, and
29shall be exempt from the review or approval of any division of the
30Department of General Services.

31(f) The department may seek approval of any necessary state
32plan amendments or waivers to implement this section. The
33department shall make any state plan amendments or waiver
34requests public at least 30 days prior to submitting to the federal
35Centers for Medicare and Medicaid Services, and the department
36shall work with stakeholders to address the public comments in
37the state plan amendment or waiver request.

38(g) This section shall be implemented only to the extent that
39federal financial participation is available and any necessary federal
40approvals have been obtained.

P13   1

begin deleteSEC. 4.end delete
2
begin insertSEC. 5.end insert  

No reimbursement is required by this act pursuant to
3Section 6 of Article XIII B of the California Constitution because
4the only costs that may be incurred by a local agency or school
5district will be incurred because this act creates a new crime or
6infraction, eliminates a crime or infraction, or changes the penalty
7for a crime or infraction, within the meaning of Section 17556 of
8the Government Code, or changes the definition of a crime within
9the meaning of Section 6 of Article XIII B of the California
10Constitution.



O

    96