BILL NUMBER: SB 1034 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 30, 2016
AMENDED IN SENATE MAY 31, 2016
AMENDED IN SENATE APRIL 26, 2016
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, and to amend Section 14132.56 of the
Welfare and Institutions Code, 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. 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.
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.
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. The bill also
would make clarifying and 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 1. Section 1374.73 of the Health and Safety Code is
amended to read:
1374.73. (a) (1) Every health care service plan contract that
provides hospital, medical, or surgical coverage shall also provide
coverage for behavioral health treatment for pervasive developmental
disorder or autism no later than July 1, 2012. The coverage shall be
provided in the same manner and shall be subject to the same
requirements as provided in Section 1374.72.
(2) Notwithstanding paragraph (1), as of the date that proposed
final rulemaking for essential health benefits is issued, this
section does not require any benefits to be provided that exceed the
essential health benefits that all health plans will be required by
federal regulations to provide under Section 1302(b) of the federal
Patient Protection and Affordable Care Act (Public Law 111-148), as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152).
(3) This section shall not affect services for which an individual
is eligible pursuant to Division 4.5 (commencing with Section 4500)
of the Welfare and Institutions Code or Title 14 (commencing with
Section 95000) of the Government Code.
(4) This section shall not affect or reduce any obligation to
provide services under an individualized education program, as
defined in Section 56032 of the Education Code, or an individual
service plan, as described in Section 5600.4 of the Welfare and
Institutions Code, or under the federal Individuals with Disabilities
Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
regulations.
(b) Every health care service plan subject to this section shall
maintain an adequate network that includes qualified autism service
providers who supervise qualified autism service professionals or
paraprofessionals who provide and administer behavioral health
treatment. Nothing shall prevent a health care service plan from
selectively contracting with providers within these requirements.
(c) For the purposes of this section, the following definitions
shall apply:
(1) "Behavioral health treatment" means professional services and
treatment programs, including applied behavior analysis and other
evidence-based behavior intervention programs, that develop, keep, or
restore, to the maximum extent practicable, the functioning of an
individual with pervasive developmental disorder or autism and that
meet all of the following criteria:
(A) The treatment is prescribed by a physician and surgeon
licensed pursuant to Chapter 5 (commencing with Section 2000) of, or
is developed by a psychologist licensed pursuant to Chapter 6.6
(commencing with Section 2900) of, Division 2 of the Business and
Professions Code.
(B) The treatment is provided under a treatment plan prescribed by
a qualified autism service provider and is administered by one of
the following:
(i) A qualified autism service provider.
(ii) A qualified autism service professional supervised by the
qualified autism service provider.
(iii) A qualified autism service paraprofessional supervised by a
qualified autism service provider.
(C) The treatment plan has measurable goals over a specific
timeline that is developed and approved by the qualified autism
service provider for the specific patient being treated. The
treatment plan shall be reviewed no more than once every six months
by the qualified autism service provider, unless a shorter period is
recommended by the qualified autism service provider, and modified
whenever appropriate, and shall be consistent with Section 4686.2 of
the Welfare and Institutions Code pursuant to which the qualified
autism service provider does all of the following:
(i) Describes the patient's behavioral health impairments or
developmental challenges that are to be treated.
(ii) Designs an intervention plan that includes the service type,
number of hours, and parent or caregiver participation recommended by
the qualified autism service provider to achieve the plan's goal and
objectives, and the frequency at which the patient's progress is
evaluated and reported. Lack of parent or caregiver participation
shall not be used to deny or reduce medically necessary behavioral
health treatment.
(iii) Provides intervention plans that utilize evidence-based
practices, with demonstrated clinical efficacy in treating pervasive
developmental disorder or autism.
(iv) Discontinues intensive behavioral intervention services when
the treatment goals and objectives are achieved or no longer
appropriate, and continued therapy is not necessary to maintain
function or prevent deterioration.
(D) (i) The treatment plan is not used for purposes of providing
or for the reimbursement of respite, day care, or academic services
and is not used to reimburse a parent for participating in the
treatment program.
(ii) The setting, location, or time of treatment shall not be used
as a reason to deny medically necessary behavioral health treatment.
(iii) The treatment plan shall be made available to the health
care service plan upon request.
(2) "Pervasive developmental disorder or autism" shall have the
same meaning and interpretation as used in Section 1374.72.
(3) "Qualified autism service provider" means either of the
following:
(A) A person, entity, or group that is certified by a national
entity, such as the Behavior Analyst Certification Board, that is
accredited by the National Commission for Certifying Agencies, and
who designs, supervises, or provides treatment for pervasive
developmental disorder or autism, provided the services are within
the experience and competence of the person, entity, or group that is
nationally certified.
(B) A person licensed as a physician and surgeon, physical
therapist, occupational therapist, psychologist, marriage and family
therapist, educational psychologist, clinical social worker,
professional clinical counselor, speech-language pathologist, or
audiologist pursuant to Division 2 (commencing with Section 500) of
the Business and Professions Code, who designs, supervises, or
provides treatment for pervasive developmental disorder or autism,
provided the services are within the experience and competence of the
licensee.
(4) "Qualified autism service professional" means an individual
who meets all of the following criteria:
(A) Provides behavioral health treatment, including clinical
management and case supervision.
(B) Is supervised by a qualified autism service provider.
(C) Provides treatment pursuant to a treatment plan developed and
approved by the qualified autism service provider.
(D) Is a behavioral service provider who meets the education and
experience qualifications defined in Section 54342 of Title 17 of the
California Code of Regulations for an Associate Behavior Analyst,
Behavior Analyst, Behavior Management Assistant, Behavior Management
Consultant, or Behavior Management Program.
(E) Has training and experience in providing services for
pervasive developmental disorder or autism pursuant to Division 4.5
(commencing with Section 4500) of the Welfare and Institutions Code
or Title 14 (commencing with Section 95000) of the Government Code.
(5) "Qualified autism service paraprofessional" means an
unlicensed and uncertified individual who meets all of the following
criteria:
(A) Is supervised by a qualified autism service provider.
(B) Provides treatment and implements services pursuant to a
treatment plan developed and approved by the qualified autism service
provider or qualified autism service professional.
(C) Meets the education and training qualifications defined in the
regulations adopted pursuant to Section 4686.3 of the Welfare and
Institutions Code.
(D) Has adequate education, training, and experience, as certified
by a qualified autism service provider.
(d) This section shall not apply to the following:
(1) A specialized health care service plan that does not deliver
mental health or behavioral health services to enrollees.
(2) A health care service plan contract in the Medi-Cal program
(Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of
the Welfare and Institutions Code). The provision of behavioral
health treatment in the Medi-Cal program, including any associated
obligation of a health care service plan in the Medi-Cal program, is
governed by Section 14132.56 of the Welfare and Institutions Code,
the approved Medi-Cal state plan and waivers, and applic
able federal Medicaid law.
(e) This section does not limit the obligation to provide services
pursuant to Section 1374.72.
(f) As provided in Section 1374.72 and in paragraph (1) of
subdivision (a), in the provision of benefits required by this
section, a health care service plan may utilize case management,
network providers, utilization review techniques, prior
authorization, copayments, or other cost sharing.
(g) This section shall not be construed to require coverage for
services that are included in a patient's individualized education
program.
(h) This section shall remain in effect only until January 1,
2022, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2022, deletes or extends
that date.
SEC. 2. Section 10144.51 of the Insurance Code is amended to read:
10144.51. (a) (1) Every health insurance policy shall also
provide coverage for behavioral health treatment for pervasive
developmental disorder or autism no later than July 1, 2012. The
coverage shall be provided in the same manner and shall be subject to
the same requirements as provided in Section 10144.5.
(2) Notwithstanding paragraph (1), as of the date that proposed
final rulemaking for essential health benefits is issued, this
section does not require any benefits to be provided that exceed the
essential health benefits that all health insurers will be required
by federal regulations to provide under Section 1302(b) of the
federal Patient Protection and Affordable Care Act (Public Law
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152).
(3) This section shall not affect services for which an individual
is eligible pursuant to Division 4.5 (commencing with Section 4500)
of the Welfare and Institutions Code or Title 14 (commencing with
Section 95000) of the Government Code.
(4) This section shall not affect or reduce any obligation to
provide services under an individualized education program, as
defined in Section 56032 of the Education Code, or an individual
service plan, as described in Section 5600.4 of the Welfare and
Institutions Code, or under the federal Individuals with Disabilities
Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
regulations.
(b) Pursuant to Article 6 (commencing with Section 2240) of Title
10 of the California Code of Regulations, every health insurer
subject to this section shall maintain an adequate network that
includes qualified autism service providers who supervise qualified
autism service professionals or paraprofessionals who provide and
administer behavioral health treatment. Nothing shall prevent a
health insurer from selectively contracting with providers within
these requirements.
(c) For the purposes of this section, the following definitions
shall apply:
(1) "Behavioral health treatment" means professional services and
treatment programs, including applied behavior analysis and other
evidence-based behavior intervention programs, that develop, keep, or
restore, to the maximum extent practicable, the functioning of an
individual with pervasive developmental disorder or autism, and that
meet all of the following criteria:
(A) The treatment is prescribed by a physician and surgeon
licensed pursuant to Chapter 5 (commencing with Section 2000) of, or
is developed by a psychologist licensed pursuant to Chapter 6.6
(commencing with Section 2900) of, Division 2 of the Business and
Professions Code.
(B) The treatment is provided under a treatment plan prescribed by
a qualified autism service provider and is administered by one of
the following:
(i) A qualified autism service provider.
(ii) A qualified autism service professional supervised by the
qualified autism service provider.
(iii) A qualified autism service paraprofessional supervised by a
qualified autism service provider.
(C) The treatment plan has measurable goals over a specific
timeline that is developed and approved by the qualified autism
service provider for the specific patient being treated. The
treatment plan shall be reviewed no more than once every six months
by the qualified autism service provider, unless a shorter period is
recommended by the qualified autism service provider, and modified
whenever appropriate, and shall be consistent with Section 4686.2 of
the Welfare and Institutions Code pursuant to which the qualified
autism service provider does all of the following:
(i) Describes the patient's behavioral health impairments or
developmental challenges that are to be treated.
(ii) Designs an intervention plan that includes the service type,
number of hours, and parent or caregiver participation recommended by
a qualified autism service provider to achieve the plan's goal and
objectives, and the frequency at which the patient's progress is
evaluated and reported. Lack of parent or caregiver participation
shall not be used to deny or reduce medically necessary behavioral
health treatment.
(iii) Provides intervention plans that utilize evidence-based
practices, with demonstrated clinical efficacy in treating pervasive
developmental disorder or autism.
(iv) Discontinues intensive behavioral intervention services when
the treatment goals and objectives are achieved or no longer
appropriate, and continued therapy is not necessary to maintain
function or prevent deterioration.
(D) (i) The treatment plan is not used for purposes of providing
or for the reimbursement of respite, day care, or academic services
and is not used to reimburse a parent for participating in the
treatment program.
(ii) The setting, location, or time of treatment shall not be used
as a reason to deny medically necessary behavioral health treatment.
(iii) The treatment plan shall be made available to the insurer
upon request.
(2) "Pervasive developmental disorder or autism" shall have the
same meaning and interpretation as used in Section 10144.5.
(3) "Qualified autism service provider" means either of the
following:
(A) A person, entity, or group that is certified by a national
entity, such as the Behavior Analyst Certification Board, that is
accredited by the National Commission for Certifying Agencies, and
who designs, supervises, or provides treatment for pervasive
developmental disorder or autism, provided the services are within
the experience and competence of the person, entity, or group that is
nationally certified.
(B) A person licensed as a physician and surgeon, physical
therapist, occupational therapist, psychologist, marriage and family
therapist, educational psychologist, clinical social worker,
professional clinical counselor, speech-language pathologist, or
audiologist pursuant to Division 2 (commencing with Section 500) of
the Business and Professions Code, who designs, supervises, or
provides treatment for pervasive developmental disorder or autism,
provided the services are within the experience and competence of the
licensee.
(4) "Qualified autism service professional" means an individual
who meets all of the following criteria:
(A) Provides behavioral health treatment, including clinical
management and case supervision.
(B) Is employed and supervised by a qualified autism service
provider.
(C) Provides treatment pursuant to a treatment plan developed and
approved by the qualified autism service provider.
(D) Is a behavioral service provider who meets the education and
experience qualifications defined in Section 54342 of Title 17 of the
California Code of Regulations for an Associate Behavior Analyst,
Behavior Analyst, Behavior Management Assistant, Behavior Management
Consultant, or Behavior Management Program.
(E) Has training and experience in providing services for
pervasive developmental disorder or autism pursuant to Division 4.5
(commencing with Section 4500) of the Welfare and Institutions Code
or Title 14 (commencing with Section 95000) of the Government Code.
(5) "Qualified autism service paraprofessional" means an
unlicensed and uncertified individual who meets all of the following
criteria:
(A) Is supervised by a qualified autism service provider.
(B) Provides treatment and implements services pursuant to a
treatment plan developed and approved by the qualified autism service
provider or qualified autism service professional.
(C) Meets the education and training qualifications defined in the
regulations adopted pursuant to Section 4686.3 of the Welfare and
Institutions Code.
(D) Has adequate education, training, and experience, as certified
by a qualified autism service provider.
(d) This section shall not apply to the following:
(1) A specialized health insurance policy that does not cover
mental health or behavioral health services or an accident only,
specified disease, hospital indemnity, or Medicare supplement policy.
(2) A health insurance policy in the Medi-Cal program (Chapter 7
(commencing with Section 14000) of Part 3 of Division 9 of the
Welfare and Institutions Code). The provision of behavioral
health treatment in the Medi-Cal program, including any associated
obligation of a health insurance policy in the Medi-Cal program, is
governed by Section 14132.56 of the Welfare and Institutions Code,
the approved Medi-Cal state plan and waivers, and applicable federal
Medicaid law.
(e) As provided in Section 10144.5 and in paragraph (1) of
subdivision (a), in the provision of benefits required by this
section, a health insurer may utilize case management, network
providers, utilization review techniques, prior authorization,
copayments, or other cost sharing.
(f) This section shall not be construed to require coverage for
services that are included in a patient's individualized education
program.
(g) This section shall remain in effect only until January 1,
2022, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2022, deletes or extends
that date.
SEC. 3. Section 10144.52 of the Insurance Code is amended to read:
10144.52. For (a)
For purposes of this part, the terms
"provider," "professional provider," "network provider," "mental
health provider," and "mental health professional" shall include the
term "qualified autism service provider," as defined in subdivision
(c) of Section 10144.51.
(b) This section shall remain in effect only until January 1,
2022, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2022, deletes or extends
that date.
SEC. 4. Section 14132.56 of the Welfare
and Institutions Code is amended to read:
14132.56. (a) (1) Only to the extent required by the federal
government and effective no sooner than required by the federal
government, behavioral health treatment (BHT), as defined by
Section 1374.73 of the Health and Safety Code, (BHT)
shall be a covered Medi-Cal service for individuals under 21
years of age.
(2) It is the intent of the Legislature that, to the extent the
federal government requires BHT to be a covered Medi-Cal service, the
department shall seek statutory authority to implement this new
benefit in Medi-Cal.
(3) For purposes of this section, "behavioral health treatment" or
"BHT" means professional services and treatment programs, including
applied behavior analysis and evidence-based behavior intervention
programs that develop or restore, to the maximum extent practicable,
the functioning of an individual with pervasive developmental
disorder or autism, and are administered as described in the approved
state plan.
(b) The department shall implement, or continue to implement, this
section only after all of the following occurs or has occurred:
(1) The department receives all necessary federal approvals to
obtain federal funds for the service.
(2) The department seeks an appropriation that would provide the
necessary state funding estimated to be required for the applicable
fiscal year.
(3) The department consults with stakeholders.
(c) The department shall develop and define eligibility criteria,
provider participation criteria, utilization controls, and delivery
system structure for services under this section, subject to
limitations allowable under federal law, in consultation with
stakeholders.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until regulations are adopted. The department
shall adopt regulations by July 1, 2017, in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code. Notwithstanding
Section 10231.5 of the Government Code, beginning six months after
the effective date of this section, the department shall provide
semiannual status reports to the Legislature, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted.
(e) For the purposes of implementing this section, the department
may enter into exclusive or nonexclusive contracts on a bid or
negotiated basis, including contracts for the purpose of obtaining
subject matter expertise or other technical assistance. Contracts may
be statewide or on a more limited geographic basis. Contracts
entered into or amended under this subdivision shall be exempt from
Part 2 (commencing with Section 10100) of Division 2 of the Public
Contract Code and Chapter 6 (commencing with Section 14825) of Part
5.5 of Division 3 of the Government Code, and shall be exempt from
the review or approval of any division of the Department of General
Services.
(f) The department may seek approval of any necessary state plan
amendments or waivers to implement this section. The department shall
make any state plan amendments or waiver requests public at least 30
days prior to submitting to the federal Centers for Medicare and
Medicaid Services, and the department shall work with stakeholders to
address the public comments in the state plan amendment or waiver
request.
(g) This section shall be implemented only to the extent that
federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 4. SEC. 5. No reimbursement is
required by this act pursuant to Section 6 of Article XIII B of the
California Constitution because the only costs that may be incurred
by a local agency or school district will be incurred because this
act creates a new crime or infraction, eliminates a crime or
infraction, or changes the penalty for a crime or infraction, within
the meaning of Section 17556 of the Government Code, or changes the
definition of a crime within the meaning of Section 6 of Article XIII
B of the California Constitution.