BILL NUMBER: SB 1034 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY AUGUST 1, 2016
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, 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. which may include clinical management
and case supervision under the direction and supervision
of a qualified autism service provider. The bill would require
that a treatment plan be reviewed that,
unless a treatment plan is modified by a qualified autism service
provider, utilization review be conducted no more than once
every 6 months, unless a shorter period is recommended by
the qualified autism service provider. months. The
bill would also provide that coverage for behavioral health treatment
for pervasive developmental disorder or autism would be dependent on
medical necessity, subject to utilization review, and required to be
in compliance with federal mental health parity requirements.
The bill would extend the operation of these provisions 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,
(1), 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.
(5) This section shall not be construed to require a health care
service plan to provide reimbursement for services delivered by
school personnel pursuant to an enrollee's individualized educational
program unless otherwise required by law.
(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 herein 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 less
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
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.
objectives.
(iii) Provides intervention plans that utilize
Utilizes 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.
(v) Makes the treatment plan available to the health care service
plan upon request.
(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. treatment,
which may include clinical management and case supervision under the
direction and supervision of a qualified autism service provider.
(B) Is supervised by a person, entity, or group that is 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.
person, entity, or group that is a qualified autism
service provider or qualified autism service professional.
(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. Section 54342 of
Article 3 of Subchapter 2 of Chapter 3 of Division 2 of Title 17 of
the California Code of Regulations.
(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 applicable 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.
(1) Unless a treatment plan is modified by a qualified autism
service provider, utilization review shall be conducted no more often
than every six months and shall be conducted in accordance with good
professional practice and consistent with the requirements of
Section 1363.5.
(2) The setting, location, or time of treatment recommended by the
qualified autism service provider shall not be used as a reason to
deny or reduce coverage for medically necessary services.
(3) Lack of parent or caregiver participation shall not be used as
the sole basis for denying or reducing coverage of medically
necessary services.
(4) Notwithstanding paragraphs (2) and (3), all services shall
remain covered only to the extent that the services are medically
necessary and subject to utilization review as described in this
subdivision.
(5) Provision of services under this section, including any limits
on the scope or duration of these services, shall be in compliance
with the Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008 (Public Law 110-343), and all rules,
regulations, or guidance issued pursuant to Section 2726 of the
federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).
(g) This section shall not be construed to require coverage for
services that are included in a patient's an
enrollee'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,
(1), 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.
(5) This section shall not be construed to require a health
insurer to provide reimbursement for services delivered by school
personnel pursuant to an insured's individualized educational program
unless otherwise required by law.
(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 herein
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 less
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
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.
objectives.
(iii) Provides intervention plans that utilize
Utilizes 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.
(v) Makes the treatment plan available to the health insurer upon
request.
(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. treatment,
which may include clinical management and case supervision under the
direction and supervision of a qualified autism service provider.
(B) Is employed and supervised by a person, entity, or group
that is 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.
person, entity, or group that is a qualified autism
service provider or qualified autism service professional.
(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. Section
54342 of Article 3 of Subchapter 2 of Chapter 3 of Division 2
of Title 17 of the California Code of Regulations.
(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.
(1) Unless a treatment plan is modified by a qualified autism
service provider, utilization review shall be conducted no more often
than every six months and shall be conducted in accordance with good
professional practice and consistent with the requirements of
subdivision (f) of Section 10123.135.
(2) The setting, location, or time of treatment recommended by the
qualified autism service provider shall not be used as a reason to
deny or reduce coverage for medically necessary services.
(3) Lack of parent or caregiver participation shall not be used as
the sole basis for denying or reducing coverage of medically
necessary services.
(4) Notwithstanding paragraphs (2) and (3), all services shall
remain covered only to the extent that the services are medically
necessary and subject to utilization review as described in this
subdivision.
(5) Provision of services under this section, including any limits
on the scope or duration of these services, shall be in compliance
with the federal Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008 (Public Law 110-343), and all
rules, regulations, or guidance issued pursuant to Section 2726 of
the federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).
(f) This section shall not be construed to require coverage for
services that are included in a patient's an
insured'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. (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) 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. 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) (1) The department, commencing on the effective date of the
act that added this subdivision until March 31, 2017, inclusive, may
make available to individuals described in paragraph (2) contracted
services to assist those individuals with health insurance
enrollment, without regard to whether federal funds are available for
the contracted services.
(2) The contracted services described in paragraph (1) may be
provided only to an individual under 21 years of age whom the
department identifies as no longer eligible for Medi-Cal solely due
to the transition of BHT coverage from the waiver program under
Section 1915(c) of the federal Social Security Act to the Medi-Cal
state plan in accordance with this section and who meets all of the
following criteria:
(A) He or she was enrolled in the home and community-based
services waiver for persons with developmental disabilities under
Section 1915(c) of the Social Security Act as of January 31, 2016.
(B) He or she was deemed to be institutionalized in order to
establish eligibility under the terms of the waiver.
(C) He or she has not been found eligible under any other
federally funded Medi-Cal criteria without a share of cost.
(D) He or she had received a BHT service from a regional center
for persons with developmental disabilities as provided in Chapter 5
(commencing with Section 4620) of Division 4.5.
(e) 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.
(f) 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, Section 19130 of the Government 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.
(g) 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.
(h) This section shall be implemented only to the extent that
federal financial participation is available and any necessary
federal approvals have been obtained.
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.