BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1034
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|AUTHOR: |Mitchell |
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|VERSION: |February 12, 2016 |
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|HEARING DATE: |April 20, 2016 | | |
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|CONSULTANT: |Teri Boughton |
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SUBJECT : Health care coverage: autism
SUMMARY : Eliminates the sunset date on the health insurance mandate to
cover behavioral health treatment for pervasive developmental
disorder or autism, and makes other revisions to the law such as
requiring all medically necessary behavioral health treatment to
be covered in all settings regardless of time or location of
delivery.
Existing law:
1)Establishes the Department of Managed Health Care (DMHC) to
regulate health plans under the Knox-Keene Health Care
Services Plan Act of 1975 in the Health and Safety Code; the
California Department of Insurance (CDI) to regulate health
insurers under the Insurance Code; and, the California Health
Benefit Exchange (Exchange) to compare and make available
through selective contracting health insurance for individual
and small business purchasers as authorized under the federal
Patient Protection and Affordable Care Act (ACA).
2)Establishes as California's essential health benefits (EHBs)
benchmark the Kaiser Small Group Health Maintenance
Organization plan, existing California mandates, and the
following 10 ACA mandated benefits:
a) Ambulatory patient services;
b) Emergency services;
c) Hospitalization;
d) Maternity and newborn care;
e) Mental health and substance use disorder
services, including behavioral health treatment;
f) Prescription drugs;
g) Rehabilitative and habilitative services
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and devices;
h) Laboratory services;
i) Preventive and wellness services and
chronic disease management; and,
j) Pediatric services, including oral and
vision care.
3)Requires every health plan contract that provides hospital,
medical, or surgical coverage and health insurance policy to
also provide coverage for behavioral health treatment for
pervasive developmental disorder or autism no later than July
1, 2012. Requires the coverage to be provided in the same
manner and to be subject to the same requirements as provided
in California's mental health parity law.
4)Requires DMHC, in consultation with CDI, to convene a task
force by February 1, 2012, to develop recommendations
regarding behavioral health treatment that are medically
necessary for the treatment of individuals with pervasive
developmental disorder or autism, as specified. Requires DMHC
to submit a report of the task force to the Governor,
President pro Tem of the Senate, the Speaker of the Assembly,
and the Senate and Assembly Committees on Health by December
31, 2012, on which date the task force ceases to exist.
5)Exempts from 3) above a specialized health plan or health
insurance policy that does not deliver mental health or
behavioral health services to enrollees, or an accident only,
specified disease, hospital indemnity, or Medicare supplement
policy, a health plan contract or health insurance policy
under Medi-Cal or Healthy Families program, and a health care
benefit plan or contract pursuant to the Public Employees'
Retirement System (PERS).
6)Sunsets the provisions described in 3) through 5) above on
January 1, 2017.
This bill:
1)Revises the definition of "behavioral health treatment" to
include other evidence-based behavior intervention programs
that maintain the functioning of an individual with pervasive
developmental disorder, as specified.
2)Deletes requirements in law that qualified autism service
professionals and paraprofessionals are employed by qualified
SB 1034 (Mitchell) Page 3 of ?
autism service providers.
3)Requires treatment plans to be reviewed no more (rather than
no less) than once every six months by the autism service
provider, unless a shorter period is recommended by the
qualified autism provider.
4)Specifies that parent or caregiver participation in the
treatment plan is recommended by the qualified autism service
provider, and prohibits lack of parent or caregiver
participation from being used to deny or reduce medically
necessary behavioral health treatment.
5)Permits intensive behavioral intervention services to be
discontinued when the treatment goals and objectives are
achieved or no longer appropriate, and continued therapy is
not necessary to maintain function or prevent deterioration.
6)Requires all medically necessary behavioral health treatment
to be covered in all settings regardless of time or location
of delivery.
7)Revises the definition of "qualified autism service
professional" to include someone who provides clinical
management and care supervision, deletes a requirement that he
or she is approved as a vendor by a California regional
center, and instead, requires him or her to meet the education
and experience qualifications defined in regulations, as
specified.
8)Revises the definition of "qualified autism service
paraprofessional" to indicate that the paraprofessional
provides treatment and implements services pursuant to a plan
developed and approved by a qualified autism service
professional.
9)Deletes exemptions from the law for plans that participate in
Healthy Families (which no longer exists) and the CalPERS.
10)Deletes the sunset date in existing law.
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FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1) Author's statement. According to the author, this bill would
ensure that children diagnosed with autism continue to have
access to medically necessary treatments to increase their
quality of life and functional independence by removing the
2017 sunset on the requirement for health plans and insurers
to provide behavioral health treatments to children with
autism.
CHBRP analysis. AB 1996 (Thomson, Chapter 795, Statutes of
2002), requests the University of California to assess
legislation proposing a mandated benefit or service and
prepare a written analysis with relevant data on the medical,
economic, and public health impacts of proposed health plan
and health insurance benefit mandate legislation. CHBRP was
created in response to AB 1996, and reviewed this bill. Key
findings include:
a) Coverage impacts and enrollees covered. In
2017, 18.3 million of 25.2 million Californians have
state-regulated health insurance that would be
subject to SB 1034. Approximately, 94% of enrollees
with health insurance subject to SB 1034 would gain
benefit coverage;
b) Essential health benefits. For two
reasons, SB 1034 would not trigger financial costs
to the state for exceeding EHBs. First, SB 1034
alters the terms and conditions of an existing
benefit mandate, but does not require an additional
benefit to be covered. Second, the current law that
SB 1034 would alter expressly indicates that it
ceases to function if it exceeds EHBs and SB 1034
does not eliminate this clause of the current law
(so neither the current law nor the version SB 1034
would create function if they are deemed to exceed
EHBs);
c) Medical effectiveness. CHBRP found
insufficient evidence to determine whether
behavioral health treatment aimed at maintaining
function derived from intensive behavioral health
treatments is effective. Studies have not separately
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examined its effects on improvement of functioning
from its effects on maintenance of improvements in
functioning. In light of the large body of evidence
from studies with moderately strong research designs
that behavioral health treatment improves
functioning across multiple domains, it stands to
reason that it could also be useful for maintaining
functioning. A preponderance of evidence from
studies with moderately strong research designs
suggests that parent/caregiver involvement in
behavioral health treatment improves outcomes.
However, evidence also suggests that behavioral
health treatments are more effective than usual care
regardless of the degree of parent/caregiver
involvement. There is a preponderance of evidence
from studies with moderately strong research designs
that behavioral health treatment can be delivered
effectively in multiple settings. There is
insufficient evidence to assess the impact of
prohibiting health plans from reviewing treatment
plans more frequently than every six months. There
is a preponderance of evidence from studies with
moderately strong research designs that behavioral
health treatment provided by persons who are trained
or supervised by experienced behavioral health
treatment providers improves outcomes;
d) Utilization. Utilization would increase to
47 annual hours per 1,000 enrollees (up by 3 hours).
Although unquantifiable, the other aspects of SB
1034 might also increase utilization of behavioral
health treatment, particularly in the long term;
e) Impact on expenditures. Total premiums and
cost sharing would increase by $8.3 million
(0.006%); and,
f) Public health. Although the evidence is
unclear, it seems reasonable to assume that there
would be some improvement of some health outcomes
for some enrollees with increased utilization.
2)Task Force. The Autism Advisory Task Force was established
pursuant to SB 946. The Chair of the task force was the DMHC
Director, who was a non-voting member, and another 17 members
were appointed by the DMHC. Members of the task force include
parents of children with autism and individuals with legal,
health plan, behavioral health, and medical expertise. The
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charge of the task force was to make recommendations to inform
state policymaking and guide future recommendations addressing
six subjects and develop recommendations regarding the
education, training, and experience requirements that
unlicensed individuals providing autism services shall meet in
order to secure a license from the state. The six subjects
are:
a) Interventions that have been
scientifically validated and have demonstrated
clinical efficacy;
b) Interventions that have measurable
treatment outcomes;
c) Patient selection, monitoring, and
duration of therapy;
d) Qualifications, training, and supervision
of providers;
e) Adequate networks of providers; and,
f) The education, training, and experience
requirements that unlicensed individuals providing
autism services shall meet in order to secure a
license from the state.
A guiding principle of the task force was that every
individual with per is unique and the task force concluded
that behavioral health treatment needs to be highly
individualized. With regard to pervasive development disorder
or autism, the task force considers the following diagnoses to
fall under the definition: pervasive developmental
disorder-not otherwise specified, Autistic Disorder, Asperger
Syndrome, Rett's Syndrome, and Childhood Disintegrative
Disorder. In all 55 recommendations were adopted, all but
one, on a consensus basis. The task force concludes that all
"top level" (undefined) providers should be licensed by the
state, and set forth a process for establishing a new
professional license for "Licensed Behavioral Health
Practitioner." The task force recommended that the license
requirement not take effect until three years after the
license is established, and an interim commission be formed to
implement the new license until a board is able to do so. The
task force also recommended all providers of autism services
be registered with the state's TrustLine Registry or
comparable system as a condition of employment by service
organizations and contracting with health plans and health
insurers. TrustLine uses the criminal history background check
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system to check the fingerprints of applicants, and checks for
evidence of additional criminal records.
3)Related legislation. AB 796 (Nazarian) would require the Board
of Psychology (BOP) to convene a committee to create a list of
evidence-based treatment modalities for purposes of developing
mandated behavioral health treatment modalities for pervasive
development disorder or autism. Extends the sunset provisions
requiring health care service plans to provide health coverage
for behavioral health treatment for pervasive development
disorder or autism to January 1, 2022. AB 796 is pending in
the Senate Health Committee.
4)SB 479 (Bates) would establish the Behavior Analyst Act which
requires a person to apply for and obtain a license from the
Board of Psychology prior to engaging in the practice of
behavior analysis, as defined, either as a behavior analyst or
an assistant behavior analyst, and meet certain educational
and training requirements. SB 479 is pending in the Senate
Rules Committee.
5)Prior legislation. AB 2041 (Jones of 2014), would have
required that a regional center classify a vendor as a
behavior management consultant or behavior management
assistant if the vendor designs or implements evidence-based
behavioral health treatment, has a specified amount of
experience in designing or implementing that treatment, and
meets other licensure and education requirements. AB 2041
would have required the Department of Developmental Services
to amend its regulations as necessary to implement the
provisions of the bill. AB 2041 died in the Senate
Appropriations Committee.
SB 126 (Steinberg, Chapter 680, Statutes of 2013), extends,
until January 1, 2017, the sunset date of an existing state
health benefit mandate that requires health plans and health
insurance policies to cover behavioral health treatment for
pervasive developmental disorder or autism and requires plans
and insurers to maintain adequate networks of these service
providers.
SB 946 (Steinberg, Chapter 650, Statutes of 2011), requires
health plans and health insurance policies to cover behavioral
health treatment for pervasive developmental disorder or
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autism, requires health plans and insurers to maintain
adequate networks of autism service providers, establishes a
task force in DMHC, sunsets the autism mandate provisions on
July 1, 2014, and makes other technical changes to existing
law regarding HIV reporting and mental health services
payments.
AB 1453 (Monning, Chapter 854, Statutes of 2012), and SB 951
(Ed Hernandez, Chapter 866, Statutes of 2012), established
California's essential health benefits.
SB 770 (Steinberg of 2010) would have required health plans
and insurance policies to provide coverage for BHT. SB 770 was
held in the Assembly Appropriations Committee.
SB 166 (Steinberg of 2011) would have required health care
service plans licensed by DMHC and health insurers licensed by
CDI to provide coverage for behavioral health treatment for
autism. SB 166 was held in the Senate Health Committee.
AB 1205 (Bill Berryhill of 2011) would have required the Board
of Behavioral Sciences to license behavioral analysts and
assistant behavioral analysts, on and after January 1, 2015,
and included standards for licensure such as specified higher
education and training, fieldwork, passage of relevant
examinations, and national board accreditation. AB 1205 was
held in the Assembly Appropriations Committee on the suspense
file.
6)Support. According to Autism Speaks, at the time SB 946
passed there were a number of outstanding questions with
regards to mandated benefits, the Affordable Care Act, and the
State's fiscal responsibility. The sunset provides an
opportunity to revisit the issue. The federal government has
since provided guidance on essential health benchmark
selection and implementation of the ACA, and behavioral health
treatments for children with autism are covered as an
essential health benefit. DMHC has determined that behavioral
health treatments for autism are covered under California and
federal mental health parity, which extends to CalPERS. Since
the passage of SB 946, countless children have received
treatment through their plans. Proponents indicate that
frequent reviews delay treatment and can harm the progress of
the child. Some health plans will not approve treatment that
is provided at a school, church or other community setting
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which can be critical for the development of the child. This
issue has gone to the Independent Medical Review on multiple
occasions where it has been determined medically necessary
services; additionally parent participation requirements have
become a hurdle to accessing treatment. The Center for Autism
and Related Disorders writes that this bill makes changes to
the existing statute that will ensure timely access and limit
delays to treatment.
7)Concern. The Association of Regional Center Agencies (ARCA)
expresses concern that allowing more flexibility in the
supervision of in-home staff without specifying how many staff
members can be supervised under one professional certification
could unintentionally diminish the quality of clinical
supervision. Additionally, ARCA writes that the goal of
behavioral services is to help individuals to become more
functional in natural settings. Expanding the settings and
limiting parent participation requirements would allow
individuals to develop skills that are not transferable to the
home or community environments and limit the effectiveness of
treatment.
8)Opposition. The California Chamber of Commerce (Chamber)
writes that this bill while well intentioned, undermines the
ability of health care issuers to promote and manage the use
of applied behavioral analysis for children with autism, and
will add to the problem of rising health care costs, making it
harder for Californians to access other important care. The
Chamber is not aware of any peer reviewed studies that suggest
a professional treatment team must remain permanently involved
in a child's life to ensure these skills are maintained. This
could lead to a shortage of available therapists and create
access issues for newly diagnosed children. The Chamber
believes issuers should have the ability to begin tapering
treatment, and to monitor the impact of that reduction of
services more frequently than every six months. It is
appropriate for issuers to make coverage contingent upon
caregiver participation since research on the effectiveness of
applied behavioral analysis shows unequivocally that it is
critical to the success of the treatment. Of greatest concern,
is if issuers are forced to cover all behavioral health
treatments in all settings, schools could deny educational
services or make these services harder to obtain, and thereby
shift these costs to public and private purchasers.
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9)Amendments.
a) Page 6, line 9, and page 10, line 21, "MDI-Cal" should
be changed to "Medi-Cal"
b) Page 3, line 20, and page 7, line 30, "maintain" should
be changed to "keep"
SUPPORT AND OPPOSITION :
Support: Autism Speaks (cosponsor)
Center for Autism and Related Disorders (cosponsor)
Special Needs Network (cosponsor)
Autism Deserves Equal Coverage Foundation (cosponsor)
California School Employees Association, AFL-CIO
National Association of Social Workers - California
Chapter
Oppose: California Association of Health Plans
California Chamber of Commerce
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