BILL ANALYSIS Ó
SENATE COMMITTEE ON APPROPRIATIONS
Senator Ricardo Lara, Chair
2015 - 2016 Regular Session
SB 1034 (Mitchell) - Health care coverage: autism
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|Version: April 26, 2016 |Policy Vote: HEALTH 6 - 0 |
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|Urgency: No |Mandate: Yes |
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|Hearing Date: May 9, 2016 |Consultant: Brendan McCarthy |
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This bill meets the criteria for referral to the Suspense File.
Bill
Summary: SB 1034 would delete the existing statutory sunset on
the mandate to provide health care coverage for behavioral
health treatment for autism and related disorders. The bill
would also revise the existing benefit mandate and apply the
benefit mandate to health care coverage provided by CalPERS.
Fiscal
Impact:
One-time costs of about $50,000 and ongoing costs of $15,000
per year to review health plan filings for compliance with the
requirements of the bill and to undertake any necessary
enforcement actions by the Department of Managed Health Care
(Managed Care Fund).
Likely costs of less than $100,000 per year for review of
health insurance plan filings and enforcement actions by the
Department of Insurance (Insurance Fund).
No state costs are anticipated due to the elimination of the
existing sunset on the benefit mandate or the extension of the
SB 1034 (Mitchell) Page 1 of
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existing benefit mandate to CalPERS coverage. While existing
law specifically mandates coverage for behavioral health
treatment, separate federal and state mental health parity
requirements and requirements for the provision of essential
health benefits implicitly require coverage for behavioral
health treatment for autism and related disorders. Therefore,
elimination of the statutory sunset and extension of the
mandate to CalPERS health coverage will not increase state
costs, because CalPERS plans would have to provide coverage
for these services even without a specific benefit mandate.
Nor will eliminating the sunset require the state to pay for
the costs to subsidize coverage for behavioral health
treatment coverage for subsidized Covered California plans.
Ongoing costs of about $300,000 per year due to a minor
increase in health care premiums to CalPERS due to the
expansion of the existing benefit mandate to require coverage
to "keep" the functioning of eligible individuals (General
Fund, special funds, and local funds). About half of the above
costs would accrue to the state and half to local governments.
See below.
Uncertain impact on CalPERS health care costs from other
changes to the existing benefit mandate in the bill (General
Fund, special funds, and local funds). According to the
California Health Benefits Review Program, there are several
changes to the existing benefit mandate that could increase
utilization of services, but that the Program was unable to
quantify. To the extent that those factors do increase
utilization, premium costs to CalPERS would increase. See
below.
No increased costs for the Medi-Cal program are anticipated
due to the bill. Current law exempts Medi-Cal managed care
plans from the existing benefit mandate. (However, federal
guidance requires coverage for behavioral health treatment for
Medi-Cal enrollees with autism or related disorders. The state
has just begun providing this benefit in Medi-Cal and is in
the process of transitioning Medi-Cal enrollee previously
served by regional centers to having coverage provided by
Medi-Cal.) This bill does not eliminate the existing Medi-Cal
exemption.
SB 1034 (Mitchell) Page 2 of
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Background: Current state law (SB 88, Thompson, Statutes of 1999) requires
health plans and health insurers who provide hospital, medical,
or surgical coverage to provide coverage for the diagnosis and
treatment of severe mental illness (as specified in statute). In
addition, health plans and health insurers are required to
provide additional coverage for serious emotional disturbances
of a child. In both cases, coverage is required to be provided
under the same terms and conditions applied to other medical
conditions. Under current federal law, health plans and health
insurers that offer coverage for mental health or substance
abuse disorders are required to provide that coverage under the
same terms and conditions as other covered benefits.
Collectively, these requirements are referred to as "mental
health parity" requirements.
In addition, current state law (SB 946, Steinberg, Statutes of
2011) specifically requires health plans and health insurers to
cover behavioral health therapy for pervasive development
disorder or autism. The statutory sunset in SB 946 was extended
to January 1, 2017 in SB 126 (Steinberg, 2013). Current law
defines behavioral health treatment to include programs that
"develop or restore, to the maximum extent practicable, the
functioning of an individual?".
Under the federal Patient Protection and Affordable Care Act,
health coverage provided in the small group or individual market
(including through health exchanges) must provide essential
health benefits. Under federal law, individuals purchasing
coverage through health benefit exchanges will be eligible for
subsidies, based on income, paid by the federal government.
However, if a state imposes a benefit mandate after January 1,
2012 that exceeds the benefits provided by the essential health
benefits benchmark plan, the state is responsible for providing
the subsidies for coverage of that mandated benefit.
Proposed Law:
SB 1034 would delete the existing statutory sunset on the
mandate to provide health care coverage for behavioral health
treatment for autism and related disorders. The bill would also
revise the existing benefit mandate and apply the benefit
mandate to health care coverage provided by CalPERS.
Specific provisions of the bill would:
Revise the definition of behavioral health treatment to
SB 1034 (Mitchell) Page 3 of
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include other evidence-based behavioral intervention programs
and also include programs designed to keep the functioning of
the individual;
Delete the requirement that autism service professionals and
paraprofessionals be employed by qualified autism service
providers (they would still require supervision by providers);
Require treatment plans to be reviewed no more than once every
six months, unless a shorter period is recommended by the
provider;
Prohibit a lack of parent or caregiver participation from
being used to deny coverage;
Permit services to be discontinued when no longer necessary;
Prohibit the setting, location, or time of treatment from
being used as a reason to deny coverage;
Revise the definitions and requirements for qualified autism
service professionals and paraprofessionals;
Delete the exemption in current law for CalPERS coverage from
the benefit mandate;
Delete the existing statutory sunset.
Related
Legislation: AB 796 (Nazarian) would require the Board of
Psychology to convene a committee to study evidenced-based
treatments for autism and related disorders. The bill would also
extend the existing benefit mandate sunset to January 1, 2022.
That bill is pending in the Senate Health Committee.
Staff
Comments: The California Health Benefits Review Program found
that there is insufficient evidence to determine whether
behavioral health treatment aimed at maintaining function
(amended to "keep" in the latest amendments) derived from
intensive behavioral health treatments is effective. However,
given that there is a large body of evidence that behavioral
health treatment improves functioning, the Program found that it
stands to reason that it could also be useful for maintaining
function.
The Program was able to make projections about the increased
utilization of services relating to maintaining function
(recently amended to "keep"). For the other changes to the
mandate in the bill (such as the prohibition of denials of
coverage based on parental participation or the elimination of
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restrictions on the time or setting of services), the Program
could not quantify the impacts of the changes. The Program
indicates that those changes are likely to increase utilization
For example, under current state and federal law, school
districts are required to provide certain services to students
to allow the students to fulfil their educational needs. The
boundary between services covered by health plans and health
insurers under the existing benefit mandate and those provided
by schools is not completely clear. There are indications that
health plans and health insurers have denied coverage for
mandated services simply because those services were to be
provided in a school setting (but by a contracted provider, not
the school or its providers). By prohibiting denial of coverage
based on time or setting, the bill may result in coverage for
some services shifting from school districts to health plans and
health insurers.
The only costs that may be incurred by a local agency relate to
crimes and infractions. Under the California Constitution, such
costs are not reimbursable by the state.
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