BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 1034|
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THIRD READING
Bill No: SB 1034
Author: Mitchell (D)
Amended: 5/31/16
Vote: 21
SENATE HEALTH COMMITTEE: 6-0, 4/20/16
AYES: Hernandez, Hall, Mitchell, Monning, Pan, Roth
NO VOTE RECORDED: Nguyen, Nielsen, Wolk
SENATE APPROPRIATIONS COMMITTEE: 5-2, 5/27/16
AYES: Lara, Beall, Hill, McGuire, Mendoza
NOES: Bates, Nielsen
SUBJECT: Health care coverage: autism
SOURCE: Autism Deserves Equal Coverage Foundation
Autism Speaks
Center for Autism and Related Disorders
Special Needs Network
DIGEST: This bill 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 prohibiting denials for medically
necessary behavioral health treatment based on the setting,
location or time of the treatment.
ANALYSIS:
Existing law:
1)Establishes the Department of Managed Health Care (DMHC) to
regulate health plans under the Knox-Keene Health Care
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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 10
ACA mandated benefits.
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. 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)Sunsets the provisions described in 3) on January 1, 2017.
This bill:
1)Revises the definition of "behavioral health treatment" to
include other evidence-based behavior intervention programs
that keep 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
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
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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 when treatment is no longer appropriate and
continued therapy is not necessary to keep function or prevent
deterioration.
6)Prohibits the setting, location or time of the treatment from
being used as a reason to deny medically necessary behavioral
health treatment. Prohibits this provision from being
construed to require coverage for services that are included
in a patient's individualized education program.
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.
Comments
1) Author's statement. According to the author, this bill
ensures 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
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to provide behavioral health treatments to children with
autism.
2)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 is be subject to SB 1034.
Approximately, 94% of enrollees with health insurance
subject to SB 1034 gain benefit coverage;
b) Essential health benefits. For two reasons, SB 1034 does
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 alters 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 creates 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
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
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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
increases 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.
1)Concern. The Association of Regional Center Agencies (ARCA)
indicates that this bill does not specify how many staff
members can be supervised under one professional
certification, which could unintentionally diminish the
quality of clinical supervision. ARCA also raises concerns
that by expanding the treatment settings and limiting parent
participation, skills developed through treatment would not be
transferable to the home or community environment and would
limit effectiveness of treatment.
Fiscal
Impact: Appropriation: No Fiscal Com.: Yes
Local:Yes
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According to the Senate Appropriations Committee:
1)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 DMHC (Managed Care Fund).
2)Likely costs of less than $100,000 per year for review of
health insurance plan filings and enforcement actions by CDI
(Insurance Fund).
3)No state costs are anticipated due to the elimination of the
existing sunset on the benefit mandate or the extension of the
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 EHBs
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.
4)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.
5)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 CHBRP,
there are several changes to the existing benefit mandate that
could increase utilization of services, but that CHBRP was
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unable to quantify. To the extent that those factors do
increase utilization, premium costs to CalPERS would increase.
6)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.
SUPPORT: (Verified5/27/16)
Autism Deserves Equal Coverage Foundation (co-source)
Autism Speaks (co-source)
Center for Autism and Related Disorders (co-source)
Special Needs Network (co-source)
A Change in Trajectory, ACT
Autism Behavior Services Inc.
Autism Business Association
Autism Learning Partners
Autism Spectrum Interventions
Bloom Behavioral Health
California Psychcare
California School Employees Association, AFL-CIO
Disability Rights California
Hope Autism Therapies
Inizio Interventions Inc.
National Association of Social Workers- California Chapter
Star of California Behavioral and Psychological Services
OPPOSITION: (Verified5/27/16)
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California Association of Health Plans
California Chamber of Commerce
ARGUMENTS IN SUPPORT: At the passage of SB 946 (Steinberg,
Chapter 650, Statutes of 2011), which established the coverage
mandate for behavioral health treatment for pervasive
developmental disorder and autism, according to Autism Speaks,
there were a number of outstanding questions with regards to
mandated benefits, the ACA, and the State's fiscal
responsibility. The sunset provides an opportunity to revisit
the issue. The federal government has since provided guidance on
EHB selection and implementation of the ACA, and behavioral
health treatments for children with autism are covered as an
EHB. 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 health
plans and insurers. Proponents indicate that frequent reviews
delay treatment and can harm the progress of the child. Some
health plans and insurers will not approve treatment that is
provided at a school, church or other community settings 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 to be 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.
ARGUMENTS IN 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
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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. The
California Association of Health Plans believes the next step in
continuing these services is to license the providers of autism
care rather than expand the nature of the existing requirement.
Prepared by:Teri Boughton / HEALTH / (916) 651-4111
5/31/16 20:45:29
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