BILL ANALYSIS Ó
SB 1034
Page 1
Date of Hearing: June 28, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
SB
1034 (Mitchell) - As Amended May 31, 2016
SENATE VOTE: 25-12
SUBJECT: Health care coverage: autism.
SUMMARY: Eliminates the sunset date on the health insurance
mandate to cover behavioral health treatment (BHT) for pervasive
developmental disorder (PDD) or autism, and prohibits health
care service plans (health plan) or health insurers from
excluding medically necessary BHT on the basis of setting,
location, time of treatment, or lack of parent or caregiver
participation. Specifically, this bill:
1)Revises the BHT definition to include other evidence-based
behavior intervention programs that maintain the functioning
of an individual with PDD, as specified.
2)Deletes requirements that qualified autism service (QAS)
professionals and paraprofessionals be employed by QAS
providers.
3)Requires treatment plans to be reviewed no more than once
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every six months by a QAS provider, unless a shorter period is
recommended by the QAS provider. Revises previous
requirements that the treatment plan be reviewed no less than
once every six months.
4)Specifies that an intervention plan include parent or
caregiver participation as recommended by a QAS provider and
prohibits lack of parent or caregiver participation from being
used to deny or reduce medically necessary BHT.
5)Allows intensive behavioral intervention services to be
discontinued when continued therapy is not necessary to
maintain function or prevent deterioration.
6)Revises the prohibition that the treatment plan not be used
for the purposes of providing or for the reimbursement of
academic services. Prohibits health plans or health insurers
from excluding medically necessary BHT on the basis of
setting, location, or time of treatment.
7)Revises the definition of a QAS professional to include an
individual providing BHT, including clinical management and
case supervision; deletes the requirement that the individual
be employed by a QAS provider; and, deletes the requirement
that the individual be a behavioral service provider approved
as a vendor by a California regional center and instead
requires the behavioral service provider meet the education
and experience qualified in existing regulations, as defined.
8)Revises the definition of QAS paraprofessional to delete the
requirement that the individual be employed by a QAS provider
and to include language indicating that the treatment plan be
developed and approved by a QAS professional.
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9)Deletes exemptions from the law for health plans that
participate in the Healthy Families Program (which no longer
exists) and California Public Employees' Retirement System
(CalPERS).
10)Deletes the sunset in existing law.
11)Prohibits construing this bill from requiring coverage for
services that are included in a patient's individualized
education program (IEP).
12)Makes other conforming and technical changes.
EXISTING LAW:
1)Establishes the Department of Managed Health Care (DMHC) to
regulate health plans; the California Department of Insurance
(CDI) to regulate health insurers; and, the California Health
Benefit Exchange (the Exchange or Covered California) 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)Requires health plans and insurers providing health coverage
in the individual and small group markets to cover, at a
minimum, essential health benefits (EHBs), including the 10
EHB benefit categories in the ACA, and consistent with
California's EHB benchmark plan, the Kaiser Foundation Health
Plan Small Group HMO 30 plan (Kaiser benchmark), as specified
in state law.
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3)Requires issuers of individual and small group coverage to, at
a minimum, cover EHBs in the following 10 categories:
ambulatory patient services, emergency services,
hospitalization, maternity and newborn care, mental health and
substance use disorder services, including BHT, prescription
drugs, rehabilitative and habilitative services and devices,
laboratory services, preventive and wellness services and
chronic disease management, and pediatric services, including
oral and vision care.
4)Requires every health plan contract that provides hospital,
medical, or surgical coverage and health insurance policy to
also provide coverage for BHT for PDD 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.
5)Defines BHT to mean specified services provided by, among
others, a QAS professional supervised and employed by a
qualified autism service provider. Defines a QAS 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.
6)Requires DMHC, in consultation with CDI, to convene a task
force by February 1, 2012, to develop recommendations
regarding BHT that are medically necessary for the treatment
of individuals with PDD 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.
7)Exempts from 4) above a specialized health plan or health
insurance policy that does not deliver mental health or
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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 with CalPERS.
8)Sunsets the provisions described in 4) through 7) above on
January 1, 2017.
9)Establishes the independent medical review (IMR) process as
part of the DMHC or CDI appeal process. Makes IMR available
to the enrollee or insured after participation in a health
plan or health insurer's grievance process.
FISCAL EFFECT: 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 this bill and to undertake any necessary
enforcement actions by the 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 the
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 BHT, separate federal
and state mental health parity requirements and requirements
for the provision of EHBs implicitly require coverage for BHT
for autism and related disorders. Therefore, elimination of
the statutory sunset and extension of the mandate to CalPERS
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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 BHT 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. See below.
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 the
California Health Benefits Review Program (CHBRP), there are
several changes to the existing benefit mandate that could
increase utilization of services, but that CHBRP was 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 this bill. Current law exempts Medi-Cal managed care
plans from the existing benefit mandate. (However, federal
guidance requires coverage for BHT 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.
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COMMENTS:
1)PURPOSE OF THIS BILL. 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 health
insurers to provide BHT to children with autism.
According to one of this bill's cosponsors, Autism Speaks,
since the passage of SB 946 (Steinberg), Chapter 650, Statutes
of 2011, countless children have received treatment through
their health plans. Prior to the passage of SB 946, families
(with health insurance) often paid upwards of $50,000 per
year. In the process, many risked their homes and the
educations of their unaffected children - essentially
mortgaging their entire futures. Alternately, services were
provided by regional and developmental centers at a high cost
to the state. Removing the sunset will allow children with
autism to continue to receive medically necessary BHT from QAS
providers.
According to the Centers for Disease Control and Prevention,
autism spectrum disorder (ASD) is a developmental disability
that can cause significant social, communication, and
behavioral challenges. A diagnosis of ASD now includes
several conditions that used to be diagnosed separately:
autistic disorder, PDD not otherwise specified, and Asperger
syndrome. These conditions are now all called ASD. About one
in 68 or 1.5% of children were identified with ASD based on
tracking in 11 communities across the United States in 2012.
2)BACKGROUND.
a) CHBRP analysis. AB 1996 (Thomson), Chapter 795,
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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. SB
125 (Hernandez), Chapter 9, Statutes of 2015, added an
impact assessment on EHBs, and legislation that impacts
health insurance benefit designs, cost sharing, premiums,
and other health insurance topics. CHBRP states in its
analysis of this bill, as introduced on February 12, 2016,
the following:
i) Enrollees covered. In 2017, 18.3 million of 25.2
million Californians would have state-regulated health
insurance that would be subject to this bill. Of the
varied requirements, this bill would place on
DMHC-regulated plans and CDI-regulated insurers, CHBRP
can only quantify the impacts of coverage for BHT for
ASD for maintenance. Currently 6% of enrollees with
health insurance that would be subject to this bill have
such coverage; postmandate 100% would. This bill's
other coverage requirements might have an impact on
enrollees' health insurance, but CHBRP is unable to
quantify such effects.
ii) Impact on expenditures. Total premiums and cost
sharing would increase by $8.3 million (0.006%). Post
mandate, as a result of the coverage change for BHT for
ASD for maintenance, assuming that maintenance BHT would
occur for persons with ASD who use a moderate amount of
BHT (defined as $10,000-$30,000 per year), CHBRP would
expect an initial year increase in utilization from
approximately 44 to 47 annual hours per 1,000 enrollees
with health insurance subject to this bill.
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iii) EHBs. For two reasons, this bill would not
trigger financial costs to the state for exceeding EHBs.
First, this bill 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 this bill would alter expressly indicates that
it ceases to function if it exceeds EHBs and this bill
does not eliminate this clause of the current law (so
neither the current law nor the version this bill would
create function if they are deemed to exceed EHBs).
iv) Medical effectiveness. CHBRP found insufficient
evidence to determine whether BHT aimed at maintaining
function derived from intensive BHT 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 BHT 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 BHT improves outcomes. However, evidence
also suggests that BHT is 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 BHT
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 BHT provided by persons who
are trained or supervised by experienced BHT providers
improves outcomes.
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v) Benefit coverage. Of the varied requirements this
bill would place on DMHC-regulated plans and
CDI-regulated insurers, CHBRP can only quantify the
impacts of coverage for BHT for ASD for maintenance.
Currently 6% of enrollees with health insurance that
would be subject to this bill have such coverage;
postmandate 100% would. This bill's other coverage
requirements might have an impact on enrollees' health
insurance, but CHBRP is unable to quantify such effects.
vi) Utilization. Post mandate, as a result of the
coverage change for BHT for ASD for maintenance,
assuming that maintenance BHT would occur for persons
with ASD who use a moderate amount of BHT (defined as
$10,000-$30,000 per year), CHBRP would expect an initial
year increase in utilization from approximately 44 to 47
annual hours per 1,000 enrollees with health insurance
subject to this bill.
vii) Public Health. CHBRP found wide variance in
individual outcomes from BHT for ASD and insufficient
literature from longitudinal studies to indicate that
ongoing maintenance therapy is effective or necessary to
preserve gains conferred by early intensive BHT.
Therefore, CHBRP concludes that the overall public
health impact of this bill is unknown. However, to the
extent that maintenance therapy is comprised of less
intensive applications of medically-effective BHT, such
as applied behavioral analysis, it would be reasonable
to assume that, for some children and adolescents with a
history of BHT for ASD, maintenance therapy would
reinforce and possibly enhance gains in intelligence
quotient, adaptive social behaviors, and language
skills.
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viii) Long-term impacts. Although CHBRP can make only
directional statements, a number of aspects of this bill
could lead to greater increases in utilization of BHT in
the first year and in years following. This bill's
prohibition against denials based on parent/caregiver
involvement may increase some enrollees' use of BHT as a
covered benefit. In addition, the elimination of
restrictions on settings may increase use, particularly
as public schools could now be covered settings. It is
also possible that utilization of maintenance BHT among
the older population with ASD may increase. Although
older people may not currently use BHT for skill
acquisition purposes, providers may develop an
applicable treatment plan for maintenance of gains made
through prior courses of BHT among their older patients.
Although not quantifiable at this time, expenditure
increases would correspond to utilization increases.
Although not quantifiable at this time, increases in
utilization could also be expected to result in some
increase in some desirable health outcomes among some
persons with ASD.
b) SB 946. SB 946 was signed into law on October 9, 2011.
SB 946 imposes a temporary set of rules regarding BHT that
health plans and health insurers in California must cover
for individuals with autism and PDD. SB 946 also
identifies the required qualifications of individuals who
provide BHT, and permits individuals who are not licensed
by the state to provide BHT, as long as the detailed
criteria set forth in the bill are met. SB 946 also
required the DMHC to convene an Autism Advisory Task Force
(Task Force) by February 1, 2012, to develop
recommendations regarding medically necessary BHT for
individuals with autism or PDD, as well as the appropriate
qualifications, training and supervision for providers of
such treatment. SB 946 also required the Task Force to
develop recommendations regarding the education, training,
and experience requirements that unlicensed individuals
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providing BHT must meet in order to obtain licensure from
the state.
c) Task Force. The Chair of the Task Force was the DMHC
Director, who was a non-voting member, and 17 other 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 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:
i) Interventions that have been scientifically
validated and have demonstrated clinical efficacy;
ii) Interventions that have measurable treatment
outcomes;
iii) Patient selection, monitoring, and duration of
therapy;
iv) Qualifications, training, and supervision of
providers;
v) Adequate networks of providers; and,
vi) The education, training, and experience requirements
that unlicensed individuals providing autism services
shall meet in order to secure a license from the state.
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A guiding principle of the Task Force was that every individual
with autism or PDD is unique. Individuals have different
combinations of characteristics, different needs for assistance,
and respond differently to treatment. Therefore, behavioral
health interventions need to be highly individualized. Since
treatment selection should be made by a team of individuals who
can consider the unique needs and history of the individual with
autism or PDD, the Task Force determined that it would not be
informative to state policymakers to merely develop a list of
BHTs that are determined to be effective, based solely on
current scientific literature. Since scientific research and
findings naturally advance, the Task Force determined that the
choice of BHTs should be grounded in scientific evidence,
clinical practice guidelines, and/or evidence based practice.
With regard to PDD or autism, the Task Force considers the
following diagnoses to fall under the definition: PDD-not
otherwise specified, Autistic Disorder, Asperger Syndrome,
Rett's Syndrome, and Childhood Disintegrative Disorder.
The Task Force reached consensus on 54 of 55 recommendations and
approved one recommendation by a vote of the majority. The Task
Force concluded 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 system to check the
fingerprints of applicants, and checks for evidence of
additional criminal records.
d) IEPs. Pursuant to the federal Individuals with
Disabilities Education Act, children with disabilities are
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guaranteed the right to a free, appropriate public
education, including necessary services for a child to
benefit from his or her education. Between 1976 and 1984,
to meet this federal mandate, California schools provided
mental health services to special education students who
needed the services pursuant to an IEP. An IEP is a
legally binding document that determines what special
education services a child will receive and why. IEPs
include a child's classification, placement, specialized
services, academic and behavioral goals, a behavior plan if
needed, percentage of time in regular education, and
progress reports from teachers and therapists. A child may
require any related services in order to benefit from
special education, including, but not limited to:
speech-language pathology and audiology services; early
identification and assessment of disabilities in children;
medical services; physical and occupational therapy;
orientation and mobility services; and, psychological
services. According to the California Department of
Education, over 700,000 (approximately 11%) California
students received special education services in the 2013-14
academic year.
3)SUPPORT. Autism Speaks, cosponsors of this bill, states that
SB 946 included a sunset to provide an opportunity for the
Legislature to revisit issues related to mandated benefits,
the ACA and the state's fiscal responsibility and now that
some of these issues have been resolved, this bill will allow
children with autism to continue to receive medically
necessary BHT from QAS professionals. The Center for Autism
and Related Disorders, cosponsors of this bill, states that
this bill makes changes to existing statute that will ensure
timely access and limit delays to treatment. Autism Deserves
Equal Coverage Foundation states that this bill cleans up the
language to address outstanding confusion and
misinterpretation of the statute by health plans and health
insurers. The California School Employees Association,
AFL-CIO, states this bill is a compassionate bill that
recognizes the challenges autistic children face and the need
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for services that help them and those who care for them.
Special Needs Network (SNN), cosponsors of this bill, states
that this bill clarifies that services cannot be denied solely
because they occur on the school-site or because they occur
between the hours of nine and three when an individual
"should" be in school. Medical necessity needs to determine
location and time of day of treatment, not arbitrary limits.
This bill also clarifies that services cannot be denied solely
due to lack of the ability for parents to participate in the
care. SNN contends that some health plans have set 100%
participation requirements, which are not appropriate and
violate federal mental health parity law. Additionally, SNN
states that such requirements have a disproportionate impact
limiting access to care for low income families and families
of color, who may not be able to take off work to be present
for 100% of their child's treatment. According to SNN, this
bill clarifies the QAS professional (middle tier) is allowed
to supervise and provide case management for health plans,
under the supervision of a licensed or certified QAS provider,
in the same way they are allowed to do so for regional
centers, which was always the intent. Without the
clarification, health plans are interpreting the law
differently. This clarification could significantly alleviate
with capacity issues for plans not using the QAS professional
in this capacity.
4)OPPOSITION. The California Chamber of Commerce contends that
this bill will limit 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. America's Health Insurance Plans
contends that this bill will drive up costs for consumers and
stifle the use of innovative, evidence-based medicine. The
Association of California Life and Health Insurance Companies
(ACLHIC) contends that this bill radically alters the standard
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of care by requiring coverage "at any location or time" as
current law requires health insurers to cover care provided in
traditional and widely accepted locations. ACLHIC contends
that this bill's expansion could lead to inadequate care being
provided in an unsuitable location with little benefit to the
patient. ACLHIC also contends that federal law requires
schools to facilitate participation in the educational
environments and should health insurers be required to cover
the cost of treatment in schools, federal funding could be
curtailed or eliminated and cause an increase in premiums and
decrease in educational assistance by school districts.
Finally, ACLHIC states that this bill's provision regarding
parental participation runs afoul of accepted best practices
and is completely unsupported by medical literature or peer
review. The California Association of Health Plans contends
that coverage for maintenance services is not supported by
medical literature and limitations on parent participation go
against clinical best practices.
5)RELATED LEGISLATION.
a) AB 796 (Nazarian) requires the Department of
Developmental Services, no later than July 1, 2018, with
input from stakeholders, as specified, to develop a
methodology for determining what constitutes an
evidence-based practice in the field of BHT for autism and
pervasive developmental disorder and to update regulations
to set forth the minimum standards of education, training,
and professional experience for QAS professionals and
paraprofessionals, as specified. AB 796 is pending in the
Senate Human Services Committee.
b) 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
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certain educational and training requirements. SB 479 is
pending in the Assembly Appropriations Committee.
6)PREVIOUS LEGISLATION.
a) 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 BHT, 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.
b) 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 BHT for PDD or
autism and requires plans and insurers to maintain adequate
networks of these service providers.
c) SB 946 requires health plans and health insurance
policies to cover BHT for PDD or 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.
d) AB 1453 (Monning), Chapter 854, Statutes of 2012, and SB
951 (Ed Hernandez), Chapter 866, Statutes of 2012,
establish California's EHBs.
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e) 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.
f) 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 BHT for autism. SB
166 was held in the Senate Health Committee.
g) 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.
7)AMENDMENTS. To address concerns raised by the Committee, the
author has agreed to amend this bill as follows:
a) To continue evaluating the BHT mandate, extend the
sunset to January 1, 2022; and,
b) Clarify language with respect to the provision of BHT
services in the Medi-Cal program.
REGISTERED SUPPORT / OPPOSITION:
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Support
Autism Deserves Equal Coverage Foundation (cosponsor)
Autism Speaks (cosponsor)
Center for Autism and Related Disorders (cosponsor)
Special Needs Network (cosponsor)
David Pine, Supervisor, First District, San Mateo County
Alliance of California Autism Organizations
Autism Behavior Services, Inc.
Autism Business Association
Autism Learning Partners
Autism Society California
Autism Society Inland Empire 5013
Autism Society Santa Barbara 5013
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Autism Spectrum Intervention Parent Network
California Association for Parent-Child Advocacy
California Coverage and Health Initiatives
California Psychological Association
California School Employees Association, AFL-CIO
Center for Autism and Related Disorders
Children Now
Children's Defense Fund
Children's Partnership
Disability Rights California
Families for Early Autism Treatment Sacramento
Families for Effective Autism Treatment Fresno Madera County
Hope Autism Therapies
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Inizio Interventions
National Association of Social Workers, California Chapter
National Health Law Program
Orange County United Way
Sacramento Asperger Syndrome Information and Support
Star of CA Behavioral and Psychological Services
United Ways of California
Opposition
America's Health Insurance Plans
Association of California Life and Health Insurance Companies
California Association of Health Plans
California Chamber of Commerce
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Analysis Prepared by:Kristene Mapile / HEALTH / (916)
319-2097