BILL ANALYSIS �
AB 171
Page 1
Date of Hearing: May 11, 2011
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Felipe Fuentes, Chair
AB 171 (Beall) - As Amended: May 3, 2011
Policy Committee: HealthVote:12-6
Urgency: No State Mandated Local Program:
Yes Reimbursable: No
SUMMARY
This bill requires health insurance plans and health care
service plans to provide coverage for screening, diagnosis, and
treatment services associated with autism spectrum disorders
(ASDs), and defines certain types of health care services that
must be covered to treat ASDs.
FISCAL EFFECT
1)According to the California Health Benefits Review Program
(CHBRP), annual state costs to:
a) CalPERS, of $9 million (58% GF).
b) The Medi-Cal program, for enrollees in managed care
plans, of $114 million (50% GF).
c) MRMIB plans (Healthy Families Program, Access for
Infants and Mothers, and the Major Risk Medical Insurance
Program) of $37 million (about 35% GF).
1)Annual increased premium costs in the private insurance market
of $177 million. These costs reflect increased premiums by
employers for group insurance, premiums paid in the individual
health insurance market, and premium costs borne by
individuals with group coverage.
2)Significant GF cost savings, conservatively in the tens of
millions of dollars. CHBRP reports $217 million in cost
savings to current payers of ASD-related services, which are
primarily school districts and the state Department of
Developmental Services (DDS). Given data limitations, it is
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not possible to estimate precisely where cost savings would
accrue.
a) Assuming 50% of the savings accrue to DDS, GF savings
would be in the range of $60-$70 million. Savings would
partially depend on the success of DDS in identifying other
payers.
b) Cost savings to school districts would not result in
direct GF savings if K-12 education was funded at the
minimum amount required by Proposition 98. However, any
funds saved by school districts due to a reduction in
expenditures for ASD-related services could be redirected
to other activities.
COMMENTS
1)Rationale . According to the author, children and adults with
ASD are frequently denied coverage for essential health care
services, in violation of the California Mental Health Parity
Act. The author states that regulators, courts and consumers
have all requested legislative clarification of this issue.
In particular, the author further contends that health plans
have attempted to use a variety of reasons to deny coverage
for behavioral intervention therapy (BIT), including applied
behavioral analysis (ABA) services, the standard of care for
treatment of ASD. This bill intends to clarify that health
plans and insurers must cover a variety of services related to
screening, diagnosis, and treatment of autism, including BIT.
2)Mental Health Parity . Under current law, California has had
partial mental health parity for specified conditions since AB
88 (Thompson), Chapter 524, Statutes of 1999. AB 88 requires
treatment parity for "serious mental illness" (SMI) such as
schizophrenia, autism, and anorexia nervosa. This bill would
further specify the types of ASD-related treatments that must
be covered.
3)Applied Behavioral Analysis . CHBRP's analysis indicates that
this bill would have a small impact on utilization of
prescription drugs and durable medical equipment, but that the
largest impact of this mandate would be on BIT, specifically
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on applied behavioral analysis (ABA) services. ABA is the
process of systematically applying interventions based upon
the principles of learning theory to improve socially
significant behaviors to a meaningful degree. Socially
significant behaviors include reading, academics, social
skills, communication, and adaptive living skills like motor
skills, eating and food preparation, personal self-care,
domestic skills, home and community orientation, and work
skills.
4)Coverage of ABA Services . ABA requires intensive treatments of
over 25 hours each week and costs around $50,000 each year.
Some consumers have complained about the refusal of health
care service plans to cover ABA services. Health plans have
listed a variety of reasons for not covering ABA services,
including the experimental nature of the services, the
contention that the services are not medically necessary, the
lack of licensed providers of the services, and the
educational or academic nature of the services. Some
independent medical reviews of health plan coverage denials
for ABA services for children diagnosed with autism overturned
the health plan's decision to deny coverage, while others did
not. The coverage of ABA has also been the subject of a
recent lawsuit that alleges that denial of coverage for ABA
services is in violation of the California Mental Health
Parity Act. In 2007, the California Blue Ribbon Commission on
Autism recommended enactment of legislation to ensure
appropriate and equitable coverage for ASD by private health
plans and insurers.
1)Other payers of ABA services. In California, a number of
entities pay for or directly provide ABA services, including
school districts, the state Department of Developmental
Services, and individuals, as well as health care and health
insurance plans. CHBRP reports that increased premium costs in
public and private programs are offset by reductions in
expenditures by individuals and other payers on newly covered
benefits (such as behavioral intervention therapy (BIT)
services) of $217 million.
1)Related Legislation . AB 1205 (Berryhill) requires the Board of
Behavioral Sciences (BBS) to license behavioral analysts (BA)
and assistant BAs. AB 1205 is pending in the Assembly Health
Committee.
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SB 166 (Steinberg) requires health plans and insurers to cover
behavioral intervention therapy as a treatment for autism. SB
166 is pending in the Senate Health Committee.
Other Health Mandates in the Current Session . There are 15
health mandates proposed legislative consideration this year,
including AB 171. Other proposed health mandates include:
a) AB 72 (Eng): Acupuncture
b) AB 137 (Portantino): Mammography
c) AB 154 (Beall): Mental Health Services
d) AB 185 (Hernandez): Maternity Services
e) AB 310 (Ma): Prescription Drugs
f) AB 369 (Huffman): Pain Prescriptions
g) AB 428 (Portantino): Fertility Preservation
h) AB 652 (Mitchell): Child Health Assessments
i) AB 1000 (Perea): Cancer Treatment
j) SB 136 (Yee): Tobacco Cessation
aa) SB 155 (Evans): Maternity Services
bb) SB 166 (Steinberg): Behavioral Intervention Therapy
cc) SB 173 (Simitian): Mammograms
dd) SB 255 (Pavley): Breast Cancer
Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081