BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 171
AUTHOR: Beall
AMENDED: January 23, 2012
HEARING DATE: June 27, 2012
CONSULTANT: Bain
SUBJECT : Pervasive developmental disorder or autism.
SUMMARY : Requires health plans and insurers to provide coverage
for the screening, diagnosis, and treatment of pervasive
developmental disorder or autism (PDD/A). Defines "treatment for
pervasive developmental disorder or autism" to mean psychiatric
care, psychological care, therapeutic care, and prescription
drugs (if covered by the plan/insurer), including necessary
equipment, that develops, maintains, or restores to the maximum
extent practicable the functioning or quality of life of an
individual with PDD/A and is prescribed or ordered by a
physician or a psychologist who determines the care to be
medically necessary.
Existing law:
1.Requires, effective July 1, 2012, health plan contract and
health insurance policies that provide hospital, medical, or
surgical coverage to also provide coverage for behavioral
health treatment for PDD/A. Requires the coverage to be
provided under the same terms and conditions are applied to
other medical conditions.
2.Defines "behavioral health treatment" to mean professional
services and treatment programs, including applied behavior
analysis and evidence-based behavior intervention programs,
that develop or restore, to the maximum extent practicable,
the functioning of an individual with PDD/A and that meet
specified criteria.
3.Prohibits, as of the date that proposed final rulemaking for
essential health benefits (EHB) is issued, the above
provisions from requiring any benefits to be provided that
exceed the EHBs that all health plans will be required by
federal regulations to provide under the Patient Protection
and Affordable Care Act (ACA).
4.Exempts health plan contracts in Medi-Cal, Healthy Families
Continued---
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and CalPERS from the requirement in 1 and 2 above.
5.Sunsets the provisions of 1 through 4 above on July 1, 2014.
6.Requires health plans and health insurers, under the state's
mental health parity statute, that provide hospital, medical,
or surgical coverage to provide coverage for the diagnosis and
medically necessary treatment of severe mental illnesses of a
person of any age, and of serious emotional disturbances of a
child under the same terms and conditions applied to other
medical conditions. "Severe mental illnesses" includes PDD/A.
7.Requires the terms and conditions applied to the benefits
required to be applied equally to all benefits under the plan
contract, including, but not be limited to, maximum lifetime
benefits, copayments, individual and family deductibles.
8.Requires health plans regulated by the Department of Managed
Health Care (DMHC) to provide basic health care services,
which include, where medically necessary, physician services,
inpatient hospital services and ambulatory care services,
(outpatient hospital services) which include diagnostic and
treatment services, physical therapy, speech therapy,
occupational therapy services as appropriate, and those
hospital services, which can reasonably be provided on an
ambulatory basis.
9.Requires, under the ACA, the Secretary of the Department of
Health and Human Services (HHS) to define the EHB. Requires
the EHB to include specified general categories and the items
and services covered within specified categories, one of which
is mental health and substance use disorder services,
including behavioral health treatment.
10. Requires, under the federal Mental Health Parity
and Addiction Equity Act (MHPAEA), group health plans and
health insurance issuers that cover mental health or substance
use disorder (MH/SUD) to ensure that financial requirements
(such as copays and deductibles) and treatment limitations
(such as visit limits) applicable to MH/SUD benefits are no
more restrictive than the predominant requirements or
limitations applied to substantially all medical/surgical
benefits. Exempts health insurance policies sold to employers
with 50 or fewer employees and policies sold to individuals.
This bill:
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1.Requires every health plan contract and health insurance
policy issued, amended, or renewed on or after January 1,
2013, that provides hospital, medical, or surgical coverage to
provide coverage for the screening, diagnosis, and treatment
of PDD/A.
2.Defines "treatment for pervasive developmental disorder or
autism" to mean all of the following care, including necessary
equipment, that develops, maintains, or restores to the
maximum extent practicable the functioning or quality of life
of an individual with PDD/A that is prescribed or ordered a
physician or a psychologist who determines the care to be
medically necessary:
a. Pharmacy care, if the plan contract includes coverage
for prescription drugs;
b. Psychiatric care;
c. Psychological care; and
d. Therapeutic care (services provided by a licensed or
certified speech therapist, occupational therapist or
physical therapist).
3.Excludes "behavioral health treatment" from the definition of
"treatment for pervasive developmental disorder or autism."
4.Prohibits a health plan from terminating coverage, or refusing
to deliver, execute, issue, amend, adjust, or renew coverage,
to an enrollee solely because the individual is diagnosed
with, or has received treatment for PDD/A.
5.Requires coverage that is required to be provided under this
bill to extend to all medically necessary services, and
prohibits the coverage from being subject to any limits
regarding age, number of visits, or dollar amounts.
6.Prohibits coverage required to be provided under this bill
from being subject to provisions relating to lifetime
maximums, deductibles, copayments, or coinsurance or other
terms and conditions that are less favorable to an enrollee
than lifetime maximums, deductibles, copayments, or
coinsurance or other terms and conditions that apply to
physical illness generally.
7.States that coverage that is required to be provided under
this bill is a health care service and a covered health care
benefit for purposes of this existing law, and prohibits
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coverage from being denied on the basis of the location of
delivery of the treatment or on the basis that the treatment
is habilitative, nonrestorative, educational, academic, or
custodial in nature.
8.Limits a health plan or insurer's ability to request a review
of treatment provided to an enrollee for PDD/A to no more than
once annually. Requires the cost of obtaining the review to be
borne by the plan. Exempts in-patient services from these
provisions.
9.Requires a health plan and insurer to establish and maintain
an adequate network of service providers with appropriate
training and experience in PDD/A to ensure that enrollees have
a choice of providers, and have timely access, continuity of
care, and ready referral to all services required to be
provided by this bill consistent with specified provisions of
existing law and the regulations adopted implementing those
provisions.
10.Prohibits this bill from being construed as:
a. Reducing any obligation to provide services to an
enrollee under an individualized family service plan, an
individualized program plan, a prevention program plan, an
individualized education program, or an individualized
service plan;
b. Limiting or excluding benefits that are otherwise
available to an enrollee under a health care service plan
or health insurer;
c. To mean that the services required to be covered under
this bill are not required to be covered under other
provisions of existing law; and
d. Affecting litigation that is pending on January 1, 2012.
11.Prohibits this bill from requiring, on and after January 1,
2014, any benefits to be provided that exceed the EHBs that
all health plans will be required by federal regulations under
the ACA.
12.Exempts dental-only or vision-only health care service plan
contracts from the provisions of this bill.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, negligible fiscal impact to the state, and to health
plans and insurers. The California Health Benefits Review
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Program (CHBRP) did not identify increased premiums associated
with this bill's requirement to cover therapy, mental health,
and durable medical equipment services.
PRIOR VOTES :
Assembly Health: 12- 6
Assembly Appropriations:12- 5
Assembly Floor: 50- 18
COMMENTS :
1.Author's statement. AB 171 will continue the step California
took last year with SB 946 (Steinberg), Chapter 650, Statutes
of 2011 to end health care discrimination against individuals
with ASD by confirming that California requires health plans
and insurers to cover screening, diagnosis and all medically
necessary treatment for individuals with autism spectrum
disorders. AB 171 simply confirms existing law and prevents
erroneous denials of essential treatments for people with
these conditions. By confirming existing law, AB 171 will mean
that DMHC and CDI will not have to repeatedly overturn
improper denials by plans and insurers. It will also mean that
families of children and adults with autism will no longer
have to face unwarranted obstacles and unreasonable delays in
obtaining medically necessary services for their family
members. AB 171 will also save taxpayer dollars by preventing
plans and insurers from continuing to shift their costs onto
public agencies, such as regional centers, school districts
and counties.
2.CHBRP. CHBRP was created by AB 1996 (Thomson), Chapter 795,
Statutes of 2002, to request the University of California to
assess legislation proposing a mandated benefit or service,
and prepare a written analysis with relevant data on the
public health, medical, and economic impact of proposed health
plan and health insurance benefit mandate legislation. CHBRP
completed an analysis of AB 171 on March 26, 2011. However,
the CHBRP analysis of this bill was on its introduced version,
which included behavioral intervention therapy, which was
identified as the main cost and benefit increase of the bill.
Since behavioral intervention therapy has been removed from
this bill (because behavioral health treatment for PDD/A was
included in SB 946 last year, which was signed into law), the
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CHBRP analysis is not on point to the current version of this
bill.
3.EHBs and state benefit mandates. Effective January 1, 2014,
federal law requires Medicaid benchmark and benchmark
equivalent plans, plans sold through the Exchange and the
Basic Health Program (if enacted), and health plans and health
insurers providing coverage to individuals and small employers
to ensure coverage of EHBs as defined by the Secretary of the
HHS. HHS is required to ensure that the scope of EHBs is equal
to the scope of benefits provided under a typical employer
plan, as determined by the Secretary. Under federal law, EHBs
must include 10 general categories and the items and services
covered within the categories:
�Ambulatory patient services;
�Emergency services;
�Hospitalization;
�Maternity and newborn care;
�Mental health and substance use disorder services, including
behavioral health treatment;
�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;
Health plans and insurers can voluntarily cover benefits above
the EHBs. Additionally, states can require that health plans
offer benefits in addition to EHBs. However, if a state
requires additional benefits, it is also required to defray
the cost of any required additional benefits for people
receiving coverage in the Exchange.
On December 16, 2011, the HHS Center for Consumer Information
and Insurance Oversight released an EHB Bulletin outlining a
regulatory approach that HHS plans to propose to define EHBs.
In the Bulletin, HHS proposed that EHBs be defined using a
benchmark approach. States would have the flexibility to
select a benchmark plan that reflects the scope of services
offered by a "typical employer plan." EHBs would include
coverage of services and items in all 10 statutory categories
above, but states would choose one of the following benchmark
health insurance plans:
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� One of the three largest small group plans in the state by
enrollment;
� One of the three largest state employee health plans by
enrollment;
� One of the three largest federal employee health plan options
by enrollment; or
� The largest HMO plan offered in the state's commercial market
by enrollment.
If a state chose not to select a benchmark, HHS proposed that
the default benchmark will be the small group plan with the
largest enrollment in the state. HHS is accepted comments on
the Bulletin until January 31, 2011.
1.Related legislation. AB 154 (Beall) requires health plans and
health insurers to provide coverage for the diagnosis and
medically necessary treatment of a mental illness of a person
of any age, including a child, under the same terms and
conditions applied to other medical conditions, defines
"mental illness" to include substance abuse, but excludes
treatment of specified diagnoses, and exempts health plan
contracts in specified state public health insurance programs
from the provisions of that bill. AB 154 is scheduled for
hearing in the Senate Health Committee on June 27, 2012.
SB 951 (Hernandez) and AB 1461 (Monning) both would designate
the Kaiser Small Group Health Maintenance Organization plan
contract as California's EHB benchmark plan for individual and
small employer coverage. SB 951 is pending before the Assembly
Health Committee and AB 1461 is scheduled for hearing in the
Senate Health Committee on June 27, 2012.
2.Independent Medical Review (IMR). California's IMR process
provides patients with an opportunity to obtain an external
review of treatment decisions made by health plans and health
insurers at no cost to the enrollee. On DMCH's IMR website,
there were 220 IMR decisions involving autism. Of the IMR
cases identified, 24 of the health plans' original decisions
were upheld and 196 were overturned. Of the IMR autism
decisions, 49 fell under the treatment subcategory of
occupational or speech therapy. Of the 49 cases, three upheld
the decision of the health plan to deny coverage.
3.Support. This bill is sponsored by the Alliance of California
Autism Organizations (ACAO) to confirm coverage for essential
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health care services in the same manner that SB 946
(Steinberg) confirmed coverage for behavioral health treatment
for individuals with autism. ACAO states that, despite
existing law requiring medically necessary treatment for
autism, individuals with autism continue to face significant
hurdles accessing care because of specious denials
mischaracterizing the care, inappropriate utilization reviews,
lack of adequate networks and arbitrary and unlawful visit
limits. ACAO states that, while everything covered in this
bill should already be addressed through existing law, the
specificity in this bill will take a big step forward in the
continued effort to end health care discrimination against
autism. ACAO states this bill is not asking for coverage of
educational, academic, or custodial care, but rather is
explicitly disallowing health plans to mischaracterize
treatment for autism as such as a basis for denial. ACAO
argues the benefits required in this bill do not exceed the
essential benefits and should be covered by any of the plans
being considered for the EHB benchmark plan, and therefore
will be long lasting benefits for Californian's with autism.
ACAO states, despite network adequacy requirements that
require access to specialists, including those who specialize
in the treatment of autism or PDD, health plans continue
falsely to claim they do not need to build such specialty
networks for autism. Additionally, ACAO states health plans
need restrictions on the frequency of monitoring treatment for
autism or PDD because plans use inappropriate and
discriminatory utilization review procedures to
inappropriately limit medically necessary care for autism.
Multiple health plans have requested as short as daily
utilization review for speech and occupational therapy for
autism, care that is routinely provided for more than a year
for a chronic condition, something that is not done for other
chronic treatments such as insulin for diabetes or dialysis
for kidney failure. ACAO states the need for limits
utilization review are a direct result of discriminatory
practices on the part of health plans.
4.Opposition. The California Association of Health Plans (CAHP)
writes in opposition that this bill would bar denials of
coverage for therapeutic, pharmacy, psychiatric, and
psychological services that are "habilitative, nonrestorative,
educational, academic, or custodial," and CAHP states health
plans do not currently cover these services although
habilitative care will be required in 2014 under the ACA.
Because this bill contains a provision that prohibits coverage
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from exceeding the EHB in the ACA, CAHP states that it
believes this bill is a one-year benefit mandate, which CAHP
argues is ill-advised not only for its costs but for its
limited duration. Additionally, CAHP states this bill also
requires guarantee issuance of health insurance for anyone
diagnosed with PDD/A, and bars health plans from charging them
a different premium rate than an enrollee with no preexisting
conditions. CAHP states this bill limits the ability of health
plans to monitor treatment by limiting the review of
outpatient treatment to once a year when plans do not have
similar limitations on their oversight of other medical
services. CAHP argues this provision will increase costs and
could result in unnecessary treatments that are inappropriate.
Finally, CAHP states this bill places an additional network
requirement on health plans based on whether providers have
experience treating PDD/A, which CAHP argues is a burdensome
requirement that will likely require adding new providers and
will increase costs.
5.Recommended amendments. This bill prohibits health plans and
insurers from terminating coverage, or refusing to deliver,
execute, issue, amend, adjust, or renew coverage, to an
enrollee solely because the individual is diagnosed with, or
has received treatment for PDD/A. Current law already
prohibits health plans from refusing to renew coverage (except
for nonpayment of premiums or other reasons). Additionally,
this language would require health plans and insurers to
"guarantee issue" coverage in advance of the ACA requirement
that health plans do so in 2014. Staff recommends amendments
to delete the references that require the "guarantee issuance"
of coverage and the provisions regarding renewals of coverage.
SUPPORT AND OPPOSITION :
Support: Alliance of California Autism Organizations (sponsor)
Alameda County Board of Supervisors
Alameda County Developmental Disabilities Council
American Association of University Women - California
American Federation of State, County and Municipal
Employees, AFL-CIO
Area 4 Board on Developmental Disabilities
Aspiranet
Association of Regional Center Agencies
Autism Deserves Equal Coverage
Autism Speaks
Behavior Frontiers
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Board of Behavioral Sciences
California Association for Behavior Analysis
California Association for Licensed Professional
Clinical Counselors
California Association for Parent-Child Advocacy
California Association of Marriage and Family
Therapists
California Association of Private Special Education
Schools
California Association of School Psychologists
California Church IMPACT
California Communities United Institute
California Disability Services Association
California School Boards Association
California School Employees Association, AFL-CIO
California State PTA
Californians for Disability Rights, Inc.
CARS+ The Organization for Special Educators
Coalition for Adequate Funding for Special Education
Contra Costa Health Services
Developmental Disabilities Area 10 Board
Easter Seals Superior California
Families for Early Autism Treatment
First 5 Los Angeles
First 5 Santa Clara County
Local Early Education Planning Council of Santa Clara
County
Los Angeles County Board of Supervisors
North Los Angeles County Regional Center
People's Care
Regional Center of the East Bay
Solano FEAT
State Council on Developmental Disabilities
The Arc of California
Two individuals
Oppose: Association of California Life and Health Insurance
Companies
America's Health Insurance Plans
California Association of Health Plans
California Chamber of Commerce
Educate.Advocate.
Health Net
Southwest California Legislative Council
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