Bill Text: CA AB796 | 2015-2016 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Health care coverage: autism and pervasive developmental disorders.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Passed) 2016-09-23 - Chaptered by Secretary of State - Chapter 493, Statutes of 2016. [AB796 Detail]

Download: California-2015-AB796-Amended.html

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BILL NUMBER: AB 796	AMENDED
	BILL TEXT

	AMENDED IN SENATE  JUNE 21, 2016
	AMENDED IN SENATE  JUNE 8, 2016
	AMENDED IN ASSEMBLY  JANUARY 13, 2016
	AMENDED IN ASSEMBLY  JANUARY 4, 2016

INTRODUCED BY   Assembly Member Nazarian
   (Coauthor: Assembly Member Rendon)

                        FEBRUARY 26, 2015

   An act to amend Section 1374.73 of the Health and Safety Code,
  and  to amend Section 10144.51 of the Insurance
Code,   and to add Section 4513.1 to the Welfare and Institutions
Code,   relating to health care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 796, as amended, Nazarian. Health care coverage: autism and
pervasive developmental disorders. 
   Existing law, the Lanterman Developmental Disabilities Services
Act, requires the State Department of Developmental Services to
contract with regional centers to provide services and supports to
individuals with developmental disabilities and their families.
Existing law defines developmental disability for these purposes, to
include, among other things, autism. 
   Existing law provides for the licensure and regulation of health
care service plans by the Department of Managed Health Care. A
violation of those provisions is a crime. Existing law provides for
the licensure and regulation of health insurers by the Department of
Insurance.
   Existing law requires every health care service plan contract and
health insurance policy to provide coverage for behavioral health
treatment for pervasive developmental disorder or autism until
January 1, 2017, and defines "behavioral health treatment" to mean
specified services provided by, among others, a qualified autism
service professional supervised and employed by a qualified autism
service provider. For purposes of this provision, existing law
defines a "qualified autism service 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.
   This bill would delete the sunset date, thereby extending the
operation of these provisions indefinitely. By extending the
operation of these provisions, the violation of which by a health
care service plan would be a crime, the bill would impose a
state-mandated local program.  The bill would require the
Department of Managed Health Care, in conjunction with the Department
of Insurance, to develop procedure codes for evidence-based
behavioral health treatment other than applied behavior analysis. The
bill would also require the Department of Managed Health Care, in
conjunction with the Department of Insurance as the lead agency, to
convene a task force, as specified. The bill would also provide that
the list of behavioral health treatment modalities developed shall
constitute evidence that a particular form of treatment is
evidence-based in an independent medical review. The bill would also
prohibit the absence of a particular form of treatment from the list
of behavioral health treatment modalities developed from constituting
evidence that a particular form of treatment is not evidence-based.
 
   The bill would also require the State 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 behavioral
health treatment for autism and pervasive developmental disorder and
to update regulations to set forth the minimum standards of
education, training, and professional experience for qualified autism
service professionals and paraprofessionals, as specified. 
   The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  The Legislature finds and declares all of the
following:
   (a) Autism and other pervasive developmental disorders are complex
neurobehavioral disorders that include impairments in social
communication and social interaction combined with rigid, repetitive
behaviors, interests, and activities.
   (b) Autism covers a large spectrum of symptoms and levels of
impairment ranging in severity from somewhat limiting to a severe
disability that may require institutional care.
   (c) One in 68 children born today will be diagnosed with autism or
another pervasive developmental disorder.
   (d) Research has demonstrated that children diagnosed with autism
can often be helped with early administration of behavioral health
treatment.
   (e) There are several forms of evidence-based behavioral health
treatment, including, but not limited to, applied behavioral
analysis.
   (f) Children diagnosed with autism respond differently to
behavioral health treatment.
   (g) It is critical that each child diagnosed with autism receives
the specific type of evidence-based behavioral health treatment best
suited to him or her, as prescribed by his or her physician or
developed by a psychologist.
   (h) The Legislature intends that  all forms of 
evidence-based behavioral health treatment be covered by health care
service plans, pursuant to Section 1374.73 of the Health and Safety
Code, and health insurance policies, pursuant to Section 10144.51 of
the Insurance Code.
   (i) The Legislature intends that health care service plan provider
networks include qualified professionals practicing all forms of
evidence-based behavioral health treatment other than just applied
behavioral analysis.
  SEC. 2.  Section 1374.73 of the Health and Safety Code is amended
to read:
   1374.73.  (a) (1) Every health care service plan contract that
provides hospital, medical, or surgical coverage shall also provide
coverage for behavioral health treatment for pervasive developmental
disorder or autism no later than July 1, 2012. The coverage shall be
provided in the same manner and shall be subject to the same
requirements as provided in Section 1374.72.
   (2) Notwithstanding paragraph (1), as of the date that proposed
final rulemaking for essential health benefits is issued, this
section does not require any benefits to be provided that exceed the
essential health benefits that all health plans will be required by
federal regulations to provide under Section 1302(b) of the federal
Patient Protection and Affordable Care Act (Public Law 111-148), as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152).
   (3) This section shall not affect services for which an individual
is eligible pursuant to Division 4.5 (commencing with Section 4500)
of the Welfare and Institutions Code or Title 14 (commencing with
Section 95000) of the Government Code.
   (4) This section shall not affect or reduce any obligation to
provide services under an individualized education program, as
defined in Section 56032 of the Education Code, or an individual
service plan, as described in Section 5600.4 of the Welfare and
Institutions Code, or under the federal Individuals with Disabilities
Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
regulations.
   (b) Every health care service plan subject to this section shall
maintain an adequate network that includes qualified autism service
providers who supervise and employ qualified autism service
professionals or paraprofessionals who provide and administer
behavioral health treatment. Nothing shall prevent a health care
service plan from selectively contracting with providers within these
requirements.
   (c) For the purposes of this section, the following definitions
shall apply:
   (1) "Behavioral health treatment" means 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 pervasive developmental disorder or autism and that
meet all of the following criteria:
   (A) The treatment is prescribed by a physician and surgeon
licensed pursuant to Chapter 5 (commencing with Section 2000) of, or
is developed by a psychologist licensed pursuant to Chapter 6.6
(commencing with Section 2900) of, Division 2 of the Business and
Professions Code.
   (B) The treatment is provided under a treatment plan prescribed by
a qualified autism service provider and is administered by one of
the following:
   (i) A qualified autism service provider.
   (ii) A qualified autism service professional supervised and
employed by the qualified autism service provider.
   (iii) A qualified autism service paraprofessional supervised and
employed by a qualified autism service provider.
   (C) The treatment plan has measurable goals over a specific
timeline that is developed and approved by the qualified autism
service provider for the specific patient being treated. The
treatment plan shall be reviewed no less than once every six months
by the qualified autism service provider and modified whenever
appropriate, and shall be consistent with Section 4686.2 of the
Welfare and Institutions Code pursuant to which the qualified autism
service provider does all of the following:
   (i) Describes the patient's behavioral health impairments or
developmental challenges that are to be treated.
   (ii) Designs an intervention plan that includes the service type,
number of hours, and parent participation needed to achieve the plan'
s goal and objectives, and the frequency at which the patient's
progress is evaluated and reported.
   (iii) Provides intervention plans that utilize evidence-based
practices, with demonstrated clinical efficacy in treating pervasive
developmental disorder or autism.
   (iv) Discontinues intensive behavioral intervention services when
the treatment goals and objectives are achieved or no longer
appropriate.
   (D) The treatment plan is not used for purposes of providing or
for the reimbursement of respite, day care, or educational services
and is not used to reimburse a parent for participating in the
treatment program. The treatment plan shall be made available to the
health care service plan upon request.
   (2) "Pervasive developmental disorder or autism" shall have the
same meaning and interpretation as used in Section 1374.72.
   (3) "Qualified autism service provider" means either of the
following:
   (A) A person, entity, or group that is certified by a national
entity, such as the Behavior Analyst Certification Board, that is
accredited by the National Commission for Certifying Agencies, and
who designs, supervises, or provides treatment for pervasive
developmental disorder or autism, provided the services are within
the experience and competence of the person, entity, or group that is
nationally certified.
   (B) A person licensed as a physician and surgeon, physical
therapist, occupational therapist, psychologist, marriage and family
therapist, educational psychologist, clinical social worker,
professional clinical counselor, speech-language pathologist, or
audiologist pursuant to Division 2 (commencing with Section 500) of
the Business and Professions Code, who designs, supervises, or
provides treatment for pervasive developmental disorder or autism,
provided the services are within the experience and competence of the
licensee.
   (4) "Qualified autism service professional" means an individual
who meets all of the following criteria:
   (A) Provides behavioral health treatment.
   (B) Is employed and supervised by a qualified autism service
provider.
   (C) Provides treatment pursuant to a treatment plan developed and
approved by the qualified autism service provider.
   (D) Is a behavioral 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 as
defined in Section 54342 of Article 3 of Subchapter 2 of Chapter 3 of
Division 2 of Title 17 of the California Code of Regulations.
   (E) Has training and experience in providing services for
pervasive developmental disorder or autism pursuant to Division 4.5
(commencing with Section 4500) of the Welfare and Institutions Code
or Title 14 (commencing with Section 95000) of the Government Code.
   (5) "Qualified autism service paraprofessional" means an
unlicensed and uncertified individual who meets all of the following
criteria:
   (A) Is employed and supervised by a qualified autism service
provider.
   (B) Provides treatment and implements services pursuant to a
treatment plan developed and approved by the qualified autism service
provider.
   (C) Meets the criteria set forth in the regulations adopted
pursuant to Section 4686.3 of the Welfare and Institutions Code.
   (D) Has adequate education, training, and experience, as certified
by a qualified autism service provider.
   (d) This section shall not apply to the following:
   (1) A specialized health care service plan that does not deliver
mental health or behavioral health services to enrollees.
   (2) A health care service plan contract in the Medi-Cal program
(Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of
the Welfare and Institutions Code).
   (3) A health care service plan contract in the Healthy Families
Program (Part 6.2 (commencing with Section 12693) of Division 2 of
the Insurance Code).
   (4) A health care benefit plan or contract entered into with the
Board of Administration of the Public Employees' Retirement System
pursuant to the Public Employees' Medical and Hospital Care Act (Part
5 (commencing with Section 22750) of Division 5 of Title 2 of the
Government Code).
   (e) Nothing in this section shall be construed to limit the
obligation to provide services under Section 1374.72.
   (f) As provided in Section 1374.72 and in paragraph (1) of
subdivision (a), in the provision of benefits required by this
section, a health care service plan may utilize case management,
network providers, utilization review techniques, prior
authorization, copayments, or other cost sharing. 
   (g) No later than July 1, 2017, the department, in conjunction
with the Department of Insurance, shall develop procedure codes for
evidence-based behavioral health treatment other than applied
behavior analysis.  
   (h) No later than December 31, 2017, and thereafter as necessary,
the department, in conjunction with the Department of Insurance as
lead agency, shall convene a task force that, at a minimum, shall
include a developmental pediatrician, a marriage and family
therapist, a child and adolescent psychiatrist, a psychologist, a
neuropsychologist, a board certified behavior analyst, and a
University of California autism researcher as voting representatives,
as well as nonvoting representatives from the State Department of
Developmental Services, the Department of Insurance, and the
department. All voting members shall be professionals trained in
interpreting research data and shall represent a balanced diversity
of treatment modalities, including both behavioral and developmental
approaches. The task force shall do all of the following: 

   (1) Develop a methodology for determining what constitutes an
evidence-based practice in the field of behavioral health treatment
for autism and pervasive developmental disorder.  
   (2) Develop a list of behavioral health treatment modalities for
autism and pervasive developmental disorder supported by research
that shall be displayed on the department Web site and distributed to
the State Department of Developmental Services, all regional
centers, and health care service plans.  
   (3) Develop minimum standards of education, training, and
professional experience for qualified autism service professionals
practicing behavioral health treatment other than applied behavior
analysis that shall be no less rigorous than the requirements as
defined in subdivision (b) of Section 54342 of Article 3 of
Subchapter 2 of Chapter 3 of Division 2 of Title 17 of the California
Code of Regulations.  
   (4) Develop minimum standards of education, training, and
professional experience for qualified autism service
paraprofessionals practicing behavioral health treatment other than
applied behavior analysis that shall be no less rigorous than the
education and training qualifications defined in the regulations
adopted pursuant to Section 4686.3 of the Welfare and Institutions
Code.  
   (i) The list of behavioral health treatment modalities developed
pursuant to this section shall constitute evidence that a particular
form of treatment is evidence-based in an independent medical review.
 
   (j) The absence of a particular form of treatment from the list of
behavioral health treatment modalities developed pursuant to this
section shall not constitute evidence that a particular form of
treatment is not evidence-based. 
  SEC. 3.  Section 10144.51 of the Insurance Code is amended to read:

   10144.51.  (a) (1) Every health insurance policy shall also
provide coverage for behavioral health treatment for pervasive
developmental disorder or autism no later than July 1, 2012. The
coverage shall be provided in the same manner and shall be subject to
the same requirements as provided in Section 10144.5.
   (2) Notwithstanding paragraph (1), as of the date that proposed
final rulemaking for essential health benefits is issued, this
section does not require any benefits to be provided that exceed the
essential health benefits that all health insurers will be required
by federal regulations to provide under Section 1302(b) of the
federal Patient Protection and Affordable Care Act (Public Law
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152).
   (3) This section shall not affect services for which an individual
is eligible pursuant to Division 4.5 (commencing with Section 4500)
of the Welfare and Institutions Code or Title 14 (commencing with
Section 95000) of the Government Code.
   (4) This section shall not affect or reduce any obligation to
provide services under an individualized education program, as
defined in Section 56032 of the Education Code, or an individual
service plan, as described in Section 5600.4 of the Welfare and
Institutions Code, or under the federal Individuals with Disabilities
Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing
regulations.
   (b) Pursuant to Article 6 (commencing with Section 2240) of
Subchapter 2 of Chapter 5 of Title 10 of the California Code of
Regulations, every health insurer subject to this section shall
maintain an adequate network that includes qualified autism service
providers who supervise and employ qualified autism service
professionals or paraprofessionals who provide and administer
behavioral health treatment. Nothing shall prevent a health insurer
from selectively contracting with providers within these
requirements.
   (c) For the purposes of this section, the following definitions
shall apply:
   (1) "Behavioral health treatment" means 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 pervasive developmental disorder or autism, and that
meet all of the following criteria:
   (A) The treatment is prescribed by a physician and surgeon
licensed pursuant to Chapter 5 (commencing with Section 2000) of, or
is developed by a psychologist licensed pursuant to Chapter 6.6
(commencing with Section 2900) of, Division 2 of the Business and
Professions Code.
   (B) The treatment is provided under a treatment plan prescribed by
a qualified autism service provider and is administered by one of
the following:
   (i) A qualified autism service provider.
   (ii) A qualified autism service professional supervised and
employed by the qualified autism service provider.
   (iii) A qualified autism service paraprofessional supervised and
employed by a qualified autism service provider.
   (C) The treatment plan has measurable goals over a specific
timeline that is developed and approved by the qualified autism
service provider for the specific patient being treated. The
treatment plan shall be reviewed no less than once every six months
by the qualified autism service provider and modified whenever
appropriate, and shall be consistent with Section 4686.2 of the
Welfare and Institutions Code pursuant to which the qualified autism
service provider does all of the following:
   (i) Describes the patient's behavioral health impairments or
developmental challenges that are to be treated.
   (ii) Designs an intervention plan that includes the service type,
number of hours, and parent participation needed to achieve the plan'
s goal and objectives, and the frequency at which the patient's
progress is evaluated and reported.
   (iii) Provides intervention plans that utilize evidence-based
practices, with demonstrated clinical efficacy in treating pervasive
developmental disorder or autism.
   (iv) Discontinues intensive behavioral intervention services when
the treatment goals and objectives are achieved or no longer
appropriate.
   (D) The treatment plan is not used for purposes of providing or
for the reimbursement of respite, day care, or educational services
and is not used to reimburse a parent for participating in the
treatment program. The treatment plan shall be made available to the
insurer upon request.
   (2) "Pervasive developmental disorder or autism" shall have the
same meaning and interpretation as used in Section 10144.5.
   (3) "Qualified autism service provider" means either of the
following:
   (A) A person, entity, or group that is certified by a national
entity, such as the Behavior Analyst Certification Board, that is
accredited by the National Commission for Certifying Agencies, and
who designs, supervises, or provides treatment for pervasive
developmental disorder or autism, provided the services are within
the experience and competence of the person, entity, or group that is
nationally certified.
   (B) A person licensed as a physician and surgeon, physical
therapist, occupational therapist, psychologist, marriage and family
therapist, educational psychologist, clinical social worker,
professional clinical counselor, speech-language pathologist, or
audiologist pursuant to Division 2 (commencing with Section 500) of
the Business and Professions Code, who designs, supervises, or
provides treatment for pervasive developmental disorder or autism,
provided the services are within the experience and competence of the
licensee.
   (4) "Qualified autism service professional" means an individual
who meets all of the following criteria:
   (A) Provides behavioral health treatment.
   (B) Is employed and supervised by a qualified autism service
provider.
   (C) Provides treatment pursuant to a treatment plan developed and
approved by the qualified autism service provider.
   (D) Is a behavioral 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 as
defined in Section 54342 of Article 3 of Subchapter 2 of Chapter 3 of
Division 2 of Title 17 of the California Code of Regulations.
   (E) Has training and experience in providing services for
pervasive developmental disorder or autism pursuant to Division 4.5
(commencing with Section 4500) of the Welfare and Institutions Code
or Title 14 (commencing with Section 95000) of the Government Code.
   (5) "Qualified autism service paraprofessional" means an
unlicensed and uncertified individual who meets all of the following
criteria:
   (A) Is employed and supervised by a qualified autism service
provider.
   (B) Provides treatment and implements services pursuant to a
treatment plan developed and approved by the qualified autism service
provider.
   (C) Meets the criteria set forth in the regulations adopted
pursuant to Section 4686.3 of the Welfare and Institutions Code.
   (D) Has adequate education, training, and experience, as certified
by a qualified autism service provider.
   (d) This section shall not apply to the following:
   (1) A specialized health insurance policy that does not cover
mental health or behavioral health services or an accident only,
specified disease, hospital indemnity, or Medicare supplement policy.

   (2) A health insurance policy in the Medi-Cal program (Chapter 7
(commencing with Section 14000) of Part 3 of Division 9 of the
Welfare and Institutions Code).
   (3) A health insurance policy in the Healthy Families Program
(Part 6.2 (commencing with Section 12693)).
   (4) A health care benefit plan or policy entered into with the
Board of Administration of the Public Employees' Retirement System
pursuant to the Public Employees' Medical and Hospital Care Act (Part
5 (commencing with Section 22750) of Division 5 of Title 2 of the
Government Code).
   (e) Nothing in this section shall be construed to limit the
obligation to provide services under Section 10144.5.
   (f) As provided in Section 10144.5 and in paragraph (1) of
subdivision (a), in the provision of benefits required by this
section, a health insurer may utilize case management, network
providers, utilization review techniques, prior authorization,
copayments, or other cost sharing.
   SEC. 4.    Section 4513.1 is added to the  
Welfare and Institutions Code   , to read: 
   4513.1.  (a) The department, no later than July 1, 2018, with
input from the stakeholders identified in subdivision (b), shall do
both of the following:
   (1) Develop a methodology for determining what constitutes an
evidence-based practice in the field of behavioral health treatment
for autism and pervasive developmental disorder.
   (2) Update regulations to set forth the minimum standards of
education, training, and professional experience for qualified autism
service professionals and paraprofessionals practicing behavioral
health treatment other than applied behavioral analysis that shall be
no less rigorous than the requirements set forth in subdivision (b)
of Section 54342 of Article 3 of Subchapter 2 of Chapter 3 of
Division 2 of Title 17 of the California Code of Regulations.
   (b) Stakeholders shall include professionals trained in
interpreting research data and shall represent a balanced diversity
of treatment modalities, including both behavioral and developmental
approaches. These professionals shall include, at a minimum, a
developmental pediatrician, a marriage and family therapist, a child
and adolescent psychiatrist, a psychologist, a neuropsychologist, a
board certified behavior analyst, and a University of California
autism researcher. 
   SEC. 4.   SEC. 5.   No reimbursement is
required by this act pursuant to Section 6 of Article XIII B of the
California Constitution because the only costs that may be incurred
by a local agency or school district will be incurred because this
act creates a new crime or infraction, eliminates a crime or
infraction, or changes the penalty for a crime or infraction, within
the meaning of Section 17556 of the Government Code, or changes the
definition of a crime within the meaning of Section 6 of Article XIII
B of the California Constitution.