BILL NUMBER: SB 166 AMENDED
BILL TEXT
AMENDED IN SENATE JANUARY 4, 2012
AMENDED IN SENATE APRIL 4, 2011
INTRODUCED BY Senator Steinberg
FEBRUARY 3, 2011
An act to add amend Section 1374.73
to of the Health and Safety Code, and
to add amend Section 10144.51
to of the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 166, as amended, Steinberg. Health care coverage: mental
illness: autism spectrum disorders.
(1) Existing law provides for licensure and regulation of health
care service plans by the Department of Managed Health Care. A
willful violation of these provisions is a crime. Existing law
provides for regulation of health insurers by the Department of
Insurance. Existing law requires health care service plan contracts
and health insurance policies , with specified exceptions,
to provide benefits for specified conditions, including
certain mental health conditions. behavioral health
treatment for pervasive development disorder or autism.
This bill would require those health care service plan
contracts and health insurance policies to also provide coverage for
behavioral intervention therapy, as defined, for pervasive
developmental disorder or autism. The bill would, however, provide
that no benefits are required to be provided that exceed the
essential health benefits required under federal law. Because a
violation of these provisions with respect to health care service
plans would be a crime, the bill would thereby impose a
state-mandated local program. exempt certain
child-only health care service plan contracts administered by
counties or other specified local entities from the requirement to
provide coverage for behavioral health treatment for pervasive
development disorder or autism.
(2) 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 no .
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. 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 individualized
service plan, as described in Section 5600.4 of the Welfare and
Institutions Code, or under the 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 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 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.
(6) "Healthy Kids coverage" means a child-only health care service
plan contract administered by a county, a county agency, a local
initiative, a county organized health system, or a health authority
providing health care coverage to eligible children whose family
income is at or below 400 percent of the federal poverty level that
is intended to provide coverage similar to the Healthy Families
Program for children who do not qualify for the Medi-Cal program or
the Healthy Families Program.
(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).
(5) A health care service plan contract that provides Healthy Kids
coverage.
(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) This section shall become inoperative on July 1, 2014, and, as
of January 1, 2015, is repealed, unless a later enacted statute,
that becomes operative on or before January 1, 2015, deletes or
extends the dates on which it becomes inoperative and is repealed.
SEC. 2. 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 individualized
service plan, as described in Section 5600.4 of the Welfare and
Institutions Code, or under the 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 2240.1) 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 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 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.
(6) "Healthy Kids coverage" means a child-only health care service
plan contract administered by a county, a county agency, a local
initiative, a county organized health system, or a health authority
providing health care coverage to eligible children whose family
income is at or below 400 percent of the federal poverty level that
is intended to provide coverage similar to the Healthy Families
Program for children who do not qualify for the Medi-Cal program or
the Healthy Families Program.
(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) of Division 2 of the
Insurance Code).
(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).
(5) A health insurance policy that provides Healthy Kids coverage.
(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.
(g) This section shall become inoperative on July 1, 2014, and, as
of January 1, 2015, is repealed, unless a later enacted statute,
that becomes operative on or before January 1, 2015, deletes or
extends the dates on which it becomes inoperative and is repealed.
SECTION 1. The Legislature finds and declares
all of the following:
(a) During the past decade, scientific research has established
that behavioral intervention therapy can significantly improve the
cognitive function and emotional capabilities of, and reduce
self-injurious behaviors of, a significant number of individuals with
pervasive developmental disorders or autism.
(b) Scientists, physicians, and other autism experts now consider
that behavioral intervention therapy is an important and medically
necessary treatment for a significant number of individuals with
pervasive developmental disorder or autism.
(c) Controversy, uncertainty, and disparities currently exist
among some health care service plans and health insurers as to
whether behavioral intervention therapy should be a covered benefit
for pervasive developmental disorder or autism.
(d) It is the intent of this act to provide clarification of
existing laws requiring mental health parity and to provide for
coverage of behavioral intervention therapy with regard to pervasive
developmental disorder or autism.
SEC. 2. Section 1374.73 is added to the Health
and Safety Code, to read:
1374.73. (a) (1) Every health care service plan contract issued,
amended, or renewed on or after January 1, 2012, that provides
hospital, medical, or surgical coverage pursuant to Section 1374.72
shall provide coverage for behavioral intervention therapy for
pervasive developmental disorder or autism. 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), this section does not require
any benefits to be provided that exceed the essential health benefits
required to be provided 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 be construed as reducing any obligation
to provide services to an individual under an individualized family
service plan, an individualized program plan, a prevention program
plan, an individualized education program, or an individualized
service plan.
(b) (1) For the purposes of this section, "behavioral intervention
therapy" shall be defined to include, but not be limited to, the
following:
(A) The design, implementation, and evaluation of environmental
modifications, such as applied behavioral analysis, using behavioral
stimuli and consequences, to produce significant improvement in human
health functions and behaviors, including the use of direct
observation, measurement, and functional analysis of the relationship
between environment and behavior.
(B) Professional services or treatment programs that have been
scientifically validated and have demonstrated clinical efficacy.
(C) Professional services or treatment programs that have
measurable treatment outcomes.
(2) For the purposes of this section, "pervasive developmental
disorder or autism" shall have the meaning as used in Section
1374.72.
SEC. 3. Section 10144.51 is added to the
Insurance Code, to read:
10144.51. (a) (1) Every health insurance policy issued, amended,
or renewed on or after January 1, 2012, that provides hospital,
medical, or surgical coverage pursuant to Section 10144.5 shall
provide coverage for the behavioral intervention therapy for
pervasive developmental disorder or autism. 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), this section does not require
any benefits to be provided that exceed the essential health benefits
required to be provided 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 be construed as reducing any obligation
to provide services to an individual under an individualized family
service plan, an individualized program plan, a prevention program
plan, an individualized education program, or an individualized
service plan.
(b) (1) For the purposes of this section, "behavioral intervention
therapy" shall be defined to include, but not be limited to, the
following:
(A) The design, implementation, and evaluation of environmental
modifications, such as applied behavioral analysis, using behavioral
stimuli and consequences, to produce significant improvement in human
health functions and behaviors, including the use of direct
observation, measurement, and functional analysis of the relationship
between environment and behavior.
(B) Professional services or treatment programs that have been
scientifically validated and have demonstrated clinical efficacy.
(C) Professional services or treatment programs that have
measurable treatment outcomes.
(2) For the purposes of this section, "pervasive developmental
disorder or autism" shall have the meaning as used in Section
10144.5.
SEC. 4. 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.