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 or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented 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 by the qualified autism service provider.
(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.
(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, when clinically appropriate, needed to achieve the plan’s goal and objectives, and the frequency at which the patient’s progress is evaluated and reported. When clinically appropriate, the plan shall include parent or caregiver participation that is individualized to the patient and that takes into account the ability of the parent or caregiver to participate in therapy sessions and other
recommended activities.
(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 who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies or the American National Standards Institute, 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 who 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, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider, provided that the services are consistent with the experience, training, or education
of the professional.
(B) Is 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 who meets one of the following criteria:
(i) Meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an associate behavior analyst, behavior analyst, behavior management assistant, behavior management consultant, or behavior management program.
(ii) Possesses a bachelor of arts or science degree and
meets one of the following qualifications:
(I) One year of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider and 12 semester units from an accredited institution of higher learning in either applied behavioral analysis or clinical coursework in behavioral health.
(II) Two years of experience in designing or implementing behavioral health treatment supervised by a qualified autism service provider.
(III) The person is a registered psychological assistant or registered psychologist pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code. A registered psychological assistant or registered
psychologist may not supervise a qualified autism service paraprofessional until he or she has obtained at least 500 hours of experience in designing or implementing behavioral health treatment.
(IV) The person is an associate clinical social worker registered with the Board of Behavioral Sciences pursuant to Section 4996.18 of the Business and Professions Code. An associate clinical social worker may not supervise a qualified autism service paraprofessional until he or she has obtained at least 500 hours of experience in designing or implementing behavioral health treatment.
(V) The person is a registered associate marriage and family therapist with the Board of Behavioral Sciences pursuant to Section 4980.44 of the Business and Professions Code. A registered associate
marriage and family therapist may not supervise a qualified autism service paraprofessional until he or she has obtained at least 500 hours of experience in designing or implementing behavioral health treatment.
(VI) The person is a registered associate professional clinical counselor with the Board of Behavioral Sciences pursuant to Section 4999.42 of the Business and Professions Code. A registered associate professional clinical counselor may not supervise a qualified autism service paraprofessional until he or she has obtained at least 500 hours of experience in designing or implementing behavioral health treatment.
(VII) The person is credentialed or certified by a national entity, including, but not limited to, the Behavior Analyst Certification Board that is accredited by
the National Commission for Certifying Agencies or the American National Standards Institute to provide applied behavior analysis or behavioral health treatment, which may include case management and case supervision under the direction and supervision of a qualified autism service provider.
(E) Has training and experience in providing services for pervasive developmental disorder or autism.
(F) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.
(G) Has completed a background check performed by a Department of Justice approved agency, with subsequent notification to his or her employer pursuant to Section
11105.2 of the Penal Code.
(5) “Qualified autism service paraprofessional” means an individual who meets all of the following criteria:
(A) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.
(B) Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.
(C) Meets one of the following:
(i) For applied behavioral analysis, the education and training qualifications described in
Section 54342 of Title 17 of the California Code of Regulations.
(ii) For other evidence-based behavioral health treatments, all of the following qualifications:
(I) Possesses an associate’s degree or has completed two years of study from an accredited college or university with coursework in a related field of study.
(II) Has 40 hours of training in the specific form of behavioral health treatment developed by a qualified autism service provider and administered by a qualified autism service provider or qualified autism service professional competent in the form of behavioral health treatment to be practiced by the paraprofessional.
(III) Has adequate
education, training, and experience, as certified by a qualified autism service provider.
(iii) Is credentialed or certified in applied behavior analysis or behavioral health treatment for paraprofessionals or technicians by a national entity that is accredited by the National Commission for Certifying Agencies, or the American National Standards Institute.
However, upon successful completion of the training and education necessary for certification or a credential described in this clause, if the applicant is otherwise qualified under this section, the applicant may provide treatment and implement services for up to 180 days while in the process of obtaining the certification or credential.
(D) Has adequate education, training,
and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.
(E) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.
(F) Has completed a background check performed by a Department of Justice approved agency, with subsequent notification to his or her employer pursuant to Section 11105.2 of the Penal Code.
(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).
(e) This section does not 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) (1) The setting,
location, or time of treatment recommended by the qualified autism service provider shall not be used as the only reason to deny or reduce coverage for medically necessary services. The setting shall be consistent with the standard of care for behavioral health treatment. This subdivision does not require a health insurer to provide reimbursement for services delivered by school personnel pursuant to an enrollee’s individualized educational program for the purpose of accessing educational services, unless otherwise required or permitted by federal and state law. This subdivision does not require a health insurer to cover services rendered outside of the health insurer’s service area unless the services are urgently needed
services to prevent serious deterioration of a covered person’s health resulting from unforeseen illness or injury for which treatment cannot be delayed until the covered person returns to the insurer’s service area, or emergency services, as defined in Section 1317.1 of the Health and Safety Code, or unless the benefit plan expressly covers out-of-area services.
(2) Parent or caregiver participation may be associated with greater improvements in functioning and should be encouraged. However, the lack of parent or caregiver participation shall not be used as a basis for denying or reducing coverage of medically necessary services.