AB 1074: Health care coverage: pervasive developmental disorder or autism.
- Session Year: 2017-2018
- House: Assembly
- Latest Version Date: 2017-09-30
Existing law, the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act), provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, 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. Under existing law, to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment, as defined under the Knox-Keene Act, is a covered service under the Medi-Cal program for individuals under 21 years of age, as specified.
This bill would revise those provisions, for purposes of health care service plans and health insurers, to require a qualified autism service professional or a qualified autism service paraprofessional to be supervised by a qualified autism service provider for purposes of providing behavioral health treatment. The bill would require a qualified autism service professional and a qualified autism service paraprofessional to be employed by a qualified autism service provider or an entity or group that employs qualified autism service providers. The bill additionally would authorize a qualified autism service professional, as specified, to supervise a qualified autism service paraprofessional. The bill would revise the definition of a qualified autism service professional to, among other things, specify that the behavioral health treatment provided by the qualified autism service professional may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The bill would make other technical changes. The bill would revise the definition of behavioral health treatment for purposes of the Medi-Cal program to be those services administered by the State Department of Health Care Services as described in the state plan approved by the Centers for Medicare and Medicaid Services.
Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.
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.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act), provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, 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. Under existing law, to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment, as defined under the Knox-Keene Act, is a covered service under the Medi-Cal program for individuals under 21 years of age, as specified.
This bill would revise those provisions, for purposes of health care service plans and health insurers, to require a qualified autism service professional or a qualified autism service paraprofessional to be supervised by a qualified autism service provider for purposes of providing behavioral health treatment. The bill would require a qualified autism service professional and a qualified autism service paraprofessional to be employed by a qualified autism service provider or an entity or group that employs qualified autism service providers. The bill additionally would authorize a qualified autism service professional, as specified, to supervise a qualified autism service paraprofessional. The bill would revise the definition of a qualified autism service professional to, among other things, specify that the behavioral health treatment provided by the qualified autism service professional may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The bill would make other technical changes. The bill would revise the definition of behavioral health treatment for purposes of the Medi-Cal program to be those services administered by the State Department of Health Care Services as described in the state plan approved by the Centers for Medicare and Medicaid Services.
Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.
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.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act), provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, 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. Under existing law, to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment, as defined under the Knox-Keene Act, is a covered service under the Medi-Cal program for individuals under 21 years of age, as specified.
This bill would revise those provisions, for purposes of health care service plans and health insurers, to require a qualified autism service professional or a qualified autism service paraprofessional to be supervised by a qualified autism service provider for purposes of providing behavioral health treatment. The bill would require a qualified autism service professional and a qualified autism service paraprofessional to be employed by a qualified autism service provider or an entity or group that employs qualified autism service providers. The bill additionally would authorize a qualified autism service professional, as specified, to supervise a qualified autism service paraprofessional. The bill would revise the definition of a qualified autism service professional to, among other things, specify that the behavioral health treatment provided by the qualified autism service professional may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The bill would make other technical changes. The bill would revise the definition of behavioral health treatment for purposes of the Medi-Cal program to be those services administered by the State Department of Health Care Services as described in the state plan approved by the Centers for Medicare and Medicaid Services.
Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.
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.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, 1975 (Knox-Keene Act), provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, 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. Under existing law, to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment, as defined under the Knox-Keene Act, is a covered service under the Medi-Cal program for individuals under 21 years of age, as specified.
This bill would revise those provisions, for purposes of health care service plans and health insurers, to require a qualified autism service professional or a qualified autism service paraprofessional to be supervised by a qualified autism service provider for purposes of providing behavioral health treatment. The bill would require a qualified autism service professional and a qualified autism service paraprofessional to be employed by a qualified autism service provider or an entity or group that employs qualified autism service providers. The bill additionally would authorize a qualified autism service professional, as specified, to supervise a qualified autism service paraprofessional. The bill would revise the definition of a qualified autism service professional to, among other things, specify that the behavioral health treatment provided by the qualified autism service professional may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. The bill would make other technical changes. The bill would revise the definition of behavioral health treatment for purposes of the Medi-Cal program to be those services administered by the State Department of Health Care Services as described in the state plan approved by the Centers for Medicare and Medicaid Services.
Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.
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.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, 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.
This bill would revise those provisions, for purposes of health care service plans and health insurers, to require a qualified autism service professional or a qualified autism service paraprofessional to be supervised by a qualified autism service provider for purposes of providing behavioral health treatment. The bill would require a qualified autism service professional and a qualified autism service paraprofessional to be employed by a qualified autism service provider or an entity or group that employs qualified autism service providers. The bill additionally would authorize a qualified autism service professional professional, as specified, to supervise a qualified autism service paraprofessional. The bill would revise the definition of a qualified autism service professional to, among other things, specify that the behavioral health treatment provided by the qualified autism service professional may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.
Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.
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.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, 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.
This bill would revise those provisions, for purposes of health care service plans and health insurers, to require a qualified autism service professional or a qualified autism service paraprofessional to be supervised by a qualified autism service provider for purposes of providing behavioral health treatment. The bill would require a qualified autism service professional and a qualified autism service paraprofessional to be employed by a qualified autism service provider or an entity or group that employs qualified autism service providers. The bill additionally would authorize a qualified autism service professional to supervise a qualified autism service paraprofessional. The bill would revise the definition of a qualified autism service professional to, among other things, specify that the behavioral health treatment provided by the qualified autism service professional may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.
Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.
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.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, 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.
This bill would revise those provisions, for purposes of health care service plans and health insurers, to require a qualified autism service professional or a qualified autism service paraprofessional to be supervised by a qualified autism service provider for purposes of providing behavioral health treatment. The bill would require a qualified autism service professional and a qualified autism service paraprofessional to be employed by a qualified autism service provider or an entity or group that employs qualified autism service providers. The bill additionally would authorize a qualified autism service professional to supervise a qualified autism service paraprofessional. The bill would revise the definition of a qualified autism service professional to, among other things, specify that the behavioral health treatment provided by the qualified autism service professional may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.
Because a willful violation of the bills provisions by a health care service plan would be a crime, it would impose a state-mandated local program.
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.
(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 or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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).
(e)This section does not 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.
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 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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.
SEC. 3.Section 14132.56 of the Welfare and Institutions Code is amended to read:14132.56.(a)(1)Only to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment (BHT) shall be a covered Medi-Cal service for individuals under 21 years of age.
(2)It is the intent of the Legislature that, to the extent the federal government requires BHT to be a covered Medi-Cal service, the department shall seek statutory authority to implement this new benefit in Medi-Cal.
(3)For purposes of this section, behavioral health treatment or BHT means professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and are administered by the department as described in the approved state plan.
(b)The department shall implement, or continue to implement, this section only after all of the following occurs or has occurred:
(1)The department receives all necessary federal approvals to obtain federal funds for the service.
(2)The department seeks an appropriation that would provide the necessary state funding estimated to be required for the applicable fiscal year.
(3)The department consults with stakeholders.
(c)The department shall develop and define eligibility criteria, provider participation criteria, utilization controls, and delivery system structure for services under this section, subject to limitations allowable under federal law, in consultation with stakeholders.
(d)(1)The department, commencing on the effective date of the act that added this subdivision until March 31, 2017, inclusive, may make available to individuals described in paragraph (2) contracted services to assist those individuals with health insurance enrollment, without regard to whether federal funds are available for the contracted services.
(2)The contracted services described in paragraph (1) may be provided only to an individual under 21 years of age whom the department identifies as no longer eligible for Medi-Cal solely due to the transition of BHT coverage from the waiver program under Section 1915(c) of the federal Social Security Act to the Medi-Cal state plan in accordance with this section and who meets all of the following criteria:
(A)He or she was enrolled in the home and community-based services waiver for persons with developmental disabilities under Section 1915(c) of the Social Security Act as of January 31, 2016.
(B)He or she was deemed to be institutionalized in order to establish eligibility under the terms of the waiver.
(C)He or she has not been found eligible under any other federally funded Medi-Cal criteria without a share of cost.
(D)He or she had received a BHT service from a regional center for persons with developmental disabilities as provided in Chapter 5 (commencing with Section 4620) of Division 4.5.
(e)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Notwithstanding Section 10231.5 of the Government Code, beginning six months after the effective date of this section, the department shall provide semiannual status reports to the Legislature, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(f)For the purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. Contracts may be statewide or on a more limited geographic basis. Contracts entered into or amended under this subdivision shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code, and shall be exempt from the review or approval of any division of the Department of General Services.
(g)The department may seek approval of any necessary state plan amendments or waivers to implement this section. The department shall make any state plan amendments or waiver requests public at least 30 days prior to submitting to the federal Centers for Medicare and Medicaid Services, and the department shall work with stakeholders to address the public comments in the state plan amendment or waiver request.
(h)This section shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
SEC. 4.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(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 or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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).
(e)This section does not 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.
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 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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.
SEC. 3.Section 14132.56 of the Welfare and Institutions Code is amended to read:14132.56.(a)(1)Only to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment (BHT) shall be a covered Medi-Cal service for individuals under 21 years of age.
(2)It is the intent of the Legislature that, to the extent the federal government requires BHT to be a covered Medi-Cal service, the department shall seek statutory authority to implement this new benefit in Medi-Cal.
(3)For purposes of this section, behavioral health treatment or BHT means professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and are administered by the department as described in the approved state plan.
(b)The department shall implement, or continue to implement, this section only after all of the following occurs or has occurred:
(1)The department receives all necessary federal approvals to obtain federal funds for the service.
(2)The department seeks an appropriation that would provide the necessary state funding estimated to be required for the applicable fiscal year.
(3)The department consults with stakeholders.
(c)The department shall develop and define eligibility criteria, provider participation criteria, utilization controls, and delivery system structure for services under this section, subject to limitations allowable under federal law, in consultation with stakeholders.
(d)(1)The department, commencing on the effective date of the act that added this subdivision until March 31, 2017, inclusive, may make available to individuals described in paragraph (2) contracted services to assist those individuals with health insurance enrollment, without regard to whether federal funds are available for the contracted services.
(2)The contracted services described in paragraph (1) may be provided only to an individual under 21 years of age whom the department identifies as no longer eligible for Medi-Cal solely due to the transition of BHT coverage from the waiver program under Section 1915(c) of the federal Social Security Act to the Medi-Cal state plan in accordance with this section and who meets all of the following criteria:
(A)He or she was enrolled in the home and community-based services waiver for persons with developmental disabilities under Section 1915(c) of the Social Security Act as of January 31, 2016.
(B)He or she was deemed to be institutionalized in order to establish eligibility under the terms of the waiver.
(C)He or she has not been found eligible under any other federally funded Medi-Cal criteria without a share of cost.
(D)He or she had received a BHT service from a regional center for persons with developmental disabilities as provided in Chapter 5 (commencing with Section 4620) of Division 4.5.
(e)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Notwithstanding Section 10231.5 of the Government Code, beginning six months after the effective date of this section, the department shall provide semiannual status reports to the Legislature, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(f)For the purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. Contracts may be statewide or on a more limited geographic basis. Contracts entered into or amended under this subdivision shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code, and shall be exempt from the review or approval of any division of the Department of General Services.
(g)The department may seek approval of any necessary state plan amendments or waivers to implement this section. The department shall make any state plan amendments or waiver requests public at least 30 days prior to submitting to the federal Centers for Medicare and Medicaid Services, and the department shall work with stakeholders to address the public comments in the state plan amendment or waiver request.
(h)This section shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
SEC. 4.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(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 or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. Nothing shall prevent a A health care service plan 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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).
(e)Nothing in this section shall be construed to This section does not 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.
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 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. Nothing shall prevent a 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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)Nothing in this section shall be construed to 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.
SEC. 3.Section 14132.56 of the Welfare and Institutions Code is amended to read:14132.56.(a)(1)Only to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment (BHT) shall be a covered Medi-Cal service for individuals under 21 years of age.
(2)It is the intent of the Legislature that, to the extent the federal government requires BHT to be a covered Medi-Cal service, the department shall seek statutory authority to implement this new benefit in Medi-Cal.
(3)For purposes of this section, behavioral health treatment or BHT means professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and are administered by the department as described in the approved state plan.
(b)The department shall implement, or continue to implement, this section only after all of the following occurs or has occurred:
(1)The department receives all necessary federal approvals to obtain federal funds for the service.
(2)The department seeks an appropriation that would provide the necessary state funding estimated to be required for the applicable fiscal year.
(3)The department consults with stakeholders.
(c)The department shall develop and define eligibility criteria, provider participation criteria, utilization controls, and delivery system structure for services under this section, subject to limitations allowable under federal law, in consultation with stakeholders.
(d)(1)The department, commencing on the effective date of the act that added this subdivision until March 31, 2017, inclusive, may make available to individuals described in paragraph (2) contracted services to assist those individuals with health insurance enrollment, without regard to whether federal funds are available for the contracted services.
(2)The contracted services described in paragraph (1) may be provided only to an individual under 21 years of age whom the department identifies as no longer eligible for Medi-Cal solely due to the transition of BHT coverage from the waiver program under Section 1915(c) of the federal Social Security Act to the Medi-Cal state plan in accordance with this section and who meets all of the following criteria:
(A)He or she was enrolled in the home and community-based services waiver for persons with developmental disabilities under Section 1915(c) of the Social Security Act as of January 31, 2016.
(B)He or she was deemed to be institutionalized in order to establish eligibility under the terms of the waiver.
(C)He or she has not been found eligible under any other federally funded Medi-Cal criteria without a share of cost.
(D)He or she had received a BHT service from a regional center for persons with developmental disabilities as provided in Chapter 5 (commencing with Section 4620) of Division 4.5.
(e)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Notwithstanding Section 10231.5 of the Government Code, beginning six months after the effective date of this section, the department shall provide semiannual status reports to the Legislature, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(f)For the purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. Contracts may be statewide or on a more limited geographic basis. Contracts entered into or amended under this subdivision shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code, and shall be exempt from the review or approval of any division of the Department of General Services.
(g)The department may seek approval of any necessary state plan amendments or waivers to implement this section. The department shall make any state plan amendments or waiver requests public at least 30 days prior to submitting to the federal Centers for Medicare and Medicaid Services, and the department shall work with stakeholders to address the public comments in the state plan amendment or waiver request.
(h)This section shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
SEC. 4.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(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 or 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 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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).
(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.
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 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 or 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 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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)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. 3.Section 14132.56 of the Welfare and Institutions Code is amended to read:14132.56.(a)(1)Only to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment (BHT), as defined by Section 1374.73 of the Health and Safety Code, (BHT) shall be a covered Medi-Cal service for individuals under 21 years of age.
(2)It is the intent of the Legislature that, to the extent the federal government requires BHT to be a covered Medi-Cal service, the department shall seek statutory authority to implement this new benefit in Medi-Cal.
(3)For purposes of this section, behavioral health treatment or BHT means professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and are administered by the department as described in the approved state plan.
(b)The department shall implement, or continue to implement, this section only after all of the following occurs or has occurred:
(1)The department receives all necessary federal approvals to obtain federal funds for the service.
(2)The department seeks an appropriation that would provide the necessary state funding estimated to be required for the applicable fiscal year.
(3)The department consults with stakeholders.
(c)The department shall develop and define eligibility criteria, provider participation criteria, utilization controls, and delivery system structure for services under this section, subject to limitations allowable under federal law, in consultation with stakeholders.
(d)(1)The department, commencing on the effective date of the act that added this subdivision until March 31, 2017, inclusive, may make available to individuals described in paragraph (2) contracted services to assist those individuals with health insurance enrollment, without regard to whether federal funds are available for the contracted services.
(2)The contracted services described in paragraph (1) may be provided only to an individual under 21 years of age whom the department identifies as no longer eligible for Medi-Cal solely due to the transition of BHT coverage from the waiver program under Section 1915(c) of the federal Social Security Act to the Medi-Cal state plan in accordance with this section and who meets all of the following criteria:
(A)He or she was enrolled in the home and community-based services waiver for persons with developmental disabilities under Section 1915(c) of the Social Security Act as of January 31, 2016.
(B)He or she was deemed to be institutionalized in order to establish eligibility under the terms of the waiver.
(C)He or she has not been found eligible under any other federally funded Medi-Cal criteria without a share of cost.
(D)He or she had received a BHT service from a regional center for persons with developmental disabilities as provided in Chapter 5 (commencing with Section 4620) of Division 4.5.
(e)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Notwithstanding Section 10231.5 of the Government Code, beginning six months after the effective date of this section, the department shall provide semiannual status reports to the Legislature, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(f)For the purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. Contracts may be statewide or on a more limited geographic basis. Contracts entered into or amended under this subdivision shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code, and shall be exempt from the review or approval of any division of the Department of General Services.
(g)The department may seek approval of any necessary state plan amendments or waivers to implement this section. The department shall make any state plan amendments or waiver requests public at least 30 days prior to submitting to the federal Centers for Medicare and Medicaid Services, and the department shall work with stakeholders to address the public comments in the state plan amendment or waiver request.
(h)This section shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
SEC. 3.SEC. 4.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(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 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:
(A)Is supervised by a qualified autism service provider or qualified autism service professional. 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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).
(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.
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 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 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(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.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:
(A)Is supervised by a qualified autism service provider or qualified autism service professional. 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 the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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.
(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)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. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(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 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(F)Is employed by a the qualified autism service provider or an entity or group that employs qualified autism service providers. providers responsible for the autism treatment plan.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:
(A)Is supervised by a qualified autism service provider or qualified autism service professional.
(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.
(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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 a the qualified autism service provider or an entity or group that employs qualified autism service providers. providers responsible for the autism treatment plan.
(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).
(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.
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 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 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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.
(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 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.
(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.
(F)Is employed by a the qualified autism service provider or an entity or group that employs qualified autism service providers. providers responsible for the autism treatment plan.
(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:
(A)Is supervised by a qualified autism service provider or qualified autism service professional.
(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.
(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(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 a the qualified autism service provider or an entity or group that employs qualified autism service providers. providers responsible for the autism treatment plan.
(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)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. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(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. 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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 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. treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.
(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 who 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 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. Program.
(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.
(F)Is employed by a qualified autism service provider or an entity or group that employs qualified autism service providers.
(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. provider or qualified autism service professional.
(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.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(D)Has adequate education, training, and experience, as certified by a qualified autism service provider. provider or an entity or group that employs qualified autism service providers.
(E)Is employed by a qualified autism service provider or an entity or group that employs qualified autism service providers.
(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.
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 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. 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 patients 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 plans goal and objectives, and the frequency at which the patients 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 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, 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 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. treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.
(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 who 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 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. Program.
(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.
(F)Is employed by a qualified autism service provider or an entity or group that employs qualified autism service providers.
(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. provider or qualified autism service professional.
(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.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.
(D)Has adequate education, training, and experience, as certified by a qualified autism service provider. provider or an entity or group that employs qualified autism service providers.
(E)Is employed by a qualified autism service provider or an entity or group that employs qualified autism service providers.
(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. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
|
Date
|
Status
|
|---|---|
| Sep 30, 2017 | Chaptered by Secretary of State - Chapter 385, Statutes of 2017. |
| Sep 30, 2017 | Approved by the Governor. |
| Sep 13, 2017 | Enrolled and presented to the Governor at 4 p.m. |
| Sep 7, 2017 | Senate amendments concurred in. To Engrossing and Enrolling. |
| Sep 5, 2017 | In Assembly. Concurrence in Senate amendments pending. May be considered on or after September 7 pursuant to Assembly Rule 77. |
| Sep 5, 2017 | Read third time. Passed. Ordered to the Assembly. |
| Aug 24, 2017 | Read second time and amended. Ordered to third reading. |
| Aug 23, 2017 | From committee: Amend, and do pass as amended. (Ayes 7. Noes 0.) (August 21). |
| Jul 12, 2017 | From committee: Do pass and re-refer to Com. on APPR. with recommendation: To Consent Calendar. (Ayes 7. Noes 0.) (July 11). Re-referred to Com. on APPR. |
| Jun 20, 2017 | Read second time and amended. Re-referred to Com. on HUMAN S. |
| Jun 19, 2017 | From committee: Amend, and do pass as amended and re-refer to Com. on HUMAN S. with recommendation: To Consent Calendar. (Ayes 9. Noes 0.) (June 14). |
| Jun 8, 2017 | Referred to Coms. on HEALTH and HUMAN S. |
| May 30, 2017 | In Senate. Read first time. To Com. on RLS. for assignment. |
| May 30, 2017 | Read third time. Passed. Ordered to the Senate. (Ayes 77. Noes 0. Page 1857.) |
| May 25, 2017 | Read second time. Ordered to Consent Calendar. |
| May 24, 2017 | From committee: Do pass. To Consent Calendar. (Ayes 17. Noes 0.) (May 24). |
| May 10, 2017 | Re-referred to Com. on APPR. |
| May 9, 2017 | From committee chair, with author's amendments: Amend, and re-refer to Com. on APPR. Read second time and amended. |
| May 1, 2017 | Re-referred to Com. on APPR. |
| Apr 27, 2017 | Read second time and amended. |
| Apr 26, 2017 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 15. Noes 0.) (April 25). |
| Mar 6, 2017 | Referred to Com. on HEALTH. |
| Feb 17, 2017 | From printer. May be heard in committee March 19. |
| Feb 16, 2017 | Read first time. To print. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Sep 7, 2017 | AB 1074 MAIENSCHEIN Concurrence in Senate Amendments | Assembly Floor |
Passed |
|
| Sep 5, 2017 | Assembly 3rd Reading AB1074 Maienschein By Mitchell | Senate Floor |
Passed |
|
| Aug 21, 2017 | Do pass as amended | Senate Standing Committee on Appropriations |
Passed |
|
| Jul 11, 2017 | Do pass, but first be re-referred to the Committee on [Appropriations] with the recommendation: To Consent Calendar | Senate Standing Committee on Human Services |
Passed |
|
| Jun 14, 2017 | Do pass as amended, but first amend, and re-refer to the Committee on [Human Services] with the recommendation: To Consent Calendar | Senate Standing Committee on Health |
Passed |
|
| May 30, 2017 | AB 1074 MAIENSCHEIN Consent Calendar Second Day Regular Session | Assembly Floor |
Passed |
|
| May 24, 2017 | Do pass. To Consent Calendar. | Assembly Standing Committee on Appropriations |
Passed |
|
| Apr 25, 2017 | Do pass as amended and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| Advanced Behavioral Pathways | ** Support | Aug 30, 2017 |
| Autism Speaks | ** Support | Aug 30, 2017 |
| California Association For Behavior Analysis | ** Support | Aug 30, 2017 |
| california association for behavioral analysis | ** Support | Jul 7, 2017 |
| California Consortium For Behavior Health Analysis | ** Support | Aug 30, 2017 |
| california consortium for behavioral analysis | ** Support | Jul 7, 2017 |
| California Council Of Behavior Health Agencies | ** Support | Aug 30, 2017 |
| California Council Of Community Behavioral Health Agencies | ** Support | Jul 7, 2017 |
| Center for Autism and Related Disorders | ** Support | Aug 30, 2017 |
CONCURRENCE IN SENATE AMENDMENTS
CSA1 Bill Id:AB 1074
Author:(Maienschein)
As Amended Ver:August 24, 2017
Majority vote
ASSEMBLY: | 77-0 | (May 30, 2017) | SENATE: | 40-0 | (September 5, 2017) |
Original Committee Reference: HEALTH
SUMMARY: Makes changes to the requirements for qualified autism service (QAS) providers and QAS paraprofessionals for purposes of behavioral health therapy (BHT) coverage by health care service plans (health plans) and health insurers. Specifically, this bill:
- Makes changes to existing employment, supervision, education and experience criteria to qualify as a QAS professional and paraprofessional.
- Deletes obsolete reference to the Healthy Families Program and exemption for California Public Employees' Retirement System (CalPERS) to cover BHT.
- Makes other clarifying, technical and non-substantive changes.
The Senate amendments add provisions to define BHT with respect to Medi-Cal, as 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 is administered by the California Department of Health Care Services as described in the approved state plan.
FISCAL EFFECT: According to Senate Appropriations:
- No significant enforcement costs are anticipated by either the Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI) due to the changes to the existing benefit mandate in the bill.
- No significant costs are anticipated for CalPERS health plans, due to the elimination of the existing exemption from the autism treatment benefit mandate. In addition to the explicit benefit mandate for coverage of autism treatment, separate federal and state mental health parity requirements and requirements for the provision of essential health benefits implicitly require coverage for behavioral health treatment for autism and related disorders. Therefore, elimination the exemption for CalPERS will not materially impact coverage for behavioral health treatment by CalPERS health plans.
- No costs are anticipated for the Medi-Cal program due to the changes in the bill.
COMMENTS: According to the author, this bill updates existing law relating to providers of BHT for children with autism to reflect existing practices and changes in the field. These changes remove unnecessary barriers and increase access to care.
SB 946 (Steinberg), Chapter 650, Statutes of 2011. SB 946 was signed into law on October 9, 2011 and imposes a temporary set of rules regarding BHT that health plans and health insurers in California must cover for individuals with autism and pervasive developmental disorder (PDD). SB 946 also identifies the required qualifications of individuals who provide BHT, and permits individuals who are not licensed by the state to provide BHT, as long as the specified criteria are met. SB 946 also required the DMHC to convene an Autism Advisory Task Force by February 1, 2012, to develop recommendations regarding medically necessary BHT for individuals with autism or PDD, as well as the appropriate qualifications, training and supervision for providers of such treatment.
BHT providers. According to background information provided by the sponsor, BHT is the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the direct observation, measurement and functional analysis of the relations between environment and behavior. BHT services teach skills through the use of behavioral observation and reinforcement, or through prompting to teach each step of targeted behavior. BHT services are based on reliable evidence and are not experimental. BHT services are designed to treat autism and include a variety of behavioral interventions that have been identified as evidenced-based by nationally recognized research reviews and/or other nationally recognized scientific and clinical evidence and are designed to be delivered primarily in the home and in other community settings.
The provision of BHT services in California is based upon the Applied Behavior Analysis (ABA) Guidelines published by the Behavior Analyst Behavior Board, a non-profit corporation established to meet professional credentialing needs identified by behavior analysts, governments, and consumers of behavior analysis services. Most ABA treatment programs involve a tiered service-delivery model in which the behavior analyst designs and supervises a treatment program delivered by assistant behavior analysts and behavior technicians. Behavior analyst's clinical, supervisory, and case management activities are often supported by other staff such as assistant behavior analysts working within the scope of their training, practice, and competence.
California Health Benefits Review Program (CHBRP) analysis. According to CHBRP, it is possible that this bill could affect 7.8 million Med-Cal beneficiaries enrolled in DMHC-regulated plans and an additional 1.5 million Medi-Cal beneficiaries enrolled in County Organized Health Systems (COHS) managed care and an additional 1.5 million Medi-Cal beneficiaries associated with the fee for service (FFS) program. Because no change in benefit coverage is expected, no change in utilization, expenditures, or public health outcomes is projected. There is a preponderance of evidence that intensive BHTs are effective in improving outcomes including cognitive functioning, language, social functioning, and adaptive behaviors. There is limited evidence that low-intensity BHTs are more effective in improving outcomes than usual care. There is a preponderance of evidence that BHTs delivered by persons with training similar to QAS professionals and paraprofessionals, as well as a variety of other specialized and non-specialist types of personnel, are effective when carried out under the training and supervision of a QAS provider. There is limited evidence that the inclusion of clinical management and case supervision in BHT can improve outcomes such as intellectual ability, learning objectives, and overall treatment fidelity.
According to CHBRP, although this bill would not alter the current benefit mandate's explicit exemption from compliance for DMHC-regulated plans enrolling Medi-Cal beneficiaries, the impact of this bill on Medi-Cal is unclear. The authorization or enabling legislation for coverage of BHT is the provisions being amended in this bill. Therefore, changes to the current mandate could impact the benefit coverage of the 7.9 million Medi-Cal beneficiaries enrolled in DMHC-regulated plans as well as the additional 3.0 million Medi-Cal beneficiaries enrolled in either COHS managed care or attached to the FFS program. However, because CHBRP expects no measureable impact from this bill to the benefit coverage of enrollees in privately funded DMHC-regulated plans or CDI-regulated policies, CHBRP would similarly expect no impact related to Medi-Cal beneficiaries. Additionally, although this bill would delete the current exemptions for CalPERS to provide BHT, this benefit is currently covered under California's Mental Health Parity benefit mandate. CHBRP has assumed that there would be no measurable impact on CalPERS.
The Center for Autism and Related Disorders, cosponsors of this bill, writes that the changes reflect existing practices in the field and remove unnecessary barriers for providers. The California Association of Behavior Analysis, cosponsors of this bill, states that this bill would refine language in current statute to ensure that legislation accurately reflects the practice as it looks on the ground. There is no registered opposition to this bill.
Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0001532
Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | AB 1074 |
THIRD READING
Bill No: AB 1074
Author: Maienschein (R), et al.
Amended: 8/24/17 in Senate
SENATE HEALTH COMMITTEE: 9-0, 6/14/17
AYES: Hernandez, Nguyen, Atkins, Leyva, Mitchell, Monning, Newman, Nielsen, Roth
SENATE HUMAN SERVICES COMMITTEE: 7-0, 7/11/17
AYES: Wiener, Berryhill, Glazer, Leyva, McGuire, Nguyen, Portantino
SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/21/17
AYES: Lara, Bates, Beall, Bradford, Hill, Nielsen, Wiener
ASSEMBLY FLOOR: 77-0, 5/30/17 (Consent) - See last page for vote
SUBJECT: Health care coverage: pervasive developmental disorder or autism
SOURCE: California Association for Behavior Analysis
Center for Autism and Related Disorders
DIGEST:
This bill permits a qualified autism service paraprofessional to be supervised by a qualified autism service professional; indicates that behavioral health treatment may include clinical case management and case supervision under the direction and supervision of a qualified autism service provide, deletes a requirement that a behavior service provider is approved as a vendor by a Regional Center based on provider definitions in specified regulations; and instead requires a behavior service provider to meet the education and experience qualifications described in the specified regulations; and, makes other technical changes.
Existing law:
- Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975 in the Health and Safety Code; the California Department of Insurance (CDI) to regulate health insurers under the Insurance Code; and, the California Health Benefit Exchange (Exchange) to compare and make available through selective contracting health insurance for individual and small business purchasers as authorized under the federal Patient Protection and Affordable Care Act (ACA).
- Establishes as California's essential health benefits benchmark the Kaiser Small Group Health Maintenance Organization plan, existing California mandates, and 10 ACA mandated benefits.
- Requires every health plan contract that provides hospital, medical, or surgical coverage and health insurance policy to also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. Requires the coverage to be provided in the same manner and to be subject to the same requirements as provided in California’s mental health parity law.
- Exempts from 3) above a specialized health plan or health insurance policy that does not deliver mental health or behavioral health services to enrollees, or an accident only, specified disease, hospital indemnity, or Medicare supplement policy, a health plan contract or health insurance policy under Medi-Cal or Healthy Families program, and a health care benefit plan or contract pursuant to the Public Employees’ Retirement System (PERS).
- Requires behavioral health treatment, as defined in the health insurance autism mandate state, to be a covered Medi-Cal service for individuals under 21 years of age. Requires the Department of Health Care Services (DHCS) to implement, or continue to implement, this requirement only after all of the following occurs or has occurred:
- DHCS receives all necessary federal approvals to obtain federal funds for the service;
- DHCS seeks an appropriation that would provide the necessary state funding estimated to be required for the applicable fiscal year; and,
- DHCS consults with stakeholders.
- Requires DHCS to develop and define eligibility criteria, provider participation criteria, utilization controls, and delivery system structure for services under 5) above, subject to limitations allowable under federal law, in consultation with stakeholders.
- Requires the Department of Social Services (DSS), with regard to a regional center, to adopt emergency regulations to address the use of paraprofessionals in group practice provider behavioral intervention services including the educational or experiential qualifications and professional supervision requirements necessary for the paraprofessional to provide behavioral intervention services.
- Requires pursuant to regulations promulgated by DSS a behavior management technician (paraprofessional) to meet the following requirements:
- Have a High School Diploma or the equivalent, completed 30 hours of competency-based training designed by a certified behavior analyst, and six months experience working with persons with developmental disabilities; or
- Possess an Associate's Degree in either a human, social, or educational services discipline, or a degree or certification related to behavior management, from an accredited community college or educational institution, and have six months experience working with persons with developmental disabilities.
This bill:
- Moves a requirement that a qualified autism service professional or paraprofessional be employed by a qualified autism service provider to other provisions of the law [see 3) and 4) below]. Permits a qualified autism service paraprofessional to be supervised by a qualified autism service professional.
- Clarifies that a qualified autism service provider is a person, and not an entity or group and that has a certification that is accredited by the National Commission for Certifying Agencies.
- Modifies the definition of qualified autism treatment professional, to:
- Indicate that behavioral health treatment may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider;
- Delete a requirement that a behavior service provider is approved as a vendor by a regional center based on provider definitions in specified regulations; and instead requires a behavior service provider to meet the education and experience qualifications described in the specified regulations; and,
- Require employment by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.
- Modifies the definition of qualified autism treatment paraprofessional, to:
- Permit supervision by a qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice;
- Delete the criteria requirements as specified in regulations, and instead require the education and training qualifications described in the specified regulation (Excludes a requirement to have six months experience working with persons with developmental disabilities.); and,
- 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.
- Deletes provisions that exempt health plans and health benefit plans that contract with Healthy Families and the Board of Administration of PERs, and health insurance policies under these programs.
- Defines “behavioral health treatment” with respect to Medi-Cal, as 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 is administered by the department as described in the approved state plan.
Comments
- Author’s statement. According to the author, this bill is needed to eliminate the burdensome and unnecessary vendor requirement for qualified autism service providers. This will reduce backlog in California’s regional centers, and increase the number of providers that are available to provide care. By clarifying the employment requirements for qualified autism service professionals and paraprofessionals, as well as the supervisory role of professionals, this bill will also make it easier for professionals and paraprofessionals to provide behavioral health treatment in a timely manner.
- Autism Spectrum Disorder. According to the National Institute for Mental Health, autism spectrum disorder is the name for a group of developmental disorders, which includes a wide range, “a spectrum,” of symptoms, skills, and levels of disability. People with autism spectrum disorder often have these characteristics: ongoing social problems that include difficulty communicating and interacting with others; repetitive behaviors as well as limited interests or activities; symptoms that typically are recognized in the first two years of life; symptoms that hurt the individual’s ability to function socially, at school or work, or other areas of life. Some people are mildly impaired by their symptoms, while others are severely disabled. Treatments and services can improve a person’s symptoms and ability to function. According to the Centers for Disease Control and Prevention around 1 in 68 children has been identified with some form of autism spectrum disorder. The California Health Benefits Review Program estimates that in 2016, the prevalence of autism spectrum disorder in California children (aged zero to nine) is about 160 in 10,000.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes
According to the Senate Appropriations Committee:
- No significant enforcement costs are anticipated by either DMHC or CDI due to the changes to the existing benefit mandate in the bill.
- No significant costs are anticipated for PERS health plans, due to the elimination of the existing exemption from the autism treatment benefit mandate. In addition to the explicit benefit mandate for coverage of autism treatment, separate federal and state mental health parity requirements and requirements for the provision of essential health benefits implicitly require coverage for behavioral health treatment for autism and related disorders. Therefore, elimination the exemption for PERS will not materially impact coverage for behavioral health treatment by PERS health plans.
- No costs are anticipated for the Medi-Cal program due to the changes in the bill.
California Association for Behavior Analysis (co-source)
Center for Autism and Related Disorders (co-source)
Advanced Behavioral Pathways
Autism Speaks
California Consortium for Behavior Health Analysis
California Council of Behavior Health Agencies
OPPOSITION: (Verified 8/22/17)
None received
ARGUMENTS IN SUPPORT: The Center for Autism and Related Disorders (CARD) writes that these changes reflect existing practices in the field and remove unnecessary barriers for providers, and that making these minor changes will provide clarity for employers and health plans, and increase access to care. Specifically, CARD writes that this bill removes the requirement for a professional to be an approved vendor at a California regional center, while maintaining the same education and experience qualifications currently used. Prior to the mandate to cover behavioral health treatment, children with autism received treatment at California regional centers. Since that time, coverage has moved away from regional centers and is now predominately funded by commercial insurance and Medi-Cal. Currently, the professional is still required to become a vendor, even though s/he will not be serving consumers in a regional center. This can create unnecessary paperwork for regional centers, cause delays with employment, and act as a barrier to maintaining an adequate network of providers. Additionally, this bill removes the experience requirement from the qualified autism service paraprofessional and maintains the education and training requirements. Current law requires six months of experience. However, no particular experience is specified, and the requirement has acted as a significant barrier to expanding the capacity of California providers to meet the needs of the autism community. The updated requirements reflect the industry standard. The bill also clarifies the ability of a qualified autism service professional, who is under the direct supervision of a qualified autism service provider, to provide clinical case management and clinical supervision to a qualified autism service paraprofessional. CARD indicates that in the field of autism treatment, the term supervise is used to describe clinical work, including professional supervision of lower tiered providers and case management, not administrative supervision. The California Association for Behavior Analysts writes that these changes would refine language in current statute to ensure that legislation accurately reflects the practice as it looks on the ground, and also remove unnecessary barriers for providers and provide increased access to care for the population served. Autism Speaks agrees that these changes remove unnecessary barriers and increase access to care.
ASSEMBLY FLOOR: 77-0, 5/30/17
AYES: Acosta, Aguiar-Curry, Travis Allen, Arambula, Baker, Berman, Bigelow, Bloom, Bocanegra, Bonta, Brough, Burke, Caballero, Calderon, Cervantes, Chávez, Chen, Chiu, Chu, Cooley, Cooper, Cunningham, Dababneh, Dahle, Daly, Flora, Fong, Frazier, Friedman, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gomez, Gonzalez Fletcher, Gray, Grayson, Harper, Holden, Irwin, Jones-Sawyer, Kalra, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Quirk, Quirk-Silva, Reyes, Ridley-Thomas, Rodriguez, Rubio, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Voepel, Waldron, Weber, Wood, Rendon
NO VOTE RECORDED: Chau, Choi, Eggman
8/30/17 17:31:03
**** END ****
SENATE COMMITTEE ON
Senator Ricardo Lara, Chair
2017 - 2018 Regular Session
AB 1074 (Maienschein) - Health care coverage: pervasive developmental disorder or autism
Version: | Policy Vote: |
Urgency: | Mandate: |
Hearing Date: | Consultant: |
This bill does not meet the criteria for referral to the Suspense File.
Bill Summary:
AB 1074 would make several changes to the training and supervision requirements for autism service providers. The bill would also make several technical changes to the current mandate for health plans and insurers to provide coverage for behavioral health treatment for autism.
Fiscal Impact:
- No significant enforcement costs are anticipated by either the Department of Managed Health Care or the Department of Insurance due to the changes to the existing benefit mandate in the bill.
- No significant costs are anticipated for CalPERS health plans, due to the elimination of the existing exemption from the autism treatment benefit mandate. In addition to the explicit benefit mandate for coverage of autism treatment, separate federal and state mental health parity requirements and requirements for the provision of essential health benefits implicitly require coverage for behavioral health treatment for autism and related disorders. Therefore, elimination the exemption for CalPERS will not materially impact coverage for behavioral health treatment by CalPERS health plans.
- No cost are anticipated for the Medi-Cal program due to the changes in the bill.
Background:
Current state law (SB 88, Thompson, Statutes of 1999) requires health plans and health insurers who provide hospital, medical, or surgical coverage to provide coverage for the diagnosis and treatment of severe mental illness (as specified in statute). In addition, health plans and health insurers are required to provide additional coverage for serious emotional disturbances of a child. In both cases, coverage is required to be provided under the same terms and conditions applied to other medical conditions. Under current federal law, health plans and health insurers that offer coverage for mental health or substance abuse disorders are required to provide that coverage under the same terms and conditions as other covered benefits. Collectively, these requirements are referred to as “mental health parity” requirements.
Current state law (SB 946, Steinberg, Statutes of 2011) specifically requires health plans and health insurers to cover behavioral health therapy for pervasive development disorder or autism. The statutory sunset in SB 946 was eliminated in AB 796 (Nazarian, Statutes of 2016).
Over the past several years, there have been a number of medical entities that have concluded that intensive behavioral treatments are effective in treating children and adults with autism. There are a several different types of behavioral health treatment. One of the best-known and most commonly accepted as being an evidence-based practice is Applied Behavioral Analysis.
Proposed Law:
AB 1074 would make several changes to the training and supervision requirements for autism service providers. The bill would also make several technical changes to the current autism treatment benefit mandate.
Specific provisions of the bill would:
- Add clinical case management and case supervision to the allowed duties of a “qualified autism service professional”;
- Delete the requirement that a qualified autism service professional be approved as a vendor by a California regional center and instead require the provider to meet the education and experience qualifications described in existing regulations governing regional center vendors;
- Authorize a “qualified autism service paraprofessional” to be supervised by a qualified autism service professional;
- Require paraprofessionals to meet the training and experience requirements in existing regulations;
- Delete the exemptions from the existing benefit mandate for health plans contracting with the Healthy Families Program and CalPERS;
- Delete the reference to the autism benefit mandate in the definition of the Medi-Cal benefit for behavioral health treatment and instead provide a specific definition for the provision of behavioral health treatment for the Medi-Cal program.
Related Legislation:
SB 399 (Portantino) would have made several changes to the benefit mandate for behavioral health treatment for autism. That bill was held in the Senate Health Committee.
Staff Comments:
According to an analysis of the bill by the California Health Benefits Review Program, there is no expected increase in utilization of services or health care costs under the bill.
Prior to the creation of an explicit mandate for health plans and insurers to provide coverage for behavioral health treatment for autism and the establishment of behavioral health treatment as a Medi-Cal benefit, most children received behavioral health treatment through the state’s regional center system. Therefore, most providers of behavioral health treatment had be approved as vendors with one or more regional centers. As coverage for behavioral health treatment has shifted to commercial health insurance and Medi-Cal, fewer behavioral health treatment providers are providing services through regional centers. By eliminating the requirement that those providers go through the “vendorization” process, the bill will make it easier for providers to begin seeing patients and reduce administrative workload for the regional centers.
Under current law, Medi-Cal managed care plans are exempt from the explicit health benefit mandate in the Health and Safety Code, but a separate provision of the Welfare and Institutions Code defines the existing Medi-Cal coverage requirement for behavioral health treatment as defined in the benefit mandate section of law. This bill revises the Welfare and Institutions Code section to eliminate the connection between the Medi-Cal benefit and the commercial health insurance benefit mandate.
The only costs that may be incurred by a local agency relate to crimes and infractions. Under the California Constitution, such costs are not reimbursable by the state.
Author’s amendments: would make technical corrections and add a coauthor.
-- END --
SENATE COMMITTEE ON HUMAN SERVICES
Senator Wiener, Chair
2017 - 2018 Regular
Bill No: AB 1074
Author: | Maienschein | ||
Version: | June 20, 2017 | Hearing Date: | July 11, 2017 |
Urgency: | No | Fiscal: | Yes |
Consultant: | Mareva Brown | ||
Subject: Health care coverage: pervasive developmental disorder or autism
SUMMARY
This bill permits a qualified autism service paraprofessional to be supervised by a qualified autism service professional and indicates that behavioral health treatment may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. Further, it deletes a requirement that a behavior service provider must be approved as a vendor by a regional center based on provider definitions in specified regulations; and instead requires a behavior service provider to meet the education and experience qualifications described in the specified regulations, and makes other technical changes.
ABSTRACT
Existing law:
- Establishes the Lanterman Developmental Disabilities Services Act, which states that California is responsible for providing an array of services and supports sufficiently complete to meet the needs and choices of each person with developmental disabilities, regardless of age or degree of disability, and at each stage of life and to support their integration into the mainstream life of the community. (WIC 4500, et seq.)
- Establishes a system of nonprofit regional centers, overseen by the Department of Developmental Services (DDS), to provide fixed points of contact in the community for all persons with developmental disabilities and their families, to coordinate services and supports best suited to them throughout their lifetime. (WIC 4620)
- Establishes an Individual Program Plan (IPP) and defines that planning process as the vehicle to ensure that services and supports are customized to meet the needs of consumers who are served by regional centers. (WIC 4512)
- Requires every health care service plan contract that provides hospital, medical, or surgical coverage to also provide coverage for behavioral health treatment for pervasive developmental disorder or autism, as specified. (WIC 1374.73. (a) (1))
- Requires that every health care service plan 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. (WIC 1374.73 (b))
- Defines behavioral health treatment, for purposes of payment under a health care service plan contract or a health insurance policy, as professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, which develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism. (HSC 1374.73(c)(1), INS 10144.51(c)(1))
- Further requires treatment to be prescribed by a physician or surgeon, as specified, and that it be provided by a qualified autism provider, or a qualified autism professional paraprofessional who is supervised and employed by a qualified autism provider. (HSC 1374.73(c)(1), INS 10144.51(c)(1))
- Includes in the definition of a "qualified autism service professional" 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. (HSC 1374.73 (c)(4)(D), INS 10144.51(c)(4)(D))
- Defines in state regulations, for purposes of regional center vendorization, the qualifications to be a Behavior Management Assistant, Behavior Management Consultant, Behavior Analyst and Associate Behavior Analyst and requires education or experience in ABA, certification by a national entity, as specified. (17 CCR §54342)
This bill:
- Removes the requirement that a qualified autism service professional or paraprofessional be directly employed by a qualified autism service provider, and clarifies that a provider is an individual, not an organization.
- Requires instead that the qualified autism service professional or paraprofessional be employed either by the provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.
- Permits a qualified autism service paraprofessional to be supervised by a qualified autism service professional.
- Permits a qualified autism service professional to provide clinical case management and case supervision under the direction and supervision of a qualified autism service provider, in addition to providing behavioral health treatment.
- Removes the requirement that a qualified autism service professional or paraprofessional be approved as vendors by a California regional center to provide services, yet retains the requirement to meet the same education and experience qualifications of regional center vendors for the same service.
- Deletes provisions that exempt health plans and health benefit plans that contract with Healthy Families and PERs, from the requirement to provide behavioral health treatment.
- Defines for the purposes of Medi-Cal treatment “behavioral health treatment” or “BHT” to mean professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and are administered by the department as described in the approved state plan.
FISCAL IMPACT
According to an analysis by the Assembly Appropriations Committee, costs are expected to be minor and absorbable to the Department of Managed Health Care (Managed Care Fund) and the Department of Insurance (Insurance Fund).
BACKGROUND AND DISCUSSION
Purpose of the bill:
According to the author, this bill makes changes to remove “the burdensome and unnecessary vendor requirement” for qualified autism service providers to provide behavioral health treatment within medical plans. The author further states the changes in this will reduce backlog in California’s regional centers and increase the number of providers that are available to provide care. “By clarifying the employment requirement of qualified autism service professionals and paraprofessionals, as well as the supervisory role of professionals, this bill will also make it easier for professionals and paraprofessionals to provide BHT in a timely manner,” the author states.
Background:
Autism is a neurodevelopmental disorder characterized by difficulty in language, social interaction, and by the presence of repetitive and stereotyped behaviors. The National Institutes of Health (NIH) describes autism as the most severe form of a range of conditions that together make up Autism Spectrum Disorder (ASD).
The most notable feature of ASD is impaired social interaction, according to the NIH. An infant with ASD may not respond to people or may focus intently on one item to the exclusion of others for long periods of time. Children with ASD may avoid eye contact with other people, or not respond to verbal commands or conversation. They cannot interpret facial expressions or changes in voice inflection, so they do not understand what others are thinking or feeling.
ASD occurs in all ethnic and socioeconomic groups and affects every age group. Males are four times more likely to have an ASD than females. DDS data shows that in April 2017, more than 93,000 regional center consumers had a diagnosis of autism or the related pervasive developmental disorder – slightly more than one-third of all consumers. For one-quarter of DDS consumers statewide, autism-related disorders is the only identified developmental disability.
The number of children diagnosed with autism has grown exponentially in the past few decades. Studies published before 1985, reported prevalence rates of 4 to 5 per 10,000 children for the broader autism spectrum. According to data published by the Centers for Disease Control and Prevention (CDC), 1 in 68 children aged 3 to 17 are diagnosed with ASD.[1] Significantly more boys than girls are diagnosed with the disorder.
Applied Behavioral Analysis (ABA)
The most recognized form of behavioral health treatment for autism is ABA, a scientifically validated method of treatment which focuses on positive reinforcement and intensive teaching to bring about a change in behavior. ABA has been acknowledged as effective by the US Surgeon General, the US Department of Education and others. Although ABA can be used with both children and adults, it is commonly associated with intensive treatment of young children who have autism. Through repetitive intervention and positive feedback, children are taught communication, social skills, play, self-care and other skills appropriate for school-based learning.
Studies have demonstrated that many children with autism experience significant improvements in learning, reasoning, communication and adaptability when they participate in high-quality ABA programs. Studies have shown that some children who participate in early, intensive ABA for two or more years before they are school aged can acquire sufficient skills to participate in regular classrooms with little or no support.
Behavioral Health Treatment coverage
SB 946 (Steinberg, Chapter 650, Statutes of 2011) required health plans to begin covering treatment for autism, which previously had been the responsibility of DDS and its 21 associated nonprofit regional centers. In doing so, the plans use criteria developed by DDS for behavioral health treatment vendors.
Medi-Cal was required to cover behavioral health treatment beginning in February 2016, prompting a shift of coverage for most of the rest of the Regional Center population. Under Medi-Cal rules, medically necessary treatment must be provided for Essential Health Benefits, including BHT, upon the recommendation of a licensed physician or other specified health professional. As a result of these two shifts in responsibility, the regional centers and DDS became responsible for a fraction of the BHT delivered, yet state law requires providers be vendored by the regional centers.
According to a review by the California Health Benefits Review Program (CHBRP) of this bill, there is a preponderance of evidence that intensive behavioral therapies are effective in improving outcomes, including cognitive function, language, social function and adaptive behaviors. There is limited evidence that low-intensity behavioral health therapies are more effective in improving outcomes than usual care.
The CHBRP analysis also identified a preponderance of evidence that behavioral health treatment delivered by persons with training similar to qualified autism service professionals and paraprofessionals as well as a variety of other specialized and non-specialist types of personnel are effective when carried out under the training and supervision of a qualified autism service provider.
Regional Centers
A developmental disability is defined as a disability that originates before an individual attains 18 years of age, is expected to continue indefinitely, and constitutes a substantial disability for that individual. It includes intellectual disabilities, cerebral palsy, epilepsy, and autism spectrum disorders (ASD).
Individuals with developmental disabilities are entitled to services under the Lanterman Act, and California’s 21 non-profit regional centers provide local services and supports to approximately 310,000 individuals through contracts with DDS. Regional centers provide diagnosis and assess of eligibility for services. For individuals who qualify, regional center case managers help plan, access, coordinate and monitor the services and supports that are needed. Services for consumers are determined through an IPP. Additionally, regional centers share primary responsibility with local education agencies for provision of early intervention services under the California Early Intervention Services Act.
California Code of Regulations
Title 17 CCR §54342 defines various types of service providers for regional center consumers, from occupational therapists to psychologists, and specifies the type of billing code for regional centers to use for each. This bill retains the definitions and required certifications that are currently in statute and regulation, but removes the requirement that BHT professionals be regional center vendors. Definitions in regulation include:
- Behavior Analyst assesses the function of a behavior of a consumer and designs, implements, and evaluates instructional and environmental modifications to produce socially significant improvements in the consumer's behavior, as specified. Permits a regional center to classify a vendor as a Behavior Analyst if the individual is certified by the national Behavior Analyst Certification Board as a Board Certified Behavior Analyst.
- An Associate Behavior Analyst provides the same analysis and treatment, under direct supervision of a Behavior Analyst or Behavior Management Consultant. Permits a regional center to classify a vendor as an Associate Behavior Analyst if recognized as a Board Certified Associate Behavior Analyst, as specified.
- A Behavior Management Consultant designs or implements behavior modification intervention services, has completed 12 semester units in applied behavior analysis and possesses a license as a psychologist or other specified professional and has two years of experience in designing and implementing these interventions.
- A Behavior Management Assistant designs or implements behavior modification intervention services under the direct supervision of a behavior management consultant or under direct supervision of a Behavior Analyst or Behavior Management Consultant, as specified. Regulations specify educational, training and professional requirements.
Related legislation:
SB 399 (Portantino, 2017) contained similar language, but additionally would have broadened the definition of provider categories, or extend the mandated timeline for review of the treatment plan. It was held in the Senate Health Committee.
SB 796 (Nazarian, Chapter 493, Statutes of 2016) contained similar language, as well as deleting the sunset date on requiring health plans and insurers to pay for behavioral health treatment. Only the sunset date deletion was passed and signed into law.
SB 1034 (Mitchell, 2016) modifies the requirements of a qualified autism service professional and requires that a treatment plan be reviewed no more than once every six months, unless a shorter period is recommended by the qualified autism service provider.
AB 2041 (Jones, 2014) would have expanded the scope of treatment providers in the regional center vendor system to include a behavior management consultant or behavior management assistant, with specified requirements.
SB 946 (Steinberg) Chapter 650, statutes of 2011 required health plans and insurers to pay for behavioral health treatment when a consumer’s IPP identified the need.
PRIOR VOTES
Senate Health 9 - 0
Assembly Floor: | 77 - 0 |
Assembly Appropriations Committee: | 17 - 0 |
Assembly Health Committee: | 15 - 0 |
POSITIONS
Support:
California Association for Behavioral Analysis (Co-Sponsor)
The Center for Autism and Related Disorders (Co-Sponsor)
Advanced Behavioral Pathways
Autism Speaks
California Consortium for Behavioral Analysis
California Council of Community Behavioral Health Agencies
Oppose:
None received.
-- END --
https://www.cdc.gov/ncbddd/autism/data.html ↑
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1074
AUTHOR: | Maienschein | ||
VERSION: | May 9, 2017 | ||
HEARING DATE: | June 14, 2017 | ||
CONSULTANT: | Teri Boughton | ||
SUBJECT: Health care coverage: pervasive developmental disorder or autism
SUMMARY:
Permits a qualified autism service paraprofessional to be supervised by a qualified autism service professional; indicates that behavioral health treatment may include clinical case management and case supervision under the direction and supervision of a qualified autism service provide, deletes a requirement that a behavior service provider is approved as a vendor by a Regional Center based on provider definitions in specified regulations; and instead requires a behavior service provider to meet the education and experience qualifications described in the specified regulations; and, makes other technical changes.
Existing law:
- Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975 in the Health and Safety Code; the California Department of Insurance (CDI) to regulate health insurers under the Insurance Code; and, the California Health Benefit Exchange (Exchange) to compare and make available through selective contracting health insurance for individual and small business purchasers as authorized under the federal Patient Protection and Affordable Care Act (ACA).
- Establishes as California's essential health benefits (EHBs) benchmark the Kaiser Small Group Health Maintenance Organization plan, existing California mandates, and the following 10 ACA mandated benefits:
- 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.
- Requires every health plan contract that provides hospital, medical, or surgical coverage and health insurance policy to also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. Requires the coverage to be provided in the same manner and to be subject to the same requirements as provided in California’s mental health parity law.
- Exempts from 3) above a specialized health plan or health insurance policy that does not deliver mental health or behavioral health services to enrollees, or an accident only, specified disease, hospital indemnity, or Medicare supplement policy, a health plan contract or health insurance policy under Medi-Cal or Healthy Families program, and a health care benefit plan or contract pursuant to the Public Employees’ Retirement System (PERS).
- Requires behavioral health treatment, as defined in the health insurance autism mandate state, to be a covered Medi-Cal service for individuals under 21 years of age. Requires the Department of Health Care Services (DHCS) to implement, or continue to implement, this requirement only after all of the following occurs or has occurred:
- DHCS receives all necessary federal approvals to obtain federal funds for the service;
- DHCS seeks an appropriation that would provide the necessary state funding estimated to be required for the applicable fiscal year; and,
- DHCS consults with stakeholders.
- Requires DHCS to develop and define eligibility criteria, provider participation criteria, utilization controls, and delivery system structure for services under 5) above, subject to limitations allowable under federal law, in consultation with stakeholders.
- Requires the Department of Social Services (DSS), with regard to a regional center, to adopt emergency regulations to address the use of paraprofessionals in group practice provider behavioral intervention services including the educational or experiential qualifications and professional supervision requirements necessary for the paraprofessional to provide behavioral intervention services.
- Requires pursuant to regulations promulgated by DSS a behavior management technician (paraprofessional) to meet the following requirements:
- Have a High School Diploma or the equivalent, completed 30 hours of competency-based training designed by a certified behavior analyst, and six months experience working with persons with developmental disabilities; or
- Possess an Associate's Degree in either a human, social, or educational services discipline, or a degree or certification related to behavior management, from an accredited community college or educational institution, and have six months experience working with persons with developmental disabilities.
This bill:
- Moves a requirement that a qualified autism service professional or paraprofessional be employed by a qualified autism service provider to other provisions of the law [see 3) and 4) below]. Permits a qualified autism service paraprofessional to be supervised by a qualified autism service professional.
- Clarifies that a qualified autism service provider is a person, and not an entity or group and that has a certification that is accredited by the National Commission for Certifying Agencies.
- Modifies the definition of qualified autism treatment professional, to:
- Indicate that behavioral health treatment may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider;
- Delete a requirement that a behavior service provider is approved as a vendor by a regional center based on provider definitions in specified regulations; and instead requires a behavior service provider to meet the education and experience qualifications described in the specified regulations; and,
- Require employment by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.
- Modifies the definition of qualified autism treatment paraprofessional, to:
- Permit supervision by a qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice;
- Delete the criteria requirements as specified in regulations, and instead require the education and training qualifications described in the specified regulation (Excludes a requirement to have six months experience working with persons with developmental disabilities.); and,
- 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.
- Deletes provisions that exempt health plans and health benefit plans that contract with Healthy Families and the Board of Administration of PERs, and health insurance policies under these programs.
FISCAL EFFECT:
Costs are expected to be minor and absorbable to the Department of Managed Health Care (Managed Care Fund) and the Department of Insurance (Insurance Fund).
PRIOR VOTES:
Assembly Floor: | 77 - 0 |
Assembly Appropriations Committee: | 17 - 0 |
Assembly Health Committee: | 15 - 0 |
COMMENTS:
- Author’s statement. According to the author, this bill is needed to eliminate the burdensome and unnecessary vendor requirement for qualified autism service providers. This will reduce backlog in California’s regional centers, and increase the number of providers that are available to provide care. By clarifying the employment requirements for qualified autism service professionals and paraprofessionals, as well as the supervisory role of professionals, this bill will also make it easier for professionals and paraprofessionals to provide behavioral health treatment in a timely manner.
- Background on Autism Spectrum Disorder. According to the National Institute for Mental Health, autism spectrum disorder is the name for a group of developmental disorders, which includes a wide range, “a spectrum,” of symptoms, skills, and levels of disability. People with autism spectrum disorder often have these characteristics: ongoing social problems that include difficulty communicating and interacting with others; repetitive behaviors as well as limited interests or activities; symptoms that typically are recognized in the first two years of life; symptoms that hurt the individual’s ability to function socially, at school or work, or other areas of life. Some people are mildly impaired by their symptoms, while others are severely disabled. Treatments and services can improve a person’s symptoms and ability to function. According to the Centers for Disease Control and Prevention (CDC) around 1 in 68 children has been identified with some form of autism spectrum disorder. The California Health Benefits Review Program (CHBRP) estimates that in 2016, the prevalence of autism spectrum disorder in California children (aged zero to nine) is about 160 in 10,000.
- California Health Benefits Review Program (CHBRP) analysis. AB 1996 (Thomson, Chapter 795, Statutes of 2002) requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996, and reviewed this bill. CHBRP’s analysis is based on an earlier version of this bill and does not incorporate the April 17, 2017 amendments. Key findings related to parental involvement, setting and location, or time of treatment, frequency of review of treatment plan include:
- Coverage impacts and enrollees covered. Postmandate, CHBRP anticipates no change;
- Essential health benefits. CHBRP believes this bill would not trigger financial costs to the state for exceeding EHBs because this bill alters the terms and conditions of an existing benefit mandate, but does not require an additional benefit to be covered. CHBRP also points to a provision in the existing mandate law that indicates that the law would cease to function if it exceeds EHBs. However, the actual provision states that Notwithstanding paragraph (1), as of the date that proposed final rulemaking for EHBS is issued, this section does not require any benefits to be provided that exceed the EHBs that all health plans will be required by federal regulations to provide under the ACA;
- Medical effectiveness. There is a preponderance of evidence that intensive behavioral health therapies are effective in improving outcomes including cognitive functioning, language, social functioning, and adaptive behaviors. There is limited evidence that low-intensity behavioral health therapies are more effective in improving outcomes than usual care. There is a preponderance of evidence that behavioral health therapies delivered by persons with training similar to qualified autism service professionals and paraprofessionals, as well as a variety of other specialized and non-specialist types of personnel, are effective when carried out under the training and supervision of a qualified autism service provider. There is limited evidence that the inclusion of clinical management and case supervision in behavioral health treatment can improve outcomes such as intellectual ability, learning objectives, and overall treatment fidelity;
- Impact on expenditures. Because no change in benefit coverage is expected, no change in utilization, expenditures, or public health outcomes is projected. CHBRP indicates that case management and care supervision are both reported as currently covered aspects of behavioral health treatment for autism spectrum disorder. Although, this bill would make alterations to provider definitions, CHBRP does not anticipate measureable change within the first year of implementation;
- Medi-Cal. The interaction of the bill, the current benefit mandate it would alter, and the Medi-Cal law is unclear. It is possible that this bill could be relevant to the benefit coverage of Med-Cal beneficiaries enrolled in a DMHC-regulated plans as well as those associated with the Medi-Cal fee-for-service program or county organized health system managed care. However, because CHBRP expects no measurable impact from this bill to the benefit coverage of enrollees in privately funded plans or policies, CHBRP would expect no impact related to Medi-Cal beneficiaries; and,
- CalPERS. This bill would end the current benefit mandate’s explicit exemption for the benefit coverage of enrollees and insureds associated with CalPERS, the interaction of the current benefit mandate, California’s separate Mental Health Parity benefit mandate, and case law are complex. However, CHBRP expects no measurable impact since there is no impact to health plans or insurers.
- Double Referral. This bill is double referred. Should it pass out of this committee, it will be referred to the Senate Committee on Human Services.
- Related legislation. SB 399 (Portantino) makes several changes to the mandate on health plans and health insurers to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, including revising the definition of behavioral health treatment to include other evidence-based behavior interventions that maintain the functioning of the individual, requiring the plan to include parent or caregiver participation that takes into account the ability of the parent or caregiver to participate in therapy sessions and activities, and broadens the eligibility criteria to become a qualified autism service professional and paraprofessional. SB 399 is pending in the Senate Health Committee.
- Prior legislation. AB 796 (Nazarian, Chapter 493, Statutes of 2016) eliminated the sunset date on the health insurance mandate to cover behavioral health treatment for pervasive developmental disorder or autism.
SB 1034 (Mitchell of 2016) would have eliminated the sunset date on the health insurance mandate to cover behavioral health treatment for pervasive developmental disorder or autism, and made other revisions to the law such as prohibiting denials for medically necessary behavioral health treatment based on the setting, location or time of the treatment. SB 1034 died in the Assembly Appropriations Committee.
AB 1715 (Holden of 2016) would have established the Behavior Analyst Act (Act), which provides for the licensure, registration, and regulation of behavior analysts and assistant behavior analysts, and requires the California Board of Psychology, until January 1, 2022, to administer and enforce the Act. AB 1715 died in the Senate Business, Professions and Economic Development Committee.
SB 479 (Bates of 2015) would have established the Behavior Analyst Act, which provided for the licensure, registration, and regulation of behavior analysts and assistant behavior analysts, and required the California Board of Psychology, until January 1, 2021, to administer and enforce the Act. SB 479 died in the Assembly Appropriations Committee.
AB 2041 (Jones of 2014) would have required that a regional center classify a vendor as a behavior management consultant or behavior management assistant if the vendor designs or implements evidence-based behavioral health treatment, has a specified amount of experience in designing or implementing that treatment, and meets other licensure and education requirements. AB 2041 would have required DDS to amend its regulations as necessary to implement the provisions of the bill. AB 2041 died in the Senate Appropriations Committee.
SB 126 (Steinberg, Chapter 680, Statutes of 2013) extends, until January 1, 2017, the sunset date of an existing state health benefit mandate that requires health plans and health insurance policies to cover behavioral health treatment for pervasive developmental disorder or autism and requires plans and insurers to maintain adequate networks of these service providers.
SB 946 (Steinberg, Chapter 650, Statutes of 2011) requires health plans and health insurance policies to cover behavioral health treatment for pervasive developmental disorder or autism, requires health plans and insurers to maintain adequate networks of autism service providers, establishes a task force in DMHC, sunsets the autism mandate provisions on July 1, 2014, and makes other technical changes to existing law regarding HIV reporting and mental health services payments.
SB 770 (Steinberg of 2010) would have required health plans and insurance policies to provide coverage for behavioral health treatment. SB 770 was held in the Assembly Appropriations Committee.
SB 166 (Steinberg of 2011) would have required health care service plans licensed by DMHC and health insurers licensed by CDI to provide coverage for behavioral health treatment for autism. SB 166 was held in the Senate Health Committee.
AB 1205 (Bill Berryhill of 2011) would have required the Board of Behavioral Sciences to license behavioral analysts and assistant behavioral analysts, on and after January 1, 2015, and included standards for licensure such as specified higher education and training, fieldwork, passage of relevant examinations, and national board accreditation. AB 1205 was held in the Assembly Appropriations Committee on the suspense file.
- Support. The Center for Autism and Related Disorders (CARD) writes that these changes reflect existing practices in the field and remove unnecessary barriers for providers, and that making these minor changes will provide clarity for employers and health plans, and increase access to care. Specifically, CARD writes that this bill removes the requirement for a professional to be an approved vendor at a California regional center, while maintaining the same education and experience qualifications currently used. Prior to the mandate to cover behavioral health treatment, children with autism received treatment at California regional centers. Since that time, coverage has moved away from regional centers and is now predominately funded by commercial insurance and Medi-Cal. Currently, the professional is still required to become a vendor, even though s/he will not be serving consumers in a regional center. This can create unnecessary paperwork for regional centers, cause delays with employment, and act as a barrier to maintaining an adequate network of providers. Additionally, this bill removes the experience requirement from the qualified autism service paraprofessional and maintains the education and training requirements. Current law requires six months of experience. However, no particular experience is specified, and the requirement has acted as a significant barrier to expanding the capacity of California providers to meet the needs of the autism community. The updated requirements reflect the industry standard. The bill also clarifies the ability of a qualified autism service professional, who is under the direct supervision of a qualified autism service provider, to provide clinical case management and clinical supervision to a qualified autism service paraprofessional. CARD indicates that in the field of autism treatment, the term supervise is used to describe clinical work, including professional supervision of lower tiered providers and case management, not administrative supervision. The California Association for Behavior Analysts writes that these changes would refine language in current statute to ensure that legislation accurately reflects the practice as it looks on the ground, and also remove unnecessary barriers for providers and provide increased access to care for the population served. Autism Speaks agrees that these changes remove unnecessary barriers and increase access to care.
- Amendments. The author requests the committee adopt the following amendments to address technical assistance provided by DMHC and DHCS:
HSC §1374.73(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise and or 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.
INS §10144.51 (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 or 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.
WSC §14132.56 (a)(1) Only to the extent required by the federal government and effective no sooner than required by the federal government, BHT, as defined by Section 1374.73 of the Health and Safety Code, shall be a covered Medi-Cal service for individuals under 21 years of age.
(3) For purposes of this section, “behavioral health treatment” means professional services and treatment programs, including applied behavior analysis (ABA) 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 is administered by the department as described in the approved state plan.
SUPPORT AND OPPOSITION:
Support: California Association for Behavior Analysis (cosponsor)
Center for Autism and Related Disorders (cosponsor)
Autism Speaks
Oppose: None Received
-- END --
Date of Hearing: May 24, 2017
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Lorena Gonzalez Fletcher, Chair
ABPCA Bill Id:AB 1074
Author:(Maienschein) – As Amended Ver:May 9, 2017
Policy Committee: | Health | Vote: | 15 - 0 |
Urgency: No State Mandated Local Program: Yes Reimbursable: No
SUMMARY:
This bill changes the existing structure of who qualifies to provide behavioral health therapy (BHT) for purposes of coverage by health plans and insurers. Specifically, this bill
- Modifies employment, supervision, education, and experience criteria for a qualified autism services (QAS) professional and a QAS paraprofessional.
- Removes the requirement for a professional to be an approved vendor at a California regional center.
- Makes other minor, technical, and related changes, including a non-substantive change that removes an exemption for CalPERS and the defunct Healthy Families Program.
FISCAL EFFECT:
Costs are expected to be minor and absorbable to the Department of Managed Health Care (Managed Care Fund) and the Department of Insurance (Insurance Fund).
COMMENTS:
- Purpose. According to the author, this bill updates existing law relating to providers of behavioral health treatment (BHT) for children with autism to reflect existing practices and changes in the field. These changes remove unnecessary barriers and will streamline access to care.
- Background. BHT is the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior. The state's BHT mandate [(SB 946 (Steinberg), Chapter 650, Statutes of 2011], imposes a set of rules regarding BHT that health plans and health insurers in California must cover for individuals with autism. SB 946 also sets up a structure of QAS providers, professionals, and paraprofessionals, and identifies the required qualifications of each. These criteria were necessary to permit non-licensed individuals by the state to provide BHT. BHT has also been found to be required under different provisions of law, namely under regulatory interpretation of federal mental health parity laws for commercial plans, and under federal Centers for Medicare and Medicaid Services (CMS) guidance for Medi-Cal. However, the structure and qualifications of providers pursuant to SB 946 prescribes the delivery of care by private health plans and Medi-Cal. This bill updates the statute to reflect changes in the BHT delivery system,
Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081
Date of Hearing: April 25, 2017
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
ABPCA Bill Id:AB 1074
Author:(Maienschein) – As Introduced Ver:February 16, 2017
SUBJECT: Health care coverage: pervasive developmental disorder or autism.
SUMMARY: Makes changes to the requirements for qualified autism service (QAS) providers and QAS paraprofessionals for purposes of behavioral health therapy (BHT) coverage by health care service plans (health plans) and health insurers. Specifically, this bill:
- Deletes the existing requirement for a QAS provider or QAS paraprofessional to be employed by a supervisor in order to administer BHT.
- Redefines a QAS provider to mean a person and not an entity or group, as specified, and clarifies a certification requirement.
- Makes the following changes to existing criteria to qualify as a QAS professional:
- Provides that BHT includes clinical case management and case supervision under the direction of a QAS provider;
- Meets education and experience qualification, as described; and,
- Is employed by a QAS provider or an entity or group that employs QAS providers.
- Makes the following changes to existing criteria for QAS paraprofessionals:
- Deletes the requirement to be employed by a QAS provider and allows supervision by a QAS professional;
- Meets specified education and training qualifications, as described;
- Allows certification by an entity or group that employs QAS providers; and,
- Is employed by a QAS provider or an entity or group that employs QAS providers.
- Deletes obsolete reference to the Healthy Families Program.
- Deletes the exemption for California Public Employees' Retirement System (CalPERS) to cover BHT.
- Makes other clarifying, technical and non-substantive changes
EXISTING LAW:
- Establishes the Department of Managed Health Care (DMHC) to regulate health plans; the California Department of Insurance (CDI) to regulate health insurers; and, the California Health Benefit Exchange (the Exchange or Covered California) to compare and make available through selective contracting health insurance for individual and small business purchasers as authorized under the federal Patient Protection and Affordable Care Act.
- Under federal law, requires large group carriers that cover mental health or substance use disorders to ensure that financial requirements (such as copays and deductibles) and treatment limitations (such as visit limits) applicable to mental health benefits are no more restrictive than those applied to medical or surgical benefits.
- Requires issuers of individual and small group coverage to, at a minimum, cover essential health benefits (EHBs) in the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including BHT; 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.
- Requires every health plan contract that provides hospital, medical, or surgical coverage and health insurance policy to also provide coverage for BHT for pervasive developmental disorder (PDD) or autism no later than July 1, 2012. Requires the coverage to be provided in the same manner and to be subject to the same requirements as provided in California’s mental health parity law.
- Defines BHT to mean specified services provided by, among others, a QAS professional supervised and employed by a qualified autism service provider. Defines a QAS 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.
- Exempts from 4) above a specialized health plan or health insurance policy that does not deliver mental health or behavioral health services to enrollees, or an accident only, specified disease, hospital indemnity, or Medicare supplement policy, a health plan contract or health insurance policy under Medi-Cal or Healthy Families Program, and a health care benefit plan or contract with CalPERS.
- Establishes the Medi-Cal program, administered by the Department of Health Care Services, under which qualified low-income individuals receive health care benefits, including coverage for BHT services for individuals under 21 years of age with autism and as defined in existing law.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
- PURPOSE OF THIS BILL. According to the author, this bill updates existing law relating to providers of BHT for children with autism to reflect existing practices and changes in the field. These changes remove unnecessary barriers and increase access to care.
- BACKGROUND.
- SB 946 (Steinberg), Chapter 650, Statutes of 2011. SB 946 was signed into law on October 9, 2011 and imposes a temporary set of rules regarding BHT that health plans and health insurers in California must cover for individuals with autism and PDD. SB 946 also identifies the required qualifications of individuals who provide BHT, and permits individuals who are not licensed by the state to provide BHT, as long as the specified criteria are met. SB 946 also required the DMHC to convene an Autism Advisory Task Force (Task Force) by February 1, 2012, to develop recommendations regarding medically necessary BHT for individuals with autism or PDD, as well as the appropriate qualifications, training and supervision for providers of such treatment. SB 946 also required the Task Force to develop recommendations regarding the education, training, and experience requirements that unlicensed individuals providing BHT must meet in order to obtain licensure from the state.
- BHT providers. According to background information provided by the sponsor, BHT is the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the direct observation, measurement and functional analysis of the relations between environment and behavior. BHT services teach skills through the use of behavioral observation and reinforcement, or through prompting to teach each step of targeted behavior. BHT services are based on reliable evidence and are not experimental. BHT services are designed to treat autism and include a variety of behavioral interventions that have been identified as evidenced-based by nationally recognized research reviews and/or other nationally recognized scientific and clinical evidence and are designed to be delivered primarily in the home and in other community settings.
The provision of BHT services in California is based upon the Applied Behavior Analysis (ABA) Guidelines published by the Behavior Analyst Behavior Board, a non-profit corporation established to meet professional credentialing needs identified by behavior analysts, governments, and consumers of behavior analysis services. Most ABA treatment programs involve a tiered service-delivery model in which the behavior analyst designs and supervises a treatment program delivered by assistant behavior analysts and behavior technicians. Behavior analyst’s clinical, supervisory, and case management activities are often supported by other staff such as assistant behavior analysts working within the scope of their training, practice, and competence.
- CHBRP analysis. AB 1996 (Thomson), Chapter 795, Statutes of 2002, requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996. SB 125 (Hernandez), Chapter 9, Statutes of 2015, added an impact assessment on EHBs, and legislation that impacts health insurance benefit designs, cost sharing, premiums, and other health insurance topics. CHBRP states in its analysis of this bill, as introduced on February 12, 2016, the following:
- Enrollees covered. According to CHBRP, it is possible that this bill could affect 7.8 million Med-Cal beneficiaries enrolled in DMHC-regulated plans and an additional 1.5 million Medi-Cal beneficiaries enrolled in County Organized Health Systems (COHS) managed care and an additional 1.5 million Medi-Cal beneficiaries associated with the fee for service (FFS) program.
- Impact on expenditures. Because no change in benefit coverage is expected, no change in utilization, expenditures, or public health outcomes is projected.
- EHBs. This bill would not trigger financial costs to the state for exceeding EHBs.
- Medical effectiveness. There is a preponderance of evidence that intensive BHTs are effective in improving outcomes including cognitive functioning, language, social functioning, and adaptive behaviors. There is limited evidence that low-intensity BHTs are more effective in improving outcomes than usual care. There is a preponderance of evidence that BHTs delivered by persons with training similar to QAS professionals and paraprofessionals, as well as a variety of other specialized and nonspecialist types of personnel, are effective when carried out under the training and supervision of a QAS provider. There is limited evidence that the inclusion of clinical management and case supervision in BHT can improve outcomes such as intellectual ability, learning objectives, and overall treatment fidelity.
- Benefit coverage. CHBRP anticipates no change, because all enrollees with health insurance that would be subject to this bill have compliant benefit coverage. Although this bill would not alter the current benefit mandate’s explicit exemption from compliance for DMHC-regulated plans enrolling Medi-Cal beneficiaries, the impact of this bill on Medi-Cal is unclear. The authorization or enabling legislation for coverage of BHT is the provisions being amended in this bill. Therefore, changes to the current mandate could impact the benefit coverage of the 7.9 million Medi-Cal beneficiaries enrolled in DMHC-regulated plans as well as the additional 3.0 million Medi-Cal beneficiaries enrolled in either COHS managed care or attached to the FFS program. However, because CHBRP expects no measureable impact from this bill to the benefit coverage of enrollees in privately funded DMHC-regulated plans or CDI-regulated policies, CHBRP would similarly expect no impact related to Medi-Cal beneficiaries. Additionally, although this bill would delete the current exemptions for CalPERS to provide BHT, this benefit is currently covered under California’s Mental Health Parity benefit mandate. CHBRP has assumed that there would be no measurable impact on CalPERS.
- Utilization. Because no change in benefit coverage is expected, no change in utilization, expenditures, or public health outcomes is projected.
- Public Health. Because no change in benefit coverage is expected, no change in utilization, expenditures, or public health outcomes is projected.
- Long-term impacts. Although clinical case management, case supervision, and this bill’s definition of QAS providers are found to be medically effective, CHBRP concludes that passage of this bill would have no short-term or long-term public health impact due to no change in coverage. For this reason, CHBRP also concludes that this bill would have no impact on disparities in health outcomes (by gender, race/ethnicity, sexual orientation/gender identity, or other determinants) and no impact on societal economic loss.
- CHBRP analysis. AB 1996 (Thomson), Chapter 795, Statutes of 2002, requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996. SB 125 (Hernandez), Chapter 9, Statutes of 2015, added an impact assessment on EHBs, and legislation that impacts health insurance benefit designs, cost sharing, premiums, and other health insurance topics. CHBRP states in its analysis of this bill, as introduced on February 12, 2016, the following:
- SUPPORT. The Center for Autism and Related Disorders, cosponsors of this bill, writes that the changes reflect existing practices in the field and remove unnecessary barriers for providers. The California Association of Behavior Analysis, cosponsors of this bill, states that this bill would refine language in current statute to ensure that legislation accurately reflects the practice as it looks on the ground.
- OPPOSE UNLESS AMENDED. The California Association of Health Plans is requesting amendments to require the QAS professional and paraprofessional be employed by the service provider that is responsible for the autism case.
- RELATED LEGISLATION. SB 399 (Portantino), among other provisions, will no longer permit entities or groups to be QAS providers and expand the definition of “QAS professional” to include behavioral service providers who meet specified educational, professional, and work experience qualifications. SB 399, with regard to the definition of “QAS paraprofessional,” would also authorize the substitution of specified education, work experience, and training
- PREVIOUS LEGISLATION.
- AB 796 (Nazarian), Chapter 493, Statutes of 2016, deleted the sunset date of coverage for BHT services.
- SB 1034 (Mitchell) would have eliminated the sunset date on the health insurance mandate to cover BHT for PDD or autism, and prohibited health plan or health insurers from excluding medically necessary BHT on the basis of setting, location, time of treatment, or lack of parent or caregiver participation. SB 1034 died in the Assembly Appropriations Committee.
- SB 479 (Bates) would have established the Behavior Analyst Act which requires a person to apply for and obtain a license from the Board of Psychology prior to engaging in the practice of behavior analysis, as defined, either as a behavior analyst or an assistant behavior analyst, and meet certain educational and training requirements. SB 479 died in the Assembly Appropriations Committee.
- AB 2041 (Jones) of 2014 would have required that a regional center classify a vendor as a behavior management consultant or behavior management assistant if the vendor designs or implements evidence-based BHT, has a specified amount of experience in designing or implementing that treatment, and meets other licensure and education requirements. AB 2041 died in the Senate Appropriations Committee.
- SB 126 (Steinberg), Chapter 680, Statutes of 2013, extends, until January 1, 2017, the sunset date of the benefit mandate to cover BHT for PDD or autism and required health plans and insurers to maintain adequate networks of these service providers.
- SB 946 requires until July 1, 2014, health plans and health insurance policies to cover BHT for PDD or autism, requires health plans and insurers to maintain adequate networks of autism service providers, established a task force in DMHC, and makes other technical changes to existing law regarding HIV reporting and mental health services payments.
- AB 1453 (Monning), Chapter 854, Statutes of 2012, and SB 951 (Hernandez), Chapter 866, Statutes of 2012, established California's EHBs.
- SB 770 (Steinberg) of 2010 would have required health plans and insurance policies to provide coverage for BHT. SB 770 was held in the Assembly Appropriations Committee.
- SB 166 (Steinberg) of 2011 would have required health care service plans licensed by DMHC and health insurers licensed by CDI to provide coverage for BHT for autism. SB 166 was held in the Senate Health Committee.
- AB 1205 (Berryhill) of 2011 would have required the Board of Behavioral Sciences to license behavioral analysts and assistant behavioral analysts, on and after January 1, 2015, and included standards for licensure such as specified higher education and training, fieldwork, passage of relevant examinations, and national board accreditation. AB 1205 was held in the Assembly Appropriations Committee on the suspense file.
REGISTERED SUPPORT / OPPOSITION:
Support
California Association for Behavior Analysis (cosponsor)
Center for Autism and Related Disorders (cosponsor)
Advanced Behavioral Pathways
Autism Speaks
California Council of Community Behavioral Health Agencies
Opposition
None on file.
Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097
Discussed in Hearing
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Bill Author
Bill Co-Author(s):
