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 and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional who is supervised as specified. Existing law defines a qualified autism service professional to refer to a person who meets specified educational, training, and other requirements and is supervised and employed by a qualified autism service provider. Existing law defines a qualified autism service paraprofessional to mean an unlicensed and uncertified individual who meets specified educational, training, and other criteria, is supervised by a qualified autism service provider or a qualified autism service professional, and is employed by the qualified autism service provider.

This bill would expand the criteria for a qualified autism service professional to include a psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as specified. The bill would require those positions to meet the criteria for a Behavioral Health Professional, as provided.

Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities and their families. Existing law defines developmental disability for these purposes to include, among other things, autism.

This bill would require the department to adopt regulations, on or before July 1, 2026, to address the use of Behavioral Health Professionals and Behavioral Health Paraprofessionals in behavioral health treatment group practice. The bill would require the department to establish rates and the educational or experiential qualifications and professional supervision requirements necessary for these positions to provide behavioral intervention services, as specified.

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 and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional who is supervised as specified. Existing law defines a qualified autism service professional to refer to a person who meets specified educational, training, and other requirements and is supervised and employed by a qualified autism service provider. Existing law defines a qualified autism service paraprofessional to mean an unlicensed and uncertified individual who meets specified educational, training, and other criteria, is supervised by a qualified autism service provider or a qualified autism service professional, and is employed by the qualified autism service provider.

This bill would expand the criteria for a qualified autism service professional to include a psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as specified. The bill would require those positions to meet the criteria for a Behavioral Health Professional, as provided.

Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities and their families. Existing law defines developmental disability for these purposes to include, among other things, autism.

This bill would require the department to adopt regulations, on or before July 1, 2026, to address the use of Behavioral Health Professionals and Behavioral Health Paraprofessionals in behavioral health treatment group practice. The bill would require the department to establish rates and the educational or experiential qualifications and professional supervision requirements necessary for these positions to provide behavioral intervention services, as specified.

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 and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional who is supervised as specified. Existing law defines a qualified autism service professional to refer to a person who meets specified educational, training, and other requirements and is supervised and employed by a qualified autism service provider. Existing law defines a qualified autism service paraprofessional to mean an unlicensed and uncertified individual who meets specified educational, training, and other criteria, is supervised by a qualified autism service provider or a qualified autism service professional, and is employed by the qualified autism service provider.

This bill would expand the criteria for a qualified autism service professional to include a behavioral health professional and a psychology psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as specified. The bill would expand the criteria for a qualified autism service paraprofessional to include a behavioral health paraprofessional, as specified. require those positions to meet the criteria for a Behavioral Health Professional, as provided.

Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities and their families. Existing law defines developmental disability for these purposes to include, among other things, autism.

This bill would require the department to adopt emergency regulations regulations, on or before July 1, 2026, to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services. Behavioral Health Professionals and Behavioral Health Paraprofessionals in behavioral health treatment group practice. The bill would require the department to establish rates and the educational or experiential qualifications and professional supervision requirements necessary for these positions to provide behavioral intervention services, as specified.

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 and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional who is supervised as specified. Existing law defines a qualified autism service professional to refer to a person who meets specified educational, training, and other requirements and is supervised and employed by a qualified autism service provider. Existing law defines a qualified autism service paraprofessional to mean an unlicensed and uncertified individual who meets specified educational, training, and other criteria, is supervised by a qualified autism service provider or a qualified autism service professional, and is employed by the qualified autism service provider.

This bill would expand the criteria for a qualified autism service professional to include a behavioral health professional and a registered, certified, or licensed health care associate or assistant, as specified. a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as specified. The bill would expand the criteria for a qualified autism service paraprofessional to include a behavioral health paraprofessional, as specified.

Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities and their families. Existing law defines developmental disability for these purposes to include, among other things, autism.

This bill would require the department to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services. The bill would require the department to establish rates and the educational or experiential qualifications and professional supervision requirements necessary for these positions to provide behavioral intervention services, as specified.

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.

This bill would expand the criteria for a qualified autism service professional to include a behavioral health professional and a registered, certified, or licensed health care associate or assistant, as specified. The bill would expand the criteria for a qualified autism service paraprofessional to include a behavioral health paraprofessional, as specified.

Existing law establishes the State Department of Public Health and transfers the duties, powers, purposes, functions, responsibilities, and jurisdiction of the former State Department of Health Services to the State Department of Public Health as they relate to public health, licensing and certification of health facilities, and specified functions.

This bill would make technical, nonsubstantive changes to that provision.

 UNFINISHED BUSINESS  

Bill No: SB 805

Author: Portantino (D)

Amended: 9/7/23

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 4/19/23

AYES: Eggman, Nguyen, Dahle, Glazer, Gonzalez, Limón, Menjivar, Roth, Rubio, Wahab, Wiener

NO VOTE RECORDED: Hurtado

SENATE HUMAN SERVICES COMMITTEE: 5-0, 4/24/23

AYES: Alvarado-Gil, Ochoa Bogh, Hurtado, Menjivar, Wahab

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/18/23

AYES: Portantino, Jones, Ashby, Bradford, Seyarto, Wahab, Wiener

SENATE FLOOR: 40-0, 5/25/23

AYES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ASSEMBLY FLOOR: 78-1, 9/11/23 - See last page for vote

SUBJECT: Health care coverage: pervasive developmental disorders or autism

SOURCE: DIRFloortime Coalition of California

DIGEST:

This bill expands the qualifications for Qualified Autism Service (QAS) professionals as found in California’s mandate on health plans and insurers to cover behavioral health treatment (BHT) for pervasive developmental disorders or autism. This bill requires these QAS professionals to also meet educational or experiential qualifications and supervision requirements for these providers adopted by the Department of Developmental Services (DDS) on or before July 1, 2026 through regulations that also develop a rate.

Assembly Amendments

require on or before July 1, 2026, DDS to adopt regulations (rather than emergency regulations) to address the use of Behavioral Health Professionals in BHT group practice to provide evidence-based behavioral intervention services. Limit the expanded authority to QAS professionals.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program; and the Department of Developmental Disabilities (DDS) to administer services to people with developmental disabilities. [HSC §1340, et seq., INS §106, et seq.,WIC §14000, et seq., and WIC §4400, et seq.]
2. Requires every health plan contract and health insurance policy that provides hospital, medical, or surgical coverage to cover BHT for pervasive developmental disorder or autism. 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. [HSC §1374.73 and INS §10144.51]
3. Defines BHT for purposes of 2) above as 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 that meet specified criteria regarding the treatment plan, the professionals who can prescribe (physicians and psychologists) and supervise treatment, and administer a treatment plan. [HSC §1374.73 and INS §10144.51]
4. Requires every health plan or health insurer subject to 2) and 3) above to maintain an adequate network that includes qualified autism service (QAS) providers who supervise or employ QAS professionals and QAS paraprofessionals who provide and administer BHT. [HSC §1374.73 and INS §10144.51]
5. Makes BHT a covered Medi-Cal service for individuals under 21 years of age. [WIC §14132.56]

This bill:

1. Includes as a QAS professional: a behavioral service provider, or, a psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Psychology, or the Board of Behavioral Sciences, as defined, and supervised by a QAS provider licensed and practicing in the associate’s or assistant’s field of medicine under any and all applicable statutory or regulatory supervisory requirements.
2. Includes as a QAS professional someone who also meets the criteria set forth in the regulations described in 3) below.
3. Requires DDS to adopt regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services and establish a rate. Requires the regulations to also establish a rate and the educational or experiential qualifications and professional supervision requirements necessary for the behavioral health professional to provide behavioral intervention services.

Comments

According to the author, this bill corrects a long-standing problem regarding services for autistic individuals in California. In 2011, SB 946 (Steinberg, Chapter 650, Statutes of 2011) introduced insurance coverage for BHT for autism. The definition of BHT given is “professional services and treatment programs, including 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.” Unfortunately the description of QAS professionals and QAS paraprofessionals became only those clinicians providing ABA. Those professionals using other “evidence-based behavior intervention programs” are not included in insurance coverage. This bill will correct this problem by expanding the descriptions of qualified professionals and qualified paraprofessionals. This will allow for choice in treatment approaches and offer greater access to urgently needed services. Research has clearly shown that there is a variety of approaches that are accepted as ‘evidence-based.’ Individuals with autism are all unique and deserve to have access to the approach which best suits their needs. This was clearly the intent of the legislation, originally passed in 2011.

Pervasive Developmental Disorder or Autism. According to the California Health Benefits Review Program (CHBRP), autism spectrum disorder is a developmental disability characterized by deficits in social interactions and communication, sensory processing, stereotypic (repetitive) behaviors or interests, and sometimes cognitive function. The symptoms fall along a continuum, ranging from mild impairment to profound disability. Diagnoses are often made in early childhood. In California, among those with autism spectrum disorder served by DDS (the largest California-specific dataset), Hispanics accounted for 38% of recipients, followed by whites (28%), Asians (9%), and blacks (7%). However, the proportion of individuals receiving DDS services who are enrollees in DMHC-regulated plans or CDI-regulated policies is unknown. California studies have showed Blacks having the highest prevalence in birth year 2013, with 1.8%, compared to whites at 1.5% and Hispanics at 1.2%. Studies consistently show that children from low income, less educated, and more rural families are less likely to receive BHT than their higher income, better educated, and urban counterparts. One study revealed that parents with a lower educational level accessed less intensive therapies compared to parents with higher educational levels who accessed higher intensity services. A literature review found three of six studies on geographic variation in age of autism diagnosis (the start of autism treatment services) identified barriers for rural compared to urban families and two qualitative studies also found rural families had more difficulty than urban families in accessing providers for timely diagnosis and treatment.

Related/Prior Legislation

SB 562 (Portantino of 2022) would have revised and expanded the definition of BHT for pervasive developmental disorder or autism for purposes of health plan and insurer mandated coverage including expands the definitions of QAS providers, professionals, and paraprofessionals. Prohibited the setting, location, or time of treatment recommended by the QAS provider from being used as a reason to deny or reduce coverage for medically necessary services. SB 562 was vetoed by Governor Newsom. In his veto message the Governor states:

“This bill would require health plans and insurers to cover relationship-based and developmental behavioral therapies for the treatment of autism spectrum disorder (ASD). The bill would also authorize additional types of providers and professionals that can provide behavioral health therapy to individuals with ASD.

Early diagnosis of ASD and subsequent participation in evidence-based intervention and therapies, provided by licensed and certified individuals, make all the difference in an individual's long-term health outcomes. Research finds that Black and Latino children are often misdiagnosed and diagnosed later with ASD than their White peers. It is incumbent upon us to ensure that any intervention is medically-necessary, evidence-based and grounded in research that is conducted to reduce disparities.

Under existing law, health plans and insurers must cover evidence-based and medically-necessary behavioral therapies. This bill proposes to change the existing evidence-based standard by requiring coverage of therapies where there is insufficient, or only emerging, evidence to assess the impact of the interventions. Furthermore, the bill proposes changes to professional standards by expanding the types of individuals who can serve as qualified autism service professionals, which could result in long-term ramifications for individuals with ASD who receive the services.

I appreciate the author's dedication to supporting children diagnosed with ASD and their families. While the bill's intent is laudable, expanding access to certain therapies and interventions must be grounded in evidence-based practices and be provided by qualified professionals. I encourage the author to continue discussions related to the expansion of provider types and changes to professional standards through a formal licensing scheme that includes clinical expertise and administrative oversight to address qualification standards for practitioners, to ensure equity and quality of care, and provide effective consumer protection, as I expressed when I vetoed a similar bill in 2019.”

SB 163 (Portantino of 2019) was substantially similar to this bill, but deleted the Medi-Cal exemption from the state mandate. SB 163 was vetoed by Governor Newsom. The veto message states:

“This bill seeks to change the qualification standards necessary to be a qualified autism service professional or paraprofessional. When the Legislature enacted SB 946 (Steinberg, Chapter 650, Statutes of 2011), it clearly anticipated subsequent action to develop a comprehensive structure to license providers of behavioral health treatment to individuals with autism spectrum disorder. A formal licensing scheme that includes clinical expertise and administrative oversight is a more appropriate venue to address qualification standards for practitioners, ensure quality of care, and provide effective consumer protection. I encourage the Legislature to complete the work begun by SB 946.

In addition, by removing the health plan coverage exemption for contracts in the Medi-Cal program, this bill inadvertently creates conflicting requirements within the Medi-Cal program that could result in unintentional delays in access to care and jeopardizes continued receipt of federal financial participation for behavioral health treatment.”

SB 399 (Portantino of 2018) would have revised existing requirements on health plans and health insurers to cover BHT for pervasive developmental disorder or autism, such as allowing the substitution of specified current education, work experience, and training qualifications to meet the criteria of a QAS professional or paraprofessional. SB 399 would have prohibited a health plan and health insurer from denying or reducing medically necessary BHT based on a lack of parent or caregiver participation, or on the setting, location, or time of treatment, as specified. SB 399 was vetoed by Governor Brown. In his veto message, the Governor stated:

“This bill would revise qualification standards for providers of BHT for individuals with autism. Standards for autism providers were updated last year. I'm not inclined to revise them again.”

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Assembly Appropriations Committee:

• DDS estimates ongoing costs of $287,000 ($230,000 General Fund) for administration. In addition, DDS indicates that to the extent this bill results in increased utilization or higher rates, the associated costs for services could be substantial. DDS estimates that, for example, an increase of 1% in behavioral health related service expenditures may result in a $4.4 million ($2.6 million General Fund) increase.
• No costs to CDI.
• Minor and absorbable costs to the DMHC.
• Unknown, potentially significant increases in CalPERS premiums, approximately 60% of which are paid by the state (Public Employees Health Care Fund).

SUPPORT: (Verified 9/7/23)

DIRFloortime Coalition of California (source)

American Academy of Pediatrics, California

Amigo Baby

Autism Self Advocacy Network

Bridges Academy

California Board of Psychology

California Psychological Association

Center for Developmental Plan and Learning

Cherry Crisp Entertainment and Productions

Child Development Institute

Connect, Enrich, Achieve

Disability Rights California

Disability Voices United

Easterseals Northern California

Exceptional Minds

Fresno City College

Greenhouse Therapy Center

Infant Development Association of California

Institute for Girls’ Development

Interdisciplinary Council on Development and Learning

ITS Integrated Therapy Solutions

Lanterman Regional Center

Mental Health and Autism Insurance Project

National Association of Social Workers, California Chapter

OurTism

Positive Development

Professional Child Development Associates

Quicksilver Softwore, Inc.

San Diego Academy of Child and Adolescent Psychiatry

Spirited Play Labs

The Center for Connection

Therapeeps

Total Spectrum Counseling

Touchstone Family Development Center, Inc.

Four individuals

OPPOSITION: (Verified 9/7/23)

California Association for Behavior Analysis

One individual

ARGUMENTS IN SUPPORT: Disability Voices United (DVU) writes current legislation limits insurance to funding only one form of BHT, namely ABA. Although this treatment may work well for some children, it does not work for all. Autistic youth are unique and each needs access to the form of BHT best suited to their needs. It is important that all children receive individualized care. This bill would ensure that only evidence-based treatments are used, and that they are prescribed and supervised by licensed providers. All children need access to care to address their treatment needs in a timely way rather than wasting precious time on long wait lists due to the overly limited supply of service providers. Most families, particularly families of limited financial means, cannot afford to pay privately for costly ongoing intensive therapies denied by their insurance if their loved one requires a treatment approach that is not ABA. This unfair situation furthers healthcare access disparities in California’s historically disadvantaged communities. In DVU’s experience, many families, especially those from underserved communities, struggle for timely access to appropriate autism services. A parent writes by definition in the DSM-5 Diagnostic criteria, autism is a persistent deficit in “social communication” and “social interaction.” One of the primary deficits in autism is in social-emotional reciprocity. Social reciprocity is vitally important during early development because reciprocity (turn-taking between parents and young children) builds connectivity and efficiency in the brains of young children (Romeo et al. 2018).

ARGUMENTS IN OPPOSITION: The California Association of Behavior Analysis (CalABA) writes that they continue to oppose legislation that expands criteria for providers of BHT for individuals with autism. While this attempt does not have the far reaching negative implications of similar previous legislation, CalABA continues to have concerns about lowering/expanding provider qualifications. This bill requires that DDS establish educational and experiential qualifications for these providers which should be and have been set by national accreditation and credentialing boards. This bill alters the eligibility requirements for practitioners serving this vulnerable population. CalABA is concerned that as written this bill would lead to individuals providing BHT without the appropriate qualifications, and believes that many of the issues raised through this legislation can, and should, be addressed through legislation providing a comprehensive licensing framework for individuals providing this service.

ASSEMBLY FLOOR: 78-1, 9/11/23

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Wicks, Wilson, Wood, Zbur, Robert Rivas

NOES: Mathis

NO VOTE RECORDED: Weber

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

9/11/23 19:53:14

**** END ****

SENATE THIRD READING

STR Bill Id:SB 805

Author:(Portantino)

As Amended Ver:September 7, 2023

Majority vote

SUMMARY

Expands the criteria for a qualified autism service professional (QASP) to include a psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as specified. Requires these individuals to also meet specified criteria set forth in regulations adopted by the Department of Developmental Services (DDS). Requires DDS, on or before July 1, 2026, to adopt regulations to address the use of Behavioral Health Professionals in behavioral health treatment (BHT) group practice, and to establish rates and the educational or experiential qualifications and professional supervision requirements necessary for these positions to provide evidence-based behavioral intervention services, as specified.

Major Provisions

COMMENTS

1. SB 946 (Steinberg), Chapter 650, Statutes of 2011. SB 946 imposes a set of rules regarding BHT that health plans and health insurers in California must cover for individuals with autism and pervasive developmental disorders (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 detailed criteria set forth in the bill are met. SB 946 also required the Department of Managed Health Care (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.
2. Task Force. The Task Force was charged with making recommendations to inform state policymaking and guide future recommendations addressing specified subjects and develop recommendations regarding the education, training, and experience requirements that unlicensed individuals providing autism services must meet in order to secure a license from the state. The Task Force reached consensus on 54 of 55 recommendations and approved one recommendation by a vote of the majority. The Task Force concluded that all "top level" (undefined) providers should be licensed by the state, and set forth a process for establishing a new professional license for "Licensed Behavioral Health Practitioner." The Task Force recommended that the license requirement not take effect until three years after the license is established, and an interim commission be formed to implement the new license until a board is able to do so. The Task Force also recommended all providers of autism services to be registered with the state's TrustLine Registry or comparable system as a condition of employment by service organizations and contracting with health plans and health insurers. TrustLine uses the criminal history background check system to check the fingerprints of applicants, and checks for evidence of additional criminal records.
3. QASP Qualifications. Existing law requires a QASP to meet specific education and training requirements as determined by DDS to be a vendor of a regional center. AB 1074 (Maienschein), Chapter 385, Statutes of 2017, eliminated the requirement for a QASP to be regional center vendors. This bill would expand the definition of who could qualify as a QASP by allowing an alternative pathway if specified education, work experience and training qualifications are met and requires DDS to develop regulations to determine the education and training qualifications for behavioral health professionals.

According to the Author

This bill is needed so that children with autism can receive the behavioral health services they desperately need. For too long, BHT has been limited to only one form of therapy. Research clearly shows that other forms of treatment are also "evidence-based." The author concludes that it is time to remove this barrier to care and implement full access to services as envisioned at the outset of the legislation for behavioral health services in 2011.

Arguments in Support

DIR/Floortime Coalition of California (DIR) writes that this bill will help lessen the waiting period between diagnosis and treatment by providing a greater variety of covered treatment approaches. The DMHC was tasked with convening a Task Force to provide recommendations concerning that legislation. They unanimously adopted the guiding principle that behavioral health interventions should be highly individualized and that the choice of BHT should be grounded in scientific evidence, clinical practice guidelines, and evidence-based practice. Research has clearly demonstrated that a variety of forms of BHT are effective for improving functioning of children with autism. Despite this, the specific language in SB 946 limits the choice of treatment modalities in practice and therefore insurers have denied too many children the specific form of therapy they need. Specifically, the language in SB 946 regarding QASP severely limits the type of BHT covered. This bill would correct this oversight and will allow health professionals who are California registered and California certified assistants and associates of licensed QASP to provide all forms of evidence-based BHT under formal supervision. This bill expands the pool of professionals and paraprofessionals who are able to provide covered BHT by creating two new positions: Behavioral Health Professional and Behavioral Health Paraprofessional. This bill directs DDS to develop the education, training, and clinical supervision requirements for these two positions in the same manner it developed the qualifications for Behavior Management Technician. The qualifications DDS develops should be equivalent in rigor to the currently authorized providers, but simply expand the types of intervention approach from the current highly restrictive single form of BHT now covered, ABA. All Californians with autism deserve the type of evidence-based treatment that will provide them with the most benefit. By passing this bill, DIR concludes that individuals with autism in California will be able to receive the specific type of treatment they need and deserve, just as SB 946 intended.

Arguments in Opposition

The California Association for Behavior Analysis (CalABA) has concerns about lowering/expanding provider qualifications. This bill requires DDS to establish educational and experiential qualifications for these providers which should be and have been set by national accreditation and credentialing boards. As written, this bill alters the eligibility requirements for practitioners serving this vulnerable population. CalABA is concerned that this bill would lead to individuals providing BHT without the appropriate qualifications. CalABA believes that many of the issues raised through this legislation can, and should, be addressed through legislation providing a comprehensive licensing framework for individuals providing these services. Without sufficient minimum standards to practice competently in place, consumers will be at increasing risk of the erosion of quality of service.

FISCAL COMMENTS

According to the Assembly Appropriations Committee:

1. DDS estimates ongoing costs of $287,000 ($230,000 General Fund) for administration. In addition, DDS indicates that to the extent this bill results in increased utilization or higher rates, the associated costs for services could be substantial. DDS estimates that, for example, an increase of 1% in behavioral health related service expenditures may result in a $4.4 million ($2.6 million General Fund) increase.
2. No costs to the Department of Insurance.
3. Minor and absorbable costs to the DMHC.
4. Unknown, potentially significant increases in CalPERS premiums, approximately 60% of which are paid by the state (Public Employees Health Care Fund).

VOTES

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM HUMAN SERVICES: 7-0-1

YES: Jackson, Sanchez, Alanis, Arambula, Bonta, Bryan, Garcia

ABS, ABST OR NV: Calderon

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Papan, Pellerin, Sanchez, Soria, Weber, Wilson

ABS, ABST OR NV: Mathis

UPDATED

VERSION: September 7, 2023

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0001869

SENATE THIRD READING

STR Bill Id:SB 805

Author:(Portantino)

As Amended Ver:April 24, 2023

Majority vote

SUMMARY

Expands the criteria for a qualified autism service professional (QASP) to include a behavioral health professional and a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as specified. Expands the criteria for a qualified autism service paraprofessional (QASPP) to include a behavioral health paraprofessional, as specified. Requires the Department of Developmental Services (DDS) to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services. Requires DDS to establish rates and the educational or experiential qualifications and professional supervision requirements necessary for these positions to provide behavioral intervention services, as specified.

Major Provisions

COMMENTS

1. SB 946 (Steinberg), Chapter 650, Statutes of 2011. SB 946 imposes a set of rules regarding behavioral health treatment (BHT) that health plans and health insurers in California must cover for individuals with autism and pervasive developmental disorders (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 detailed criteria set forth in the bill are met. SB 946 also required the Department of Managed Health Care (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.
2. Task Force. The Task Force was charged with making recommendations to inform state policymaking and guide future recommendations addressing specified subjects and develop recommendations regarding the education, training, and experience requirements that unlicensed individuals providing autism services must meet in order to secure a license from the state. The Task Force reached consensus on 54 of 55 recommendations and approved one recommendation by a vote of the majority. The Task Force concluded that all "top level" (undefined) providers should be licensed by the state, and set forth a process for establishing a new professional license for "Licensed Behavioral Health Practitioner." The Task Force recommended that the license requirement not take effect until three years after the license is established, and an interim commission be formed to implement the new license until a board is able to do so. The Task Force also recommended all providers of autism services to be registered with the state's TrustLine Registry or comparable system as a condition of employment by service organizations and contracting with health plans and health insurers. TrustLine uses the criminal history background check system to check the fingerprints of applicants, and checks for evidence of additional criminal records.
3. QASP and QASPP Qualifications. Existing law requires a QASP or QASPP to meet specific education and training requirements as determined by DDS to be a vendor of a regional center. AB 1074 (Maienschein), Chapter 385, Statutes of 2017, eliminated the requirement for a QASP to be regional center vendors. This bill would expand the definition of who could qualify as a QASP or QASPP by allowing an alternative pathway if specified education, work experience and training qualifications are met and requires DDS to develop regulations to determine the education and training qualifications for behavioral health professionals and paraprofessionals.

According to the Author

This bill is needed so that children with autism can receive the behavioral health services they desperately need. For too long, BHT has been limited to only one form of therapy. Research clearly shows that other forms of treatment are also "evidence-based." The author concludes that it is time to remove this barrier to care and implement full access to services as envisioned at the outset of the legislation for behavioral health services in 2011.

Arguments in Support

DIR/Floortime Coalition of California (DIR) writes that this bill will help lessen the waiting period between diagnosis and treatment by providing a greater variety of covered treatment approaches. The DMHC was tasked with convening a Task Force to provide recommendations concerning that legislation. They unanimously adopted the guiding principle that behavioral health interventions should be highly individualized and that the choice of BHT should be grounded in scientific evidence, clinical practice guidelines, and evidence-based practice. Research has clearly demonstrated that a variety of forms of BHT are effective for improving functioning of children with autism. Despite this, the specific language in SB 946 limits the choice of treatment modalities in practice and therefore insurers have denied too many children the specific form of therapy they need. Specifically, the language in SB 946 regarding QASP and the definitions of QASPP severely limits the type of BHT covered. This bill would correct this oversight and will allow health professionals who are California registered and California certified assistants and associates of licensed QASP to provide all forms of evidence-based BHT under formal supervision. This bill expands the pool of professionals and paraprofessionals who are able to provide covered BHT by creating two new positions: Behavioral Health Professional and Behavioral Health Paraprofessional. This bill directs DDS to develop the education, training, and clinical supervision requirements for these two positions in the same manner it developed the qualifications for Behavior Management Technician. The qualifications DDS develops should be equivalent in rigor to the currently authorized providers, but simply expand the types of intervention approach from the current highly restrictive single form of BHT now covered, ABA. All Californians with autism deserve the type of evidence-based treatment that will provide them with the most benefit. By passing this bill, DIR concludes that individuals with autism in California will be able to receive the specific type of treatment they need and deserve, just as SB 946 intended.

Arguments in Opposition

The California Association for Behavior Analysis (CalABA) has concerns about lowering/expanding provider qualifications. This bill requires DDS to establish educational and experiential qualifications for these providers which should be and have been set by national accreditation and credentialing boards. As written, this bill alters the eligibility requirements for practitioners serving this vulnerable population. CalABA is concerned that this bill would lead to individuals providing BHT without the appropriate qualifications. CalABA believes that many of the issues raised through this legislation can, and should, be addressed through legislation providing a comprehensive licensing framework for individuals providing these services. Without sufficient minimum standards to practice competently in place, consumers will be at increasing risk of the erosion of quality of service.

FISCAL COMMENTS

According to the Assembly Appropriations Committee:

1. DDS estimates ongoing costs of $287,000 ($230,000 General Fund) for administration. In addition, DDS indicates that to the extent this bill results in increased utilization or higher rates, the associated costs for services could be substantial. DDS estimates that, for example, an increase of 1% in behavioral health related service expenditures may result in a $4.4 million ($2.6 million General Fund) increase.
2. No costs to the Department of Insurance.
3. Minor and absorbable costs to the DMHC.
4. Unknown, potentially significant increases in CalPERS premiums, approximately 60% of which are paid by the state (Public Employees Health Care Fund).

VOTES

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM HUMAN SERVICES: 7-0-1

YES: Jackson, Sanchez, Alanis, Arambula, Bonta, Bryan, Garcia

ABS, ABST OR NV: Calderon

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Papan, Pellerin, Sanchez, Soria, Weber, Wilson

ABS, ABST OR NV: Mathis

UPDATED

VERSION: April 24, 2023

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0001574

Date of Hearing: August 23, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

SBPCA Bill Id:SB 805

Author:(Portantino) – As Amended Ver:April 24, 2023

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill, for purposes of coverage of behavioral health treatment for pervasive developmental disorder or autism by a health care service plan (health plan) or health insurance policy, expands the definition of a “qualified autism service professional” (QASP) and a “qualified autism service paraprofessional” (QASPP).

Specifically, this bill:

1. Expands the definition of a QASP to include a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology, or who meets the criteria to be established in the regulations in 3), below.
   
2. Includes in the definition of a QASPP a person who meets the criteria for a behavioral health paraprofessional, to be established in the regulations described in 3), below.
   
3. Requires the Department of Developmental Services (DDS) to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services and establish a rate. Requires the regulations to also establish educational or experiential qualifications and professional supervision requirements necessary for the behavioral health professional or behavioral health paraprofessional to provide behavioral intervention services.
4. Deems the adoption, amendment, repeal, or re-adoption of a regulation authorized by this bill necessary for the immediate preservation of the public peace, health and safety, or general welfare, and exempts DDS from the requirement to describe specific facts showing the need for immediate action. Requires a certificate of compliance for these implementing regulations to be filed within 24 months following the adoption of the first emergency regulations filed pursuant to this bill.
    

FISCAL EFFECT:

1. DDS estimates ongoing costs of $287,000 ($230,000 General Fund) for administration. In addition, DDS indicates that to the extent this bill results in increased utilization or higher rates, the associated costs for services could be substantial. DDS estimates that, for example, an increase of 1% in behavioral health related service expenditures may result in a $4.4 million ($2.6 million General Fund) increase.
   
2. No costs to the Department of Insurance.
   
3. Minor and absorbable costs to the Department of Managed Health Care (DMHC).
4. Unknown, potentially significant increases in CalPERS premiums, approximately 60% of which are paid by the state (Public Employees Health Care Fund).

COMMENTS:

1. Purpose. This bill is sponsored by DIR/Floortime Coalition of California. According to the author:

SB 805 is needed so that children with autism can receive the behavioral health services they desperately need. For too long, behavioral health treatment has been limited to only one form of therapy. Research clearly shows that other forms of treatment are also “evidence-based.” It is time to remove this barrier to care and implement full access to services as envisioned at the outset of the legislation for behavioral health services in 2011.

1. Background. SB 946 (Steinberg and Evans), Chapter 650, Statutes of 2011, imposed a set of rules regarding behavioral health treatment (BHT) that health plans and health insurers in California must cover for individuals with autism and pervasive developmental disorder (PDD). SB 946 identified the required qualifications of individuals who provide BHT, and allowed individuals who are not licensed by the state to provide BHT, as long as the detailed criteria set forth in the bill were met. SB 946 also required DMHC to convene an Autism Advisory Task Force (Task Force) to develop recommendations regarding, among other things, the education, training, and experience requirements that unlicensed individuals providing BHT must meet to obtain licensure from the state.
2. QASP and QASPP Qualifications. A QASP or QASPP is required to meet specific education and training requirements determined by DDS to be a vendor of a regional center. This bill expands the definition of who qualifies as a QASP or QASPP by allowing an alternative pathway if specified education, work experience and training qualifications are met, and requires DDS to develop regulations to determine the education and training qualifications for behavioral health professionals and paraprofessionals.
3. Support. DIR/Floortime Coalition of California (DIR) writes this bill will help lessen the waiting period between diagnosis and treatment by providing a greater variety of covered treatment approaches. The DMHC Task Force unanimously adopted the guiding principle that behavioral health interventions should be highly individualized and the choice of BHT should be grounded in scientific evidence, clinical practice guidelines, and evidence-based practice. DIR contends research has clearly demonstrated that a variety of forms of BHT are effective for improving functioning of children with autism. Despite this, DIR argues, SB 946 limits the choice of treatment modalities in practice and therefore insurers have denied too many children the specific form of therapy they need. This bill expands the pool of professionals and paraprofessionals who are able to provide covered BHT by creating two new positions.
4. Opposition. The California Association for Behavior Analysis (CalABA) is concerned this bill would lead to individuals providing BHT without the appropriate qualifications. CalABA believes that many of the issues raised through this bill can, and should, be addressed through legislation providing a comprehensive licensing framework for individuals providing these services. CalABA argues that without sufficient minimum standards to practice competently in place, consumers will be at increasing risk of the erosion of quality of service.
5. Prior Legislation.
   1. SB 855 (Wiener), Chapter 151, Statutes of 2020, repealed California’s mental health parity law and replaced it with a broader requirement on health plans and insurers to cover medically necessary treatment of mental health and substance use disorders under the same terms and conditions applied to other medical conditions, established new requirements for medically necessary care determinations and utilization review, and banned discretionary clauses in health plan contracts.
   2. SB 562 (Portantino), of the 2021-22 Legislative Session, would have revised the definition of BHT to require the services and treatment programs provided to be based on behavioral, developmental, relationship-based, or other evidence-based models, and would have revised the definition of a QASP and the training requirements for a QASPP, among other provisions. SB 562 was vetoed by Governor Newsom, who stated, in part:

Under existing law, health plans and insurers must cover evidence-based and medically-necessary behavioral therapies. This bill proposes to change the existing evidence-based standard by requiring coverage of therapies where there is insufficient, or only emerging, evidence to assess the impact of the interventions. Furthermore, the bill proposes changes to professional standards by expanding the types of individuals who can serve as qualified autism service professionals, which could result in long-term ramifications for individuals with [autism spectrum disorder (ASD)] who receive the services.

…[E]xpanding access to certain therapies and interventions must be grounded in evidence-based practices and be provided by qualified professionals. I encourage the author to continue discussions related to the expansion of provider types and changes to professional standards through a formal licensing scheme that includes clinical expertise and administrative oversight to address qualification standards for practitioners, to ensure equity and quality of care, and provide effective consumer protection, as I expressed when I vetoed a similar bill in 2019.

• 1. SB 163 (Portantino), of the 2019-20 Legislative Session, was substantially similar to SB 562 and was vetoed by Governor Newsom, who stated, in part:

This bill seeks to change the qualification standards necessary to be a qualified autism service professional or paraprofessional. When the Legislature enacted SB 946 (Steinberg), Chapter 650, Statutes of 2011, it clearly anticipated subsequent action to develop a comprehensive structure to license providers of behavioral health treatment to individuals with autism spectrum disorder. A formal licensing scheme that includes clinical expertise and administrative oversight is a more appropriate venue to address qualification standards for practitioners, ensure quality of care, and provide effective consumer protection. I encourage the Legislature to complete the work begun by SB 946.

• 1. SB 399 (Portantino), of the 2017-18 Legislative Session, was similar to this bill and was vetoed by Governor Brown, who stated:

This bill would revise qualification standards for providers of behavioral health treatment for individuals with autism.
Standards for autism providers were updated last year. I'm not inclined to revise them again.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: July 11, 2023

ASSEMBLY COMMITTEE ON HUMAN SERVICES

Corey A. Jackson, Chair

SBPCA Bill Id:SB 805

Author:(Portantino) – As Amended Ver:April 24, 2023

SENATE VOTE: 40-0

SUBJECT: Health care coverage: pervasive developmental disorders or autism

SUMMARY: Expands the criteria for a qualified autism service professional (QASP) and a qualified autism service paraprofessional (QASPP); requires the Department of Developmental Services (DDS) to adopt emergency regulations; and, requires DDS to establish rates and the educational or experiential qualifications and professional supervision requirements necessary for these positions to provide behavioral intervention services. Specifically, this bill:

1. Expands the definition of QASP in existing law to include either of the following:
   1. Meets the criteria to be set forth in the regulations adopted pursuant to 3) and 4) below for a behavioral health professional; or,
   2. A psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.
2. Expands the definition of QASPP to meets the criteria set forth in the regulations to be adopted pursuant to 3) and 4) below for a behavioral health paraprofessional. 
3. Requires DDS to adopt emergency regulations to address the use of behavioral health professionals and paraprofessionals in group practice provider behavioral intervention services and establish a rate.
4. Requires the emergency regulations to also establish a rate and the educational or experiential qualifications and professional supervision requirements necessary for the behavioral health professional and paraprofessional to provide behavioral intervention services. Deems the adoption, amendment, repeal, or readoption of a regulation authorized by this bill to be necessary for the immediate preservation of the public peace, health and safety, or general welfare.

EXISTING LAW:

1. 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. (Welfare and Institutions Code Section [WIC] 4500, et seq.)
2. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program; and DDS to administer services to people with developmental disabilities. (Health and Safety Code Section [HSC] 1340, et seq., Insurance Code Section [INS] 106, et seq., WIC 14000, et seq., and WIC 4400, et seq.)
3. Establishes a system of nonprofit regional centers overseen by 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)
4. 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(b))
5. Requires every health care service plan contract that provides hospital, medical, or surgical coverage to also provide coverage for behavioral health treatment (BHT) for pervasive developmental disorder or autism, as specified. (WIC 1374.73(a)(1))
6. Requires that every health care service plan maintain an adequate network that includes qualified autism service (QAS) providers who supervise and employ QASP or QASPP who provide and administer BHT. Provides that nothing will prevent a health care service plan from selectively contracting with providers within these requirements. (HSC 1374.73(b))
7. Defines BHT, 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 (ABA) 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))
8. Requires treatment be prescribed by a physician or surgeon, as specified, and that it be provided by a QASP, or a QASPP who is supervised and employed by a qualified autism provider. (HSC 1374.73(c)(1); INS 10144.51(c)(1))
9. Includes in the definition of a "QASP" 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))
10. Defines in state regulations, for purposes of regional center vendorization, Behavior Management Assistant, Behavior Management Consultant, Behavior Analyst and Associate Behavior Analyst and requires education or experience in Applied Behavioral Analysis (ABA), as specified. (17 California Code of Regulations 54342)

FISCAL EFFECT: According to the Senate Appropriations Committee on May 5, 2023:

• DDS estimates ongoing costs of $287,000 ($230,000 General Fund) for state staffing for administration. In addition, DDS indicates that to the extent this bill results in increased utilization or higher rates, the associated costs for purchase of services could be substantial. DDS estimates that, for example, an increase of 1% in behavioral health related service expenditures may result in a $4.4 million ($2.6 million General Fund) increase;
• Unknown, potential increases in CalPERS employer premiums;
• DMHC estimates costs to administer the provisions would be minor and absorbable; and,
• The CDI estimates no fiscal impact to administer the provisions.

COMMENTS:

Background: Lanterman Developmental Disabilities Services Act. California’s Lanterman Act was originally passed in 1969. The Lanterman Act provides entitlement to services and supports for individuals ages three and older who have a qualifying developmental disability. Qualifying disabilities include autism, epilepsy, cerebral palsy, intellectual disabilities, and other conditions closely related to intellectual disabilities that require similar treatment. To qualify, an individual must have a disability that is substantial that began before the age of 18 and is expected to be life-long. There are no income‑related eligibility criteria. As of December 2022, DDS serves about 330,000 Lanterman‑eligible individuals and another 2,900 children ages three and four who are provisionally eligible.

Regional Center Services. The 21 regional centers serve approximately 370,000 consumers, providing services such as: information and referral; assessment and diagnosis; counseling; lifelong individualized planning and service coordination; purchase of necessary services included in the IPP; resource development; outreach; assistance in finding and using community and other resources; advocacy for the protection of legal, civil and service rights; early intervention services for at-risk infants and their families; genetic counseling; family support; planning, placement, and monitoring for 24-hour out-of-home care; training and educational opportunities for individuals and families; and, community education about developmental disabilities. Regional centers services vary at each location. One location might offer one program and the next might offer what they consider an alternative or nothing comparable. Geographically, regional centers’ spending also varies. For continuity of care, it makes it difficult for eligible consumers to move from one regional center to another. It is unclear why the services vary so widely.

Autism Spectrum Disorder and Evidence-Based Interventions. According to the National Institute of Mental Health (NIMH), Autism spectrum disorder (ASD) is a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave. Although autism can be diagnosed at any age, it is described as a “developmental disorder” because symptoms generally appear in the first two years of life. ASD is prevalent in 1 in 59 children in the United States.

According to an article published in the American Academy of Pediatrics entitled Identification, evaluation, and management of children with autism spectrum disorder, “The goals of treatment of children with ASD are to (1) minimize core deficits (social communication and interaction and restricted or repetitive behaviors and interests) and co-occurring associated impairments; (2) maximize functional independence by facilitating learning and acquisition of adaptive skills; and, (3) eliminate, minimize, or prevent problem behaviors that may interfere with functional skills.” Based on the goals of the individual, there are multiple avenues for therapeutic intervention including, but not limited to:

ABA is one of the most commonly used which is defined as “the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior.”

Developmental Relationship-Focused Interventions is focused on the relationship between the caregiver’s level of responsiveness and the child’s development of social communication.

Naturalistic Developmental Behavioral Intervention incorporates elements of ABA and developmental principles, such as emphasis on developmentally based learning targets and foundational social learning skills, with delivery of interventions in the context of naturally occurring social activities within natural environments.

SB 946 (Steinberg), Chapter 650, Statutes of 2011, required health plans and health insurance policies to cover behavioral health therapy for pervasive developmental disorder or autism, required plans and insurers to maintain adequate networks of autism service providers, and established an “Autism Advisory Task Force” (Task Force) within DMHC. The Task Force developed recommendations regarding medically necessary BHT for individuals with autism or pervasive developmental disorder, as well as the appropriate qualifications, training and supervision for providers of such treatment. The Task Force also developed recommendations regarding the education, training, and experience requirements that unlicensed individuals providing BHT must meet in order to obtain licensure from the state.

The Task Force’s report to the Governor and the Legislature in 2013 recommended that “all top level providers should be licensed by the state, and set forth a process for establishing a new professional license titled ― ‘Licensed Behavioral Health Practitioner’” The report further recommends that a ‘Licensed Behavioral Health Practitioner’ should possess one of the following: 1) Certification by and in good standing with a national entity; 2) Certification by and in good standing with a national entity that is accredited by the National Commission for Certifying Agencies in the design, supervision and delivery of behavioral health treatment, provided the services are within the experience and competence of the licensee; or, 3) Master’s or doctoral degree in behavior analysis, developmental psychology, special education, or related field, significant supervised experience in the development of treatment plans, and supervision and provision of behavioral health treatment for individuals with autism, successfully pass an examination, and letters of recommendation.

Governor’s veto message: This bill is substantially similar to SB 562 (Portantino) of 2021, which was vetoed by Governor Newsom. In his veto message, The Governor stated:

“This bill would require health plans and insurers to cover relationship-based and developmental behavioral therapies for the treatment of autism spectrum disorder (ASD). The bill would also authorize additional types of providers and professionals that can provide behavioral health therapy to individuals with ASD.

Early diagnosis of ASD and subsequent participation in evidence-based intervention and therapies, provided by licensed and certified individuals, make all the difference in an individual's long-term health outcomes. Research finds that Black and Latino children are often misdiagnosed and diagnosed later with ASD than their White peers. It is incumbent upon us to ensure that any intervention is medically-necessary, evidence-based and grounded in research that is conducted to reduce disparities.

Under existing law, health plans and insurers must cover evidence-based and medically-necessary behavioral therapies. This bill proposes to change the existing evidence-based standard by requiring coverage of therapies where there is insufficient, or only emerging, evidence to assess the impact of the interventions. Furthermore, the bill proposes changes to professional standards by expanding the types of individuals who can serve as qualified autism service professionals, which could result in long-term ramifications for individuals with ASD who receive the services.

I appreciate the author's dedication to supporting children diagnosed with ASD and their families. While the bill's intent is laudable, expanding access to certain therapies and interventions must be grounded in evidence-based practices and be provided by qualified professionals. I encourage the author to continue discussions related to the expansion of provider types and changes to professional standards through a formal licensing scheme that includes clinical expertise and administrative oversight to address qualification standards for practitioners, to ensure equity and quality of care, and provide effective consumer protection, as I expressed when I vetoed a similar bill in 2019.”

In response to the Governor’s veto message, the sponsor, DIRFloortime Coalition of California states,

“SB 805 has four differences from SB 562 (2022).

1. SB 562 proposed a revision in the definition of behavioral health treatment, whereas in SB 805 the definition of behavioral health treatment remains unchanged. “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…”
   
2. Whereas SB 562 included revisions to the requirements for qualified autism professionals and paraprofessionals, SB 805 leaves those unchanged and instead proposes that two new positions will be created and that the qualifications for these positions will be developed by DDS through the regulatory process.
   
3. Whereas SB 562 revised the definition of qualified autism service professional to include a registered, certified, or licensed associate or assistant regulated by one of a list of specified professional boards, SB 805 adds only four specific “Associates” to the definition of qualified autism service professional. These four positions are Psychological Associate, Associate Marriage Family Therapist, Associate Clinical Social Worker, and Associate Professional Counselor. These four positions are all under the supervision of a board-certified licensed provider and have a Master’s degree requirement.
   
4. SB 562 also addressed the issue of parent participation and place of treatment, and included a requirement that the qualified autism service provider would prohibit using the lack of parent or caregiver participation, implementation of an alternative plan, or the setting, location, or time of treatment as a reason to deny or reduce coverage for medically necessary services. This provision is not included in SB 805.”

Author’s Statement: According to the Author, “[This bill] is needed so that children with autism can receive the behavioral health services they desperately need. For too long, behavioral health treatment has been limited to only one form of therapy. Research clearly shows that other forms of treatment are also ‘evidence-based.’ It is time to remove this barrier to care and implement full access to services as envisioned at the outset of the legislation for behavioral health services in 2011.”

Need for this bill: The provisions of this bill seek to expand services offered to children with ASD by expanding the criteria of QASPs and QASPPs. Further, this bill requires DDS to work on regulations to address the use of behavioral health professionals and paraprofessionals in group practice provider behavioral intervention services and establish a rate.

Equity Implications: According to a CDC study, about 1 in 22 four-year-old children were identified with autism in California in 2020. The study also showed that white children, for the first time, were less likely to be identified with ASD than other races and/or ethnicities. Nationally, it is estimated that about three percent of Black, Hispanic or Latino and Asian or Pacific Islander children have been diagnosed with autism, compared with about two percent of white children. Experts attributed the data changes to improved screening and autism services for all kids, and to improved awareness and advocacy for Black and Hispanic families.

DDS data shows that as of March 2023, approximately 164,472 of the state’s 407,134 developmental services consumers have an ASD or pervasive developmental disorder diagnosis. Additionally, DDS reports that among those consumers receiving services for ASD, 40.24% identified as Latino, 25.82% identified as white, 8.51 percent identified as Asian, 7.2 percent identified as Black, 3.11 percent identified as Filipino, .29 percent identified as Native American, and .22 percent identified as Polynesian.

Currently, private payees are able to access any desired intervention, but due to current law not all treatments are recognized. This bill would allow additional providers and might expand access.

Policy Considerations: As outlined in Assembly Health Committee analysis, this Committee echoes policy comments to improve clarity in this bill.

This bill requires DDS to adopt emergency regulations, in part, to establish rates for behavioral health professionals and paraprofessionals.

The author may wish to consider adding a date in which DDS must adopt these emergency regulations.

It is unclear as to whom these provider rates will apply to and whether or not these rates will apply to health plans, insurers, and Medi-Cal.

As this bill moves forward, the author may wish to clarify these rates and DDS’ authority.

Double referral: This bill passed out of the Assembly Health Committee on June 28, 2023, with a 15-0 vote.

RELATED AND PRIOR LEGISLATION:

SB 562 (Portantino) of 2021, would have revised and expanded the definition of BHT for pervasive developmental disorder or autism for purposes of health plan and insurer mandated coverage, would have expanded the definitions of “QAS providers, professionals and paraprofessionals,” as well as prohibited the setting, location, or time of treatment recommended by the QAS provider from being used as a reason to deny or reduce coverage for medically necessary services. SB 562 was vetoed by Governor Newsom.

SB 163 (Portantino) of 2019, was identical to SB 562 of 2021, except it would have also removed the Medi-Cal exclusion. SB 163 was vetoed by Governor Newsom.

SB 399 (Portantino) of 2018, would have broadened the eligibility criteria to become a “QAS professional” and would have authorized the substitution of specified education, work experience, and training qualifications to meet the criteria of a “QAS professional.” SB 399 would also have eliminated the requirement for a professional or paraprofessional to be directly employed by a qualified autism provider and would have prohibited the lack of parent or caregiver participation from being used to deny or reduce medically necessary behavioral health treatment, among other changes. SB 399 was vetoed by Governor Brown.

AB 1074 (Maienschein), Chapter 385, Statues of 2017, permits a QASPP to be supervised by a QASP; indicates that BHT may include clinical case management and case supervision under the direction and supervision of a QAS provider, deletes a requirement that a behavioral service provider is approved as a vendor by a Regional Center based on provider definitions in specified regulations; and, instead requires a behavioral service provider to meet the education and experience qualifications described in the specified regulations; and, makes other technical changes. Revises the definition of BHT for purposes of the Medi-Cal program to be those services administered by DHCS as described in the state plan approved by the Centers for Medicare & Medicaid Services.

SB 796 (Nazarian), Chapter 493, Statutes of 2016, deletes the sunset date of coverage for BHT services.

SB 1034 (Mitchell) of 2016, would have eliminated the sunset date on the health insurance mandate to cover BHT for PDD or autism, and prohibited health plans 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 was held on the Assembly Appropriations Committee suspense file.

AB 2041 (Jones) of 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. The bill was held on the Senate Appropriations Committee suspense file.

SB 946 (Steinberg), Chapter 650, Statutes of 2011, required health plans and health insurance policies to cover BHT for pervasive developmental disorder or autism, required health plans and insurers to maintain adequate networks of autism service providers, established a task force in DMHC, sunset the autism mandate provisions on July 1, 2014, and made other technical changes to existing law regarding HIV reporting and mental health services payments.

REGISTERED SUPPORT / OPPOSITION:

Support

DIR/Floortime Coalition of California (Sponsor)

California Psychological Association

Center for Developmental Play and Learning

Cherry Crisp Entertainment and Productions

Child Development Institute

Disability Rights California

Disability Voices United

Easterseals Northern California

Exceptional Minds

Fresno City College

Greenhouse Therapy Center

Institute for Girls' Development

Interdisciplinary Council on Development and Learning

ITS Integrated Therapy Solutions

Mental Health and Autism Insurance Project

National Association of Social Workers, California Chapter

Positive Development

Professional Child Development Associates

Quicksilver Software

San Diego Academy of Child and Adolescent Psychiatry

Spirited Play Labs

The Center for Connection

TheraPeeps

Touchstone Family Development Center, INC.

Opposition

California Association for Behavior Analysis

Analysis Prepared by: Alexandria Smith / HUM. S. / (916) 319-2089

Date of Hearing: June 27, 2023

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 805

Author:(Portantino) – As Amended Ver:April 24, 2023

SENATE VOTE: 40-0

SUBJECT: Health care coverage: pervasive developmental disorders or autism.

SUMMARY: Expands the criteria for a qualified autism service professional (QASP) to include a behavioral health professional and a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as specified. Expands the criteria for a qualified autism service paraprofessional (QASPP) to include a behavioral health paraprofessional, as specified. Requires the Department of Developmental Services (DDS) to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services. Requires DDS to establish rates and the educational or experiential qualifications and professional supervision requirements necessary for these positions to provide behavioral intervention services, as specified. Specifically, this bill:

1. Expands the definition of QASP in existing law to include either of the following:
   1. Meets the criteria to be set forth in the regulations adopted pursuant to 3) below for a behavioral health professional; or,
   2. A psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.
2. Expands the definition of QASPP to meets the criteria set forth in the regulations to be adopted pursuant to 3) below for a behavioral health paraprofessional. 
3. Requires DDS to adopt emergency regulations to address the use of behavioral health professionals and paraprofessionals in group practice provider behavioral intervention services and establish a rate. Requires regulations to also establish a rate and the educational or experiential qualifications and professional supervision requirements necessary for the behavioral health professional and paraprofessional to provide behavioral intervention services. Deems the adoption, amendment, repeal, or readoption of a regulation authorized by this this bill to be necessary for the immediate preservation of the public peace, health and safety, or general welfare, as specified.

EXISTING LAW:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program; and the DDS to administer services to people with developmental disabilities. [Health and Safety Code (HSC) §1340, et seq., Insurance Code (INS) §106, et seq. Welfare and Institutions Code (WIC) §14000, et seq., and WIC §4400, et seq.]
2. Requires every health plan contract and health insurance policy that provides hospital, medical, or surgical coverage to cover Behavioral Health Treatment (BHT) for pervasive developmental disorder (PDD) or autism. 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. [HSC §1374.73 and INS §10144.51]
3. Defines BHT for purposes of 2) above as 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 PDD or autism and that meet specified criteria regarding the treatment plan, the professionals who can prescribe (physicians and psychologists) and supervise treatment, and administer a treatment plan. [HSC §1374.73 and INS §10144.51]
4. Defines BHT to mean specified services provided by, among others, a QASP or QASPP supervised and employed by a qualified autism services (QAS) provider.
   1. Defines a QASP 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.
   2. Defines a QASPP an unlicensed and uncertified individual who meets specified criteria, including supervision by a QAS provider or QASP at a level of clinical supervision that meets professionally recognized standards of practice, provides treatment and implements services pursuant to a treatment plan developed and approved by the QAS provider; and meets the education and training qualifications described in regulations.
   3. Requires every health plan or health insurer subject to 2) above to maintain an adequate network that includes QAS providers who supervise or employ QASP or QASPP who provide and administer BHT. [HSC §1374.73(c) and INS §10144.51(c)]
5. Makes BHT a covered Medi-Cal service for individuals under 21 years of age. [WIC §14132.56]
6. Prohibits a health plan and disability insurer from limiting benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and from including or enforcing a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program. [HSC §1374.72 and INS §10144.5]

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. DDS estimates ongoing costs of $287,000 ($230,000 General Fund) for state staffing for administration. In addition, DDS indicates that to the extent this bill results in increased utilization or higher rates, the associated costs for purchase of services could be substantial. DDS estimates that, for example, an increase of 1% in behavioral health related service expenditures may result in a $4.4 million ($2.6 million General Fund) increase;
2. Unknown, potential increases in CalPERS employer premiums;
3. DMHC estimates costs to administer the provisions would be minor and absorbable; and,
4. The CDI estimates no fiscal impact to administer the provisions.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill is needed so that children with autism can receive the behavioral health services they desperately need. For too long, BHT has been limited to only one form of therapy. Research clearly shows that other forms of treatment are also “evidence-based.” The author concludes that it is time to remove this barrier to care and implement full access to services as envisioned at the outset of the legislation for behavioral health services in 2011.
2. BACKGROUND.
   1. SB 946. SB 946 (Steinberg and Evans), 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 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 detailed criteria set forth in the bill 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.
   2. Task Force. The Task Force was charged with making recommendations to inform state policymaking and guide future recommendations addressing specified subjects and develop recommendations regarding the education, training, and experience requirements that unlicensed individuals providing autism services must meet in order to secure a license from the state. The Task Force reached consensus on 54 of 55 recommendations and approved one recommendation by a vote of the majority. The Task Force concluded that all "top level" (undefined) providers should be licensed by the state, and set forth a process for establishing a new professional license for "Licensed Behavioral Health Practitioner." The Task Force recommended that the license requirement not take effect until three years after the license is established, and an interim commission be formed to implement the new license until a board is able to do so. The Task Force also recommended all providers of autism services to be registered with the state's TrustLine Registry or comparable system as a condition of employment by service organizations and contracting with health plans and health insurers. TrustLine uses the criminal history background check system to check the fingerprints of applicants, and checks for evidence of additional criminal records.
   3. QASP and QASPP Qualifications. Existing law requires a QASP or QASPP to meet specific education and training requirements as determined by DDS to be a vendor of a regional center. AB 1074 (Maienschein), Chapter 385, Statutes of 2017, eliminated the requirement for a QASP to be regional center vendors. This bill would expand the definition of who could qualify as a QASP or QASPP by allowing an alternative pathway if specified education, work experience and training qualifications are met and requires DDS to develop regulations to determine the education and training qualifications for behavioral health professionals and paraprofessionals.
3. SUPPORT. DIR/Floortime Coalition of California (DIR) writes that this bill will help lessen the waiting period between diagnosis and treatment by providing a greater variety of covered treatment approaches. The DMHC was tasked with convening a Task Force to provide recommendations concerning that legislation. They unanimously adopted the guiding principle that behavioral health interventions should be highly individualized and that the choice of BHT should be grounded in scientific evidence, clinical practice guidelines, and evidence-based practice. Research has clearly demonstrated that a variety of forms of BHT are effective for improving functioning of children with autism. Despite this, the specific language in SB 946 limits the choice of treatment modalities in practice and therefore insurers have denied too many children the specific form of therapy they need. Specifically, the language in SB 946 regarding QASP and the definitions of QASPP severely limits the type of BHT covered. This bill would correct this oversight and will allow health professionals who are California registered and California certified assistants and associates of licensed QASP to provide all forms of evidence-based BHT under formal supervision. This bill expands the pool of professionals and paraprofessionals who are able to provide covered BHT by creating two new positions: Behavioral Health Professional and Behavioral Health Paraprofessional. This bill directs DDS to develop the education, training, and clinical supervision requirements for these two positions in the same manner it developed the qualifications for Behavior Management Technician. The qualifications DDS develops should be equivalent in rigor to the currently authorized providers, but simply expand the types of intervention approach from the current highly restrictive single form of BHT now covered, ABA. All Californians with autism deserve the type of evidence-based treatment that will provide them with the most benefit. By passing this bill, DIR concludes that individuals with autism in California will be able to receive the specific type of treatment they need and deserve, just as SB 946 intended.
4. OPPOSITION. The California Association for Behavior Analysis (CalABA) has concerns about lowering/expanding provider qualifications. This bill requires DDS to establish educational and experiential qualifications for these providers which should be and have been set by national accreditation and credentialing boards. As written, this bill alters the eligibility requirements for practitioners serving this vulnerable population. CalABA is concerned that this bill would lead to individuals providing BHT without the appropriate qualifications. CalABA believes that many of the issues raised through this legislation can, and should, be addressed through legislation providing a comprehensive licensing framework for individuals providing these services. Without sufficient minimum standards to practice competently in place, consumers will be at increasing risk of the erosion of quality of service.
5. PREVIOUS LEGISLATION.
   1. SB 562 (Portantino) of 2022 would have revised the definition of BHT to require the services and treatment programs provided to be based on behavioral, developmental, relationship-based, or other evidence-based models. Would have revised the definition of a QASP to include a registered, certified, or licensed associate or assistant regulated by one of a list of specified professional boards, and supervised by a QAS provider practicing in the associate’s or assistant’s field of medicine. Would have revised the training requirements for a QASPP by authorizing training to be provided by a QASP practicing the evidence-based treatment modality that the QASPP will administer. Would have required the QASP to design an intervention plan that includes parent or caregiver participation, when clinically appropriate, that is individualized to the patient, or to develop an alternative plan if a parent or caregiver cannot participate, as specified. Would have prohibited using the lack of parent or caregiver participation, implementation of an alternative plan, or the setting, location, or time of treatment as a reason to deny or reduce coverage for medically necessary services. SB 562 was vetoed by Governor Newsom, who stated:

“This bill would require health plans and insurers to cover relationship-based and developmental behavioral therapies for the treatment of autism spectrum disorder (ASD). The bill would also authorize additional types of providers and professionals that can provide behavioral health therapy to individuals with ASD.

Early diagnosis of ASD and subsequent participation in evidence-based intervention and therapies, provided by licensed and certified individuals, make all the difference in an individual's long-term health outcomes. Research finds that Black and Latino children are often misdiagnosed and diagnosed later with ASD than their White peers. It is incumbent upon us to ensure that any intervention is medically-necessary, evidence-based and grounded in research that is conducted to reduce disparities.

Under existing law, health plans and insurers must cover evidence-based and medically-necessary behavioral therapies. This bill proposes to change the existing evidence-based standard by requiring coverage of therapies where there is insufficient, or only emerging, evidence to assess the impact of the interventions. Furthermore, the bill proposes changes to professional standards by expanding the types of individuals who can serve as qualified autism service professionals, which could result in long-term ramifications for individuals with ASD who receive the services.

I appreciate the author's dedication to supporting children diagnosed with ASD and their families. While the bill's intent is laudable, expanding access to certain therapies and interventions must be grounded in evidence-based practices and be provided by qualified professionals. I encourage the author to continue discussions related to the expansion of provider types and changes to professional standards through a formal licensing scheme that includes clinical expertise and administrative oversight to address qualification standards for practitioners, to ensure equity and quality of care, and provide effective consumer protection, as I expressed when I vetoed a similar bill in 2019.”

• 1. SB 855 (Wiener), Chapter 151, Statutes of 2020, repeals California’s mental health parity law and replaces it with a broader requirement on health plans and disability insurers to cover medically necessary treatment of mental health and substance use disorders under the same terms and conditions applied to other medical conditions; establishes new requirements for medically necessary care determinations and utilization review; and bans discretionary clauses in health plan contracts.
  2. SB 163 (Portantino) of 2019 is substantially similar SB 562 and was vetoed by Governor Newsom, who stated:

“This bill seeks to change the qualification standards necessary to be a qualified autism service professional or paraprofessional. When the Legislature enacted SB 946 (Steinberg), Chapter 650, Statutes of 2011, it clearly anticipated subsequent action to develop a comprehensive structure to license providers of behavioral health treatment to individuals with autism spectrum disorder. A formal licensing scheme that includes clinical expertise and administrative oversight is a more appropriate venue to address qualification standards for practitioners, ensure quality of care, and provide effective consumer protection. I encourage the Legislature to complete the work begun by SB 946.

In addition, by removing the health plan coverage exemption for contracts in the Medi-Cal program, this bill inadvertently creates conflicting requirements within the Medi-Cal program that could result in unintentional delays in access to care and jeopardizes continued receipt of federal financial participation for behavioral health treatment.”

• 1. SB 399 (Portantino) of 2018, was similar to this bill and was vetoed by Governor Brown, who stated:

“This bill would revise qualification standards for providers of behavioral health treatment for individuals with autism.

Standards for autism providers were updated last year. I'm not inclined to revise them again.”

• 1. AB 1074 permits a QASPP to be supervised by a QASP; indicates that BHT may include clinical case management and case supervision under the direction and supervision of a QAS provider, deletes a requirement that a behavioral service provider is approved as a vendor by a Regional Center based on provider definitions in specified regulations; and instead requires a behavioral service provider to meet the education and experience qualifications described in the specified regulations; and, makes other technical changes. Revises the definition of BHT for purposes of the Medi-Cal program to be those services administered by DHCS as described in the state plan approved by the Centers for Medicare & Medicaid Services.
  2. AB 796 (Nazarian), Chapter 493, Statutes of 2016, deletes the sunset date of coverage for BHT services.
  3. SB 1034 (Mitchell) of 2016 would have eliminated the sunset date on the health insurance mandate to cover BHT for PDD or autism, and prohibited health plans 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.
  4. AB 1715 (Holden) of 2016 would have established the Behavior Analyst Act (BAA), which provides for the licensure, registration, and regulation of behavior analysts and assistant behavior analysts, and would have required the California Board of Psychology, until January 1, 2022, to administer and enforce. AB 1714 died in the Senate Business, Professions and Economic Development Committee.
     
  5. SB 479 (Bates) of 2015 would have established the BAA 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.
  6. 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.
  7. 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 requires health plans and insurers to maintain adequate networks of these service providers.
  8. 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.
  9. AB 1453 (Monning), Chapter 854, Statutes of 2012, and SB 951 (Hernandez), Chapter 866, Statutes of 2012, establish California's essential health benefits.
  10. 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.
  11. SB 166 (Steinberg) of 2011 would have required health 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.
  12. 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.

1. DOUBLE REFERRAL. This bill is double referred, upon passage of this committee; it will be referred to the Assembly Committee on Human Services.
2. POLICY COMMENTS. This bill requires DDS to adopt emergency regulations, in part, to establish rates for behavioral health professionals and paraprofessionals.
   1. The author may wish to consider adding a date in which DDS must adopt these emergency regulations.
   2. It is also unclear as to whom these provider rates will apply to and whether or not these rates will apply to health plans, insurers, and Medi-Cal. As this bill moves forward, the author may wish to clarify these rates and DDS’s authority.

REGISTERED SUPPORT / OPPOSITION:

Support

DIR/Floortime Coalition of California (sponsor)
California Psychological Association
Center for Developmental Play and Learning
Cherry Crisp Entertainment and Productions
Child Development Institute
Disability Rights California
Disability Voices United
Easterseals Northern California
Exceptional Minds
Greenhouse Therapy Center
Institute for Girls' Development
Its Integrated Therapy Solutions
Mental Health and Autism Insurance Project
National Association of Social Workers, California Chapter
Positive Development
Professional Child Development Associates
Quicksilver Software
San Diego Academy of Child and Adolescent Psychiatry
Spirited Play Labs
The Center for Connection

Opposition

California Association for Behavior Analysis

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097

 THIRD READING  

Bill No: SB 805

Author: Portantino (D)

Amended: 4/24/23

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 4/19/23

AYES: Eggman, Nguyen, Dahle, Glazer, Gonzalez, Limón, Menjivar, Roth, Rubio, Wahab, Wiener

NO VOTE RECORDED: Hurtado

SENATE HUMAN SERVICES COMMITTEE: 5-0, 4/24/23

AYES: Alvarado-Gil, Ochoa Bogh, Hurtado, Menjivar, Wahab

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/18/23

AYES: Portantino, Jones, Ashby, Bradford, Seyarto, Wahab, Wiener

SUBJECT: Health care coverage: pervasive developmental disorders or autism

SOURCE: DIRFloortime Coalition of California

DIGEST:

This bill expands the qualifications for Qualified Autism Service professionals and paraprofessionals as found in California’s mandate on health plans and insurers to cover behavioral health treatment for pervasive developmental disorders or autism, and, requires the Department of Developmental Services to establish emergency regulations to develop educational or experiential qualifications and supervision requirements for these providers and a rate.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program; and the Department of Developmental Disabilities (DDS) to administer services to people with developmental disabilities. [HSC §1340, et seq., INS §106, et seq.,WIC §14000, et seq., and WIC §4400, et seq.]
2. Requires every health plan contract and health insurance policy that provides hospital, medical, or surgical coverage to cover Behavioral Health Treatment (BHT) for pervasive developmental disorder or autism. 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. [HSC §1374.73 and INS §10144.51]
3. Defines BHT for purposes of 2) above as 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 that meet specified criteria regarding the treatment plan, the professionals who can prescribe (physicians and psychologists) and supervise treatment, and administer a treatment plan. [HSC §1374.73 and INS §10144.51]
4. Requires every health plan or health insurer subject to 2) and 3) above to maintain an adequate network that includes qualified autism service (QAS) providers who supervise or employ QAS professionals and QAS paraprofessionals who provide and administer BHT. [HSC §1374.73 and INS §10144.51]
5. Makes BHT a covered Medi-Cal service for individuals under 21 years of age. [WIC §14132.56]

This bill:

1. Includes as a QAS provider: a behavioral service provider who meets the criteria set forth in regulations for a behavioral health professional described in this 3) below; or, a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Psychology, or the Board of Behavioral Sciences, as defined, and supervised by a QAS provider licensed and practicing in the associate’s or assistant’s field of medicine under any and all applicable statutory or regulatory supervisory requirements.
2. Includes as a QAS paraprofessional someone who meets the criteria set forth in the regulations described in 3) below.
3. Requires DDS to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services and establish a rate. Requires the regulations to also establish a rate and the educational or experiential qualifications and professional supervision requirements necessary for the behavioral health professional to provide behavioral intervention services.

Comments

According to the author, this bill corrects a long-standing problem regarding services for autistic individuals in California. In 2011, SB 946 (Steinberg, Chapter 650, Statutes of 2011) introduced insurance coverage for BHT for autism. The definition of BHT given is “professional services and treatment programs, including 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.” Unfortunately the description of QAS professionals and QAS paraprofessionals became only those clinicians providing ABA. Those professionals using other “evidence-based behavior intervention programs” are not included in insurance coverage. This bill will correct this problem by expanding the descriptions of qualified professionals and qualified paraprofessionals. This will allow for choice in treatment approaches and offer greater access to urgently needed services. Research has clearly shown that there is a variety of approaches that are accepted as ‘evidence-based.’ Individuals with autism are all unique and deserve to have access to the approach which best suits their needs. This was clearly the intent of the legislation, originally passed in 2011.

Pervasive Developmental Disorder or Autism. According to the California Health Benefits Review Program (CHBRP), autism spectrum disorder is a developmental disability characterized by deficits in social interactions and communication, sensory processing, stereotypic (repetitive) behaviors or interests, and sometimes cognitive function. The symptoms fall along a continuum, ranging from mild impairment to profound disability. Diagnoses are often made in early childhood. In California, among those with autism spectrum disorder served by DDS (the largest California-specific dataset), Hispanics accounted for 38% of recipients, followed by whites (28%), Asians (9%), and blacks (7%). However, the proportion of individuals receiving DDS services who are enrollees in DMHC-regulated plans or CDI-regulated policies is unknown. California studies have showed Blacks having the highest prevalence in birth year 2013, with 1.8%, compared to whites at 1.5% and Hispanics at 1.2%. Studies consistently show that children from low income, less educated, and more rural families are less likely to receive BHT than their higher income, better educated, and urban counterparts. One study revealed that parents with a lower educational level accessed less intensive therapies compared to parents with higher educational levels who accessed higher intensity services. A literature review found three of six studies on geographic variation in age of autism diagnosis (the start of autism treatment services) identified barriers for rural compared to urban families and two qualitative studies also found rural families had more difficulty than urban families in accessing providers for timely diagnosis and treatment.

Task Force. The Autism Advisory Task Force was established pursuant to SB 946 and concluded that all "top level" providers should be licensed by the state, and set forth a process for establishing a new professional license for "Licensed Behavioral Health Practitioner."

Medi-Cal. Medi-Cal covers all medically necessary BHT for eligible beneficiaries under 21 years of age, for children with autism spectrum disorder and others for whom a physician or psychologist determines it is medically necessary. A physician or a psychologist must recommend BHT services as medically necessary based on whether BHT services will correct or ameliorate any physical and/or behavioral conditions. BHT services include ABA and a variety of other behavioral interventions that have been identified as evidence-based approaches that prevent or minimize the adverse effects of behaviors that interfere with learning and social interaction, and promote, to the maximum extent practicable, the functioning of a beneficiary, including those with or without autism spectrum disorder. Examples include behavioral interventions, cognitive behavioral intervention, comprehensive behavioral treatment, language training, modeling, natural teaching strategies, parent/guardian training, peer training, pivotal response training, schedules, scripting, self-management, social skills package, and story-based interventions.

Assumptions. CHBRP assumes for purposes of this bill that BHT would require coverage of developmental-based modalities (such as DIR®/Floortime™) as well as behavior-based modalities (such as Pivotal Response Training) and hybrid modalities (such as Early Start Denver Model and Social Skills Group Therapy).

Medical effectiveness. CHBRP found evidence that BHT modalities based on ABA, developmental theory, and hybrids of both theories improve outcomes for people with autism spectrum disorder. Prominent outcomes include improvements in communication, social skills, cognition, adaptive behavior, language, motor skills, play skills, and symptom severity. CHBRP’s literature review also found that BHT can be delivered effectively by people with similar training as QAS professionals when supervised by a QAS provider. Regardless of the theory on which BHT modalities are based, many studies of them are observational or quasi-experimental studies that do not randomly assign participants to the intervention or control condition. Some do not include any sort of comparison group. Lack of random assignment decreases confidence that any differences that are found between the treatment and control groups are due to the BHT treatment being tested and not to differences between the people with autism spectrum disorder in the treatment and control groups. Lack of a control group further decreases confidence in a study’s findings because one cannot rule out the possibility that any differences observed over time are due to factors other than the BHT modality. In cases where random control groups (RCTs) of BHT interventions were conducted, caution should be exercised when interpreting the findings of RCTs with small sample sizes. Moreover, most articles in CHBRP’s medical effectiveness literature review were about research in children; a few articles on adolescents were identified. The findings may be difficult to generalize to adults.

Related/Prior Legislation

SB 562 (Portantino of 2022) would have revised and expanded the definition of BHT for pervasive developmental disorder or autism for purposes of health plan and insurer mandated coverage including expands the definitions of QAS providers, professionals, and paraprofessionals. Prohibited the setting, location, or time of treatment recommended by the QAS provider from being used as a reason to deny or reduce coverage for medically necessary services. SB 562 was vetoed by Governor Newsom. In his veto message the Governor states:

“This bill would require health plans and insurers to cover relationship-based and developmental behavioral therapies for the treatment of autism spectrum disorder (ASD). The bill would also authorize additional types of providers and professionals that can provide behavioral health therapy to individuals with ASD.

Early diagnosis of ASD and subsequent participation in evidence-based intervention and therapies, provided by licensed and certified individuals, make all the difference in an individual's long-term health outcomes. Research finds that Black and Latino children are often misdiagnosed and diagnosed later with ASD than their White peers. It is incumbent upon us to ensure that any intervention is medically-necessary, evidence-based and grounded in research that is conducted to reduce disparities.

Under existing law, health plans and insurers must cover evidence-based and medically-necessary behavioral therapies. This bill proposes to change the existing evidence-based standard by requiring coverage of therapies where there is insufficient, or only emerging, evidence to assess the impact of the interventions. Furthermore, the bill proposes changes to professional standards by expanding the types of individuals who can serve as qualified autism service professionals, which could result in long-term ramifications for individuals with ASD who receive the services.

I appreciate the author's dedication to supporting children diagnosed with ASD and their families. While the bill's intent is laudable, expanding access to certain therapies and interventions must be grounded in evidence-based practices and be provided by qualified professionals. I encourage the author to continue discussions related to the expansion of provider types and changes to professional standards through a formal licensing scheme that includes clinical expertise and administrative oversight to address qualification standards for practitioners, to ensure equity and quality of care, and provide effective consumer protection, as I expressed when I vetoed a similar bill in 2019.”

SB 163 (Portantino, 2019) was substantially similar to this bill, but deleted the Medi-Cal exemption from the state mandate. SB 163 was vetoed by Governor Newsom. The veto message states:

“This bill seeks to change the qualification standards necessary to be a qualified autism service professional or paraprofessional. When the Legislature enacted SB 946 (Steinberg, Chapter 650, Statutes of 2011), it clearly anticipated subsequent action to develop a comprehensive structure to license providers of behavioral health treatment to individuals with autism spectrum disorder. A formal licensing scheme that includes clinical expertise and administrative oversight is a more appropriate venue to address qualification standards for practitioners, ensure quality of care, and provide effective consumer protection. I encourage the Legislature to complete the work begun by SB 946.

In addition, by removing the health plan coverage exemption for contracts in the Medi-Cal program, this bill inadvertently creates conflicting requirements within the Medi-Cal program that could result in unintentional delays in access to care and jeopardizes continued receipt of federal financial participation for behavioral health treatment.”

SB 399 (Portantino of 2018) would have revised existing requirements on health plans and health insurers to cover BHT for pervasive developmental disorder or autism, such as allowing the substitution of specified current education, work experience, and training qualifications to meet the criteria of a QAS professional or paraprofessional. SB 399 would have prohibited a health plan and health insurer from denying or reducing medically necessary BHT based on a lack of parent or caregiver participation, or on the setting, location, or time of treatment, as specified. SB 399 was vetoed by Governor Brown. In his veto message, the Governor stated:

“This bill would revise qualification standards for providers of BHT for individuals with autism. Standards for autism providers were updated last year. I'm not inclined to revise them again.”

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Senate Appropriations Committee:

• DDS estimates ongoing costs of $287,000 ($230,000 General Fund) for state staffing for administration. In addition, DDS indicates that to the extent the bill results in increased utilization or higher rates, the associated costs for purchase of services could be substantial. DDS estimates that, for example, an increase of 1% in behavioral health related service expenditures may result in a $4.4 million ($2.6 million General Fund) increase.
• Unknown, potential increases in CalPERS employer premiums.
• DMHC estimates costs to administer the provisions would be minor and absorbable.
• The CDI estimates no fiscal impact to administer the provisions.

SUPPORT: (Verified 5/18/23)

DIRFloortime Coalition of California (source)

California Psychological Association

Center for Developmental Plan and Learning

Cherry Crisp Entertainment and Productions

Child Development Institute

Disability Voices United

Easterseals Northern California

Fresno City College

Greenhouse Therapy Center

Institute for Girls’ Development

Mental Health and Autism Insurance Project

National Association of Social Workers, California Chapter

Positive Development

Professional Child Development Associates

Quicksilver Softwore, Inc.

San Diego Academy of Child and Adolescent Psychiatry

The Center for Connection

Touchstone Family Development Center, Inc.

One Individual

OPPOSITION: (Verified 5/18/23)

California Association for Behavior Analysis

ARGUMENTS IN SUPPORT: Disability Voices United (DVU) writes current legislation limits insurance to funding only one form of BHT, namely ABA. Although this treatment may work well for some children, it does not work for all. Autistic youth are unique and each needs access to the form of BHT best suited to their needs. It is important that all children receive individualized care. This bill would ensure that only evidence-based treatments are used, and that they are prescribed and supervised by licensed providers. All children need access to care to address their treatment needs in a timely way rather than wasting precious time on long wait lists due to the overly limited supply of service providers. Most families, particularly families of limited financial means, cannot afford to pay privately for costly ongoing intensive therapies denied by their insurance if their loved one requires a treatment approach that is not ABA. This unfair situation furthers healthcare access disparities in California’s historically disadvantaged communities. In DVU’s experience, many families, especially those from underserved communities, struggle for timely access to appropriate autism services. A parent writes by definition in the DSM-5 Diagnostic criteria, autism is a persistent deficit in “social communication” and “social interaction.” One of the primary deficits in autism is in social-emotional reciprocity. Social reciprocity is vitally important during early development because reciprocity (turn-taking between parents and young children) builds connectivity and efficiency in the brains of young children (Romeo et al. 2018).

ARGUMENTS IN OPPOSITION: The California Association of Behavior Analysis (CalABA) writes that they continue to oppose legislation that expands criteria for providers of BHT for individuals with autism. While this attempt does not have the far reaching negative implications of similar previous legislation, CalABA continues to have concerns about lowering/expanding provider qualifications. This bill requires that DDS establish educational and experiential qualifications for these providers which should be and have been set by national accreditation and credentialing boards. This bill alters the eligibility requirements for practitioners serving this vulnerable population. CalABA is concerned that as written this bill would lead to individuals providing BHT without the appropriate qualifications, and believes that many of the issues raised through this legislation can, and should, be addressed through legislation providing a comprehensive licensing framework for individuals providing this service. Click here to enter text.

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

5/20/23 13:09:39

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SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

SB 805 (Portantino) - Health care coverage: pervasive developmental disorders or autism

Bill Summary:

SB 805 would expand the qualifications for Qualified Autism Service (QAS) professionals and paraprofessionals as it relates to health plan and insurer coverage of behavioral health treatment for pervasive developmental disorders or autism. The bill would require the Department of Developmental Services (DDS) to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services, as specified.

Fiscal Impact:

• DDS estimates ongoing costs of $287,000 ($230,000 General Fund) for state staffing for administration. In addition, DDS indicates that to the extent the bill results in increased utilization or higher rates, the associated costs for purchase of services could be substantial. DDS estimates that, for example, an increase of 1 percent in behavioral health related service expenditures may result in a $4.4 million ($2.6 million General Fund) increase.
• Unknown, potential increases in CalPERS employer premiums.
• Department of Managed Health Care (DMHC) estimates costs to administer the provisions would be minor and absorbable.
• The Department of Insurance estimates no fiscal impact to administer the provisions.

Background:

The Department of Managed Health Care (DMHC) regulates health plans under the Knox-Keene Act and the California Department of Insurance (CDI) regulates health insurance.

Current law requires every health plan contract and health insurance policy that provides hospital, medical, or surgical coverage to cover Behavioral Health Treatment (BHT) for pervasive developmental disorder or autism. Current law defines BHT as 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 that meet specified criteria regarding the treatment plan, the professionals who can prescribe and supervise treatment, and the administration of the treatment plan. Health plans and health insurers must maintain an adequate network that includes qualified autism service (QAS) providers who supervise or employ QAS professionals and QAS paraprofessionals who provide and administer BHT. Current law defines QAS providers, professionals, and paraprofessionals for these purposes.

DDS is responsible for administering the Lanterman Developmental Disabilities Services Act (Lanterman Act). The Lanterman Act provides for the coordination and provision of services and supports to enable people with intellectual and developmental disabilities (IDD) to lead more independent, integrated and productive lives. Under the Lanterman Act, individuals with IDD are entitled to an array of services and supports to meet their individual needs and choices, at each stage of their life, and regardless of age or degree of disability.

Proposed Law:

Specific provisions of the bill would:

• Expand the criteria for a qualified autism service professional to include a behavioral health professional, as defined; or a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined.
• Expand the criteria for a qualified autism service paraprofessional to include a behavioral health paraprofessional, as specified.
• Require DDS to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services, and to establish rates and the educational or experiential qualifications and professional supervision requirements necessary for these positions to provide behavioral intervention services, as specified.

Related Legislation:

SB 562 (Portantino, 2022) would have, among other provisions, expanded the definition of qualified autism service professionals. This bill was vetoed by the Governor.

Staff Comments:

According to the California Health Benefits Review Program (CHBRP) analysis of SB 562, the bill would have increased total net annual expenditures (premiums and enrollee expenses for covered and noncovered benefits) enrollees in DMHC-regulated plans and CDI-regulated policies by $4,112,000. This included an increase in CalPERS employer premiums of $204,000.

-- END --

SENATE COMMITTEE ON HUMAN SERVICES

Senator Alvarado-Gil, Chair

2023 - 2024 Regular

Subject: Health care coverage: pervasive developmental disorders or autism

SUMMARY

This bill expands the qualifications for Qualified Autism Service (QAS) professionals and paraprofessionals as found in California’s mandate on health plans and insurers to cover behavioral health treatment for pervasive developmental disorders or autism. This bill requires the California Department of Developmental Services (DDS) to establish emergency regulations to develop educational or experiential qualifications and supervision requirements for these providers and a rate.

ABSTRACT

Existing Law:

1. 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.)
2. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program; and DDS to administer services to people with developmental disabilities. (HSC 1340, et seq., INS 106, et seq., WIC 14000, et seq., and WIC 4400, et seq.)
3. Establishes a system of nonprofit Regional Centers (RC), overseen by 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)
4. 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(b))
5. Requires every health care service plan contract that provides hospital, medical, or surgical coverage to also provide coverage for behavioral health treatment (BHT) for pervasive developmental disorder or autism, as specified. (WIC 1374.73. (a) (1))
6. Requires that every health care service plan maintain an adequate network that includes QAS providers who supervise and employ QAS professionals or paraprofessionals who provide and administer BHT. Provides that nothing will prevent a health care service plan from selectively contracting with providers within these requirements. (WIC 1374.73 (b))
7. Defines BHT, 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 (ABA) 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))
8. Requires treatment 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))
9. Includes in the definition of a "QAS 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))
10. Defines in state regulations, for purposes of regional center vendorization, Behavior Management Assistant, Behavior Management Consultant, Behavior Analyst and Associate Behavior Analyst and requires education or experience in Applied Behavioral Analysis (ABA), as specified. (17 CCR 54342)

This Bill:

1. Includes as a QAS professional: a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology, and who meets the criteria set forth in the regulations described in 3) below.
2. Includes as a QAS paraprofessional a “behavioral health paraprofessional” who meets the criteria set forth in the regulations described in 3) below.
3. Requires DDS to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services and establish a rate. Further, requires the regulations to also establish a rate and the educational or experiential qualifications and professional supervision requirements necessary for the behavioral health professional to provide behavioral intervention services.
4. Deems the adoption, amendment, repeal, or re-adoption of a regulation authorized by this bill to be necessary for the immediate preservation of the public peace, health and safety, or general welfare, as specified, and exempts DDS from the requirement that it describe specific facts showing the need for immediate action. Further, requires a certificate of compliance for these implementing regulations to be filed within 24 months following the adoption of the first emergency regulations filed pursuant to this bill.

FISCAL IMPACT

This bill has not yet been analyzed by a fiscal committee.

BACKGROUND AND DISCUSSION

Purpose of the Bill:

According to the author, “This bill corrects a long-standing problem regarding services for autistic individuals in California. In 2011, SB 946 (Steinberg, Chapter 650) introduced insurance coverage for behavioral health treatment for autism. The definition of behavioral health treatment given is “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.” Unfortunately, the description of QAS Professionals and QAS Paraprofessionals became only those clinicians providing applied behavior analysis. Those professionals using other “evidence-based behavior intervention programs” are not included in insurance coverage. SB 805 will correct this problem by expanding the descriptions of qualified professionals and qualified paraprofessionals. This will allow for choice in treatment approaches and offer greater access to urgently needed services. Research has clearly shown that there is a variety of approaches that are accepted as ‘evidence-based.’ Individuals with autism are all unique and deserve to have access to the approach which best suits their needs. This was clearly the intent of the legislation, originally passed in 2011.”

Autism

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). According to the National Institute for Mental Health (NIMH), autism is known as a “spectrum” disorder because there is wide variation in the type and severity of symptoms people experience.

According to the NIH, the most notable feature of ASD is impaired social interaction. As described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a clinical guide developed by the American Psychiatric Association, individuals with ASD have persistent difficulty with reciprocal social communication and social interaction with other people, restricted interests and repetitive behaviors, and symptoms that worsen the person’s ability to function properly in school, work, and other areas of life. For example, 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 and adults with ASD may avoid eye contact with other people, or not respond to verbal commands or conversation. Many children with ASD also have odd play patterns, cannot interpret facial expressions or changes in voice inflection, and do not understand what others are thinking or feeling. As symptoms generally appear during the first two years of life, ASD is said to be a developmental disorder; however a diagnosis may be made at any age. Although symptoms are normally lifelong, treatments and services can improve an individual’s symptoms and their ability to function.

ASD occurs in all ethnic and socioeconomic groups and affects every age group. Males are four times more likely to have ASD than females. According to a CDC study, about 1 in 22 four-year-old children were identified with autism in California in 2020. The study also showed that white children, for the first time, were less likely to be identified with ASD than other races and/or ethnicities. Nationally, it is estimated that about 3 percent of Black, Hispanic or Latino and Asian or Pacific Islander children have been diagnosed with autism, compared with about 2 percent of white children. Experts attributed the data changes to improved screening and autism services for all kids, and to improved awareness and advocacy for Black and Hispanic families.^[1]

DDS data shows that as of March 2023, approximately 164,472 of the state’s 407,134 developmental services consumers have an ASD or pervasive developmental disorder diagnosis. Additionally, DDS reports that among those consumers receiving services for ASD, 40.24 percent identified as Latino, 25.82 percent identified as white, 8.51 percent identified as Asian, 7.2 percent identified as Black, 3.11 percent identified as Filipino, .29 percent identified as Native American, and .22 percent identified as Polynesian.

Agency for Health Care Research and Quality

Autism, as a condition, that is still considered a relatively new in the field of scientific intervention. Researchers and health providers for years have debated the merits of various forms of BHT. The federal Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services conducts systematic reviews on emerging treatments to provide clinicians with information and context on the usefulness of these new treatments. In 2014, the Agency published a 513-page report entitled, “Therapies for Children with Autism Spectrum Disorder: Behavioral Interventions Update.”^[2]

The report concluded that while a growing evidence base “suggests that behavioral interventions can be associated with positive outcomes for children with ASD … a need remains for studies of interventions across settings and continued improvements in methodological rigor. Substantial scientific advances are needed to enhance our understanding of which interventions are most effective for specific children with ASD and to isolate elements or components of interventions most associated with effects.” The report underscores a debate about which therapies are evidence-based and whether to approve state and federal funding for emerging therapies.

Treatment Modalities for ASD

The two most comprehensive and commonly referenced reviews on treatments for Autism include the National Clearinghouse on Autism Evidence and Practice (NCAEP) at the University of North Carolina and the National Standards Project Phase 2 (NSP2) at the National Autism Center. Some treatment modalities for ASD that have been reviewed by the NCAEP or NSP2 include the following:

• Applied Behavioral Analysis (ABA). The most recognized form of behavioral 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 U.S. Surgeon General, the U.S. Department of Education and many 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 also 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. ABA is considered to be an evidenced based practice.

• Early Start Denver Model (ESDM). ABA encompasses several different treatment modalities, and there are other interventions that have been scientifically studied and found to be effective. One of those is the ESDM, which is a relationship-based intervention provided in the home by trained therapists and parents during natural play and daily routines. ESDM is considered to be an evidence-based intervention that was specifically developed for very young children with autism. ESDM uses a data based approach and empirically supported teaching practices that have been found effective from research in applied behavior analysis. ESDM trainings are offered at the UC Davis MIND Institute for professionals interested in becoming ESDM certified.
• Floortime. Sponsors of this bill, DIR®/Floortime™, Inc., implement a practice concept that centers around meeting children at their level – literally by playing on the floor with them. In Floortime, therapists and parents interact with children through the activities each child enjoys. They follow the child's lead and play the child’s games. Therapists then teach parents how to direct their children into increasingly complex interactions. For example, if the child is tapping a toy truck, the parent might tap a toy car in the same way, according to an example on the Autism Speaks website. The parent might then put the car in front of the child’s truck or add language to the game to further communication. Floortime may be used with other behavioral interventions. Floortime is considered an “emerging treatment,” or those for which one or more studies suggest the intervention may produce favorable outcomes for ASD and is not currently recognized by NSP2 as meeting the criteria to be considered an evidenced-based model.

The Autism Advisory Task Force (Task Force)

The Task Force was established pursuant to SB 946 (Steinberg, Chapter 650, statutes of 2011) to make recommendations to inform state policymaking and develop recommendations regarding the education, training, and experience requirements that unlicensed individuals providing autism services are required to meet in order to secure a license from the state. A guiding principle of the Task Force was that every individual with autism or pervasive developmental disorder is unique and the behavioral health interventions would need to be highly individualized. The Task Force’s final report concluded that all "top level" providers should be licensed by the state, and set up a process for establishing a new professional license for "Licensed Behavioral Health Practitioner." Recommendations from the Task Force included: that the licensure requirements not take effect until three years after the license is established; an interim commission be formed to implement the new license until a board is able to do so; and for all providers of autism services be registered with the state's TrustLine Registry or comparable criminal history background check system as a condition of employment and contracting with health plans and health insurers.

California Health Benefits Review Program (CHBRP)

The CHBRP was authorized by the Legislature and established in AB 1996 (Thomson, Chapter 795, Statutes of 2022) in response to Legislative requests for an independent analysis of the medical, financial and public health impacts of proposed health insurance benefit mandates and repeals. Staffed by the University of California Office of the President, the program works with a task force of faculty from several UC campuses and actuarial consultants. CHBRP was created in response to AB 1996, and reviewed SB 562 of 2022, which is similar to SB 805, as SB 805 is altering the current mandate, by expanding the mandate to include certain professionals who provide developmental-based treatment modalities as described below. Key findings relevant to this bill include the following as was reported in the Senate Health Committee bill analysis from April 17, 2023:

• 1. Assumptions. CHBRP assumes that behavioral health treatment (BHT) would require coverage of developmental-based modalities (such as DIR®/Floortime™) as well as behavior-based modalities (such as Pivotal Response Training) and hybrid modalities (such as Early Start Denver Model and Social Skills Group Therapy).
  2. Coverage impacts and enrollees covered. At baseline, 100 percent of commercial/CalPERS enrollees with health insurance that would be subject to this bill have coverage for modalities of BHT based on behavioral theory and hybrid modalities (behavioral and developmental). Postmandate, coverage for modalities based on developmental theory would rise among these enrollees from 77 percent to 100 percent.
  3. Medical effectiveness. CHBRP found evidence that BHT modalities based on ABA, developmental theory, and hybrids of both theories improve outcomes for people with autism spectrum disorder. Prominent outcomes include improvements in communication, social skills, cognition, adaptive behavior, language, motor skills, play skills, and symptom severity. CHBRP’s literature review also found that BHT can be delivered effectively by people with similar training as QAS professionals when supervised by a QAS provider. Regardless of the theory on which BHT modalities are based, many studies of them are observational or quasi-experimental studies that do not randomly assign participants to the intervention or control condition. Some do not include any sort of comparison group. Lack of random assignment decreases confidence that any differences that are found between the treatment and control groups are due to the BHT treatment being tested and not to differences between the people with autism spectrum disorder in the treatment and control groups. Lack of a control group further decreases confidence in a study’s findings because one cannot rule out the possibility that any differences observed over time are due to factors other than the BHT modality. In cases where random control groups (RCTs) of BHT interventions were conducted, caution should be exercised when interpreting the findings of RCTs with small sample sizes. Moreover, most articles in CHBRP’s medical effectiveness literature review were about research in children; a few articles on adolescents were identified. The findings may be difficult to generalize to adults.
  4. Utilization. CHBRP estimates that 24,000 enrollees with autism spectrum disorder in DMHC-regulated plans and CDI-regulated policies have health insurance that would be subject to this bill. Postmandate, CHBRP assumes the number of enrollees with autism spectrum disorder using BHT will not increase, because the use of this type of treatment overall is based on clinical diagnosis and determination that BHT is medically necessary.
  5. Medi-Cal. This bill would not change the current law’s Medi-Cal related exemption, CHBRP projects no change in premium expenditures for the 8.9 million Medi-Cal beneficiaries enrolled in DMHC-regulated plans.
  6. Essential health benefits (EHBs). CHBRP believes this bill would not trigger financial costs to the state for exceeding EHBs, because it alters the terms and conditions of an existing benefit mandate law, but does not require an additional benefit to be covered. Additionally, the law indicates that it ceases to function if it exceeds EHBs and this bill does not eliminate this clause of the current law.

The bill seeks to expand the types of individuals who can serve as QAS professionals and QAS paraprofessionals by creating new designations known as “Behavioral Health Professionals” and “Behavioral Health Paraprofessionals”. This bill also would require DDS to establish educational and experiential qualifications and rates for these providers.

Related/Prior Legislation:

SB 562 (Portantino, 2021) would have revised and expanded the definition of BHT for pervasive developmental disorder or autism for purposes of health plan and insurer mandated coverage, would have expanded the definitions of “QAS providers, professionals and paraprofessionals,” as well as prohibited the setting, location, or time of treatment recommended by the QAS provider from being used as a reason to deny or reduce coverage for medically necessary services. SB 562 was vetoed by the Governor.

SB 163 (Portantino, 2019) was identical to SB 562 (2021), except it would have also removed the Medi-Cal exclusion. SB 163 was vetoed by Governor.

SB 399 (Portantino, 2018) would have broadened the eligibility criteria to become a “QAS professional” and would have authorized the substitution of specified education, work experience, and training qualifications to meet the criteria of a “QAS professional.” SB 399 would also have eliminated the requirement for a professional or paraprofessional to be directly employed by a qualified autism provider and would have prohibited the lack of parent or caregiver participation from being used to deny or reduce medically necessary behavioral health treatment, among other changes. SB 399 was vetoed by the Governor.

AB 1074 (Maienschein, Chapter 385, 2017) is substantially similar to this bill. It requires a QAS professional or a QAS paraprofessional to be supervised by a QAS provider, and makes other parallel changes. However it does not include the language of this bill which broadens the definition of provider categories, or extend the mandated timeline for review of the treatment plan.

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) would have modified the requirements of a QAS professional and would have required that a treatment plan be reviewed no more than once every 6 months, unless a shorter period is recommended by the QAS provider. The bill was held in the Assembly Appropriations Committee.

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. The bill was held in the Senate Appropriations Committee.

SB 946 (Steinberg, Chapter 650, statutes of 2011) requires health plans and health insurance policies to cover BHT 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.

COMMENTS

The sponsors of this bill and other supporters note they are seeking to change QAS Professional and QAS Paraprofessional as currently defined because it results in insurance covering only one form of behavioral health treatment rather than all forms of evidence-based behavioral health treatment. They believe that changes to the existing law are needed “to ensure that Californians with autism will receive the form of behavioral health care that is appropriate to their individual needs.” The opponents of the bill do not agree there is a need to expand the definition of QAS Professional and QAS Paraprofessional. They believe that it would “lead to individuals providing behavioral health treatment without the appropriate qualifications and without sufficient minimum standards to practice competently in place consumers will be at increasing risk of the erosion of quality of service.”

This bill is very similar to SB 562 (Portantino, 2021), which would have revised and expanded the definition of BHT for pervasive developmental disorder or autism for purposes of health plan and insurer mandated coverage including expanding the definitions of QAS providers, professionals, and paraprofessionals. SB 562, additionally, would have also prohibited the setting, location, or time of treatment recommended by the QAS provider from being used as a reason to deny or reduce coverage for medically necessary services. This bill was vetoed by Governor Newsom. The Governor’s veto message states the following:

“This bill would require health plans and insurers to cover relationship-based and developmental behavioral therapies for the treatment of autism spectrum disorder (ASD). The bill would also authorize additional types of providers and professionals that can provide behavioral health therapy to individuals with ASD.

Early diagnosis of ASD and subsequent participation in evidence-based intervention and therapies, provided by licensed and certified individuals, make all the difference in an individual's long-term health outcomes. Research finds that Black and Latino children are often misdiagnosed and diagnosed later with ASD than their White peers. It is incumbent upon us to ensure that any intervention is medically-necessary, evidence-based and grounded in research that is conducted to reduce disparities.

Under existing law, health plans and insurers must cover evidence-based and medically-necessary behavioral therapies. This bill proposes to change the existing evidence-based standard by requiring coverage of therapies where there is insufficient, or only emerging, evidence to assess the impact of the interventions. Furthermore, the bill proposes changes to professional standards by expanding the types of individuals who can serve as qualified autism service professionals, which could result in long-term ramifications for individuals with ASD who receive the services.

I appreciate the author's dedication to supporting children diagnosed with ASD and their families. While the bill's intent is laudable, expanding access to certain therapies and interventions must be grounded in evidence-based practices and be provided by qualified professionals. I encourage the author to continue discussions related to the expansion of provider types and changes to professional standards through a formal licensing scheme that includes clinical expertise and administrative oversight to address qualification standards for practitioners, to ensure equity and quality of care, and provide effective consumer protection, as I expressed when I vetoed a similar bill in 2019.”

This bill was double referred to Senate Health Committee. The Senate Health Committee amended the bill to clarify that a QAS professional includes a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, who is supervised by a licensed professional as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.

SUPPORT/OPPOSITION

Arguments in Support:

The DIR/Floortime Coalition of California writes, “The DMHC unanimously adopted the guiding principle that behavioral health interventions should be highly individualized and that the choice of BHT should be grounded in scientific evidence, clinical practice guidelines, and evidence-based practice. Research has clearly demonstrated that a variety of forms of BHT are effective. Despite this, the specific language in SB 946 limits the choice of treatment modalities in practice and too many children have been denied the specific form of therapy they need. Specifically, the language in SB 946 and subsequent definitions of Qualified Autism Paraprofessionals pursuant to AB 104 (2011), and in CCR 54342 severely limits the type of BHT covered. SB 805 would correct this oversight. SB 805 will allow health professionals who are assistants or associates of professionals already licensed in California to provide all forms of evidence-based BHT under supervision. In addition, SB 805 will expand the pool of professionals and paraprofessionals able to provide covered BHT by creating two new categories: behavioral health professional and behavioral health paraprofessional and directs DDS to develop the requirements for these positions. In this way, a broader array of types of BHT will become available for those in need. The qualifications should be equivalent in rigor to the currently authorized providers, and simply expand the types of intervention from the current highly restrictive form of BHT covered.

Arguments in Opposition:

The California Association for Behavior Analysis writes, “We continue to oppose legislation that expands criteria for providers of behavioral health treatment for individuals with autism. While this attempt does not have the far reaching negative implications of similar previous legislation, we continue to have concerns about lowering/expanding provider qualifications. SB 805 requires that DDS establish educational and experiential qualifications for these providers which should be and have been set by national accreditation and credentialing boards. We applaud the efforts to increase access to behavioral health services for individuals with autism and their families but believe that the language of SB 805 has negative unintended consequences. As written, this bill alters the eligibility requirements for practitioners serving this vulnerable population. We are concerned that as written SB 805 would lead to individuals providing behavioral health treatment without the appropriate qualifications. We believe that many of the issues raised through this legislation can, and should, be addressed through legislation providing a comprehensive licensing framework for individuals providing these services. Without sufficient minimum standards to practice competently in place consumers will be at increasing risk of the erosion of quality of service. CalABA seeks to ensure sufficient consumer protections are in place for individuals with autism and their families and this bill goes against that value.”

PRIOR VOTES

POSITIONS

Support:

California Psychological Association

Center for Developmental Play and Learning

Cherry Crisp Entertainment and Productions

Child Development Institute

Dirfloortime Coalition of California

Disability Voices United

Easterseals Northern California

Greenhouse Therapy Center

Positive Development

Professional Child Development Associates

Quicksilver Software

The Center for Connection

Touchstone Family Development Center, INC.

Oppose:

California Association for Behavior Analysis

-- END --

1. https://www.cdc.gov/ncbddd/autism/addm-community-report/california.html ↑

2. Weitlauf AS, et al, “Therapies for Children with Autism Spectrum Disorder: Behavioral Interventions Update.” Comparative Effectiveness Review No. 137. ↑

SENATE COMMITTEE ON HUMAN SERVICES

Senator Alvarado-Gil, Chair

2023 - 2024 Regular

Subject: Health care coverage: pervasive developmental disorders or autism

SUMMARY

This bill expands the qualifications for Qualified Autism Service (QAS) professionals and paraprofessionals as found in California’s mandate on health plans and insurers to cover behavioral health treatment for pervasive developmental disorders or autism. This bill requires the California Department of Developmental Services (DDS) to establish emergency regulations to develop educational or experiential qualifications and supervision requirements for these providers and a rate.

ABSTRACT

Existing Law:

1. 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.)
2. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program; and DDS to administer services to people with developmental disabilities. (HSC 1340, et seq., INS 106, et seq., WIC 14000, et seq., and WIC 4400, et seq.)
3. Establishes a system of nonprofit Regional Centers (RC), overseen by 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)
4. 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(b))
5. Requires every health care service plan contract that provides hospital, medical, or surgical coverage to also provide coverage for behavioral health treatment (BHT) for pervasive developmental disorder or autism, as specified. (WIC 1374.73. (a) (1))
6. Requires that every health care service plan maintain an adequate network that includes QAS providers who supervise and employ QAS professionals or paraprofessionals who provide and administer BHT. Provides that nothing will prevent a health care service plan from selectively contracting with providers within these requirements. (WIC 1374.73 (b))
7. Defines BHT, 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 (ABA) 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))
8. Requires treatment 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))
9. Includes in the definition of a "QAS 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))
10. Defines in state regulations, for purposes of regional center vendorization, Behavior Management Assistant, Behavior Management Consultant, Behavior Analyst and Associate Behavior Analyst and requires education or experience in Applied Behavioral Analysis (ABA), as specified. (17 CCR 54342)

This Bill:

1. Includes as a QAS professional: a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology, and who meets the criteria set forth in the regulations described in 3) below.
2. Includes as a QAS paraprofessional a “behavioral health paraprofessional” who meets the criteria set forth in the regulations described in 3) below.
3. Requires DDS to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services and establish a rate. Further, requires the regulations to also establish a rate and the educational or experiential qualifications and professional supervision requirements necessary for the behavioral health professional to provide behavioral intervention services.
4. Deems the adoption, amendment, repeal, or re-adoption of a regulation authorized by this bill to be necessary for the immediate preservation of the public peace, health and safety, or general welfare, as specified, and exempts DDS from the requirement that it describe specific facts showing the need for immediate action. Further, requires a certificate of compliance for these implementing regulations to be filed within 24 months following the adoption of the first emergency regulations filed pursuant to this bill.

FISCAL IMPACT

This bill has not yet been analyzed by a fiscal committee.

BACKGROUND AND DISCUSSION

Purpose of the Bill:

According to the author, “This bill corrects a long-standing problem regarding services for autistic individuals in California. In 2011, SB 946 (Steinberg, Chapter 650) introduced insurance coverage for behavioral health treatment for autism. The definition of behavioral health treatment given is “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.” Unfortunately, the description of QAS Professionals and QAS Paraprofessionals became only those clinicians providing applied behavior analysis. Those professionals using other “evidence-based behavior intervention programs” are not included in insurance coverage. SB 805 will correct this problem by expanding the descriptions of qualified professionals and qualified paraprofessionals. This will allow for choice in treatment approaches and offer greater access to urgently needed services. Research has clearly shown that there is a variety of approaches that are accepted as ‘evidence-based.’ Individuals with autism are all unique and deserve to have access to the approach which best suits their needs. This was clearly the intent of the legislation, originally passed in 2011.”

Autism

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). According to the National Institute for Mental Health (NIMH), autism is known as a “spectrum” disorder because there is wide variation in the type and severity of symptoms people experience.

According to the NIH, the most notable feature of ASD is impaired social interaction. As described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a clinical guide developed by the American Psychiatric Association, individuals with ASD have persistent difficulty with reciprocal social communication and social interaction with other people, restricted interests and repetitive behaviors, and symptoms that worsen the person’s ability to function properly in school, work, and other areas of life. For example, 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 and adults with ASD may avoid eye contact with other people, or not respond to verbal commands or conversation. Many children with ASD also have odd play patterns, cannot interpret facial expressions or changes in voice inflection, and do not understand what others are thinking or feeling. As symptoms generally appear during the first two years of life, ASD is said to be a developmental disorder; however a diagnosis may be made at any age. Although symptoms are normally lifelong, treatments and services can improve an individual’s symptoms and their ability to function.

ASD occurs in all ethnic and socioeconomic groups and affects every age group. Males are four times more likely to have ASD than females. According to a CDC study, about 1 in 22 four-year-old children were identified with autism in California in 2020. The study also showed that white children, for the first time, were less likely to be identified with ASD than other races and/or ethnicities. Nationally, it is estimated that about 3 percent of Black, Hispanic or Latino and Asian or Pacific Islander children have been diagnosed with autism, compared with about 2 percent of white children. Experts attributed the data changes to improved screening and autism services for all kids, and to improved awareness and advocacy for Black and Hispanic families.^[1]

DDS data shows that as of March 2023, approximately 164,472 of the state’s 407,134 developmental services consumers have an ASD or pervasive developmental disorder diagnosis. Additionally, DDS reports that among those consumers receiving services for ASD, 40.24 percent identified as Latino, 25.82 percent identified as white, 8.51 percent identified as Asian, 7.2 percent identified as Black, 3.11 percent identified as Filipino, .29 percent identified as Native American, and .22 percent identified as Polynesian.

Agency for Health Care Research and Quality

Autism, as a condition, that is still considered a relatively new in the field of scientific intervention. Researchers and health providers for years have debated the merits of various forms of BHT. The federal Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services conducts systematic reviews on emerging treatments to provide clinicians with information and context on the usefulness of these new treatments. In 2014, the Agency published a 513-page report entitled, “Therapies for Children with Autism Spectrum Disorder: Behavioral Interventions Update.”^[2]

The report concluded that while a growing evidence base “suggests that behavioral interventions can be associated with positive outcomes for children with ASD … a need remains for studies of interventions across settings and continued improvements in methodological rigor. Substantial scientific advances are needed to enhance our understanding of which interventions are most effective for specific children with ASD and to isolate elements or components of interventions most associated with effects.” The report underscores a debate about which therapies are evidence-based and whether to approve state and federal funding for emerging therapies.

Treatment Modalities for ASD

The two most comprehensive and commonly referenced reviews on treatments for Autism include the National Clearinghouse on Autism Evidence and Practice (NCAEP) at the University of North Carolina and the National Standards Project Phase 2 (NSP2) at the National Autism Center. Some treatment modalities for ASD that have been reviewed by the NCAEP or NSP2 include the following:

• Applied Behavioral Analysis (ABA). The most recognized form of behavioral 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 U.S. Surgeon General, the U.S. Department of Education and many 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 also 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. ABA is considered to be an evidenced based practice.

• Early Start Denver Model (ESDM). ABA encompasses several different treatment modalities, and there are other interventions that have been scientifically studied and found to be effective. One of those is the ESDM, which is a relationship-based intervention provided in the home by trained therapists and parents during natural play and daily routines. ESDM is considered to be an evidence-based intervention that was specifically developed for very young children with autism. ESDM uses a data based approach and empirically supported teaching practices that have been found effective from research in applied behavior analysis. ESDM trainings are offered at the UC Davis MIND Institute for professionals interested in becoming ESDM certified.
• Floortime. Sponsors of this bill, DIR®/Floortime™, Inc., implement a practice concept that centers around meeting children at their level – literally by playing on the floor with them. In Floortime, therapists and parents interact with children through the activities each child enjoys. They follow the child's lead and play the child’s games. Therapists then teach parents how to direct their children into increasingly complex interactions. For example, if the child is tapping a toy truck, the parent might tap a toy car in the same way, according to an example on the Autism Speaks website. The parent might then put the car in front of the child’s truck or add language to the game to further communication. Floortime may be used with other behavioral interventions. Floortime is considered an “emerging treatment,” or those for which one or more studies suggest the intervention may produce favorable outcomes for ASD and is not currently recognized by NSP2 as meeting the criteria to be considered an evidenced-based model.

The Autism Advisory Task Force (Task Force)

The Task Force was established pursuant to SB 946 (Steinberg, Chapter 650, statutes of 2011) to make recommendations to inform state policymaking and develop recommendations regarding the education, training, and experience requirements that unlicensed individuals providing autism services are required to meet in order to secure a license from the state. A guiding principle of the Task Force was that every individual with autism or pervasive developmental disorder is unique and the behavioral health interventions would need to be highly individualized. The Task Force’s final report concluded that all "top level" providers should be licensed by the state, and set up a process for establishing a new professional license for "Licensed Behavioral Health Practitioner." Recommendations from the Task Force included: that the licensure requirements not take effect until three years after the license is established; an interim commission be formed to implement the new license until a board is able to do so; and for all providers of autism services be registered with the state's TrustLine Registry or comparable criminal history background check system as a condition of employment and contracting with health plans and health insurers.

California Health Benefits Review Program (CHBRP)

The CHBRP was authorized by the Legislature and established in AB 1996 (Thomson, Chapter 795, Statutes of 2022) in response to Legislative requests for an independent analysis of the medical, financial and public health impacts of proposed health insurance benefit mandates and repeals. Staffed by the University of California Office of the President, the program works with a task force of faculty from several UC campuses and actuarial consultants. CHBRP was created in response to AB 1996, and reviewed SB 562 of 2022, which is similar to SB 805, as SB 805 is altering the current mandate, by expanding the mandate to include certain professionals who provide developmental-based treatment modalities as described below. Key findings relevant to this bill include the following as was reported in the Senate Health Committee bill analysis from April 17, 2023:

• 1. Assumptions. CHBRP assumes that behavioral health treatment (BHT) would require coverage of developmental-based modalities (such as DIR®/Floortime™) as well as behavior-based modalities (such as Pivotal Response Training) and hybrid modalities (such as Early Start Denver Model and Social Skills Group Therapy).
  2. Coverage impacts and enrollees covered. At baseline, 100 percent of commercial/CalPERS enrollees with health insurance that would be subject to this bill have coverage for modalities of BHT based on behavioral theory and hybrid modalities (behavioral and developmental). Postmandate, coverage for modalities based on developmental theory would rise among these enrollees from 77 percent to 100 percent.
  3. Medical effectiveness. CHBRP found evidence that BHT modalities based on ABA, developmental theory, and hybrids of both theories improve outcomes for people with autism spectrum disorder. Prominent outcomes include improvements in communication, social skills, cognition, adaptive behavior, language, motor skills, play skills, and symptom severity. CHBRP’s literature review also found that BHT can be delivered effectively by people with similar training as QAS professionals when supervised by a QAS provider. Regardless of the theory on which BHT modalities are based, many studies of them are observational or quasi-experimental studies that do not randomly assign participants to the intervention or control condition. Some do not include any sort of comparison group. Lack of random assignment decreases confidence that any differences that are found between the treatment and control groups are due to the BHT treatment being tested and not to differences between the people with autism spectrum disorder in the treatment and control groups. Lack of a control group further decreases confidence in a study’s findings because one cannot rule out the possibility that any differences observed over time are due to factors other than the BHT modality. In cases where random control groups (RCTs) of BHT interventions were conducted, caution should be exercised when interpreting the findings of RCTs with small sample sizes. Moreover, most articles in CHBRP’s medical effectiveness literature review were about research in children; a few articles on adolescents were identified. The findings may be difficult to generalize to adults.
  4. Utilization. CHBRP estimates that 24,000 enrollees with autism spectrum disorder in DMHC-regulated plans and CDI-regulated policies have health insurance that would be subject to this bill. Postmandate, CHBRP assumes the number of enrollees with autism spectrum disorder using BHT will not increase, because the use of this type of treatment overall is based on clinical diagnosis and determination that BHT is medically necessary.
  5. Medi-Cal. This bill would not change the current law’s Medi-Cal related exemption, CHBRP projects no change in premium expenditures for the 8.9 million Medi-Cal beneficiaries enrolled in DMHC-regulated plans.
  6. Essential health benefits (EHBs). CHBRP believes this bill would not trigger financial costs to the state for exceeding EHBs, because it alters the terms and conditions of an existing benefit mandate law, but does not require an additional benefit to be covered. Additionally, the law indicates that it ceases to function if it exceeds EHBs and this bill does not eliminate this clause of the current law.

The bill seeks to expand the types of individuals who can serve as QAS professionals and QAS paraprofessionals by creating new designations known as “Behavioral Health Professionals” and “Behavioral Health Paraprofessionals”. This bill also would require DDS to establish educational and experiential qualifications and rates for these providers.

Related/Prior Legislation:

SB 562 (Portantino, 2021) would have revised and expanded the definition of BHT for pervasive developmental disorder or autism for purposes of health plan and insurer mandated coverage, would have expanded the definitions of “QAS providers, professionals and paraprofessionals,” as well as prohibited the setting, location, or time of treatment recommended by the QAS provider from being used as a reason to deny or reduce coverage for medically necessary services. SB 562 was vetoed by the Governor.

SB 163 (Portantino, 2019) was identical to SB 562 (2021), except it would have also removed the Medi-Cal exclusion. SB 163 was vetoed by Governor.

SB 399 (Portantino, 2018) would have broadened the eligibility criteria to become a “QAS professional” and would have authorized the substitution of specified education, work experience, and training qualifications to meet the criteria of a “QAS professional.” SB 399 would also have eliminated the requirement for a professional or paraprofessional to be directly employed by a qualified autism provider and would have prohibited the lack of parent or caregiver participation from being used to deny or reduce medically necessary behavioral health treatment, among other changes. SB 399 was vetoed by the Governor.

AB 1074 (Maienschein, Chapter 385, 2017) is substantially similar to this bill. It requires a QAS professional or a QAS paraprofessional to be supervised by a QAS provider, and makes other parallel changes. However it does not include the language of this bill which broadens the definition of provider categories, or extend the mandated timeline for review of the treatment plan.

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) would have modified the requirements of a QAS professional and would have required that a treatment plan be reviewed no more than once every 6 months, unless a shorter period is recommended by the QAS provider. The bill was held in the Assembly Appropriations Committee.

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. The bill was held in the Senate Appropriations Committee.

SB 946 (Steinberg, Chapter 650, statutes of 2011) requires health plans and health insurance policies to cover BHT 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.

COMMENTS

The sponsors of this bill and other supporters note they are seeking to change QAS Professional and QAS Paraprofessional as currently defined because it results in insurance covering only one form of behavioral health treatment rather than all forms of evidence-based behavioral health treatment. They believe that changes to the existing law are needed “to ensure that Californians with autism will receive the form of behavioral health care that is appropriate to their individual needs.” The proponents of the bill do not agree there is a need to expand the definition of QAS Professional and QAS Paraprofessional. They believe that it would “lead to individuals providing behavioral health treatment without the appropriate qualifications and without sufficient minimum standards to practice competently in place consumers will be at increasing risk of the erosion of quality of service.”

This bill is very similar to SB 562 (Portantino, 2021), which would have revised and expanded the definition of BHT for pervasive developmental disorder or autism for purposes of health plan and insurer mandated coverage including expanding the definitions of QAS providers, professionals, and paraprofessionals. SB 562, additionally, would have also prohibited the setting, location, or time of treatment recommended by the QAS provider from being used as a reason to deny or reduce coverage for medically necessary services. This bill was vetoed by Governor Newsom. The Governor’s veto message states the following:

“This bill would require health plans and insurers to cover relationship-based and developmental behavioral therapies for the treatment of autism spectrum disorder (ASD). The bill would also authorize additional types of providers and professionals that can provide behavioral health therapy to individuals with ASD.

Early diagnosis of ASD and subsequent participation in evidence-based intervention and therapies, provided by licensed and certified individuals, make all the difference in an individual's long-term health outcomes. Research finds that Black and Latino children are often misdiagnosed and diagnosed later with ASD than their White peers. It is incumbent upon us to ensure that any intervention is medically-necessary, evidence-based and grounded in research that is conducted to reduce disparities.

Under existing law, health plans and insurers must cover evidence-based and medically-necessary behavioral therapies. This bill proposes to change the existing evidence-based standard by requiring coverage of therapies where there is insufficient, or only emerging, evidence to assess the impact of the interventions. Furthermore, the bill proposes changes to professional standards by expanding the types of individuals who can serve as qualified autism service professionals, which could result in long-term ramifications for individuals with ASD who receive the services.

I appreciate the author's dedication to supporting children diagnosed with ASD and their families. While the bill's intent is laudable, expanding access to certain therapies and interventions must be grounded in evidence-based practices and be provided by qualified professionals. I encourage the author to continue discussions related to the expansion of provider types and changes to professional standards through a formal licensing scheme that includes clinical expertise and administrative oversight to address qualification standards for practitioners, to ensure equity and quality of care, and provide effective consumer protection, as I expressed when I vetoed a similar bill in 2019.”

This bill was double referred to Senate Health Committee. The Senate Health Committee amended the bill to clarify that a QAS professional includes a psychology associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, who is supervised by a licensed professional as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.

SUPPORT/OPPOSITION

Arguments in Support:

The DIR/Floortime Coalition of California writes, “The DMHC unanimously adopted the guiding principle that behavioral health interventions should be highly individualized and that the choice of BHT should be grounded in scientific evidence, clinical practice guidelines, and evidence-based practice. Research has clearly demonstrated that a variety of forms of BHT are effective. Despite this, the specific language in SB 946 limits the choice of treatment modalities in practice and too many children have been denied the specific form of therapy they need. Specifically, the language in SB 946 and subsequent definitions of Qualified Autism Paraprofessionals pursuant to AB 104 (2011), and in CCR 54342 severely limits the type of BHT covered. SB 805 would correct this oversight. SB 805 will allow health professionals who are assistants or associates of professionals already licensed in California to provide all forms of evidence-based BHT under supervision. In addition, SB 805 will expand the pool of professionals and paraprofessionals able to provide covered BHT by creating two new categories: behavioral health professional and behavioral health paraprofessional and directs DDS to develop the requirements for these positions. In this way, a broader array of types of BHT will become available for those in need. The qualifications should be equivalent in rigor to the currently authorized providers, and simply expand the types of intervention from the current highly restrictive form of BHT covered.

Arguments in Opposition:

The California Association for Behavior Analysis writes, “We continue to oppose legislation that expands criteria for providers of behavioral health treatment for individuals with autism. While this attempt does not have the far reaching negative implications of similar previous legislation, we continue to have concerns about lowering/expanding provider qualifications. SB 805 requires that DDS establish educational and experiential qualifications for these providers which should be and have been set by national accreditation and credentialing boards. We applaud the efforts to increase access to behavioral health services for individuals with autism and their families but believe that the language of SB 805 has negative unintended consequences. As written, this bill alters the eligibility requirements for practitioners serving this vulnerable population. We are concerned that as written SB 805 would lead to individuals providing behavioral health treatment without the appropriate qualifications. We believe that many of the issues raised through this legislation can, and should, be addressed through legislation providing a comprehensive licensing framework for individuals providing these services. Without sufficient minimum standards to practice competently in place consumers will be at increasing risk of the erosion of quality of service. CalABA seeks to ensure sufficient consumer protections are in place for individuals with autism and their families and this bill goes against that value.”

PRIOR VOTES

POSITIONS

Support:

California Psychological Association

Center for Developmental Play and Learning

Cherry Crisp Entertainment and Productions

Child Development Institute

Dirfloortime Coalition of California

Disability Voices United

Easterseals Northern California

Greenhouse Therapy Center

Positive Development

Professional Child Development Associates

Quicksilver Software

The Center for Connection

Touchstone Family Development Center, INC.

Oppose:

California Association for Behavior Analysis

-- END --

1. https://www.cdc.gov/ncbddd/autism/addm-community-report/california.html ↑

2. Weitlauf AS, et al, “Therapies for Children with Autism Spectrum Disorder: Behavioral Interventions Update.” Comparative Effectiveness Review No. 137. ↑

SENATE COMMITTEE ON HEALTH

Senator Dr. Susan Talamantes Eggman, Chair

BILL NO: SB 805

SUBJECT: Health care coverage: pervasive developmental disorders or autism

SUMMARY:

Expands the qualifications for Qualified Autism Service professionals and paraprofessionals as found in California’s mandate on health plans and insurers to cover behavioral health treatment for pervasive developmental disorders or autism, and, requires the Department of Developmental Services to establish emergency regulations to develop educational or experiential qualifications and supervision requirements for these providers and a rate.

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Services Plan Act of 1975; the California Department of Insurance (CDI) to regulate health and other insurers; the Department of Health Care Services (DHCS) to administer the Medi-Cal program; and the Department of Developmental Disabilities (DDS) to administer services to people with developmental disabilities. [HSC §1340, et seq., INS §106, et seq.,WIC §14000, et seq., and WIC §4400, et seq.]
2. Requires every health plan contract and health insurance policy that provides hospital, medical, or surgical coverage to cover Behavioral Health Treatment (BHT) for pervasive developmental disorder or autism. 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. [HSC §1374.73 and INS §10144.51]
3. Defines BHT for purposes of 2) above as 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 that meet specified criteria regarding the treatment plan, the professionals who can prescribe (physicians and psychologists) and supervise treatment, and administer a treatment plan. [HSC §1374.73 and INS §10144.51]
4. Requires every health plan or health insurer subject to 2) and 3) above to maintain an adequate network that includes qualified autism service (QAS) providers who supervise or employ QAS professionals and QAS paraprofessionals who provide and administer BHT. [HSC §1374.73 and INS §10144.51]
5. Makes BHT a covered Medi-Cal service for individuals under 21 years of age. [WIC §14132.56]
6. Prohibits a health plan and disability insurer from limiting benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and from including or enforcing a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program. [HSC §1374.72 and INS §10144.5]

This bill:

1. Includes as a QAS provider: a behavioral service provider who meets the criteria set forth in regulations for a behavioral health professional described in this 3) below; or, a registered, certified, or licensed health care “associate” or “assistant” regulated by the Board of Psychology, the Board of Behavioral Sciences, or the California Board of Occupational Therapy, as defined, and supervised by a QAS provider licensed and practicing in the associate’s or assistant’s field of medicine under any and all applicable statutory or regulatory supervisory requirements.
   
2. Includes as a QAS paraprofessional someone who meets the criteria set forth in the regulations described in 4) below.
   
3. Requires DDS to adopt emergency regulations to address the use of behavioral health professionals and behavioral health paraprofessionals in group practice provider behavioral intervention services and establish a rate. Requires the regulations to also establish a rate and the educational or experiential qualifications and professional supervision requirements necessary for the behavioral health professional to provide behavioral intervention services.
   
4. Deems the adoption, amendment, repeal, or readoption of a regulation authorized by this bill to be necessary for the immediate preservation of the public peace, health and safety, or general welfare, as specified, and exempts DDS from the requirement that it describe specific facts showing the need for immediate action. Requires a certificate of compliance for these implementing regulations to be filed within 24 months following the adoption of the first emergency regulations filed pursuant to this bill.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, this bill corrects a long-standing problem regarding services for autistic individuals in California. In 2011, SB 946 (Steinberg, Chapter 650, Statutes of 2011) introduced insurance coverage for BHT for autism. The definition of BHT given is “professional services and treatment programs, including 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.” Unfortunately the description of QAS professionals and QAS paraprofessionals became only those clinicians providing ABA. Those professionals using other “evidence-based behavior intervention programs” are not included in insurance coverage. This bill will correct this problem by expanding the descriptions of qualified professionals and qualified paraprofessionals. This will allow for choice in treatment approaches and offer greater access to urgently needed services. Research has clearly shown that there is a variety of approaches that are accepted as ‘evidence-based.’ Individuals with autism are all unique and deserve to have access to the approach which best suits their needs. This was clearly the intent of the legislation, originally passed in 2011.
2. Pervasive Developmental Disorder or Autism. According to the California Health Benefits Review Program (CHBRP), autism spectrum disorder is a developmental disability characterized by deficits in social interactions and communication, sensory processing, stereotypic (repetitive) behaviors or interests, and sometimes cognitive function. The symptoms fall along a continuum, ranging from mild impairment to profound disability. Diagnoses are often made in early childhood. In California, among those with autism spectrum disorder served by DDS (the largest California-specific dataset), Hispanics accounted for 38% of recipients, followed by whites (28%), Asians (9%), and blacks (7%). However, the proportion of individuals receiving DDS services who are enrollees in DMHC-regulated plans or CDI-regulated policies is unknown. California studies have showed Blacks having the highest prevalence in birth year 2013, with 1.8%, compared to whites at 1.5% and Hispanics at 1.2%. Studies consistently show that children from low income, less educated, and more rural families are less likely to receive BHT than their higher income, better educated, and urban counterparts. One study revealed that parents with a lower educational level accessed less intensive therapies compared to parents with higher educational levels who accessed higher intensity services. A literature review found three of six studies on geographic variation in age of autism diagnosis (the start of autism treatment services) identified barriers for rural compared to urban families and two qualitative studies also found rural families had more difficulty than urban families in accessing providers for timely diagnosis and treatment.
   
3. Task Force. The Autism Advisory Task Force was established pursuant to SB 946 to make recommendations to inform state policymaking and develop recommendations regarding the education, training, and experience requirements that unlicensed individuals providing autism services are required to meet in order to secure a license from the state. A guiding principle of the task force was that every individual with autism or pervasive developmental disorder is unique. According to the task force report, individuals have different combinations of characteristics, different needs for assistance, and respond differently to treatment. Therefore, behavioral health interventions need to be highly individualized. Since treatment selection should be made by a team of individuals who can consider the unique needs and history of the individual with autism or pervasive developmental disorder, the task force determined that it would not be informative to state policy makers to merely develop a list of BHTs that are determined to be effective, based solely on current scientific literature. Since scientific research and findings naturally advance, the task force determined that the choice of BHT should be grounded in scientific evidence, clinical practice guidelines, and/or evidence-based practice.
   
   The task force report concludes that all "top level" providers should be licensed by the state, and set forth a process for establishing a new professional license for "Licensed Behavioral Health Practitioner." The task force recommended that the license requirement not take effect until three years after the license is established, and an interim commission be formed to implement the new license until a board is able to do so. The task force also recommended all providers of autism services be registered with the state's TrustLine Registry or comparable system as a condition of employment by service organizations and contracting with health plans and health insurers. TrustLine uses the criminal history background check system to check the fingerprints of applicants, and checks for evidence of additional criminal records.
   
4. Medi-Cal. Medi-Cal covers all medically necessary BHT for eligible beneficiaries under 21 years of age. This may include children with autism spectrum disorder as well as children for whom a physician or psychologist determines it is medically necessary. Consistent with state and federal requirements, a physician or a psychologist must recommend BHT services as medically necessary based on whether BHT services will correct or ameliorate any physical and/or behavioral conditions. BHT services include ABA and a variety of other behavioral interventions that have been identified as evidence-based approaches that prevent or minimize the adverse effects of behaviors that interfere with learning and social interaction, and promote, to the maximum extent practicable, the functioning of a beneficiary, including those with or without autism spectrum disorder. Examples of BHT services include behavioral interventions, cognitive behavioral intervention, comprehensive behavioral treatment, language training, modeling, natural teaching strategies, parent/guardian training, peer training, pivotal response training, schedules, scripting, self-management, social skills package, and story-based interventions. Beneficiaries in a Medi-Cal managed care plan receive BHT services from their plan. Children with fee-for-service Medi-Cal will receive BHT services from their local Regional Center.
   
5. 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 SB 562 of 2022, which is similar to this bill in that this bill is altering the mandate to expand the mandate to include certain professionals who provide developmental-based treatment modalities as described below. Key findings relevant to this bill include:
   
   1. Assumptions. CHBRP assumes that BHT would require coverage of developmental-based modalities (such as DIR®/Floortime™) as well as behavior-based modalities (such as Pivotal Response Training) and hybrid modalities (such as Early Start Denver Model and Social Skills Group Therapy).
   2. Coverage impacts and enrollees covered. At baseline, 100% of commercial/CalPERS enrollees with health insurance that would be subject to this bill have coverage for modalities of BHT based on behavioral theory and hybrid modalities (behavioral and developmental). Postmandate, coverage for modalities based on developmental theory would rise among these enrollees from 77% to 100%.
      
   3. Medical effectiveness. CHBRP found evidence that BHT modalities based on ABA, developmental theory, and hybrids of both theories improve outcomes for people with autism spectrum disorder. Prominent outcomes include improvements in communication, social skills, cognition, adaptive behavior, language, motor skills, play skills, and symptom severity. CHBRP’s literature review also found that BHT can be delivered effectively by people with similar training as QAS professionals when supervised by a QAS provider. Regardless of the theory on which BHT modalities are based, many studies of them are observational or quasi-experimental studies that do not randomly assign participants to the intervention or control condition. Some do not include any sort of comparison group. Lack of random assignment decreases confidence that any differences that are found between the treatment and control groups are due to the BHT treatment being tested and not to differences between the people with autism spectrum disorder in the treatment and control groups. Lack of a control group further decreases confidence in a study’s findings because one cannot rule out the possibility that any differences observed over time are due to factors other than the BHT modality. In cases where random control groups (RCTs) of BHT interventions were conducted, caution should be exercised when interpreting the findings of RCTs with small sample sizes. Moreover, most articles in CHBRP’s medical effectiveness literature review were about research in children; a few articles on adolescents were identified. The findings may be difficult to generalize to adults.
   4. Utilization. CHBRP estimates that 24,000 enrollees with autism spectrum disorder in DMHC-regulated plans and CDI-regulated policies have health insurance that would be subject to this bill. Postmandate, CHBRP assumes the number of enrollees with autism spectrum disorder using BHT will not increase, because the use of this type of treatment overall is based on clinical diagnosis and determination that BHT is medically necessary.
      
   5. Medi-Cal. This bill would not change the current law’s Medi-Cal related exemption, CHBRP projects no change in premium expenditures for the 8.9 million Medi-Cal beneficiaries enrolled in DMHC-regulated plans.
      
   6. Essential health benefits (EHBs). CHBRP believes this bill would not trigger financial costs to the state for exceeding EHBs, because it alters the terms and conditions of an existing benefit mandate law, but does not require an additional benefit to be covered. Additionally, the law indicates that it ceases to function if it exceeds EHBs and this bill does not eliminate this clause of the current law.
6. Double referral. This bill has been double referred. Should it pass out of this committee it will be referred to the Senate Committee on Human Services.
   
7. Prior legislation. SB 562 (Portantino of 2022) would have revised and expanded the definition of BHT for pervasive developmental disorder or autism for purposes of health plan and insurer mandated coverage including expands the definitions of QAS providers, professionals, and paraprofessionals. Prohibited the setting, location, or time of treatment recommended by the QAS provider from being used as a reason to deny or reduce coverage for medically necessary services. SB 562 was vetoed by Governor Newsom. In his veto message the Governor states:
   
   “This bill would require health plans and insurers to cover relationship-based and developmental behavioral therapies for the treatment of autism spectrum disorder (ASD). The bill would also authorize additional types of providers and professionals that can provide behavioral health therapy to individuals with ASD.
   
   Early diagnosis of ASD and subsequent participation in evidence-based intervention and therapies, provided by licensed and certified individuals, make all the difference in an individual's long-term health outcomes. Research finds that Black and Latino children are often misdiagnosed and diagnosed later with ASD than their White peers. It is incumbent upon us to ensure that any intervention is medically-necessary, evidence-based and grounded in research that is conducted to reduce disparities.
   
   Under existing law, health plans and insurers must cover evidence-based and medically-necessary behavioral therapies. This bill proposes to change the existing evidence-based standard by requiring coverage of therapies where there is insufficient, or only emerging, evidence to assess the impact of the interventions. Furthermore, the bill proposes changes to professional standards by expanding the types of individuals who can serve as qualified autism service professionals, which could result in long-term ramifications for individuals with ASD who receive the services.
   
   I appreciate the author's dedication to supporting children diagnosed with ASD and their families. While the bill's intent is laudable, expanding access to certain therapies and interventions must be grounded in evidence-based practices and be provided by qualified professionals. I encourage the author to continue discussions related to the expansion of provider types and changes to professional standards through a formal licensing scheme that includes clinical expertise and administrative oversight to address qualification standards for practitioners, to ensure equity and quality of care, and provide effective consumer protection, as I expressed when I vetoed a similar bill in 2019.”

SB 163 (Portantino) was substantially similar to this bill, but deleted the Medi-Cal exemption from the state mandate. SB 163 was vetoed by Governor Newsom. The veto message states:

“This bill seeks to change the qualification standards necessary to be a qualified autism service professional or paraprofessional. When the Legislature enacted SB 946 (Steinberg, Chapter 650, Statutes of 2011), it clearly anticipated subsequent action to develop a comprehensive structure to license providers of behavioral health treatment to individuals with autism spectrum disorder. A formal licensing scheme that includes clinical expertise and administrative oversight is a more appropriate venue to address qualification standards for practitioners, ensure quality of care, and provide effective consumer protection. I encourage the Legislature to complete the work begun by SB 946.

In addition, by removing the health plan coverage exemption for contracts in the Medi-Cal program, this bill inadvertently creates conflicting requirements within the Medi-Cal program that could result in unintentional delays in access to care and jeopardizes continued receipt of federal financial participation for behavioral health treatment.”

SB 399 (Portantino of 2018) would have revised existing requirements on health plans and health insurers to cover BHT for pervasive developmental disorder or autism, such as allowing the substitution of specified current education, work experience, and training qualifications to meet the criteria of a QAS professional or paraprofessional. SB 399 would have prohibited a health plan and health insurer from denying or reducing medically necessary BHT based on a lack of parent or caregiver participation, or on the setting, location, or time of treatment, as specified. SB 399 was vetoed by Governor Brown. In his veto message, the Governor stated:

“This bill would revise qualification standards for providers of BHT for individuals with autism. Standards for autism providers were updated last year. I'm not inclined to revise them again.”

AB 1074 (Maienschein, Chapter 385, Statutes of 2017) permits a QAS paraprofessional to be supervised by a QAS professional; indicates that BHT may include clinical case management and case supervision under the direction and supervision of a QAS provider, deletes a requirement that a behavioral service provider is approved as a vendor by a Regional Center based on provider definitions in specified regulations; and instead requires a behavioral service provider to meet the education and experience qualifications described in the specified regulations; and, makes other technical changes.

AB 796 (Nazarian, Chapter 493, Statutes of 2016) eliminates the sunset date on the health insurance mandate to cover BHT for pervasive developmental disorder or autism.

SB 1034 (Mitchell of 2016) would have eliminated the sunset date on the health insurance mandate to cover BHT for pervasive developmental disorder or autism, and made other revisions to the law such as prohibiting denials for medically necessary BHT based on the setting, location or time of the treatment. SB 1034 was held on the Assembly Appropriations suspense file.

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. Hearing canceled at the request of the author 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 was held on the Assembly Appropriations suspense file.

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 would have required DDS to amend its regulations as necessary to implement the provisions of the bill. AB 2041 was held on the Senate Appropriations suspense file.

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 BHT 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 BHT 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.

1. Support. Disability Voices United (DVU) writes current legislation limits insurance to funding only one form of BHT, namely ABA. Although this treatment may work well for some children, it does not work for all. Autistic youth are unique and each needs access to the form of BHT best suited to their needs. It is important that all children receive individualized care. This bill would ensure that only evidence-based treatments are used, and that they are prescribed and supervised by licensed providers. All children need access to care to address their treatment needs in a timely way rather than wasting precious time on long wait lists due to the overly limited supply of service providers. Most families, particularly families of limited financial means, cannot afford to pay privately for costly ongoing intensive therapies denied by their insurance if their loved one requires a treatment approach that is not ABA. This unfair situation furthers healthcare access disparities in California’s historically disadvantaged communities. In DVU’s experience, many families, especially those from underserved communities, struggle for timely access to appropriate autism services. A parent writes by definition in the DSM-5 Diagnostic criteria, autism is a persistent deficit in “social communication” and “social interaction.” One of the primary deficits in autism is in social-emotional reciprocity. Social reciprocity is vitally important during early development because reciprocity (turn-taking between parents and young children) builds connectivity and efficiency in the brains of young children (Romeo et al. 2018). We also know from recent neuroscience research that reciprocity builds social communication competence (Gomez et al. 2021). The problem with ABA, and specifically discrete trial training, is that the emphasis of the treatment is on compliance, not on reciprocity. When Governor Newsom vetoed SB 562, and the previous bill proposed in 2019, he cited that “interventions must be grounded in evidence-based practices and be provided by qualified professionals.” If we are concerned about evidence we need to start recognizing recent research highlighting other evidence-based practices besides ABA For example, a recent meta-analysis found improvements in social communication using developmental and NDBI (Naturalistic Developmental Behavior Interventions), and conversely NO compelling evidence for traditional ABA interventions (Crank et al. 2021). Likewise, if we are concerned about qualified professionals we need to look at who is providing early intervention services in California. Many of the early intervention practitioners being trained in developmental and NDBI methods (which are currently not covered by insurance) are professionals with training in child development including infant educators, speech-language pathologists (SLP), and occupational therapists. Conversely, the RBTs (registered behavior technicians) who are often providing ABA early intervention here in California have a fraction of the training and education when compared to other professionals. For example, an SLP has a Master’s degree and 400 clinical hours whereas an RBT only needs a high school diploma and 40 hours of training, and that RBT training is solely on delivery of the RBT tasks, NOT on child development. In addition to my experience as a parent, I have over 12 years of experience in providing early intervention speech-language therapy home visits. I have seen the difference that relationship-based approaches rather than behavioral approaches make in changing the lives of young autistic children and their caregivers. One of the largest initiatives in early intervention in California is on relationship building between parents and their children and empowering parents that THEY are best their child’s best teacher. Many ABA programs do NOT include parents in delivering treatment and are therefore not following the model that is recommended as evidenced-based practice by the Early Start Comprehensive System of Personnel Development.
   
2. Oppose. The California Association of Behavior Analysis (CalABA) writes that they continue to oppose legislation that expands criteria for providers of BHT for individuals with autism. While this attempt does not have the far reaching negative implications of similar previous legislation, CalABA continues to have concerns about lowering/expanding provider qualifications. This bill requires that DDS establish educational and experiential qualifications for these providers which should be and have been set by national accreditation and credentialing boards. This bill alters the eligibility requirements for practitioners serving this vulnerable population. CalABA is concerned that as written this bill would lead to individuals providing BHT without the appropriate qualifications, and believes that many of the issues raised through this legislation can, and should, be addressed through legislation providing a comprehensive licensing framework for individuals providing this service. CalABA writes without sufficient minimum standards to practice competently in place consumers will be at increasing risk of the erosion of quality of service.
   
3. Amendments. The author requests the committee amend the bill as follows:
   (ii)  A registered, certified, or licensed health care “associate” or “assistant” of a licensed provider, regulated by the Board of Psychology, the Board of Behavioral Sciences, or the California Board of Occupational Therapy, as defined in the Business and Professions Code, and supervised by a qualified autism service provider licensed and practicing in the associate’s or assistant’s field of medicine under any and all applicable statutory or regulatory supervisory requirements.

SUPPORT AND OPPOSITION:

Support: DIRFloortime Coalition of California (sponsor)

California Psychological Association

Center for Developmental Plan and Learning

Cherry Crisp Entertainment and Productions

Child Development Institute

Disability Voices United

Greenhouse Therapy Center

Positive Development

Professional Child Development Associates

Quicksilver Softwore, Inc.

Touchstone Family Development Center, Inc.

One Individual

Oppose: California Association for Behavior Analysis

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