CDCAN REPORT #161-2011: Landmark health care reform bill introduced to require health plans to provide behavioral health treatment

LANDMARK HEALTH CARE REFORM LEGISLATION INTRODUCED BY SENATE PRESIDENT STEINBERG TO REQUIRE HEALTH PLANS TO PROVIDE BEHAVIORAL HEALTH TREATMENT FOR PERSONS WITH AUTISM

Provisions Amended Into SB 770 Will Be Heard August 24th In Assembly Appropriations Committee - Steinberg Committed to Passage of Bill Before September 9th Adjournment - Bill Could Have Sweeping Impact for Tens of Thousands of Children and Adults With Autism Covered by Managed Health Plans and Private Health Insurance - Disability Advocates Say Bill Could Result In Hundreds of Millions of Dollars in Savings to State General Fund - Fierce Opposition from Health Plans Expected

SACRAMENTO, CALIF (CDCAN)  [Last updated 08/18/2011 04:40 AM] - Potential sweeping landmark health care insurance reform legislation was introduced Tuesday by Senate President Pro Tem Darrell Steinberg (Democrat - Sacramento, 6th State Senate District) that would require health managed care plans and health insurance plans to provide as a covered benefit behavioral health treatment for persons with autism spectrum disorders.  The legislation would take effect, if passed by the Legislature before it adjourns for the year on September 9th and signed by the Governor on or before October 9th, on January 1, 2012.

The bill, which Steinberg said he was committed to see passed before the Legislature adjourns for the year on September 9th, will likely meet fierce opposition from health managed care plans and strong support from advocates for children and adults with autism spectrum disorders and their families. Health plans who have opposed previous efforts, have said that behavioral health treatments for persons with autism are more appropriately provided by school districts and other entities.

A copy of the 10 page bill, as amended August 16th is attached to this CDCAN Report and titled "2011-08-16 - SB 770.pdf "  The text of the bill (from the Legislative Information website) was saved as a document and as a result, persons who are blind or sight impaired can read it using a screen reading device.  A copy of the complete text (except the strike-outs) is copied below).

SB 770 would require or mandate coverage of behavioral health treatment, such as Applied Behavioral Analysis (ABA) and other  intensive early intervention therapy, for thousands of people with autism spectrum disorders. The bill also defines the scope of these treatments and eliminates what Steinberg says are "unwarranted restrictions" on those who are qualified to provide the treatment.

“Parents of autistic children shouldn’t have to spend their days and sleepless nights battling with insurance companies because of a lack of clarity regarding this highly effective therapy. ABA [Applied Behavioral Analysis]  has long been considered medically necessary and has proven remarkably effective for a majority of families,” Steinberg said.

Advocates in favor the legislation and previous efforts in AB 171, say the new requirement would achieve significant major cost savings to the State general fund that they estimate could run as high as over $200 million because private health plans would be required to provide those services and pay for it - a contention that health plan advocates strongly disagree with.

Families of children with autism and other advocates have fought with various health plans and the Department of Managed Health Care and other agencies for years on the issue of providing critically needed behavioral health treatments for their children.

The position of Governor Brown on the issue and the bill is not known yet - but will become crucial in the coming weeks if the bill passes the Legislature.

Bill Scheduled For Hearing in Assembly Appropriations Committee August 24th - Intense Opposition from Health Plans Expected

• The legislation was amended August 16th into SB 770, a bill that previously focused on marine protected areas and Indian tribes, and will be heard in the Assembly Appropriations Committee on August 24th according to Steinberg's office.
• More amendments to the bill are likely, according to Steinberg's office.

SB 770 Similar to Previous AB 171 by Assemblymember Beall

• SB 770 as amended August 16 now focuses on the same issues covered by AB 171 by Assemblymember Jim Beall, Jr. (Democrat - San Jose), which was held in Assembly Appropriations Committee in May  and who is now a co-author of SB 770.
• The bill also covers the same overall issue addressed by Steinberg's SB 166, which was held in Senate Health Committee earlier this year . That bill however did not contain the new requirements on health plans that are in SB 770 - and AB 171 
• Sponsors of the bill include Autism Speaks, Alliance of California Autism Organizations, Special Needs Network, and The Help Group.

Key Provisions of SB 770

• Every health care service plan contract issued,amended, or renewed on or after January 1, 2012, that provides hospital, medical, or surgical coverage pursuant to Section 1374.72 shall provide coverage for behavioral health treatment for pervasive developmental disorder or autism. The coverage shall be provided in the same manner and shall be subject to the same requirements as provided in Section 1374.72.
• Notwithstanding any other provision of law, unlicensed or uncertified staff may implement services if the qualified autism service provider ensures that each staff person implementing services pursuant to this section has adequate training and the qualified autism service provider supervises these staff persons.
• "Behavioral health treatment" means professional services and treatment programs, including, but not limited to, applied behavior analysis and other intervention programs, such as Pivotal Response Therapy and Early Start Denver Model, that meet all of the criteria in the bill (SB 770). 

Action By Steinberg Comes After Settlement With Managed Care Plans With Department of Managed Health Care 

The action by Steinberg comes weeks after the announcement by the Department of Managed Health Care of a settlement with two managed health care plans regarding coverage for children with autism, which many advocates called a “sham,” and that the agreement created a situation that would result in a significant loss of access to those services because it would require that those Applied Behavioral Analysis providers be licensed - a requirement that does not exist under current federal or state laws.

Steinberg was critical of the limitations of the agreement saying that “The recent agreement added urgency to clarify who is authorized to perform treatment. We need a more expansive network which includes those who are expertly trained and on the cutting edge of ABA [Applied Behavioral Analysis] therapy so parents don’t have to jump through bureaucratic hoops to get children the services they need.”

SB 770 expands the list of qualified autism providers to include any licensed or nationally certified professional, or any provider of these services approved as a vendor by one of California’s 21 non-profit regional centers which contract with the Department of Developmental Services to provide or coordinate services and supports for individuals with developmental disabilities.

CDCAN SUMMARY AND STATUS OF SB 770

SB 770 - HEALTH CARE COVERAGE: MENTAL ILLNESS - DEVELOPMENTAL DISORDER AND AUTISM

AUTHOR: Sen. Darrell Steinberg (Democrat - Sacramento, 6th State Senate District)
CDCAN SUMMARY: As amended August 16, 2011, would require, for policies issued , amended or renewed after January 1, 2012, health care service plan contracts under the Department of Managed Health Care and health insurance policies under the Department of Insurance to also provide coverage for behavioral health treatment  for pervasive developmental disorder or autism.
Would not require any benefits to be provided that exceed the essential health benefits required to be provided under Section 1302(b) of the federal "Patient Protection and Affordable Care Act " (Public Law 111-148), as amended  by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).[sometimes referred to as the health care reform act]
LATEST ACTION 08/16/2011:  In Assembly Appropriations Committee.  Amended (author's amendments) and referred back to Assembly Appropriations Committee.
NEXT STEPS:  Will be scheduled to be heard in Assembly Appropriations Committee on August 24th (Wednesday),  
LATEST VERSION OF BILL - HTML:  http://www.leginfo.ca.gov/pub/11-12/bill/sen/sb_0751-0800/sb_770_bill_20110816_amended_asm_v93.html
LATEST VERSION OF BILL - PDF:   http://www.leginfo.ca.gov/pub/11-12/bill/sen/sb_0751-0800/sb_770_bill_20110816_amended_asm_v93.pdf
PRIORITY: VERY HIGH
CDCAN COMMENT: This bill replaces the contents of the previous version of SB 770 that dealt with marine protected areas and American Indian Tribes.
Watch for CDCAN Action Alert on this bill to be issued later tonight.

TEXT OF SB 770 AS AMENDED

The contents of the bill dealing with autism and insurance reforms replaced the existing bill which focused on marine protected areas and Indian tribes.  Those provisions were struck out or deleted from the bill, noted by text with "strike-outs".  Those strike-outs are not included in the text below.

SB 770 AMENDED

AMENDED IN ASSEMBLY  AUGUST 16, 2011
 AMENDED IN ASSEMBLY  JUNE 30, 2011
 AMENDED IN SENATE  MAY 31, 2011
 AMENDED IN SENATE  APRIL 25, 2011
 AMENDED IN SENATE  MARCH 24, 2011
 AMENDED IN SENATE  MARCH 21, 2011

INTRODUCED BY  Senators   Steinberg   and Evans
    (   Principal coauthor:   Assembly Member Beall   )
    (   Coauthor:   Assembly Member Fuentes   )

                        FEBRUARY 18, 2011

An act to add Section 1374.73 to the Health and Safety Code, and to add Sections 10144.51 and 10144.52 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL'S DIGEST

   SB 770, as amended, Steinberg
 Health care coverage: mental illness: developmental disorder and autism.
   (1) Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of these provisions is a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide benefits for specified conditions, including certain mental health conditions.
   This bill would require those health care service plan contracts and health insurance policies to also provide coverage for behavioral health treatment, as defined, for pervasive developmental disorder or autism. The bill would provide, however, that no benefits are required to be provided that exceed the essential health benefits required under specified federal law. Because a violation of these provisions with respect to health care service plans would be a crime, the bill would impose a state-mandated local program.

   (2) The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
   This bill would provide that no reimbursement is required by this act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes

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

   SECTION 1.    The Legislature finds and declares all of the following:

   (a) Scientific research has established that behavioral health treatment can significantly improve the cognitive function and emotional capabilities, and reduce self-injurious behavior, for a significant number of individuals with pervasive developmental disorder or autism.

   (b) Existing law requires health care service plan contracts and health insurance policies to provide coverage for all medically necessary treatment for individuals with pervasive developmental disorder or autism pursuant to Section 1374.72 of the Health and Safety Code and Section 10144.5 of the Insurance Code.

   (c) Scientists, physicians, and other autism experts consider behavioral health treatment an important and medically necessary treatment for a significant number of individuals with pervasive developmental disorder or autism.

   (d) Despite Section 1374.72 of the Health and Safety Code, Section 10144.5 of the Insurance Code, and the scientific literature findings that behavioral health treatment is efficacious in the treatment of pervasive developmental disorder and autism, some health care service plans and health insurers continue to refuse to cover medically necessary behavioral health treatment for individuals with these disorders.

   (e) Of the grievances and appeals that have been filed with the Department of Managed Health Care and the Department of Insurance, an increasing number of independent medical review decisions have determined that behavioral health treatment is medically necessary for the treatment of pervasive developmental disorder or autism.

   (f) Therefore, it is the intent of the Legislature to ensure that behavioral health treatment is considered a covered benefit, when it is medically necessary, for the treatment of pervasive developmental disorder or autism.

   SEC. 2.    Section 1374.73 is added to the Health and Safety Code, to read:

   1374.73.  (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2012, that provides hospital, medical, or surgical coverage pursuant to Section 1374.72 shall provide coverage for behavioral health treatment for pervasive developmental disorder or autism. The coverage shall be provided in the same manner and shall be subject to the same requirements as provided in Section 1374.72.

   (2) Notwithstanding paragraph (1), this section does not require any benefits to be provided that exceed the essential health benefits required to be provided under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).

   (3) This section shall not be construed as reducing any obligation to provide services to an individual under an individualized family service plan as described in Section 95020 of the Government Code, an individualized program plan as described in Section 4646 of the Welfare and Institutions Code, a prevention program plan as described in Section 4435 of the Welfare and Institutions Code, an individualized education program as defined in Section 56032 of the Education Code, or an individualized service plan as described in Section 5600.4 of the Welfare and Institutions Code.

   (b) Every health care service plan subject to this section shall maintain an adequate network of qualified autism service providers, and the plan shall comply with all applicable provisions of this act or regulations adopted thereunder.

   (c) (1) Notwithstanding any other provision of law, unlicensed or uncertified staff may implement services if the qualified autism service provider ensures that each staff person implementing services pursuant to this section has adequate training and the qualified autism service provider supervises these staff persons.

   (2) Prior to implementing services, all unlicensed or uncertified staff shall be subject to criminal background screening and fingerprinting meeting requirements established by the department.

   (d) For the purposes of this section, the following definitions
shall apply:

   (1) "Behavioral health treatment" means professional services and treatment programs, including, but not limited to, applied behavior analysis and other intervention programs, such as Pivotal Response Therapy and Early Start Denver Model, that meet all of the following criteria:

   (A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code.

   (B) The treatment shall be derived from peer-reviewed literature or scientific evidence-based research that has demonstrated clinical efficacy in treating the symptoms or manifestations associated with pervasive developmental disorder or autism.

   (C) The treatment is provided or supervised by a qualified autism service provider.

   (2) "Pervasive developmental disorder or autism" shall have the same meaning and interpretation as used in Section 1374.72.

  (3) "Qualified autism service provider" shall include any person, entity, or group that is nationally certified by an entity, such as, but not limited to, the Behavior Analyst Certification Board, that is accredited by the National Commission for Certifying Agencies, or any person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person, entity, or group that is nationally certified or the licensee. A "qualified autism service provider" shall also include both of the following:

   (A) Any service provider that is approved as a vendor of a regional center to provide those same services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.

   (B) A State Department of Education nonpublic, nonsectarian agency, as defined in Section 56035 of the Education Code, that is approved to provide those same services for pervasive developmental disorder or autism.

   SEC. 3.    Section 10144.51 is added to the Insurance Code, to read:

   10144.51.  (a) (1) Every health insurance policy issued, amended, or renewed on or after January 1, 2012, that provides hospital, medical, or surgical coverage pursuant to Section 10144.5 shall provide coverage for behavioral health treatment for pervasive developmental disorder or autism. The coverage shall be provided in the same manner and shall be subject to the same requirements as provided in Section 10144.5.

   (2) Notwithstanding paragraph (1), this section does not require any benefits to be provided that exceed the essential health benefits required to be provided under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).

   (3) This section shall not be construed as reducing any obligation to provide services to an individual under an individualized family service plan as described in Section 95020 of the Government Code, an individualized program plan as described in Section 4646 of the Welfare and Institutions Code, a prevention program plan as described in Section 4435 of the Welfare and Institutions Code, an individualized education program as defined in Section 56032 of the Education Code, or an individualized service plan as described in Section 5600.4 of the Welfare and Institutions Code.

   (b) Pursuant to Article 6 (commencing with Section 2240.1) of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network of qualified autism service providers to ensure that all insureds have timely access to qualified autism service providers, continuity of care, and ready referral to in-network qualified autism service providers.

   (c) (1) Notwithstanding any other provision of law, unlicensed or uncertified staff may implement services if the qualified autism service provider ensures that each staff person implementing services pursuant to this section has adequate training and the qualified autism service provider supervises these staff persons.

   (2) All unlicensed or uncertified staff implementing services pursuant to this section shall be subject to criminal background screening and fingerprinting meeting requirements established by the department.

   (d) For the purposes of this section, the following definitions shall apply:

   (1) "Behavioral health treatment" means professional services and treatment programs, including, but not limited to, applied behavior analysis and other intervention programs, such as Pivotal Response Therapy and Early Start Denver Model, that meet all of the following criteria:

   (A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code.

   (B) The treatment shall be derived from peer-reviewed literature or scientific evidence-based research that has demonstrated clinical efficacy in treating the symptoms or manifestations associated with pervasive developmental disorder or autism.

   (C) The treatment is provided or supervised by a qualified autism service provider.

   (2) "Pervasive developmental disorder or autism" shall have the same meaning and interpretation as used in Section 10144.5.

   (3) "Qualified autism service provider" shall include any person, entity, or group that is nationally certified by an entity, such as, but not limited to, the Behavior Analyst Certification Board, that is accredited by the National Commission for Certifying Agencies, or any person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person, entity, or group that is nationally certified or the licensee. A "qualified autism service provider" shall also include both of the following:

   (A) Any service provider that is approved as a vendor of a regional center to provide those same services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.

   (B) A State Department of Education nonpublic, nonsectarian agency as defined in Section 56035 of the Education Code, approved to provide those same services for pervasive developmental disorder or autism.

   SEC. 4.    Section 10144.52 is added to the Insurance Code   , to read:

   10144.52.  For purposes of this part, the terms "provider," "professional provider," "network provider," "mental health provider," and "mental health professional" shall include the term "qualified autism service provider" as defined in subdivision (d) of Section 10144.51.

   SEC. 5.    No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution. 

File Attachments: 

2011-08-16 - SB 770.pdf (173.65 KB)